1
|
Influence of Total Body Irradiation Dose Rate on Idiopathic Pneumonia Syndrome in Acute Leukemia Patients Undergoing Allogeneic Hematopoietic Cell Transplantation. Int J Radiat Oncol Biol Phys 2018; 103:180-189. [PMID: 30205123 DOI: 10.1016/j.ijrobp.2018.09.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/24/2018] [Accepted: 09/03/2018] [Indexed: 11/23/2022]
Abstract
PURPOSE To determine the relationship between dose rate and other factors in the development of idiopathic pneumonia syndrome (IPS) in patients with acute lymphoblastic leukemia or acute myeloid leukemia who are undergoing total body irradiation (TBI)-based myeloablative conditioning for allogeneic hematopoietic cell transplantation (HCT). METHODS AND MATERIALS From 2006 to 2016, 202 patients with acute leukemia (111 acute lymphoblastic leukemia, 91 acute myeloid leukemia) ranging in age from 1 to 57 years (median, 25 years) underwent allogeneic HCT at University of Minnesota. Pretransplantation conditioning included cyclophosphamide (120 mg/kg) with (68%) or without fludarabine (75 mg/m2) followed by 13.2 Gy TBI given in 8 twice-daily fractions of 1.65 Gy over 4 days. Dose rate varied based on linear accelerator availability and ranged from 8.7 to 19.2 cGy/min. Patients were stratified by receipt of high-dose-rate (HDR; >15 cGy/min; 56%) or low-dose-rate (LDR; ≤15 cGy/min; 44%) TBI for all 8 fractions. IPS was defined as pulmonary injury based on clinical symptoms, radiographic evidence, or pulmonary function testing within 100 days of HCT in the absence of concurrent infection. RESULTS IPS developed in 42 patients (21%) between 4 and 73 days (median, 16 days) after transplantation. HDR TBI was associated with a higher rate of IPS compared with LDR TBI (29% vs 10%; P < .01). On multiple regression analysis, HDR remained a significant predictor of IPS (hazard ratio, 2.6; 95% confidence interval, 1.2-5.3; P = .01), and this led to inferior 1-year overall survival (60% vs 76%; P = .01) and increased 1-year nonrelapse mortality (28% vs 15%; P = .02). CONCLUSIONS TBI dose rates ≤15 cGy/min reduce the risk of posttransplantation IPS and improve overall survival. LDR TBI should be strongly considered as an easily implemented parameter to improve the safety of pretransplantation TBI-based conditioning.
Collapse
|
2
|
Takahashi K, Go P, Stone CH, Safwan M, Putchakayala KG, Kane WJ, Malinzak LE, Kim DY, Denny JE. Mycophenolate Mofetil and Pulmonary Fibrosis After Kidney Transplantation: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:399-404. [PMID: 28408734 PMCID: PMC5398249 DOI: 10.12659/ajcr.902380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 50 Final Diagnosis: Pulmonary fibrosis Symptoms: Short of breath Medication: — Clinical Procedure: — Specialty: Transplantology
Collapse
Affiliation(s)
- Kazuhiro Takahashi
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Pauline Go
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Chad H Stone
- Department of Pathology, Henry Ford Hospital, Detroit, MI, USA
| | - Mohamed Safwan
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Krishna G Putchakayala
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - William J Kane
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Lauren E Malinzak
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Dean Y Kim
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| | - Jason E Denny
- Department of Transplant and Hepatobiliary Surgery, Henry Ford Hospital, Detroit, MI, USA
| |
Collapse
|
3
|
Acute respiratory failure during first cyclophosphamide infusion in a patient with systemic lupus erythematosus. Z Rheumatol 2014; 73:939-41. [DOI: 10.1007/s00393-014-1381-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
4
|
Gorgan M, Bockorny B, Lawlor M, Volpe J, Fiel-Gan M. Pulmonary hemorrhage with capillaritis secondary to mycophenolate mofetil in a heart-transplant patient. Arch Pathol Lab Med 2013; 137:1684-7. [PMID: 24168511 DOI: 10.5858/arpa.2012-0460-cr] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Immunosuppressive drugs are an integral part of therapy in organ transplantation. However, they are not without side effects, and although rare, these agents should be considered in the differential diagnosis of pulmonary complications in patients receiving transplants. We present a case of a patient who developed acute respiratory failure 7 days after orthotopic heart transplantation and who had been on both mycophenolate mofetil (MMF) and tacrolimus agents. Lung biopsy revealed features of pulmonary hemorrhage with capillaritis. Considered as a possible etiology, MMF was withdrawn. There was immediate improvement of the patient's symptoms. The temporal relationship between MMF exposure and onset of pulmonary symptoms in the absence of other possible etiologies strongly suggests a causal relationship. Previously published reports of pulmonary toxicity from MMF included interstitial fibrosis. To the best of our knowledge, this is the first reported case of pulmonary hemorrhage with capillaritis because of administration of MMF.
