1
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Rotz SJ, Bhatt NS, Hamilton BK, Duncan C, Aljurf M, Atsuta Y, Beebe K, Buchbinder D, Burkhard P, Carpenter PA, Chaudhri N, Elemary M, Elsawy M, Guilcher GM, Hamad N, Karduss A, Peric Z, Purtill D, Rizzo D, Rodrigues M, Ostriz MBR, Salooja N, Schoemans H, Seber A, Sharma A, Srivastava A, Stewart SK, Baker KS, Majhail NS, Phelan R. International Recommendations for Screening and Preventative Practices for Long-Term Survivors of Transplantation and Cellular Therapy: A 2023 Update. Transplant Cell Ther 2024; 30:349-385. [PMID: 38413247 DOI: 10.1016/j.jtct.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 02/29/2024]
Abstract
As hematopoietic cell transplantation (HCT) and cellular therapy expand to new indications and international access improves, the number of HCTs performed annually continues to rise. Parallel improvements in HCT techniques and supportive care entails more patients surviving long term, creating further emphasis on survivorship needs. Survivors are at risk for developing late complications secondary to pretransplantation, peritransplantation, and post-transplantation exposures and other underlying risk factors. Guidelines for screening and preventive practices for HCT survivors were originally published in 2006 and then updated in 2012. An international group of experts was convened to review the contemporary literature and update the recommendations while considering the changing practices of HCT and cellular therapy. This review provides updated pediatric and adult survivorship guidelines for HCT and cellular therapy. The contributory role of chronic graft-versus-host disease (cGVHD) to the development of late effects is discussed, but cGVHD management is not covered in detail. These guidelines emphasize the special needs of patients with distinct underlying HCT indications or comorbidities (eg, hemoglobinopathies, older adults) but do not replace more detailed group-, disease-, or condition-specific guidelines. Although these recommendations should be applicable to the vast majority of HCT recipients, resource constraints may limit their implementation in some settings.
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Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Neel S Bhatt
- Fred Hutchinson Cancer Center, Seattle, Washington
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christine Duncan
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard University, Boston, Massachusetts
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Yoshiko Atsuta
- Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan
| | - Kristen Beebe
- Phoenix Children's Hospital and Mayo Clinic Arizona, Phoenix, Arizona
| | - David Buchbinder
- Division of Hematology, Children's Hospital of Orange County, Orange, California
| | | | | | - Naeem Chaudhri
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Mohamed Elemary
- Hematology and BMT, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mahmoud Elsawy
- Division of Hematology, Dalhousie University, QEII Health Sciences Center, Halifax, Nova Scotia, Canada
| | - Gregory Mt Guilcher
- Section of Pediatric Oncology/Transplant and Cellular Therapy, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital Sydney, St Vincent's Clinical School Sydney, University of New South Wales, School of Medicine Sydney, University of Notre Dame Australia, Australia
| | - Amado Karduss
- Bone Marrow Transplant Program, Clinica las Americas, Medellin, Colombia
| | - Zinaida Peric
- BMT Unit, Department of Hematology, University Hospital Centre Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Duncan Purtill
- Fiona Stanley Hospital, Murdoch, PathWest Laboratory Medicine WA, Australia
| | - Douglas Rizzo
- Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Maria Belén Rosales Ostriz
- Division of hematology and bone marrow transplantation, Instituto de trasplante y alta complejidad (ITAC), Buenos Aires, Argentina
| | - Nina Salooja
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven, Department of Public Health and Primary Care, ACCENT VV, KU Leuven, University of Leuven, Leuven, Belgium
| | | | - Akshay Sharma
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | | | | | - Navneet S Majhail
- Sarah Cannon Transplant and Cellular Therapy Network, Nashville, Tennessee
| | - Rachel Phelan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
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2
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Rotz SJ, Bhatt NS, Hamilton BK, Duncan C, Aljurf M, Atsuta Y, Beebe K, Buchbinder D, Burkhard P, Carpenter PA, Chaudhri N, Elemary M, Elsawy M, Guilcher GMT, Hamad N, Karduss A, Peric Z, Purtill D, Rizzo D, Rodrigues M, Ostriz MBR, Salooja N, Schoemans H, Seber A, Sharma A, Srivastava A, Stewart SK, Baker KS, Majhail NS, Phelan R. International recommendations for screening and preventative practices for long-term survivors of transplantation and cellular therapy: a 2023 update. Bone Marrow Transplant 2024:10.1038/s41409-023-02190-2. [PMID: 38413823 DOI: 10.1038/s41409-023-02190-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/08/2023] [Accepted: 12/19/2023] [Indexed: 02/29/2024]
Abstract
As hematopoietic cell transplantation (HCT) and cellular therapy expand to new indications and international access improves, the volume of HCT performed annually continues to rise. Parallel improvements in HCT techniques and supportive care entails more patients surviving long-term, creating further emphasis on survivorship needs. Survivors are at risk for developing late complications secondary to pre-, peri- and post-transplant exposures and other underlying risk-factors. Guidelines for screening and preventive practices for HCT survivors were originally published in 2006 and updated in 2012. To review contemporary literature and update the recommendations while considering the changing practice of HCT and cellular therapy, an international group of experts was again convened. This review provides updated pediatric and adult survivorship guidelines for HCT and cellular therapy. The contributory role of chronic graft-versus-host disease (cGVHD) to the development of late effects is discussed but cGVHD management is not covered in detail. These guidelines emphasize special needs of patients with distinct underlying HCT indications or comorbidities (e.g., hemoglobinopathies, older adults) but do not replace more detailed group, disease, or condition specific guidelines. Although these recommendations should be applicable to the vast majority of HCT recipients, resource constraints may limit their implementation in some settings.
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Affiliation(s)
- Seth J Rotz
- Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | | | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Christine Duncan
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard University, Boston, MA, USA
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Yoshiko Atsuta
- Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Nagakute, Japan
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan
| | - Kristen Beebe
- Phoenix Children's Hospital and Mayo Clinic Arizona, Phoenix, AZ, USA
| | - David Buchbinder
- Division of Hematology, Children's Hospital of Orange County, Orange, CA, USA
| | - Peggy Burkhard
- National Bone Marrow Transplant Link, Southfield, MI, USA
| | | | - Naeem Chaudhri
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Mohamed Elemary
- Hematology and BMT, University of Saskatchewan, Saskatoon, SK, Canada
| | - Mahmoud Elsawy
- Division of Hematology, Dalhousie University, Halifax, NS, Canada
- QEII Health Sciences Center, Halifax, NS, Canada
| | - Gregory M T Guilcher
- Section of Pediatric Oncology/Transplant and Cellular Therapy, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital Sydney, Sydney, NSW, Australia
- St Vincent's Clinical School Sydney, University of New South Wales, Sydney, NSW, Australia
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, WA, Australia
| | - Amado Karduss
- Bone Marrow Transplant Program, Clinica las Americas, Medellin, Colombia
| | - Zinaida Peric
- BMT Unit, Department of Hematology, University Hospital Centre Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Duncan Purtill
- Fiona Stanley Hospital, Murdoch, WA, Australia
- PathWest Laboratory Medicine, Nedlands, WA, Australia
| | - Douglas Rizzo
- Medical College of Wisconsin, Milwaukee, WI, USA
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Maria Belén Rosales Ostriz
- Division of hematology and bone marrow transplantation, Instituto de trasplante y alta complejidad (ITAC), Buenos Aires, Argentina
| | - Nina Salooja
- Centre for Haematology, Imperial College London, London, UK
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, ACCENT VV, KU Leuven-University of Leuven, Leuven, Belgium
| | | | - Akshay Sharma
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | - Susan K Stewart
- Blood & Marrow Transplant Information Network, Highland Park, IL, 60035, USA
| | | | - Navneet S Majhail
- Sarah Cannon Transplant and Cellular Therapy Network, Nashville, TN, USA
| | - Rachel Phelan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
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Kostoff RN, Briggs MB, Kanduc D, Dewanjee S, Kandimalla R, Shoenfeld Y, Porter AL, Tsatsakis A. Modifiable contributing factors to COVID-19: A comprehensive review. Food Chem Toxicol 2023; 171:113511. [PMID: 36450305 PMCID: PMC9701571 DOI: 10.1016/j.fct.2022.113511] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/01/2022] [Accepted: 11/03/2022] [Indexed: 11/29/2022]
Abstract
The devastating complications of coronavirus disease 2019 (COVID-19) result from an individual's dysfunctional immune response following the initial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Multiple toxic stressors and behaviors contribute to underlying immune system dysfunction. SARS-CoV-2 exploits the dysfunctional immune system to trigger a chain of events ultimately leading to COVID-19. The current study identifies eighty immune system dysfunction-enabling toxic stressors and behaviors (hereafter called modifiable contributing factors (CFs)) that also link directly to COVID-19. Each CF is assigned to one of the five categories in the CF taxonomy shown in Section 3.3.: Lifestyle (e.g., diet, substance abuse); Iatrogenic (e.g., drugs, surgery); Biotoxins (e.g., micro-organisms, mycotoxins); Occupational/Environmental (e.g., heavy metals, pesticides); Psychosocial/Socioeconomic (e.g., chronic stress, lower education). The current study shows how each modifiable factor contributes to decreased immune system capability, increased inflammation and coagulation, and increased neural damage and neurodegeneration. It is unclear how real progress can be made in combatting COVID-19 and other similar diseases caused by viral variants without addressing and eliminating these modifiable CFs.
