Pulmonary complications after hematopoietic stem cell transplantation

Pulmonary Complications After Pediatric Stem Cell Transplant

The number of disorders that benefit from hematopoietic stem cell transplantation (HSCT) has increased, causing the overall number of HSCT to increase accordingly. Disorders treated by HSCT include malignancy, benign hematologic disorders, bone marrow failure syndromes, and certain genetic diagnoses. Thus, understanding the complications, diagnostic workup of complications, and subsequent treatments has become increasingly important. One such category of complications includes the pulmonary system. While the overall incidence of pulmonary complications has decreased, the morbidity and mortality of these complications remain high. Therefore, having a clear differential diagnosis and diagnostic workup is imperative. Pulmonary complications can be subdivided by time of onset and whether the complication is infectious or non-infectious. While most infectious complications have clear diagnostic criteria and treatment courses, the non-infectious complications are more varied and not always well understood. This review article discusses pulmonary complications of HSCT recipients and outlines current knowledge, gaps in knowledge, and current treatment of each complication. This article includes some adult studies, as there is a significant paucity of pediatric data.

Psychosocial aspects of hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) has become a conventional and potentially curative treatment for various hematological diseases. As more sophisticated procedures have been developed and mortality rates have decreased, attention has shifted to the psychosocial challenges associated with transplantation. The psychosocial difficulties accompanying transplantation are addressed in the context of both quality of life (QOL) and psychopathological research. Among the psychiatric comorbidities of HSCT, anxiety, depression, sleep and sexual disorders, delirium and post-traumatic stress disorder are the most studied conditions. Recently, more attention has been focused on the psychosocial burden of caregivers. Devising recommendations for the management of psychiatric symptoms and psychosocial interventions in HSCT sufferers and close relatives is a major concern to consultation–liaison psychiatrists and transplant teams. This review synthesizes and critically evaluates the current literature on the psychosocial aspects of HSCT and appraises the clinical significance of these outcomes. Issues of QOL assessment; psychosocial functioning and QOL in the course of HSCT; impact of graft-versus-host disease and other predictors of QOL and psychosocial functioning; comorbid psychiatric disorders; and interventions to maintain or improve QOL and reduce psychopathology and psychosocial burden on family members are presented.

The role of microbiota in allogeneic hematopoietic stem cell transplantation

INTRODUCTION

Allogeneic hematopoietic stem cell transplantation (Allo-HSCT) is commonly performed to treat a variety of benign and malignant hematological diseases. Acute graft-versus-host disease (GVHD) is a major life-threatening complication that often occurs following allo-HSCT. Recently, improvements in methods to characterize the microbiota have led to a greater appreciation for how frequently and profoundly an alteration in microbial composition, or dysbiosis, can occur in allo-HSCT recipients to better decipher the complex interplay between microbiota and allo-HSCT outcomes.

AREAS COVERED

This article reviews the current knowledge of the microbiota's impact on allo-HSCT outcomes, including effects of microbiota-derived metabolites, and crosstalk between commensals and the allogeneic immune response. This article also summarizes the effects of HSCT and transplant-related procedures on microbiota, and recent developments in interventional strategies.

EXPERT OPINION

A growing body of literature indicates that the composition of the intestinal microbiota can function as a predictive biomarker for the risk and severity of acute GVHD, as well as overall survival, in patients undergoing allo-HSCT. Mechanisms underpinning these associations, however, are not well understood, and clinical strategies that modulate the microbiome to improve outcomes have yet to be fully developed. There is an unmet need to determine mechanisms to improve the efficacy of allo-HSCT.

Therapeutic Impact and Complications Associated with Surgical Lung Biopsy after Allogeneic Hematopoietic Stem Cell Transplantation in Children

