APOL1 Gene Variants and Risk for Cardiovascular Disease

INTRODUCTION

The association of APOL1 risk variants with cardiovascular risk and cardiovascular disease (CVD) in observational and clinical trials has had inconsistent results. We aim to assess the relationship between the presence of APOL1 risk variants and the CVD risk in Afro-descendant patients with end-stage renal disease (ESRD).

METHODS

We performed an observational, cross-sectional study of Afro-descendant adult patients with ESRD who were on the waitlist for a kidney transplant. Associations of APOL1 genotypes (high-risk [HR] = 2 alleles; low-risk [LR] = 0 or 1 allele) with cardiovascular risk were the primary clinical endpoint. The relation was evaluated using univariate and multivariate analysis.

RESULTS

We enrolled a total of 102 patients with ESRD; 37% (38 patients) had APOL1 HR status with two alleles in homozygous (G1/G1 = 21 and G2/G2 = 3) or compound heterozygote (G1/G2 = 14) form and 63% (64 patients) had APOL1 LR status. No significant association was found between HR APOL1 genotypes and high cardiovascular risk (in adjusted Colombia Framingham Risk Score). APOL1 HR versus LR variants were not independently associated with left ventricular hypertrophy or systolic dysfunction. No cardiovascular deaths occurred during the follow-up.

CONCLUSION

In Afro-descendent patients with ESRD, APOL1 HR status is not associated with the increase in cardiovascular risk profile and metabolic disturbances.

Veno-arterial extracorporeal membrane oxygenation as a perioperative support to redo cardiac surgery for inoperable adult patients: a case series

Background

The present article describes three cases of patients in cardiogenic shock (CS) with previous cardiac surgery that made them initially inoperable. Perioperative support with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) improved haemodynamic status and results in these high-risk patients.

Case summary

Case 1 is a 57-year-old male morbidly obese with previous aortic valve replacement (AVR) who presented with chest pain and developed cardiac arrest. Cardiopulmonary resuscitation and femoral VA-ECMO were initiated. Three days later, a redo AVR was performed. Veno-arterial extracorporeal membrane oxygenation was maintained for 12 days, followed by 7 days of veno-venous ECMO for complete recovery. Case 2 features a 39-year-old male with two previous mitral valve replacements (MVRs). The first is due to papillary muscle rupture, and the second is due to endocarditis of the mitral prosthesis. He presented with CS and pulmonary oedema. Emergency surgery was performed and the patient was then placed in VA-ECMO. Weaning off was achieved 3 days after surgery. Case 3 is a 21-year-old female with a previous MVR due to rheumatic disease. She presented with CS, severe mitral prosthesis stenosis, and a pulmonary embolism. Femoral VA-ECMO was initiated, and one day later, she underwent a redo MVR operation. Extracorporeal membrane oxygenation was discontinued 4 days later.

Discussion

Dysfunctional prosthetic valves leading to CS may benefit from a redo cardiac operation supported by a perioperative VA-ECMO to optimize haemodynamic status. Despite the results from risk prediction scores, this approach has the potential to reduce operative mortality in initial inoperable patients and allow a definitive redo cardiac surgery.

Haploidentical and Matched Sibling Transplantation for Acute Myeloid Leukemia: A Hospital-Based Study

Background

Allogeneic peripheral blood stem cell transplantation (PBSCT) has been increasing for the last years in Latin America. The objective of this study was to describe clinical outcomes in acute myeloid leukemia (AML) receiving allogeneic PBSCT between 2013 and 2019 in a single center of Cali, Colombia.

Methods

A retrospective cohort study was conducted in Fundacion Valle del Lili. Patients diagnosed with AML who received an allogeneic PBSCT between 2013 and 2019 using human leukocyte antigen (HLA)-matched sibling donors (MSDs) or haploidentical related donors (HRDs) with myeloablative conditioning regimen were included. Cases with diagnosis of promyelocytic leukemia, myelodysplastic syndrome-related AML and therapy-related AML were excluded. Data were obtained directly from the hospital PBSCT database and clinical records.

Results

A total of 50 patients were included (HRD, n = 32; MSD, n = 18). Sixty-two percent was in the first complete remission (CR1) at the time of the transplant, of which 26% were MSD and 74% were HRD. The European Group for Blood and Marrow Transplantation (EBMT) risk score was: 44% vs. 50% low, 28% vs. 28% intermediate and 28% vs. 22% high for MSD vs. HRD, respectively. Overall survival at 5 years for MSD was 62% (95% confidence interval (CI): 31-83%) and 43% (95% CI: 25-60%) for HRD. Event-free survival was 56% (95% CI: 26-78%) and 35.6% (95% CI: 18-53%), respectively. Non-relapse mortality at day-100 was 6% (95% CI: 0.8-35%) and 20% (95% CI: 9-39%). Relapse at5 years was 18% (95% CI: 4-58%) and 25% (95% CI: 10-52%). Overall mortality rate was 46%. The grade II-IV, III-IV acute graft-versus-host disease and severe chronic graft-versus-host disease was 44%, 11% and 12% for MSD, and 43%, 9% and 0% for HRD.

Conclusion

These results underline that MSD remains the first donor choice for AML patients in CR1 when available. HRDs are still our next option among alternative donors. It is necessary to find strategies that have a positive impact on those outcomes that markedly affect the quality of allogeneic PBSCT and the prognosis of patients. Comparative, randomized, prospective studies with longer follow-up of haploidentical allogeneic PBSCT with other donor types are required to definitely establish its role among alternative donors.