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Affiliation(s)
- Ronald Neil Kostoff
- Independent Consultant, Gainesville, VA, 20155, USA,Corresponding author. Independent Consultant, 13500 Tallyrand Way, Gainesville, VA, 20155, USA
| | | | - Darja Kanduc
- Dept. of Biosciences, Biotechnologies, and Biopharmaceutics, University of Bari, Via Orabona 4, Bari, 70125, Italy
| | - Saikat Dewanjee
- Advanced Pharmacognosy Research Laboratory, Department of Pharmaceutical Technology, Jadavpur University, Kolkata, 700032, India
| | - Ramesh Kandimalla
- Applied Biology, CSIR-Indian Institute of Chemical Technology, Uppal Road, Tarnaka, Hyderabad, 500007, Telangana, India
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, 5265601, Israel
| | - Alan L. Porter
- School of Public Policy, Georgia Institute of Technology, Atlanta, GA, 30332, USA
| | - Aristidis Tsatsakis
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, 71003, Heraklion, Greece
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4
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Ha J, Park SH, Park SS, Han S. Metabolic Disease Incidence After Allogeneic Stem Cell Transplantation: A Nationwide Korean Case-Control Study. J Clin Endocrinol Metab 2022; 107:943-952. [PMID: 34905058 DOI: 10.1210/clinem/dgab900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT There have been no large-scale reports elucidating the relative risks of developing metabolic diseases in adult allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients compared to the general population. OBJECTIVE This work aimed to investigate the relative risk of developing metabolic diseases and cerebrovascular or cardiovascular disease (CVA) in allo-HSCT recipients compared to the general population in a real-world setting, using a large Korean cohort under long-term observation. METHODS We conducted a population-based case-control study and analyzed data of 8230 adult allo-HSCT recipients and 32 920 healthy individuals matched for age, sex, and index date in a 1:4 ratio, using a nationwide database of the Korean National Health Insurance Service. Thereafter, we established 4 substudies to investigate the relative risks of metabolic disease development following allo-HSCT: hypertension (cohort A study), diabetes (cohort B study), dyslipidemia (cohort C study), and CVA (cohort D study). RESULTS The 10-year cumulative incidence of metabolic disease in each experimental cohort was statistically significantly higher than that in the control cohort (overall P value < .001 for all): cohort A study, 17.6% vs 11.8%; cohort B study, 23.5% vs 14.4%; cohort C study for dyslipidemia, 44.5% vs 32.1%; and cohort D study for CVA, 4.2% vs 3.2%. In comparison to the incidence of metabolic diseases in the general population, allo-HSCT recipients presented adjusted hazard ratios of 1.58 for hypertension, 2.06 for diabetes, 1.62 for dyslipidemia, and 1.45 for CVA. CONCLUSION Recipients of allo-HSCT need to be rigorously monitored for the development of metabolic diseases, including hypertension, diabetes, dyslipidemia, and CVA, based on an enhanced lifelong health care policy including a robust screening program compared to the general population.
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Affiliation(s)
- Jeonghoon Ha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - See Hyun Park
- Department of Pharmacology, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Sung-Soo Park
- Seoul St. Mary's Hematology Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Leukemia Research Institute, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Seunghoon Han
- Department of Pharmacology, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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5
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Wilcox NS, Rotz SJ, Mullen M, Song EJ, Hamilton BK, Moslehi J, Armenian S, Wu JC, Rhee JW, Ky B. Sex-Specific Cardiovascular Risks of Cancer and Its Therapies. Circ Res 2022; 130:632-651. [PMID: 35175846 PMCID: PMC8915444 DOI: 10.1161/circresaha.121.319901] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In both cardiovascular disease and cancer, there are established sex-based differences in prevalence and outcomes. Males and females may also differ in terms of risk of cardiotoxicity following cancer therapy, including heart failure, cardiomyopathy, atherosclerosis, thromboembolism, arrhythmias, and myocarditis. Here, we describe sex-based differences in the epidemiology and pathophysiology of cardiotoxicity associated with anthracyclines, hematopoietic stem cell transplant (HCT), hormone therapy and immune therapy. Relative to males, the risk of anthracycline-induced cardiotoxicity is higher in prepubertal females, lower in premenopausal females, and similar in postmenopausal females. For autologous hematopoietic cell transplant, several studies suggest an increased risk of late heart failure in female lymphoma patients, but sex-based differences have not been shown for allogeneic hematopoietic cell transplant. Hormone therapies including GnRH (gonadotropin-releasing hormone) modulators, androgen receptor antagonists, selective estrogen receptor modulators, and aromatase inhibitors are associated with cardiotoxicity, including arrhythmia and venous thromboembolism. However, sex-based differences have not yet been elucidated. Evaluation of sex differences in cardiotoxicity related to immune therapy is limited, in part, due to low participation of females in relevant clinical trials. However, some studies suggest that females are at increased risk of immune checkpoint inhibitor myocarditis, although this has not been consistently demonstrated. For each of the aforementioned cancer therapies, we consider sex-based differences according to cardiotoxicity management. We identify knowledge gaps to guide future mechanistic and prospective clinical studies. Furthering our understanding of sex-based differences in cancer therapy cardiotoxicity can advance the development of targeted preventive and therapeutic cardioprotective strategies.
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Affiliation(s)
- Nicholas S. Wilcox
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Seth J. Rotz
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA,Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - McKay Mullen
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - Evelyn J. Song
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Betty Ky Hamilton
- Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Javid Moslehi
- Section of Cardio-Oncology & Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Saro Armenian
- Department of Population Sciences, City of Hope Comprehensive Cancer Center; Duarte, CA, USA
| | - Joseph C. Wu
- Stanford Cardiovascular Institute, Stanford, CA, USA
| | - June Wha Rhee
- Department of Medicine, City of Hope Comprehensive Cancer Center; Duarte, CA, USA
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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6
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Ren X, Huang Q, Qu Q, Cai X, Fu H, Mo X, Wang Y, Zheng Y, Jiang E, Ye Y, Luo Y, Chen S, Yang T, Zhang Y, Han W, Tang F, Mo W, Wang S, Li F, Liu D, Zhang X, Zhang Y, Feng S, Gao F, Yuan H, Wang D, Wan D, Chen H, Chen Y, Wang J, Chen Y, Wang Y, Xu K, Lang T, Wang X, Meng H, Li L, Wang Z, Fan Y, Chang Y, Xu L, Huang X, Zhang X. Predicting mortality from intracranial hemorrhage in patients who undergo allogeneic hematopoietic stem cell transplantation. Blood Adv 2021; 5:4910-4921. [PMID: 34448835 PMCID: PMC9153001 DOI: 10.1182/bloodadvances.2021004349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023] Open
Abstract
Intracranial hemorrhage (ICH) is a rare but fatal central nervous system complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT). However, factors that are predictive of early mortality in patients who develop ICH after undergoing allo-HSCT have not been systemically investigated. From January 2008 to June 2020, a total of 70 allo-HSCT patients with an ICH diagnosis formed the derivation cohort. Forty-one allo-HSCT patients with an ICH diagnosis were collected from 12 other medical centers during the same period, and they comprised the external validation cohort. These 2 cohorts were used to develop and validate a grading scale that enables the prediction of 30-day mortality from ICH in all-HSCT patients. Four predictors (lactate dehydrogenase level, albumin level, white blood cell count, and disease status) were retained in the multivariable logistic regression model, and a simplified grading scale (termed the LAWS score) was developed. The LAWS score was adequately calibrated (Hosmer-Lemeshow test, P > .05) in both cohorts. It had good discrimination power in both the derivation cohort (C-statistic, 0.859; 95% confidence interval, 0.776-0.945) and the external validation cohort (C-statistic, 0.795; 95% confidence interval, 0.645-0.945). The LAWS score is the first scoring system capable of predicting 30-day mortality from ICH in allo-HSCT patients. It showed good performance in identifying allo-HSCT patients at increased risk of early mortality after ICH diagnosis. We anticipate that it would help risk stratify allo-HSCT patients with ICH and facilitate future studies on developing individualized and novel interventions for patients within different LAWS risk groups.