Hematopoietic stem cell transplantation (HSCT) in the pediatric population is associated with pulmonary complications in 25% of recipients. The role of surgical lung biopsy (SLB) remains unclear because of concerns about both the therapeutic impact and morbidity associated with the procedure. A retrospective review of consecutive allogeneic HSCT recipients at Dana-Farber and Boston Children's Hospital Cancer and Blood Disorders Center between 2006 and 2016 was performed. All recipients who underwent SLB during the study period were identified and charts reviewed for perioperative complications, histopathologic findings, and changes in therapy delivered. Pearson's chi-square test and Student's t-test (or appropriate nonparametric test) were used to evaluate the associations between perioperative complication and categorical and continuous variables, respectively. Five hundred fifty-five HSCTs were included, among which 48 SLBs (8.6%) were identified. Median follow-up time was 24 months (range, 0 to 139). Thirty-day postoperative morbidity was 16.7% and 30-day postoperative mortality 10.4% (n = 5). The overall 30-day postoperative complication rate (including mortality) was 20.8% (n = 10). No mortalities were directly attributable to SLB. Definitive diagnoses were identified in 70.8% of SLBs (n = 34), and therapeutic changes occurred in 79.2% (n = 38). Overall, 83.3% of SLBs (n = 40) either provided a diagnosis or led to a change in therapy. SLB has an acceptable risk of perioperative complications in this medically complicated and often severely ill population. In most HSCT patients, SLB aids in defining the etiology of pulmonary infiltrates and can inform therapeutic decisions in patients where noninvasive diagnostic modalities have failed to provide a definitive diagnosis.

[Post-transplant pulmonary complications: Guidelines from the francophone Society of bone marrow transplantation and cellular therapy (SFGM-TC)]

Pulmonary complications after allogeneic hematopoietic stem cell transplantation occur frequently (30-75%), vary in severity, and sometimes prove lethal. They may occur at an early stage post-transplant before D100 but may also surface later. Etiological support for these complications has shown a beneficial impact on survival. When faced with early complications, non-invasive tests, scans, and microbiological tests must be rapidly implemented. In the majority of cases, these tests facilitate diagnosis. In cases where microbiological non-invasive tests are negative, and the patient shows a steady respiratory condition, bronchoalveolar lavage can be effective if it is implemented in the first four days following the onset of pulmonary symptoms. This diagnostic approach should in no way occlude the introduction of broad-spectrum antibiotics in these profoundly immunocompromised patients. Later pulmonary complications are the most often not infectious. They include different anatomo-clinical conditions: cryptogenic organizing pneumonia; interstitial lung disease; idiopathic pleuroparenchymal fibroelastosis. Vascular disorders may include hypertension, thrombotic microangiopathy, venous thromboembolism, and pleural effusions. These conditions must be monitored using RFE (respiratory functional exploration) which allows early detection and therapeutic intervention. A combination of RFE and thoracic radiology scans will provide diagnostic assessment. Bronchoalveolar lavage is indicated when an infection is suspected or before systemic corticosteroid therapy. A lung biopsy should be discussed on a case-by-case basis, such as in cases of interstitial pulmonary disorders.

Pulmonary complications in hematopoietic SCT: a prospective study

Pulmonary complications are common and often lethal in hematopoietic SCT recipients. The objective of this prospective interventional study was to evaluate the etiology, diagnostic procedures, risk factors and outcome of pulmonary complications in a cohort of hematopoietic SCT recipients followed up for 1 year. For patients suffering from a pulmonary complication, a diagnostic algorithm that included non-invasive and bronchoscopic procedures was performed. We identified 73 pulmonary complications in 169 patients: 50 (68%) were pneumonias; 21 (29%) were non-infectious complications and 2 (3%) were undiagnosed. Viruses (particularly Rhinovirus) and bacteria (particularly P. aeruginosa) (28 and 26%, respectively) were the most common causes of pneumonia. A specific diagnosis was obtained in 83% of the cases. A non-invasive test gave a specific diagnosis in 59% of the episodes. The diagnostic yield of bronchoscopy was 67 and 78% in pulmonary infections. Early bronchoscopy (⩽5 days) had higher diagnostic yield than late bronchoscopy (78 vs 23%; P=0.02) for pulmonary infections. Overall mortality was 22 and 32% of all fatalities were due to pulmonary complications. Pulmonary complications are common and constitute an independent risk factor for mortality, stressing the importance of an appropriate clinical management.

Quality of life and its socio-demographic and psychological determinants after bone marrow transplantation

OBJECTIVES

A host of medical, socio-demographic, and psychological factors that affect bone marrow transplantation (BMT) patients' quality of life (QOL) have been identified, but due to the methodological diversity of the studies, the findings have been contradictory. The aim of this study was to examine the influence of somatic status, social characteristics, and psychological symptoms on QOL in BMT patients.