Collapse
Affiliation(s)
- Maria Gorgan
- From the Departments of Pathology (Drs Gorgan and Fiel-Gan), Radiology (Dr Volpe), Infectious Diseases (Dr Lawlor), and Internal Medicine (Dr Bockorny), Hartford Hospital, Hartford, Connecticut
| | | | | | | | | |
Collapse
|
5
|
Olson AL, Brown KK, Fischer A. Connective Tissue Disease–Associated Lung Disease. Immunol Allergy Clin North Am 2012; 32:513-36. [DOI: 10.1016/j.iac.2012.09.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
6
|
Bertolini L, Vaglio A, Bignardi L, Buzio C, De Filippo M, Palmisano A, Mercati K, Zompatori M, Maggiore U. Subclinical interstitial lung abnormalities in stable renal allograft recipients in the era of modern immunosuppression. Transplant Proc 2012; 43:2617-23. [PMID: 21911134 DOI: 10.1016/j.transproceed.2011.06.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 05/13/2011] [Accepted: 06/03/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Interstitial lung abnormalities have been detected in up to 24% of kidney transplant patients receiving traditional immunosuppressive therapies (eg, cyclosporine, azathioprine); they usually occur early after transplantation and tend to resolve over time. Newer immunosuppressants such as mycophenolic acid and, particularly, mammalian target of rapamycin (mTOR) inhibitors (eg, sirolimus) may cause significant lung toxicity. However, the prevalence and severity of interstitial lung lesions in long-term, stable kidney transplant patients receiving either traditional or newer immunosuppressants is not known. METHODS We conducted a prospective, cross-sectional study examining high-resolution lung computed tomography (CT) scans in 63 stable kidney transplant recipients whose immunosuppressive therapy had remained unchanged for over 24 months. We compared CT findings of patients taking newer (mycophenolic acid and mTOR inhibitors) and traditional (calcineurin inhibitors and azathioprine) immunosuppressive drugs. RESULTS Interstitial lung alterations were observed in only 3/63 patients (4.8%); the prevalence was 11.5% (3/26) versus 0% (0/37) among the newer versus traditional immunosuppressive therapy groups, respectively (P = .065). The CT patterns were usual interstitial pneumonia and nonspecific interstitial pneumonia-like. The median time between transplant and CT was 49 months in the three patients with CT alterations and 95 months in the remaining 23 patients on newer immunosuppressants. It was 75 months for all patients on newer immunosuppressive drugs and 133 months for those on traditional therapies (P = .0015). A follow-up CT, performed in 2/3 patients with interstitial abnormalities, showed that the lesions were stable in one, while they had disappeared in the other. CONCLUSIONS Interstitial lung abnormalities are infrequent and mild in stable kidney transplant patients treated with newer as well as traditional immunosuppressive drugs. As such abnormalities were detected in patients screened earlier after transplantation, the time since transplantation rather than the drug type is probably the major determinant.
Collapse
Affiliation(s)
- L Bertolini
- Department of Radiology, Nephrology and Health Science, University Hospital of Parma, Parma, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Ogimi C, Honma N, Tanaka R, Oh-ishi T. Mycophenolate mofetil therapy for juvenile dermatomyositis with immune thrombocytopenic purpura. Mod Rheumatol 2011; 22:280-3. [PMID: 21710356 DOI: 10.1007/s10165-011-0489-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 06/02/2011] [Indexed: 11/29/2022]
Abstract
A 6-year-old girl, who had received corticosteroid and cyclosporine on the diagnosis of interstitial pneumonitis related to juvenile dermatomyositis, developed severe thrombocytopenia. Her thrombocytopenia was resistant to repeated intravenous immunoglobulin administration and methylprednisolone pulse therapy. After additional treatment with mycophenolate mofetil (MMF), instead of cyclosporine, the thrombocytopenia improved, facilitating a reduction in the dose of corticosteroid without exacerbation of the interstitial pneumonitis. We propose MMF as effective option in the treatment of immune thrombocytopenic purpura with autoimmune disease.