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Affiliation(s)
- Xiying Ren
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qiusha Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Qingyuan Qu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xuan Cai
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Haixia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiaodong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yawei Zheng
- Center of Hematopoietic Stem Cell Transplantation, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Erlie Jiang
- Center of Hematopoietic Stem Cell Transplantation, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yishan Ye
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yi Luo
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaozhen Chen
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Ting Yang
- Department of Hematology, Fujian Institute of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yuanyuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Feifei Tang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Wenjian Mo
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Shunqing Wang
- Department of Hematology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, China
| | - Fei Li
- Department of Hematology, Chinese PLA General Hospital, Beijing, China
| | - Daihong Liu
- Department of Hematology, Chinese PLA General Hospital, Beijing, China
| | - Xiaoying Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yicheng Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuqing Feng
- Department of Hematology, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Feng Gao
- Department of Hematology, North China University of Science and Technology Affiliated Hospital, Tangshan, China
| | - Hailong Yuan
- Hematology Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | | | - Dingming Wan
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yao Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Jingzhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Yuhong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Ying Wang
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Kailin Xu
- Department of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Tao Lang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Xiaomin Wang
- Department of Hematology, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Hongbin Meng
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China; and
| | - Limin Li
- Department of Hematology, The First Affiliated Hospital, Harbin Medical University, Harbin, China; and
| | - Zhiguo Wang
- Bone Marrow Transplantation Department, Harbin Institute of Hematology and Oncology, Harbin, China
| | - Yanling Fan
- Bone Marrow Transplantation Department, Harbin Institute of Hematology and Oncology, Harbin, China
| | - Yingjun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Lanping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiaojun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
| | - Xiaohui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
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7
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Wang Z, Zhao M, Gao S. Epileptic Seizures After Allogeneic Hematopoietic Stem Cell Transplantation. Front Neurol 2021; 12:675756. [PMID: 34335446 PMCID: PMC8322618 DOI: 10.3389/fneur.2021.675756] [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] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
Technique in allogeneic hematopoietic stem cell transplantation has greatly advanced over the past decades, which has led to an increase in the number of patients receiving transplantation, but the complex procedure places these transplant recipients at high risk of a large spectrum of complications including neurologic involvement. As a common manifestation of neurological disorders, epileptic seizures after transplantation have been of great concern to clinicians because it seriously affects the survival rate and living quality of those recipients. The aim of this review is to elucidate the incidence of seizures after allogeneic hematopoietic stem cell transplantation, and to further summarize in detail its etiologies, possible mechanisms, clinical manifestations, therapeutic schedule, and prognosis, hoping to improve doctors' understandings of concurrent seizures following transplantation, so they can prevent, process, and eventually improve the survival and outlook for patients in a timely manner and correctly.
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Affiliation(s)
- Zhuo Wang
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
| | - Munan Zhao
- Department of Oncology, The First Hospital of Jilin University, Changchun, China
| | - Sujun Gao
- Department of Hematology, The First Hospital of Jilin University, Changchun, China
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8
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Sheikh MA, Toledano M, Ahmed S, Gul Z, Hashmi SK. Noninfectious neurologic complications of hematopoietic cell transplantation: A systematic review. Hematol Oncol Stem Cell Ther 2020; 14:87-94. [PMID: 32516577 DOI: 10.1016/j.hemonc.2020.05.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 04/01/2020] [Accepted: 05/02/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE/BACKGROUND Neurological complications occur at a high frequency after hematopoietic cell transplantation (HCT). However, an absence is noted in the published literature as regards the quantification of the exact burden and the outcomes thereof. In this systematic review, we endeavored to detail if the recipients of HCT developed any noninfectious neurological events/complications. METHODS According to the PICO criteria, medical literature was searched. Complications that were evaluated included: stroke, peripheral neuropathy, myasthenia gravis, seizures, and posterior reversible encephalopathy syndrome. After strictly defining relevant variables and parameters, data from 173 eligible articles were then extracted accordingly, from the full text for each, for quantitative analysis; additionally, two American Society of Hematology conference abstracts were also subject to data extraction. RESULTS As is evident from the results of the data analysis, an increased frequency of these complications was seen in the HCT recipient population in comparison to the general population. The relative risk ranged from 1.33× to 142× depending on the complication studied. CONCLUSION These findings demonstrate that the recipients of HCT had a significantly higher risk of neurological complications and that their early recognition can enhance the monitoring of HCT survivors for the early developmental signs of neurological toxicity. This would facilitate timely interventions, thus ensuring a better quality of life.
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Affiliation(s)
| | | | - Sairah Ahmed
- Department of Stem Cell Transplant and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zartash Gul
- Department of Hematology/Oncology, University of Cincinnati, Cincinnati, OH, USA
| | - Shahrukh K Hashmi
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Department of Medicine, Mayo Clinic, Rochester, MN, USA
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9
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Comparison of hemorrhagic and ischemic stroke after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2020; 55:2087-2097. [PMID: 32332920 DOI: 10.1038/s41409-020-0903-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/01/2020] [Accepted: 04/03/2020] [Indexed: 12/12/2022]
Abstract
Stroke is an important complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT). Nevertheless, few studies have been published to analyzed the occurrence and prognosis of stroke after allo-HSCT. From January 2007 to December 2018 in Peking University People's Hospital, 6449 patients received HSCT and there were 2.3% of patients diagnosed with stroke after allo-HSCT (hemorrhagic: 1.0%, ischemic: 1.3%). The median time to hemorrhagic and ischemic stroke after HSCT was 161 days and 137 days, respectively. In total, 8.4% of patients experienced neurological sequelae. The outcome was much worse in patients with stroke than in control subjects. The comparison of prognosis showed no statistical differences between patients with hemorrhagic stroke and those with ischemic stroke. Significant risk factors for hemorrhagic stroke were pretransplant central nervous system leukemia (CNSL), and delayed platelet engraftment. Risk factors associated with the occurrence of ischemic stroke included high-risk disease, prior venous thromboembolism (VTE), grade III-IV acute graft-versus-host disease (aGVHD), and thrombotic microangiopathy (TMA). Haplo-identical transplantation was not a risk factor for stroke and had no impact on the prognosis compared with HLA-matched HSCT. Altogether, these results show that stroke is a severe complication after allo-HSCT. The prognosis of posttransplant stroke did not differ between hemorrhagic and ischemic stroke.
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10
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Imaging Assessment of Complications from Transplantation from Pediatric to Adult Patients: Part 2: Hematopoietic Stem Cell Transplantation. Radiol Clin North Am 2020; 58:569-582. [PMID: 32276704 DOI: 10.1016/j.rcl.2019.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Hematopoietic stem cell transplantation is an intravenous transfusion of pluripotent stem cells to repopulate the marrow and restore immunocompetence. However, before transplantation, the patient undergoes a conditioning regimen to eradicate the underlying disease, subsequently resulting in an immunocompromised state. Serious and some life-threatening complications involving any organ can occur. Currently, with advances in hematopoietic stem cell transplantation techniques and posttransplant management, more pediatric patients are now living longer and into their adulthood. The goal of this review article is to discuss the common neurologic, pulmonary, and abdominal complications associated with hematopoietic stem cell transplantation with emphasis on their imaging characteristics.
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11
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Lin TA, Gau JP, Liu YC, Ko PS, Wang HY, Chien SH, Liu CJ, Hsiao LT, Chiou TJ, Liu JH. Cerebrovascular disease after allogeneic hematopoietic stem cell transplantation: incidence, risk, and clinical outcome. Int J Hematol 2019; 109:584-592. [PMID: 30864116 DOI: 10.1007/s12185-019-02624-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 11/30/2022]
Abstract
Cerebrovascular complications after hematopoietic stem cell transplantation (HSCT) cause serious morbidity and often contribute to mortality. The incidence, risk factors, and outcome of cerebrovascular disease (CVD) after allogeneic HSCT remain poorly defined. We retrospectively evaluated 459 adult patients who underwent allogeneic HSCT at a tertiary medical center between January 2003 and December 2015. A total of 20 patients (4.4%) developed post-transplant CVD. All cerebrovascular accidents occurred in the first two years post-transplant. The two-year incidences of post-transplant CVD, intracranial hemorrhage, and cerebrovascular infarction were 6.1%, 3.2%, and 3.2%, respectively. The incidence rate of CVD within two years after HSCT was 34.7 (95% CI 22.3 to - 53.7) per 1000 person-years, which was about tenfold higher than the general Taiwanese population. The only significant risk factor associated with post-transplant CVD is prior exposure to three or more courses of high-dose cytarabine. Post-transplant CVD is associated with dismal outcome and early mortality. The median overall survival of patients with post-transplant CVD was markedly reduced compared with those without CVD (8.0 vs. 60.6 months). Most patients with post-transplant CVD died within two months after the CVD events. Our study demonstrates that CVD remains a devastating complication after allogeneic HSCT in the modern era.