METHODS

The study had a cross-sectional design. QOL was evaluated using the Hungarian version of the Functional Assessment of Cancer Therapy-Bone Marrow Transplant (FACT-BMT) scale. Anxiety and depression were assessed using Spielberger's State and Trait Anxiety Inventory (SSTAI) and the Beck Depression Inventory (BDI). A questionnaire designed for the study was used to record socio-demographic variables.

RESULTS

One hundred and twenty-one patients formed the study sample. Patients' QOL was better in our sample than in another study with similar mean time after BMT. BDI scores indicated mild depression; SSTAI scores corresponded with healthy population levels. QOL was strongly influenced by psychological symptoms (depression P < 0.001; anxiety P = 0.001; psychiatric comorbidity P = 0.001), employment status (P = 0.042), and gender (P = 0.05). The somatic factors influenced only separate aspects of QOL; somatic comorbidity only affected cancer-associated QOL (P = 0.004).

CONCLUSION

This is the first study on a Hungarian BMT sample that included economic factors in the assessment of QOL. Psychological variables were the strongest determinants of QOL in this study.

Defective pulmonary innate immune responses post-stem cell transplantation; review and results from one model system

Infectious pulmonary complications limit the success of hematopoietic stem cell transplantation (HSCT) as a therapy for malignant and non-malignant disorders. Susceptibility to pathogens in both autologous and allogeneic HSCT recipients persists despite successful immune reconstitution. As studying the causal effects of these immune defects in the human population can be limiting, a bone marrow transplant (BMT) mouse model can be used to understand the defect in mounting a productive innate immune response post-transplantation. When syngeneic BMT is performed, this system allows the study of BMT-induced alterations in innate immune cell function that are independent of the confounding effects of immunosuppressive therapy and graft-versus-host disease. Studies from several laboratories, including our own show that pulmonary susceptibility to bacterial infections post-BMT are largely due to alterations in the lung alveolar macrophages. Changes in these cells post-BMT include cytokine and eicosanoid dysregulations, scavenger receptor alterations, changes in micro RNA profiles, and alterations in intracellular signaling molecules that limit bacterial phagocytosis and killing. The changes that occur highlight mechanisms that promote susceptibility to infections commonly afflicting HSCT recipients and provide insight into therapeutic targets that may improve patient outcomes post-HSCT.

Pulmonary infections in transplant recipients

PURPOSE OF REVIEW

Hematopoietic stem cell as well as solid-organ transplantation is being carried out with increasing frequency throughout the world. Lower respiratory tract infections (LRTIs) remain a common life-threatening complication faced by the transplant recipients. The purpose of this review is to provide up-to-date information on pulmonary infections among the transplant recipients, especially emphasizing the endemicity of microorganisms, epidemiology, work-up of infections, and principles of their management.

RECENT FINDINGS

A lower respiratory tract infection such as pneumonia is the most frequent of all the infections and is associated with high morbidity and mortality. Factors increasing the risk of pulmonary infections include surgical techniques, immune status, chemoradiotherapy, alloimmune mechanisms between the host and the graft, and the environment. A high degree of suspicion, computed tomography (CT) scan of the chest, and flexible bronchoscopy are required in most to establish the diagnosis.

SUMMARY

Proper management of LRTI in transplant recipients requires a high degree of suspicion, thorough knowledge of the epidemiology and endemicity of the suspected organisms, CT scan of the chest, and expertise at bronchoscopy. Utmost teamwork among transplant physicians, infectious disease specialist, and bronchoscopist is essential.

Pulmonary function testing prior to reduced intensity conditioning allogeneic stem cell transplantation in an unselected patient cohort predicts posttransplantation pulmonary complications and outcome

Pretransplant pulmonary function tests (PFTs) have been checked mostly in myeloablative allogeneic stem cell transplantation (Allo-SCT). Their value in the setting of reduced intensity conditioning Allo-SCT (Allo-RIC) has been less explored. We retrospectively evaluated the predictive value of PFTs on posttransplant pulmonary complications (PPC) and outcomes in 195 consecutive Allo-RIC patients, based on fludarabine plus busulphan or melphalan. PFT parameters included forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), FEV1/FVC ratio, total lung capacity (TLC), residual volume, and diffusion capacity for carbon monoxide (DLCo) corrected for the hemoglobin levels. Pretransplant PFTs abnormalities were observed in 130 patients (66%). The most frequent abnormalities were abnormal DLCO (n = 83, 44%), followed by FEV1/FVC (n = 75, 38%) and FVC (n = 47, 24%). The abnormalities were severe in 25 (13%) patients, moderate in 65 (33%) and mild in 40 patients (21%). Multivariate analysis showed that TLC was significantly associated with PPC, nonrelapse mortality and overall survival (OS), (HR 4.2, 95% CI. 2-8.5; HR 3.8, 95% CI. 1.7-8.5; HR 2.3, 95% CI. 1.3-4.1, respectively, P = 0.01), while abnormal FVC had a negative impact on PPC and OS (HR 1.8, 95% CI. 0.98-3.6, P = 0.06 and HR 1.7, 95% CI. 1.1-2.6, P = 0.008). This study emphasizes the valuable role of PFTs in identifying patients at risk for PPC, NRM, and lower OS in the Allo-RIC setting.