Collapse
Affiliation(s)
- Chikara Ogimi
- Division of Infectious Disease, Immunology, and Allergy, Saitama Children's Medical Center, Saitama, Japan.
| | | | | | | |
Collapse
|
8
|
Reynolds BC, Paton JY, Howatson AG, Ramage IJ. Reversible chronic pulmonary fibrosis associated with MMF in a pediatric patient: a case report. Pediatr Transplant 2008; 12:228-31. [PMID: 18307673 DOI: 10.1111/j.1399-3046.2007.00707.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We describe a case of chronic mineralizing pulmonary elastosis in a seven-yr-old boy following DD renal transplantation for Wilms tumour. Fourteen months post-transplantation he developed respiratory symptoms with lung biopsy demonstrating chronic mineralizing pulmonary elastosis thought to be secondary to immunosuppression with MMF. Symptomatic resolution occurred following MMF cessation.
Collapse
Affiliation(s)
- B C Reynolds
- Department of Renal Medicine, Royal Hospital for Sick Children, Glasgow, UK.
| | | | | | | |
Collapse
|
9
|
Cransberg K, Pijnenburg M, Lunstroot M, Lilien M, Cornelissen E, Davin JC, VanHoeck K, Merkus P, Nauta J. Pulmonary complaints and lung function after pediatric kidney transplantation. Pediatr Transplant 2008; 12:201-6. [PMID: 18307669 DOI: 10.1111/j.1399-3046.2007.00810.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Recently four of 38 children with a kidney transplant were diagnosed with bronchiectasis. The aim of the current study was to identify patients with increased risk for pulmonary damage. In this cross-sectional observational study, children with a functioning kidney graft in the Netherlands and Antwerp, Belgium, were screened with the use of a symptom checklist and spirometry. Maximum score for upper airway complaints was 21 (normal: <8), for lower airway complaints 28 (<10). Results of FVC, FEV(1) and MEF(25) were expressed as percentage predicted for height and sex. One hundred and thirty-five patients completed the interview (122) and/or spirometry (103); 91 did both. Lower airways symptoms were above acceptable levels in 18 (14%) patients. Forty-nine patients (48%) had an abnormal lung function test: in 12 concerning FVC%, in 11 FEV(1)%, in 24 MEF(25)% and in 36 FEV(1)/FVC. Of correlations between symptomatology or spirometry data, and clinical parameters, only that between GFR and MEF(25)% was statistically significant. Children with a kidney transplant are at increased risk for obstructive lung disease. We recommend to monitor lung function during the follow-up after renal transplantation.
Collapse
Affiliation(s)
- Karlien Cransberg
- Department of Pediatric Nephrology, Erasmus MC/Sophia Children's Hospital, Rotterdam, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Sweet SC. Therapeutic idiosyncrasy. Pediatr Transplant 2008; 12:121-2. [PMID: 18086249 DOI: 10.1111/j.1399-3046.2007.00866.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
11
|
Pageaux GP, Rostaing L, Calmus Y, Duvoux C, Vanlemmens C, Hardgwissen J, Bernard PH, Barbotte E, Vercambre L, Bismuth M, Puche P, Navarro F, Larrey D. Mycophenolate mofetil in combination with reduction of calcineurin inhibitors for chronic renal dysfunction after liver transplantation. Liver Transpl 2006; 12:1755-60. [PMID: 17133564 DOI: 10.1002/lt.20903] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
UNLABELLED The purpose of the study was to introduce mycophenolate mofetil (MMF) in liver transplant recipients with renal dysfunction to decrease calcineurin inhibitor (CNI) dosages without increasing rejection risk. In this prospective, multicenter, randomized study, chronic CNI-related renal dysfunction was defined by an increase in serum creatinine with values >140 micromol/L and <300 micromol/L. Patients were randomized in 2 groups. STUDY GROUP combination of MMF (2 to 3 g/day) and reduced dose of CNI >or=50% of initial dose; control group: no MMF, but with the ability to reduce CNI doses, but not below 75% of initial dose. Fifty-six patients were included, 27 in the study group and 29 in the control group. In the study group, there was a significant decrease in serum creatinine values, from 171.7 +/- 24.2 micromol/L at day 0 to 143.4 +/- 19 micromol/L at month 12 and a significant increase in creatinine clearance, from 42.6 +/- 10.9 mL/min to 51.7 +/- 13.8 mL/min. No rejection episode was observed in the study group. In the control group, there was no improvement of renal function, assessed by the changes in serum creatinine values, from 175.4 +/- 23.4 micromol/L at day 0 to 181.6 +/- 63 micromol/L at month 12, and in creatinine clearance, from 42.8 +/- 12.8 mL/min to 44.8 +/- 19.7 mL/min. The differences between the 2 groups were significant: P = 0.001 for serum creatinine, and P = 0.04 for creatinine clearance. In conclusion, the introduction of MMF combined with the reduction of at least 50% of CNI dose allowed the renal function of liver transplant recipients to significantly improve at 1 year, without any rejection episode and without significant secondary effects.