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Affiliation(s)
- Ting-An Lin
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan
| | - Jyh-Pyng Gau
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yao-Chung Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan. .,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Po-Shen Ko
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Hao-Yuan Wang
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Sheng-Hsuan Chien
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Transfusion Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chia-Jen Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Liang-Tsai Hsiao
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tzeon-Jye Chiou
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Transfusion Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jin-Hwang Liu
- Division of Hematology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Sec 2, Shih-Pai Road, Taipei, 112, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Hematology and Oncology, Department of Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
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12
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Bonardi M, Turpini E, Sanfilippo G, Mina T, Tolva A, Zappoli Thyrion F. Brain Imaging Findings and Neurologic Complications after Allogenic Hematopoietic Stem Cell Transplantation in Children. Radiographics 2018; 38:1223-1238. [PMID: 29995615 DOI: 10.1148/rg.2018170139] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) is the only therapy for a subset of patients with malignant and nonmalignant diseases. Central nervous system (CNS) complications continue to be an important cause of morbidity and significantly contribute to mortality after HSCT. These complications include infections, cerebrovascular lesions, therapy-induced diseases, metabolic disturbances, and post-HSCT carcinogenesis. Following HSCT, three phases can be identified on the basis of the patient's immune status: the pre-engraftment period (<30 days after HSCT), the early postengraftment period (30-100 days after HSCT), and the late postengraftment period (>100 days after HSCT). There is a distinct relationship between the patient's degree of immunodeficiency after HSCT and the incidence of various complications that may occur. Early diagnosis of CNS complications is crucial for successful management and a good prognosis, and computed tomography and magnetic resonance imaging play an important role in achieving these goals. The global increase in the use of HSCT requires radiologists to be familiar with CNS complications, their relationship to the patient's immune status, and their imaging appearances. This article describes the clinical background of HSCT; reviews the incidence, causes, and timeline of brain complications in children who underwent allogenic HSCT; and identifies the characteristic imaging findings of these disorders. ©RSNA, 2018.
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Affiliation(s)
- Mara Bonardi
- From the Department of Diagnostic and Interventional Radiology and Neuroradiology (M.B., G.S., F.Z.T.), Department of Radiology (E.T.), and Department of Pediatric Hematology Oncology (T.M., A.T.), Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Elena Turpini
- From the Department of Diagnostic and Interventional Radiology and Neuroradiology (M.B., G.S., F.Z.T.), Department of Radiology (E.T.), and Department of Pediatric Hematology Oncology (T.M., A.T.), Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Giuseppina Sanfilippo
- From the Department of Diagnostic and Interventional Radiology and Neuroradiology (M.B., G.S., F.Z.T.), Department of Radiology (E.T.), and Department of Pediatric Hematology Oncology (T.M., A.T.), Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Tommaso Mina
- From the Department of Diagnostic and Interventional Radiology and Neuroradiology (M.B., G.S., F.Z.T.), Department of Radiology (E.T.), and Department of Pediatric Hematology Oncology (T.M., A.T.), Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Alessandra Tolva
- From the Department of Diagnostic and Interventional Radiology and Neuroradiology (M.B., G.S., F.Z.T.), Department of Radiology (E.T.), and Department of Pediatric Hematology Oncology (T.M., A.T.), Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
| | - Federico Zappoli Thyrion
- From the Department of Diagnostic and Interventional Radiology and Neuroradiology (M.B., G.S., F.Z.T.), Department of Radiology (E.T.), and Department of Pediatric Hematology Oncology (T.M., A.T.), Fondazione IRCCS Policlinico San Matteo, Viale Golgi 19, 27100 Pavia, Italy
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13
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Neurologic complications after allogeneic hematopoietic stem cell transplantation: risk factors and impact. Bone Marrow Transplant 2017; 53:199-206. [PMID: 29131150 DOI: 10.1038/bmt.2017.239] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/08/2017] [Accepted: 09/12/2017] [Indexed: 01/16/2023]
Abstract
Neurologic complications (NCs) may be a significant source of morbidity and mortality after hematopoietic cell transplantation (HCT). We performed a retrospective study of 263 consecutive patients undergoing allogeneic HCT for hematological malignancies to determine the incidence, risk factors and clinical impact of NCs in the first 5 years after HCT. We determined the incidence of central nervous system (CNS) infection, intracranial hemorrhage, ischemic stroke, metabolic encephalopathy, posterior reversal encephalopathy syndrome, seizure and peripheral neuropathy. In all, 50 patients experienced 63 NCs-37 early (⩽day +100), 21 late (day +101 to 2 years) and 5 very late (2 to 5 years). The 1- and 5-year cumulative incidences of all NCs were 15.6% and 19.2%, respectively, and of CNS complication (CNSC; all of the above complications except peripheral neuropathy) were 12.2 and 14.5%. Risk factors for CNSC were age (hazard ratio (HR)=1.06 per year, P=0.0034), development of acute GvHD grade III-IV (HR=2.78, P=0.041), transfusion-dependent thrombocytopenia (HR=3.07, P=0.025) and delayed platelet engraftment (>90th centile; HR=2.77, P=0.043). CNSCs negatively impacted progression-free survival (HR=2.29, P=0.0001), overall survival (HR=2.63, P<0.0001) and non-relapse mortality (HR=8.51, P<0.0001). NCs after HCT are associated with poor outcomes, and usually occur early after HCT.
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14
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Imaging spectrum of central nervous system complications of hematopoietic stem cell and solid organ transplantation. Neuroradiology 2017; 59:105-126. [PMID: 28255902 DOI: 10.1007/s00234-017-1804-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
Neurologic complications are common after hematopoietic stem cell transplantation (HSCT) and solid organ transplantation (SOT) and affect 30-60% of transplant recipients. The aim of this article is to provide a practical imaging approach based on the timeline and etiology of CNS abnormalities, and neurologic complications related to transplantation of specific organs. The lesions will be classified based upon the interval from HSCT procedure: pre-engraftment period <30 days, early post-engraftment period 30-100 days, late post-engraftment period >100 days, and the interval from SOT procedure: postoperative phase 1-4 weeks, early posttransplant syndromes 1-6 months, late posttransplant syndromes >6 months. Further differentiation will be based on etiology: infections, drug toxicity, metabolic derangements, cerebrovascular complications, and posttransplantation malignancies. In addition, differentiation will be based on complications specific to the type of transplantation: allogeneic and autologous hematopoietic stem cells (HSC), heart, lung, kidney, pancreas, and liver. Thus, in this article we emphasize the strategic role of neuroradiology in the diagnosis and response to treatment by utilizing a methodical approach in the work up of patients with neurologic complications after transplantation.
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15
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Maffini E, Festuccia M, Brunello L, Boccadoro M, Giaccone L, Bruno B. Neurologic Complications after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2016; 23:388-397. [PMID: 28039081 DOI: 10.1016/j.bbmt.2016.12.632] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 12/20/2016] [Indexed: 12/27/2022]
Abstract
Neurologic complications after hematopoietic stem cell transplantation are frequently life-threatening, and their clinical management can be highly challenging. A wide spectrum of causative factors-including drug-related toxicities; infections sustained by virus, bacteria, or invasive molds; metabolic encephalopathy; cerebrovascular disorders; immune-mediated disorders; and disease recurrence-may lead to potentially lethal complications. Moreover, given that some neurologic complications are not uncommonly diagnosed post mortem, their overall incidence is likely to be underestimated. Their prompt recognition and timely treatment are of paramount importance to reduce the risk for transplantation-related death.
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Affiliation(s)
- Enrico Maffini
- Department of Oncology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Moreno Festuccia
- Department of Oncology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Lucia Brunello
- Department of Oncology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Mario Boccadoro
- Department of Oncology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Luisa Giaccone
- Department of Oncology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy
| | - Benedetto Bruno
- Department of Oncology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, Torino, Italy; Department of Molecular Biotechnology and Health Sciences, University of Torino, Torino, Italy.
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16
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Zhang XH, Wang QM, Chen H, Chen YH, Han W, Wang FR, Wang JZ, Zhang YY, Mo XD, Chen Y, Wang Y, Chang YJ, Xu LP, Liu KY, Huang XJ. Clinical characteristics and risk factors of Intracranial hemorrhage in patients following allogeneic hematopoietic stem cell transplantation. Ann Hematol 2016; 95:1637-43. [PMID: 27485455 DOI: 10.1007/s00277-016-2767-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 07/22/2016] [Indexed: 01/17/2023]
Abstract
Intracranial hemorrhage (ICH) is one of the most life-threatening neurological complications after allogeneic hematopoietic stem cell transplantation. Although cerebral complications and its causes after allo-HSCT are well documented, assessment of the incidence and risk factors of intracranial hemorrhage following allo-HSCT are less discussed. A nested case-control study was conducted involving 160 subjects drawn from 2169 subjects who underwent HSCT at Peking University People's Hospital between 2004 and 2014. Thirty-two patients (1.5 %) with ICH were identified, and 128 controls were matched for age, gender, transplantation type, and time of transplantation. Intracranial hemorrhage was identified by CT scan and/or MRI by searching hospital records. Among the 32 ICH patients, 27 (82.9 %) developed intraparenchymal hemorrhages (IPH), 2 cases (5.7 %) suffered subdural hematomas (SDH), and 3 cases (8.6 %) had multiple hemorrhage lesions in the brain parenchyma. The median time of appearance for cerebral hemorrhages was 147.5 days. Multivariate analysis showed that systemic infections (hazard ratio 2.882, 95 % confidence interval 1.231-6.746), platelet count (5.894, 1.145-30.339), and fibrinogen levels (3.611, 1.528-8.532) were independent risk factors for intracranial hemorrhage among HSCT patients. The cumulative survival rate in the intracranial hemorrhage and control groups were 43.3 and 74.7 % (P = .001), respectively. Intracranial hemorrhage is associated with high mortality and a decreased overall survival rate. Systemic infections, platelet count, and fibrinogen levels were individual independent risk factors.
