Postautologous stem cell transplantation engraftment syndrome: Improved treatment and outcomes

Acute kidney injury during autologous stem cell transplantation in light chain amyloidosis with kidney involvement and their impact on prognosis

Acute kidney injury (AKI) is a complication related to important organ dysfunction during autologous stem cell transplantation (ASCT) in light chain (AL) amyloidosis. This study aims to validate the risk factors of AKI during different periods of ASCT and the impact of AKI on long-term outcomes. 302 patients with AL amyloidosis and kidney involvement who underwent ASCT were included. The procedures from stem cell mobilization to 30 days after transplantation were categorized into four periods: Period 0 (stem cell mobilization and harvest), Period 1 (preparation), Period 2 (conditioning and transplantation), and Period 3 (engraftment). The incidence of AKI during ASCT was 27.15% (0.66% in Period 0, 6.62% in Period 1, 15.23% in Period 2, and 6.95% in Period 3). The major causes of AKI were capillary leak syndrome in Period 0, ganciclovir or sulfamethoxazole/trimethoprim in Period 1, high-dose melphalan in Period 2, and engraftment syndrome in Period 3. AKI in different periods had distinct risk factors and predictive models. AKI was a risk factor for both kidney survival and overall survival (OS). Even recovered AKI reduced 10-year kidney survival from 91.7% to 68.4% (p = 0.002) and 10-year OS from 91.1% to 77.7% (p = 0.005).

Early allogeneic immune modulation after establishment of donor hematopoietic cell-induced mixed chimerism in a nonhuman primate kidney transplant model

Background

Mixed lymphohematopoietic chimerism is a proven strategy for achieving operational transplant tolerance, though the underlying immunologic mechanisms are incompletely understood.

Methods

A post-transplant, non-myeloablative, tomotherapy-based total lymphoid (TLI) irradiation protocol combined with anti-thymocyte globulin and T cell co-stimulatory blockade (belatacept) induction was applied to a 3-5 MHC antigen mismatched rhesus macaque kidney and hematopoietic cell transplant model. Mechanistic investigations of early (60 days post-transplant) allogeneic immune modulation induced by mixed chimerism were conducted.

Results

Chimeric animals demonstrated expansion of circulating and graft-infiltrating CD4+CD25+Foxp3+ regulatory T cells (Tregs), as well as increased differentiation of allo-protective CD8+ T cell phenotypes compared to naïve and non-chimeric animals. In vitro mixed lymphocyte reaction (MLR) responses and donor-specific antibody production were suppressed in animals with mixed chimerism. PD-1 upregulation was observed among CD8+ T effector memory (CD28-CD95+) subsets in chimeric hosts only. PD-1 blockade in donor-specific functional assays augmented MLR and cytotoxic responses and was associated with increased intracellular granzyme B and extracellular IFN-γ production.

Conclusions

These studies demonstrated that donor immune cell engraftment was associated with early immunomodulation via mechanisms of homeostatic expansion of Tregs and early PD-1 upregulation among CD8+ T effector memory cells. These responses may contribute to TLI-based mixed chimerism-induced allogenic tolerance.

Characteristics of Engraftment Syndrome following Autologous Stem Cell Transplantation in Light Chain Amyloidosis with Renal Involvement

Engraftment syndrome (ES) is a clinical complication that occurs during the neutrophil recovery phase following hematopoietic stem cell transplantation. The clinical features of ES in light chain (AL) amyloidosis remains to be thoroughly investigated. This study was conducted to better understand the characteristics of ES following autologous stem cell transplantation (ASCT) in AL amyloidosis with renal involvement. We conducted this single-center retrospective study in 302 patients with AL amyloidosis who underwent ASCT between July 2010 and December 2021. Sixty-seven of the 302 patients (22.2%) developed ES, with a median time to the occurrence of ES after stem cell reinfusion of 11 days (range, 7 to 17 days). Among the outcome measures in this study, estimated glomerular filtration rate (eGFR) at baseline and C-reactive protein (CRP) level on the day of granulocyte engraftment were statistically different between the ES patients and non-ES patients. We observed no significant difference between the 2 groups in transplantation-related adverse events (grade ≥ 2), hematologic and organ responses, overall survival, and progression-free survival. Furthermore, CRP level at granulocyte engraftment (odds ratio [OR], 1.012; 95% confidence interval [CI], 1.004 to 1.020; P = .002) and the absence of induction chemotherapy before ASCT (OR, 1.977; 95% CI, 1.047 to 3.731; P = .036) were identified as risk factors for the development of ES, whereas a higher eGFR at baseline (OR, .981; 95% CI, .969 to .993; P = .002) was identified as a protective factor against ES. Our data show a 22.2% incidence of ES in AL amyloidosis patients with renal involvement after ASCT and identify associated risk and protective factors, which can improve the understanding of this clinical complication.

The Impact of Prior Salvage Treatment With Immune Checkpoint Inhibitors on Hodgkin Lymphoma Patients Undergoing Autologous Hematopoietic Stem Cell Transplantation: A Single-Center Experience

INTRODUCTION

The objective of the study was to assess the impact of the previous use of immune-checkpoint inhibitors (ICIs) on the clinical course of Hodgkin Lymphoma (HL) patients undergoing autologous hematopoietic stem cell transplantation (ASCT).

METHODS

A single-center, retrospective chart review of adult HL patients who received ASCT from January 1, 2014, to December 31, 2019, was conducted. Primary endpoints included the length of stay (LOS) and the composite outcome of late-onset noninfectious fever (LONIF) or late-onset hypotension (LOH) requiring intravenous fluid (IVF) resuscitation. Secondary endpoints included number of days until neutrophil engraftment, documented infections, and corticosteroid use.

RESULTS

A total of 52 HL patients were included. Nine (17%) received ICI before ASCT, and 43 (83%) patients underwent standard salvage chemotherapy. The composite outcome of LONIF or LOH requiring IVF resuscitation was significantly higher in patients previously treated with ICIs compared with those who received standard non-ICI salvage chemotherapy (78% vs. 33%; P = .022). The differences between the median LOS and time to neutrophil engraftment were not statistically significant (P = .94 and P = .083, respectively). All LONIF patients received systemic corticosteroids with symptom resolution.

CONCLUSION

The composite outcome of LONIF or LOH requiring IVF resuscitation was significantly higher in patients who received prior ICI salvage therapy. LOS and time to neutrophil engraftment were not affected by prior ICI therapy. Early institution of steroids may prevent the evolution of additional sequelae associated with engraftment or engraftment-like syndrome that can complicate ASCT.