Collapse
|
12
|
Crestani B, Marchand-Adam S, Schneider S. [Drug treatments for idiopathic pulmonary fibrosis]. REVUE DE PNEUMOLOGIE CLINIQUE 2005; 61:221-31. [PMID: 16142196 DOI: 10.1016/s0761-8417(05)84815-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Idiopathic pulmonary fibrosis is a disease of unknown cause characterized by cough, progressive dyspnea, restrictive respiratory disorder, a typical honeycomb aspect on the high-resolution CT-scan, and usual interstitial pneumonia at histological examination of the lung biopsy. Most patients die 3 to 8 years after diagnosis. Current treatment is based on a combination of corticosteroids and immunosuppressants, but the efficacy of treatment remains a matter of debate. New therapeutics currently under evaluation in controlled clinical trials include interferon-gamma, pirfenidone, N-acetylcysteine, etanercept (anti-TNFalpha), bosentan (endothelin receptor antagonist), imatinib (tyrosine-kinases inhibitor of the PDGF receptor), etc. At the same time, new compounds showing efficacy in experimental models of fibrosis and the development of new pathophysiological concepts open new perspectives both in terms of concept and clinical practice.
Collapse
Affiliation(s)
- Bruno Crestani
- Service de Pneumologie, Hôpital Bichat-Claude-Bernard, AP-HP, 46, rue Henri-Huchard, 75877 Paris Cedex 18.
| | | | | |
Collapse
|
13
|
Pijnenburg MWH, Cransberg K, Wolff E, Bouquet J, Merkus PJFM. Bronchiectasis in children after renal or liver transplantation: a report of five cases. Pediatr Transplant 2004; 8:71-4. [PMID: 15009844 DOI: 10.1046/j.1397-3142.2003.00130.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
More effective immunosuppressive treatment in children following organ transplantation has significantly improved the survival of the grafts. Therefore, quality of life, long-term prognosis and adverse drug reactions have become more important. One of the main complications of immunosuppressive drugs is infections of the respiratory tract, but irreversible damage to the airways has not been described after renal or liver transplantation. Five children following transplantation of kidney or liver were referred to the Paediatric Pulmonology department because of chronic respiratory complaints. Pulmonary function tests and HRCT scan were performed as routine patient care. Four children with a renal transplant and one with a liver transplant showed chronic bronchitis and moderate to severe airways obstruction. HRCT showed bronchiectasis in all of them. We speculate that the immunosuppressive treatment (in)directly contributes to irreversible airway damage. We recommend including follow-up of lung function in the post-transplantation protocol and considering bronchiectasis in case of respiratory symptoms, to try preventing further damage to the lung.
Collapse
Affiliation(s)
- Mariëlle W H Pijnenburg
- Department of Pediatrics, Division of Respiratory Medicine, Erasmus Medical Center/Sophia Children's Hospital, PO Box 2060, 3000 CB Rotterdam, The Netherlands.
| | | | | | | | | |
Collapse
|
14
|
Abstract
Idiopathic pulmonary fibrosis (IPF) is an inflammatory disorder of the lungs of unknown etiology, with no effective treatment. Besides the recent finding of utility of mycophenolate mofetil (MMF) in a case of refractory interstitial lung disease associated with ulcerative colitis, I suggest that there are at least three other reasons to consider MMF for IPF. Previously, MMF has been found to be effective as salvage therapy in a number of diseases. MMF might work for IPF not only by white cell suppression, but also in vivo against proliferation of primary human pulmonary fibroblasts. There is one group of patients for whom, logically, MMF should be most strongly considered--those with a high likelihood of receiving a lung transplant. As MMF is often part of the post-transplant immunosuppressive regimen in these patients, logic would seem to dictate MMF should be considered for use before subjecting the patient to major surgery.
Collapse
Affiliation(s)
- E L Altschuler
- Brain and Perception Laboratory, University of California, San Diego, La Jolla 92093-0109, USA.
| |
Collapse
|
15
|
Affiliation(s)
- B D Kahan
- Department of Surgery, The University of Texas Medical School at Houston, 77030, USA.
| | | |
Collapse
|