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Affiliation(s)
- Xiao-Hui Zhang
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Qian-Ming Wang
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Huan Chen
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Yao Chen
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Ying-Jun Chang
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Institute of Hematology, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Institute of Hematology, Beijing Key Laboratory of HSCT, No. 11, Xizhimen South Street, Xicheng District, Beijing, 100044, China.
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17
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Syed FI, Couriel DR, Frame D, Srinivasan A. Central Nervous System Complications of Hematopoietic Stem Cell Transplant. Hematol Oncol Clin North Am 2016; 30:887-98. [PMID: 27444002 DOI: 10.1016/j.hoc.2016.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Hematopoietic stem cell transplantation (SCT) is now commonly used to treat several hematologic and nonhematologic diseases. Central nervous system (CNS) complications post-transplantation occur commonly in the first year and result in increased mortality from infectious, toxic, metabolic, or vascular causes. Infections secondary to aspergillus, toxoplasma and viruses cause many of the complications. Drug-related toxicities arising from conditioning regimens and graft-versus-host disease prophylaxis, as well as intraparenchymal hemorrhage, are not uncommon and can result in increased morbidity. Secondary CNS cancers have a higher incidence 5 or more years after allogeneic SCT.
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Affiliation(s)
- Faiz I Syed
- Division of Neuroradiology, Department of Radiology, VA Ann Arbor Health System, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Daniel R Couriel
- BMT Program, Huntsman Cancer Center, University of Utah, 2000 Circle of Hope. Office #2151, Salt Lake City, UT 84112, USA
| | - David Frame
- Department of Pharmacy, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Ashok Srinivasan
- Division of Neuroradiology, Department of Radiology, University of Michigan Health System, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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18
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Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis. Bone Marrow Transplant 2016; 51:1050-61. [PMID: 27042832 DOI: 10.1038/bmt.2016.72] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 12/16/2022]
Abstract
The outcome of allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients has significantly improved over the past decade. Still, a significant number of patients require intensive care unit (ICU) management because of life-threatening complications. Literature from the 1990s reported extremely poor prognosis for critically ill allo-HSCT patients requiring ICU management. Recent data justify the use of ICU resources in hematologic patients. Yet, allo-HSCT remains an independent variable associated with mortality. However, outcomes in allo-HSCT patients have improved over time and many classic determinants of mortality have become irrelevant. The main actual prognostic factors are the need for mechanical ventilation, the presence of GvHD and the number of organ failures at ICU admission. Recently, the development of reduced-intensity conditioning regimens, early ICU admission and the increased use of noninvasive ventilation, combined with time effect and general advances in hematology, in allo-HSCT procedures and in ICU management have contributed to improve general outcome. A rational policy of ICU admission triage in these patients is very hard to define, as each decision for ICU admission is a case-by-case decision at patient bedside. The collaboration between hematologists and intensivists is crucial in this context.
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19
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Straube A, Klein M, Erbguth F, Maschke M, Klawe C, Sander D, Hilz MJ, Ziemssen T, Klucken J, Kohl Z, Winkler J, Bettendorf M, Staykov D, Berrouschot J, Dörfler A. Metabolische Störungen. NEUROINTENSIV 2015. [PMCID: PMC7175475 DOI: 10.1007/978-3-662-46500-4_36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Im folgenden Kapitel werden die verschiedenen metabolischen Störungen betrachtet. Zunächst wird auf die allgemeinen und spezifischen neurologischen Komplikationen bei Organtransplantation eingegangen. Dann geht es um die metabolischen Enzephalopathien: Störungen der Gehirntätigkeit bei angeborenen und erworbenen Stoffwechselerkrankungen im engeren Sinn, Elektrolytstörungen, Hypovitaminosen, zerebrale Folgen einzelner Organdysfunktionen, zerebrale Hypoxien, Endotheliopathien und Mitochondropathien. Anschließend werden das Alkoholdelir und die Wernicke-Enzephalopathie erörtert. Bei zahlreichen akuten Erkrankungen von Gehirn, Rückenmark und peripherem Nervensystem treten typische Störungen vegetativer Systeme auf, deren Erkennung und Therapie insbesondere bei Intensivpatienten eine vitale Bedeutung haben kann: die autonomen Störungen. Bei der zentralen pontinen Myelinolyse kommt es zu einer akuten, vorwiegend fokal-symmetrischen Demyelinisierung im Hirnparenchym. Auch Basalganglienerkrankungen können intensivmedizinisch relevant werden. Und schließlich wird die akute Stressreaktion betrachtet, die aufgrund der vielfältigen metabolischen und endokrinen Veränderungen bei kritischen Erkrankungen entsteht. Gerade das RCVS als neuere Krankheitsentität und wichtige Differenzialdiagnose zur Vaskulitis des ZNS verdient einen eigenen Platz, in diesem Unterkapitel werden ebenfalls verwandte Syndrome wie die hypertensive Enzephalopathie und das PRES abgehandelt.
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A novel protein C inhibitor gene mutation in pediatric stroke patients after bone marrow transplantation. Mol Biol Rep 2013; 40:5465-8. [PMID: 23670045 DOI: 10.1007/s11033-013-2644-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 05/07/2013] [Indexed: 10/26/2022]
Abstract
Protein C inhibitor is a heparin dependent serine protease inhibitor found in human plasma, urine and other body fluids. It was originally identified as an inhibitor of activated protein C. Stroke is an important cause of morbidity and mortality in the pediatric age group. In this study we analyzed the protein C inhibitor gene mutations in Turkish pediatric stroke patients. We found a missense mutation of G to A at nucleotide 6760 in exon 2, resulting in a transition serine to asparagine (p.Ser188Asp) and in a child and his father and also we found same alteration in exon 2 in an another pediatric stroke case following bone marrow transplantation.
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Chen BT, Ortiz AO, Dagis A, Torricelli C, Parker P, Openshaw H. Brain imaging findings in symptomatic patients after allogeneic haematopoietic stem cell transplantation: correlation with clinical outcome. Eur Radiol 2012; 22:2273-81. [DOI: 10.1007/s00330-012-2490-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 03/24/2012] [Accepted: 04/01/2012] [Indexed: 11/28/2022]
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Rogers LR. Neurovascular complications of solid tumors and hematological neoplasms. HANDBOOK OF CLINICAL NEUROLOGY 2012; 105:805-23. [PMID: 22230535 DOI: 10.1016/b978-0-444-53502-3.00025-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pustavoitau A, Bhardwaj A, Stevens R. Analytic Review: Neurological Complications of Transplantation. J Intensive Care Med 2011; 26:209-22. [DOI: 10.1177/0885066610389549] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Recipients of solid organ or hematopoietic cell transplants are at risk of life-threatening neurological disorders including encephalopathy, seizures, infections and tumors of the central nervous system, stroke, central pontine myelinolysis, and neuromuscular disorders—often requiring admission to, or occurring in, the intensive care unit (ICU). Many of these complications are linked directly or indirectly to immunosuppressive therapy. However, neurological disorders may also result from graft versus host disease, or be an expression of the underlying disease which prompted transplantation, as well as injury induced during radiation, chemotherapy, surgery, and ICU stay. In rare cases, neuroinfectious pathogens may be transmitted with the transplanted tissue or organ. Diagnosis may be a challenge because clinical symptoms and findings on neuroimaging lack specificity, and a biological specimen or tissue diagnosis is often needed for definitive diagnosis. Management is centered on preventing further neurological injury, etiology-targeted therapy, and balancing the benefits and toxicities of specific immunosuppressive agents.
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Affiliation(s)
- Aliaksei Pustavoitau
- Departments of Anesthesiology Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anish Bhardwaj
- Departments of Neurology and Neurological Surgery, Tufts University School of Medicine, Boston, MA, USA,
| | - Robert Stevens
- Departments of Anesthesiology Critical Care Medicine, Neurology, Neurosurgery, and Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Diagnostic role of target lesion on diffusion-weighted imaging: a case of cerebral aspergillosis and review of the literature. Neurologist 2011; 16:364-7. [PMID: 21150384 DOI: 10.1097/nrl.0b013e3181b47001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE Target lesions on diffusion-weighted imaging are uncommon and their significance not well appreciated. To assess the diagnostic value of this neuroimaging finding, a case of cerebral aspergillosis is presented and the literature reviewed. METHODS The diffusion-weighted magnetic resonance imaging features of target lesions in a case of cerebral aspergillosis with neuropathologic correlate is presented and 8 other cases manifesting this neuroimaging finding are reviewed for etiology, patient immune status, lesion number, enhancement, and location. RESULTS The etiologies included cerebral aspergillosis, Balo concentric sclerosis, and acute necrotizing encephalopathy. The cerebral aspergillosis cases were immunocompromised with multiple lesions in 4 of 5 patients. The acute necrotizing encephalopathy and Balo concentric sclerosis patients were immunocompetent with bilateral thalamic lesions in the former and multiple random or solitary lesions in the later. Enhancement was seen in 5 patients. CONCLUSION Target lesions on diffusion-weighted imaging are compelling for a diagnosis of cerebral aspergillosis in immunocompromised patients and for acute necrotizing encephalopathy in immunocompetent patients when lesions are bilateral thalamic and Balo concentric sclerosis when white matter is involved.