[Bronchiolitis obliterans postallogeneic stem cell transplantation: what is new?]

Bronchiolitis obliterans (BO) is a severe complication of hematopoietic stem cell transplantation (HSCT). It is considered as a respiratory manifestation of chronic graft-versus-host disease. It is quite similar to the bronchiolitis obliterans after lung transplantation. Classical therapy associates steroids and immunosuppressive drugs, however theses procedure showed a modest efficacy and have an important morbidity. Recent progresses in the physiopathology of BO post-HSCT allow to use new treatments: mTOR inhibitors, immunotherapy, extra-corporeal photochemotherapy, and bronchial anti-inflammatory effects of azithromycin, statins or antileucotriens. This review will focus on the use of these new therapies in BO post-HSCT.

High-resolution computed tomography of chest complications in patients treated with hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) has become a standard method for treating patients with hematological malignancies. Preconditioning chemotherapeutic drugs, total body irradiation (TBI), or chronic graft-versus-host disease (GVHD) can cause several chest complications after HSCT. Because immunosuppression is marked after HSCT, it takes at least 1 year for the immune system to recover completely. Therefore, several infectious and noninfectious complications may occur within the year after HSCT. HSCT-specific complications occur in a characteristic temporal sequence associated with the period following HSCT. During the neutropenic phase, bacterial pneumonia, fungal infection, pulmonary edema, and diffuse alveolar hemorrhage may occur. During the early phase, pneumocystis pneumonia, cytomegalovirus pneumonia, engraftment syndrome, and idiopathic pneumonia syndrome are the common complications. During the late phase, constrictive bronchiolitis and organizing pneumonia may occur probably associated with chronic GVHD. Although high-resolution CT findings lack specificity, the frequency and likelihood of occurrence of certain complications in certain phases and sometimes characteristic features (such as a CT halo sign for fungal infection) facilitate early detection of a life-threatening complication.

[Non-infectious pulmonary complications after the hematopoietic stem cell transplantation]

Pulmonary complications are important cause of mortality and morbidity after hematopoietic stem cell transplantation, in 30% to 60% of the patients. Improvements in prophylaxis and treatment of infectious complications have been increasing the rate of non-infectious complications. Early diagnosis and treatment of those complications can significantly change the evolution of hematopoietic stem cell transplantation receptors. The objective of this study is to review the most frequent non-infection complications associated to hematopoietic stem cell transplantation since the first bone marrow transplantation performed in 1957. A systematic literature review was performed, using the PICO strategy to ask the questions. The descriptors hematopoietic stem cell transplantation, non-infectious pulmonary complications, systematic review, in portuguese and their english correspondents, were used to access the following databases: MEDLINE, EBM, Embase, Cocrane Library, LILACS and SciELO. In this review, 263 studies were identified, from which 31 were selected for full analyzis. The non-infection pulmonary complications most frequently found were: bronchiolitis obliterans, bronchiolitis obliterans organizing pneumonia, pulmonary edema, idiopathic pneumonia syndrome, delayed pulmonary toxicity syndrome, diffuse alveolar hemorrhage, engrafment syndrome and pulmonary cytolitic thrombi.