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Armenian SH, Sun CL, Mills G, Teh JB, Francisco L, Durand JB, Wong FL, Forman SJ, Bhatia S. Predictors of late cardiovascular complications in survivors of hematopoietic cell transplantation. Biol Blood Marrow Transplant 2010; 16:1138-44. [PMID: 20197101 DOI: 10.1016/j.bbmt.2010.02.021] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 02/21/2010] [Indexed: 12/30/2022]
Abstract
Long-term survival after hematopoietic cell transplantation (HCT) is now an expected outcome. The growing population of survivors is at risk of developing treatment-related complications, including cardiovascular disease (CVD). A nested case-controlled design was used to identify clinical and treatment-related risk factors for development of late (1+ years after HCT) CVD. Cases were identified from a cohort of 1+-year survivors who underwent transplantation at City of Hope between 1977 and 2006. Controls (HCT survivors without CVD) were matched on age, year of HCT, type of HCT, and duration of follow-up. Sixty-three patients with late CVD were identified, 44 (69.8%) with a coronary artery event and 19 (30.2%) with a cerebrovascular event. Median age at HCT was 49.0 years. Median age at onset of late CVD was 54.0 years; 66.7% of the affected patients had undergone autologous HCT. Multivariate logistic regression analysis showed that the presence of multiple cardiovascular risk factors (2 or more of the following: obesity, dyslipidemia, hypertension, and diabetes) after HCT was associated with a 5.2-fold increased risk of late CVD (P < .01), and that pre-HCT chest radiation exposure was associated with a 9.5-fold greater risk of coronary artery disease (P = .03). Pre-HCT exposure to chest radiation and the presence of comorbidities were primarily responsible for the risk associated with late CVD after HCT. These data form the basis for developing predictive models for identifying high-risk individuals for targeted surveillance and aggressive management of comorbidities.
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Affiliation(s)
- Saro H Armenian
- Department of Population Sciences, City of Hope, Duarte, California 91010-3000, USA
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Abstract
Neurologic complications affect posttransplant recovery of more than 20% of transplant recipients. Etiology is usually related to surgical procedure of transplantation, primary disorders causing failure of transplanted organ, opportunistic infections, and neurotoxicity of immunosuppressive medications. Risk of opportunistic infections and immunosuppressant neurotoxicity is greatest within the first six months, but it persists along with long-term maintenance immunosuppression required to prevent graft rejection. Neurotoxicity may require alteration of immunosuppressive regimen, and prompt therapy of opportunistic infections improves outcomes.
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Affiliation(s)
- Sasa A Zivković
- Neurology Service, VA Pittsburgh Healthcare System, University Drive C, Pittsburgh, PA 15240, USA.
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Tremolada M, Bonichini S, Pillon M, Messina C, Carli M. Quality of life and psychosocial sequelae in children undergoing hematopoietic stem-cell transplantation: a review. Pediatr Transplant 2009; 13:955-70. [PMID: 19515079 DOI: 10.1111/j.1399-3046.2009.01203.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This paper reviews the research published in the last 18 yr on QoL and psycho-social sequelae in pediatric patients who have undergone HSCT. A corpus of 47 empirical studies was selected and is presented here. From this selection five main topics linked to psychological adjustment to HSCT emerged: QoL; psychological symptoms; cognitive sequelae; social adaptation; psycho-social interventions for children. The information which emerged from the review of the literature is discussed with special attention to methodological issues. Directions for future research are proposed.
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Affiliation(s)
- Marta Tremolada
- Department of Developmental and Social Psychology, University of Padova, Padova, Italy
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Teive HAG, Funke V, Bitencourt MA, de Oliveira MM, Bonfim C, Zanis-Neto J, Medeiros CRD, Zétola VF, Werneck LC, Pasquini R. Neurological complications of hematopoietic stem cell transplantation (HSCT): a retrospective study in a HSCT center in Brazil. ARQUIVOS DE NEURO-PSIQUIATRIA 2009; 66:685-90. [PMID: 18949262 DOI: 10.1590/s0004-282x2008000500014] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Accepted: 07/23/2008] [Indexed: 11/22/2022]
Abstract
We present the neurological complications evaluated in a series of 1000 patients who underwent hematopoietic stem cell transplantation (HSCT). Central nervous system (CNS) neurological complications, particularly brain hemorrhages, were the most common, followed by seizures and CNS infections. An unusual neurological complication was Wernicke's encephalopathy. Less frequent neurological complications were metabolic encephalopathy, neuroleptic malignant syndrome, reversible posterior leukoencephalopathy syndrome, brain infarct and movement disorders. The most common neurological complication of the peripheral nervous system was herpes zoster radiculopathy, while peripheral neuropathies, inflammatory myopathy and myotonia were very rarely found.
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Affiliation(s)
- Hélio A G Teive
- Neurology Service, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba, PR, Brazil.
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Life-threatening Neurological Complications in Patients with Malignancies. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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30
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Ling L, He X, Zeng J, Liang Z. In-hospital cerebrovascular complications following orthotopic liver transplantation: a retrospective study. BMC Neurol 2008; 8:52. [PMID: 19102759 PMCID: PMC2636841 DOI: 10.1186/1471-2377-8-52] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2008] [Accepted: 12/22/2008] [Indexed: 12/27/2022] Open
Abstract
Background Cerebrovascular complications are severe events following orthotopic liver transplantation (OLT). This study aimed to observe the clinical and neuroimaging features and possible risk factors of in-hospital cerebrovascular complications in the patients who underwent OLT. Patients and methods We retrospectively reviewed 337 consecutive patients who underwent 358 OLTs. Cerebrovascular complications were determined by clinical and neuroimaging manifestations, and the possible risk factors were analyzed in the patients with intracranial hemorrhage. Results Ten of 337 (3.0%) patients developed in-hospital cerebrovascular complications (8 cases experienced intracranial hemorrhage and 2 cases had cerebral infarction), and 6 of them died. The clinical presentations were similar to common stroke, but with rapid deterioration at early stage. The hematomas on brain CT scan were massive, irregular, multifocal and diffuse, and most of them were located at brain lobes and might enlarge or rebleed. Infarcts presented lacunar and multifocal lesions in basal gangliar but with possible hemorrhagic transformation. The patients with intracranial hemorrhage had older age and a more frequency of systemic infection than non-intracranial hemorrhage patients. (P = 0.011 and 0.029, respectively). Conclusion Posttransplant cerebrovascular complications have severe impact on outcome of the patients who received OLT. Older age and systemic infection may be the possible risk factors of in-hospital intracranial hemorrhage following OLT.
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Affiliation(s)
- Li Ling
- Department of Neurology and Stroke Centre, First Affiliated Hospital, Sun Yat-Sen University, No, 58 Zhongshan Road 2, Guangzhou, 510080, PR China
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Abstract
Cerebrovascular disorders, including brain infarction, brain hemorrhage, and cerebral venous thrombosis, can occur as an early sign of cancer, but typically occur late in the clinical course. These disorders are due to a variety of pathogenic mechanisms, including coagulation disorders associated with the cancer, invasion or compression of vessels from tumor in or adjacent to the brain, and the adverse effects of cancer therapy. The appropriate therapy for these cerebrovascular disorders is empiric in most instances, because as yet there are no prospective treatment trials for them. A review of the existing literature reveals that improvement in patient quality of life and prevention of further cerebrovascular events can be obtained in some clinical situations.
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Pawson H, Jayaweera A, Wigmore T. Intensive care management of patients following haematopoietic stem cell transplantation. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.cacc.2008.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Schmidt K, Schulz AS, Debatin KM, Friedrich W, Classen CF. CNS complications in children receiving chemotherapy or hematopoietic stem cell transplantation: retrospective analysis and clinical study of survivors. Pediatr Blood Cancer 2008; 50:331-6. [PMID: 17455315 DOI: 10.1002/pbc.21237] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Clinical studies analyzing CNS complications in pediatric oncology systematically are rare. PROCEDURE In a single center retrospective analysis, CNS complications in 950 subsequent pediatric patients treated between 1992 and 2004 by chemotherapy or hematopoietic stem cell transplantation (HSCT) were studied. Forty-six patients had pre-existing CNS diseases and were excluded. Out of the 904 remaining, 76 (8.4%) had 82 CNS complications. RESULTS The most common manifestations were seizures (in 50.6% of the CNS episodes), altered states of consciousness, and motor deficits (in 47.5% of the episodes each). CNS complications were caused by infections (26.8%), toxicity (25.6%), neoplasma (13.4%), vascular (10.9%), and metabolic disturbances (8.5%). In 14.6%, the mechanism remained unclear. Patients (23.7%) died from the CNS event. Neoplastic disorders had the worst (50%) while metabolic the best (0% mortality) prognosis. Imaging techniques were the most effective diagnostic measures, followed by laboratory analysis, clinical examination, and CSF analysis. A neuro-psychological (CBCL, CFT-1/-20-testing) examination could be done in 21 of 32 long-term survivors. Seven had a major, 3 minor neurological impairment, 11 were normal in all tests. CONCLUSIONS These data show that there is not one typical CNS complication, but a wide variety. There is no close connection between either underlying disease or symptoms and cause of the complication. Prognosis is variable. About two thirds of the long-term survivors could lead a normal life.