The clinical importance of bronchoalveolar lavage in allogeneic SCT patients with pneumonia

Patients who undergo allogeneic hematopoietic SCT (HSCT) are prone to pulmonary infections. Between 1998 and 2004, a total of 450 patients underwent HSCT at Karolinska University Hospital, Huddinge. Pneumonia was diagnosed in 167 patients (37%), including 42 children. Bronchoalveolar lavage (BAL) was performed on 68 occasions in 57 patients (six children). In 110 patients (36 children) with pneumonia, BAL was not performed. BAL contributed to the diagnosis in 43 cases (63%) and to relevant findings in 53 cases: bacteria (n=13, 24%), viruses (n=28, 53%) and fungi (n=12, 23%). In 25 cases BAL was negative. In 15 of these cases, BAL was performed >or=4 days after chest X-ray, and in four cases not in the same segment as the infiltrations. The median time between radiographic findings and positive BAL was 2 (0-15) days, and a negative BAL 6 (1-30) days (P<0.001). Antimicrobial treatment was administered to 79% patients with positive findings, and to 92% with negative findings at the time of BAL. No serious complications due to the procedure were reported. BAL resulted in a changed treatment in 32/68 (47%) episodes of pneumonia. To conclude, BAL is a safe and useful diagnostic procedure that should be performed early after the onset of pneumonia following allogeneic HSCT.

Impact of clinical data on chest radiography sensitivity in detecting pulmonary abnormalities in immunocompromised patients with suspected pneumonia

PURPOSE

Chest radiography (CXR) of immunocompromised patients has low sensitivity in the early evaluation of pulmonary abnormalities suspected to be infectious. The purpose of the study was to evaluate whether the knowledge of clinical data improves the diagnostic sensitivity of CXR in the particular setting of immunocompromised patients after hematopoietic stem cell transplantation (HSCT).

MATERIALS AND METHODS

Sixty-four CXRs of immunocompromised patients with clinically suspected pneumonia were retrospectively and independently evaluated by two radiologists to assess the presence of radiological signs of pneumonia, before (first reading) and after (second reading) the knowledge of clinical data. A chest computed tomography (CT) performed within 3 days was assumed as the standard of reference. For each reading, sensitivity of both radiologists was calculated.

RESULTS

Readers showed a sensitivity of 39% and 58.5% for the first reading, and 43.9% and 41.5% for the second reading, respectively. For both readers, these values were not significantly different from those obtained at first reading (McNemar's test, p>0.05). Interobserver agreement at second reading was fair (Cohen test, k=0.33).

CONCLUSIONS

The sensitivity of CXR is too low to consider it a stand-alone technique for the evaluation of immunocompromised patients after HSCT with suspected pneumonia, even if the radiologist knows detailed clinical data. For these patients, an early chest CT evaluation is therefore recommended.

Early pulmonary complications after hematopoietic stem cell transplantation in pediatric patients: association with cytomegalovirus infection

Pulmonary complications resulting in high morbidity and mortality occur in a substantial proportion of hematopoietic stem cell transplantation (HSCT) recipients. We investigated the incidence, causes, and risk factors of pulmonary complications, early after HSCT in pediatric patients, and patient outcomes by retrospective analysis of patients who underwent HSCT at Seoul National University Children's Hospital between September 2003 and June 2007. A total of 145 patients were evaluated of whom 15 (10.3%) developed pulmonary complications. Eight patients were suspected to have infection-related pulmonary complications and 7 had noninfectious causes. In a multivariate analysis of allogeneic transplantation recipients, detection of cytomegalovirus antigenemia was significantly associated with the development of both pulmonary complications and acute respiratory distress syndrome. Eleven (73.3%) of the 15 patients developed acute respiratory distress syndrome, required mechanical ventilation and eventually died. Early use of methylprednisolone in 3 patients decreased the oxygenation index. Sixteen patients died due to treatment-related complications early after HSCT, and pulmonary complications accounted for a substantial portion of the mortality. Thus, improvement of prophylaxis and management for pulmonary complications is crucial to improve the overall outcome of HSCT. More aggressive prophylaxis and treatment of cytomegalovirus infection and judicious use of methylprednisolone at the appropriate time could be the means for such improvement.

Nonspecific interstitial pneumonia after peripheral blood stem cell transplantation in an 11-year-old boy

Late-onset pulmonary complications after peripheral blood stem cell transplantation include various conditions such as opportunistic infections and interstitial pneumonias. It is sometimes difficult to diagnose interstitial pneumonias because there is substantial overlap in their computed tomography appearances. We present a case of an 11-year-old boy who consecutively developed pulmonary infection and cellular nonspecific interstitial pneumonia 9 months after peripheral blood stem cell transplantation for recurrent acute lymphocytic leukemia.