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Affiliation(s)
- Katrin Schmidt
- University Children's Hospital Ulm, Eythstr. 24, D-89081 Ulm, Germany
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Metabolische Störungen. NEUROINTENSIV 2008. [PMCID: PMC7121226 DOI: 10.1007/978-3-540-68317-9_39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Bei fortgeschrittenem Organversagen von Niere, Herz, Leber oder Lunge stellt eine Organtransplantation meist das einzige kurative Therapieverfahren dar. Auch eine Knochenmarktransplantation wird bei sonst unheilbaren Leukämien oder Lymphomen eingesetzt. Nach Organtransplantation treten bei 30–60% der Patienten neurologische Komplikationen auf. Differenzialdiagnostisch müssen vorbestehende, durch die Grunderkrankung bedingte, Störungen von intraoperativen Komplikationen, von metabolisch bedingten neurologischen Störungen und von Nebenwirkungen der notwendigen immunsuppressiven Medikation abgegrenzt werden. Immunsuppressiva können dabei sowohl eine direkte Neurotoxizität als auch indirekt vermehrt Infektionen des Zentralnervensystems (ZNS) und sekundäre ZNS-Malignome verursachen. Während metabolische Enzephalopathien oder opportunistische ZNS-Infektionen bei allen Patienten nach Transplantation etwa gleich häufig auftreten können, sind andere neurologische Syndrome für bestimmte Organtransplantationen typisch.
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Charlot M, Pialat JB, Obadia N, Boibieux A, Streichenberger N, Meyronnet D, Cotton F. Diffusion-weighted imaging in brain aspergillosis. Eur J Neurol 2007; 14:912-6. [PMID: 17662014 DOI: 10.1111/j.1468-1331.2007.01874.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Brain aspergillosis is a rare pathology, occurring mainly in immunocompromised patients, responsible for multiple cerebral septic infarctions. Some researchers have described magnetic resonance (MR) findings in cerebral invasive aspergillosis, but diffusion-weighted imaging (DWI) has rarely been reported, especially in typical non-enhancing lesions, while it may be helpful for early differential diagnosis and may allow earlier antifungal treatment. We describe three cases of patients presenting brain aspergillosis, with MR imaging including diffusion-weighted sequences and apparent diffusion coefficient (ADC) cartography. The three patients described in this study presented a total of 23 circular lesions, and one patient presented an infarction area in the territory of the right middle cerebral artery. Lesions were ring-enhancing for one patient, and presented no enhancement for the other two. Eleven lesions were very bright on DWI, with reduced ADC values. Twelve lesions, either enhancing or not enhancing, presented a 'target-like' aspect with central and peripheral hypointense areas on DWI, corresponding to higher ADC value areas, and intermediate marked hypersignal on DWI. This typical aspect of aspergillosis lesions on DWI may allow early diagnosis and treatment of cerebral aspergillosis, and is helpful for differentiating aspergillosis lesions from other infectious or malignant lesions affecting immunocompromised patients.
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Affiliation(s)
- M Charlot
- Department of Radiology, Claude Bernard University, Hospices Civils de Lyon, Lyon, France
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Tichelli A, Bucher C, Rovó A, Stussi G, Stern M, Paulussen M, Halter J, Meyer-Monard S, Heim D, Tsakiris DA, Biedermann B, Passweg JR, Gratwohl A. Premature cardiovascular disease after allogeneic hematopoietic stem-cell transplantation. Blood 2007; 110:3463-71. [PMID: 17664354 DOI: 10.1182/blood-2006-10-054080] [Citation(s) in RCA: 162] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We assessed incidence and risk factors of cardiovascular events in 265 patients undergoing allogeneic hematopoietic stem-cell transplantation (HSCT) between 1980 and 2000 and who survived at least 2 years. Results were compared with a cohort of 145 patients treated during the same period with autologous HSCT. The median age of patients with allogeneic HSCT at last follow-up was 39 years, and median follow-up was 9 years. Eighteen (6.8%) patients after allogeneic and 3 (2.1%) patients after autologous HSCT experienced an arterial event. The cumulative incidence of first arterial event after allogeneic HSCT was 22.1% (95% CI, 12.0-40.9) at 25 years. The cumulative incidence 15 years after allogeneic HSCT was 7.5% as compared with 2.3% after autologous HSCT. Adjusting for age, risk of an arterial event was significantly higher after allogeneic HSCT (RR 6.92; P =.009). In multivariate analysis, allogeneic HSCT (RR: 14.5; P =.003), and at least 2 of 4 cardiovascular risk factors (hypertension, dyslipidemia, diabetes, obesity) (RR: 12.4; P =.02) were associated with a higher incidence of arterial events after HSCT. Thus, long-term survivors after allogeneic HSCT are at high risk for premature arterial vascular disease. HSCT might favor the emergence of established risk factors, such as hypertension, diabetes, and dyslipidemia.
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Affiliation(s)
- André Tichelli
- Division of Hematology, University Hospital, Petersgraben 4, CH-4031 Basel, Switzerland.
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Gasparetto EL, Benites Filho PR, Davaus T, Carvalho Neto AD. Central nervous system hemorrhage in thrombocytopenic patients: computed tomographic findings in 21 cases. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 65:268-72. [PMID: 17607426 DOI: 10.1590/s0004-282x2007000200015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2006] [Accepted: 01/11/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe the CT scan findings of 21 thrombocytopenic patients with central nervous system (CNS) hemorrhage. METHOD Retrospective study of the computed tomography (CT) of 21 platelet-depleted patients with CNS hemorrhage. One patient presented two episodes of hemorrhagic episode with different intervals. The clinical data were obtained by the review of the medical records. Two radiologists analyzed the films and reached the decisions by consensus. The following findings were studied: type of bleeding, number of lesions, topography, laterality, size and associated findings. RESULTS Intraparenchymal hemorrhage (IPH) was the most common findings, found in 20 cases, being six of them associated with subarachnoid and intraventricular hemorrhages. The size of the lesions varied between 1.8 and 10.5 cm. The parietal lobes were more commonly affected (n=11, 50%), followed by the temporal (n=7, 31.8%), frontal (n=7, 31.8%) and occipital (n=2, 9.09%) lobes. In 15 cases (68.2%) there was a single area of hemorrhage and in the remaining cases there were multiple hemorrhages. Associated findings were found in 20 cases. The most prevalent were edema (n=17, 77.3%), hydrocephalus (10, 45.4%) and midline shift (n=9, 41%). CONCLUSION The most frequent CT scan findings in thrombocytopenic patients with CNS hemorrhage are single IPH, located mostly in the parietal, temporal and frontal lobes, with varied sizes and associated with edema, hydrocephalus and midline shift.
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Affiliation(s)
- Emerson L Gasparetto
- Department of Internal Medicine, University of Paraná School of Medicine, and Hospitalde Clínicas, Curitiba, Brazil.
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Abstract
Neurologic complications are common after transplantation and affect 30-60% of transplant recipients. The etiology of most of the posttransplant neurologic disorders is related to the opportunistic infections, both systemic and involving central nervous system (CNS), toxicity of immunosuppressive medications, and the metabolic insult created by the underlying primary disease and the transplant procedure. Neuroimaging studies are one of the key tools in the evaluation and enable early diagnosis of neurologic complications in transplant patients, especially posterior reversible leukoencephalopathy syndrome, central pontine myelinolysis, intracerebral hemorrhage, and fungal and bacterial abscesses. Magnetic resonance imaging (MRI) is the preferred technique, but each of the available neuroimaging techniques offers a unique insight into the pathophysiologic mechanisms underlying neurologic complications of transplantation. The role of neuroimaging in this population includes early detection of calcineurin inhibitor neurotoxicity, opportunistic infections, neoplasia, metabolic disorders, or cerebrovascular diseases. In addition, we can monitor longitudinal progression of disease and treatment response.
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Affiliation(s)
- Sasa Zivković
- VA Pittsburgh HCS and Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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Abstract
OBJECTIVE To review the available clinical data on the critical care complications of hematopoietic stem cell transplantation (HSCT). DATA SOURCE The MEDLINE database and references from the identified articles related to the critical care in HSCT. CONCLUSION HSCT is an important treatment for a variety of malignant and nonmalignant conditions. The procedure is, however, limited by significant complications that may involve every organ of the body. Up to 40% of HSCT recipients are admitted to the intensive care unit as a result of severe complications related to the transplantation. The outcome of those critically ill patients has been traditionally poor. However, recent advances in the transplantation procedure, diagnostic studies, antimicrobial prophylaxis and therapy, and intensive care unit care have improved the outcome of these patients. The increasing number of HSCTs performed annually, the unique complications that develop in these patients, and the improvement in the intensive care unit outcome make knowledge about the critical care aspect of HSCT an essential part of the current practice of critical care medicine.
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Affiliation(s)
- Ayman O Soubani
- Division of Pulmonary, Critical Care, and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI, USA
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Abstract
Cancer patients are at increased risk for stroke from direct and indirect effects of their malignancy. Some tumors are at high risk for cerebrovascular complications. Certain stroke mechanisms are specific to cancer, such as compression and occlusion of cerebral vessels by tumor, coagulopathy predisposing to hemorrhage and thrombosis, and treatment-related atherosclerosis. Special consideration for these mechanisms needs to be made when evaluating cancer patients, and treatment aimed at secondary prevention needs to incorporate overall prognosis and goals of care.
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Affiliation(s)
- Teri Nguyen
- Department of Neurology, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA
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Affiliation(s)
- Lawrence M Brass
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520-8018, USA.
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Uckan D, Cetin M, Yigitkanli I, Tezcan I, Tuncer M, Karasimav D, Oguz KK, Topçu M. Life-threatening neurological complications after bone marrow transplantation in children. Bone Marrow Transplant 2005; 35:71-6. [PMID: 15531898 DOI: 10.1038/sj.bmt.1704749] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Neurological complications may occur in BMT recipients (11-59%), frequently contributing to morbidity or mortality. They are the main causes of death in 10-15%. Life-threatening neurological complications were seen in 11 out of 113 (9.7%) children who underwent BMT from HLA-matched family (n=7) or mismatched donors (n=4) at our institution. Diagnoses of patients with neurological complications were acute myeloblastic leukemia (AML) (five), thalassemia major (two), Fanconi anemia (two), Omenn syndrome (one) and leukodystrophy (one), and the neurological events were seen between days +13 and +85 after transplantation. Minor symptoms including reversible, nonrepetitive seizures were excluded. Cyclosporine A toxicity was diagnosed in six children. The rest of the complications were brain abscess/meningoencephalitis (two), severe hypomagnesemia (one), busulfan toxicity (one), sustained hypertension (three), and intracranial hemorrhage (three). Six patients with neurological complications suffered from >grade II graft-versus-host disease (GvHD), and all were high risk for transplant-related complications. In this study, risk status of the underlying disease, mismatched transplantation, a diagnosis of AML (advanced stage), older age and >grade II GvHD were important adverse factors for the development of severe life-threatening neurological complications.
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Affiliation(s)
- D Uckan
- Department of Pediatrics, Units of Bone Marrow Transplantation and Hematology, Hacettepe University Faculty of Medicine, Children's Hospital, Yenisehir, Ankara 06100, Turkey.
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Marchiori PE, Lino AM, Britto N, Bacchella T, Machado MC, Mies S, Massarollo P, Scaff M. Neuropsychiatric complications due to organ transplantation: a survey of 1499 Brazilian patients at a single center in São Paulo, Brazil. Transplant Rev (Orlando) 2005. [DOI: 10.1016/j.trre.2005.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Rubin J, Wide K, Remberger M, Gustafsson B. Acute neurological complications after hematopoietic stem cell transplantation in children. Pediatr Transplant 2005; 9:62-7. [PMID: 15667614 DOI: 10.1111/j.1399-3046.2004.00277.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Children undergoing hematopoietic stem cell transplantation (HSCT) may develop toxicity-related neurological complications (NC). Known risk factors include total body irradiation (TBI) and the use of busulfan or cyclosporine A, but other risk factors might also be of importance. The medical records of 144 children (0-18 yr) who underwent their first HSCT at Karolinska University Hospital (Huddinge) between 1995 and 2002 were reviewed retrospectively concerning pretransplantation parameters and clinical course during the first 3 months after HSCT. Sibling donors were used in 49 transplantations, unrelated donors in 88 and haploidentical donors in seven cases. Nineteen patients (13%) developed NC within the first 3 months after HSCT. A significant association was seen between pretransplant viral status, defined as a higher number of positive herpes group viral serologies in the recipient before transplantation, and NC (p = 0.04). A significant association was also seen for CMV-positive recipients and NC (p = 0.01) as well as for disturbances in serum levels of sodium, potassium and calcium and NC. No association was found between sex, age at HSCT, underlying disease, previous neurological symptoms, the conditioning regimen, GVHD, donor type and NC. Number of positive herpes group viral serologies in the recipient before transplantation and certain electrolyte disturbances may contribute to neurological complications after HSCT.
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Affiliation(s)
- Johanna Rubin
- Department of Pediatrics, Karolinska University Hospital, Huddinge, Karolinska Institutet, Stockholm, Sweden.
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Ohtsubo K, Takase K, Nagafuji K, Henzan H, Tanimoto T, Fukuda T, Miyamoto T, Inaba S, Harada M. Nonmyeloablative allogeneic bone marrow transplantation for treatment of myelodysplastic syndrome complicated by recent intracerebral hemorrhage. Am J Hematol 2004; 77:400-4. [PMID: 15558806 DOI: 10.1002/ajh.20213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A patient with intracerebral hemorrhage is considered ineligible for hematopoietic stem cell transplantation (HSCT). We report a 49-year-old woman with myelodysplastic syndrome (MDS) complicated by refractoriness to platelet transfusion and intracerebral hemorrhage, who underwent allogeneic bone marrow transplantation from an HLA-identical unrelated male donor. Nine days before the scheduled transplantation, she developed dysarthria and right hemiparesis; computed tomography (CT) of the brain disclosed an acute hematoma in the left parietal lobe exceeding 3 cm in diameter. She underwent conditioning with reduced-intensity, including fludarabine (30 mg/m2/day on days -8 to -3), busulfan (4 mg/kg/day on days -6 and -5), and total body irradiation (4 Gy on day -2). Two weeks after transplantation, dysarthria and right hemiparesis began to resolve, and CT showed spontaneous resolution of the hematoma. Simultaneously, engraftment was confirmed. Thus, recent stroke may be not an absolute contraindication for HSCT.
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Affiliation(s)
- Korenori Ohtsubo
- Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Renner C, Hegenbarth U, Schneider JP, Meixensberger J. Fatal bihemispheric intracerebral hemorrhage after burrhole evacuation of chronic subdural hematoma in a bone marrow-transplanted patient: case report and review of the literature. ACTA ACUST UNITED AC 2004; 62:260-3; discussion 263. [PMID: 15336875 DOI: 10.1016/j.surneu.2003.11.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2003] [Accepted: 11/24/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Intracranial hemorrhage seems to be a relatively frequent complication following bone marrow transplantation (BMT). The neurosurgical management of these patients can be problematic. CASE DESCRIPTION We report about a 46-year-old patient, who had BMT because of a Pre-T-ALL and who developed symptomatic bihemispheric chronic subdural hematomas (cSDHs). Pre-T-ALL is a form of an acute lymphatic leukemia of T cell type characterized by certain immunologic markers with a worse prognosis. A few hours after evacuation of the cSDHs, the patient developed a fulminant intracerebral hemorrhage on each hemisphere and expired 2 days later. We reviewed the literature reporting similar cases to discuss the indication for a neurosurgical intervention. CONCLUSION We presume a higher incidence of intracranial hemorrhage in BMT patients than reported. This is caused by the pathologically altered parenchyma related to the extensive therapy in these patients. BMT patients are typically at high risk for intracranial bleeding and are treated conservatively or surgically. We cannot generally recommend the conservative management for symptomatic subdural hematomas/hygromas. The risk for an acute worsening, secondary to repeated hemorrhage, is equivalent to the risk of surgical intervention. Although the outcome of our case is tragic, it should not deter surgical intervention.
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Affiliation(s)
- C Renner
- Department of Neurosurgery, University of Leipzig, Leipzig, Germany
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Gupta V, Keller A, Halliday W, Sanche S, Hassegawa W, Messner H, Kiss T, Lipton J. Cavernous sinus thrombosis presenting with diplopia in an allogeneic bone marrow transplant recipient. Am J Hematol 2004; 77:77-81. [PMID: 15307111 DOI: 10.1002/ajh.20145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Although neurological complications are common in patients undergoing allogeneic bone marrow transplant (alloBMT), cavernous sinus thrombosis (CST) has rarely been described. An allograft recipient is described who presented with diplopia and developed CST in the early post-transplant period likely caused by a filamentous fungus. Clinical course and serial radiological studies of this patient are described and correlated with autopsy findings.
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Affiliation(s)
- Vikas Gupta
- Department of Medical Oncology and Hematology, Princess Margaret Hospital/University Health Network, Toronto, Ontario, Canada.
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Sila CA. CEREBROVASCULAR COMPLICATIONS OF ORGAN TRANSPLANTATION. Continuum (Minneap Minn) 2004. [DOI: 10.1212/01.con.0000290713.56701.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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