Hypertrophic Cardiomyopathy in a Latin American Center: A Single Center Observational Study

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is a complex disorder that includes various phenotypes, leading to different manifestations. It also shares different disadvantages typical of rare diseases, including limited recognition, lack of prospective studies assessing treatment, and little or delayed access to advanced treatment options. Reliable data about the prevalence and natural history of cardiomyopathies in South America are lacking. This study summarizes the features and management of patients with HCM in a university hospital in Colombia.

METHODS

This was an observational retrospective cohort study of patients with HCM between January 2010 and December 2021. Patient data were analyzed from an institutional cardiomyopathy registry. Demographic, paraclinical, and outcome data were collected.

RESULTS

A total of 82 patients during the study period were enrolled. Of these, 67.1% were male, and the mean age at diagnosis was 49 years. Approximately 83% were in NYHA functional class I and II, and the most reported symptoms were dyspnea (38%), angina (20%), syncope (15%), and palpitations (11%). In addition, 89% had preserved left ventricular ejection fraction (LVEF) with an asymmetric septal pattern in 65%. Five patients (6%) had alcohol septal ablation and four (5%) had septal myectomy. One patient required heart transplantation during follow-up. Sudden cardiovascular death was observed in 2.6%. The overall mortality during follow-up was 7.3%.

CONCLUSIONS

HCM is a complex and heterogeneous disorder that presents with significant morbidity and mortality. Our registry provides comprehensive data on disease courses and management in a developing country.

COVID-19 in kidney transplant recipients: A experience in Colombia

Background: Patients with kidney transplants seem to be at particularly high risk for severe COVID19 disease due to their impaired immune responses and comorbidities. Purpose: This study aims to describe kidney transplant patients’ clinical characteristics and outcomes with SARSCOV-2 infection in a fourth-level hospital in Cali, Colombia. Methodology: We performed an observational study of kidney transplant recipients with SARS-CoV2 infection admitted at Fundación Valle del Lili from June to December 2020. To be eligible for this study, patients have symptoms compatible, a positive RT-PCR and inpatient management. Asymptomatic patients were excluded. Results: We enrolled a total of 50 patients. 64% were male, and the median age was 53.5 years (range 46-60). The comorbidities were 36 (70%) hypertension, 16 (32%) diabetes mellitus, 5 (10%) obesity. The most common immunosuppressive regimen was tacrolimus, mycophenolate and prednisone. The median time from symptoms onset to the positive RT-PCR was 7 days. The most common initial symptom was fever (64%), and fatigue (58%), cough (44%) and dyspnea (36%). Baseline levels of CRP was 6.43 mg/dL (3.25-11.22). The median lymphocyte count was 785 mm3/uL (550-1230). Baseline D-Dimer was 0.767 ug/ml (0.484-1153.5), ferritin median level was 1011ng/ml (670-2145). Six of the patients died (12%), 4/6 were by sepsis-related multi-organ failure and 2/6 were by ARDS. Conclusions: Major complications such as acute kidney injury, acute respiratory distress syndrome and mortality related to COVID-19 infection observed in our study are lower than those reported in other countries.

Impact of health-related quality of life on pediatric patients who underwent hematopoietic stem cell transplantation in a Colombian institution

Introduction: Hematopoietic stem cell transplantation is the curative option for some diseases and is increasing patient survival. The health-related quality of life in these patients is not systematically evaluated. Objectives: The present study sought to describe the health-related quality of life and complications in children who underwent hematopoietic stem cell transplantation. Materials and methods: A cross-sectional study was conducted on pediatric transplanted survivors. Health-related quality of life was measured using the KIDSCREEN-27 scale and Short Form-12 (SF-12) in patients between 8 and 14 years of age and those over 14 years, respectively. Statistical analysis was performed using STATA 12 software. We used the Rasch model person parameter estimates translated into T-values to score the questionnaire. Results: A total of 42 children answered the questionnaires. The most frequent adverse events were chronic graft Vs. host disease and endocrine complications. According to European norm data in the KIDSCREEN-12 scale, scores for the school dimension and social and peer support were below the 50th. percentile. The group administered immunosuppressants had lower scores on the physical component of the SF-12™ scale. Conclusions: In general, the KIDSCREEN-27 does appear to suggest some quality-of-life deficit in younger children. The scales showed reliability in this population.

Prophylaxis for invasive fungal infection in pediatric patients with allogeneic hematopoietic stem cell transplantation

Background

Antifungal prophylaxis is recommended for hematopoietic stem cell transplantation (HSCT) to decrease the incidence of invasive fungal infections (IFI). This study aimed to compare the two groups of antifungal prophylaxis in pediatric patients undergoing allogeneic HSCT.

Methods

This observational, analytic, retrospective cohort study compared the incidence of IFI with antifungal prophylaxis with voriconazole vs. other antifungals in the first 100 days after allogeneic HSCT in patients aged <18 years between 2012 and 2018. The statistical analysis included univariate and multivariate analyses and determination of the cumulative incidence of invasive fungal infection by the Kaplan‒Meier method using STATA 14 statistical software.

Results

A total of 139 allogeneic HSCT were performed. The principal diagnosis was acute leukemia (63%). The 75% had haploidentical donors, and 50% used an antifungal in the month before transplantation. Voriconazole (69%) was the most frequently administered antifungal prophylaxis. The cumulative incidence of IFI was 5% (7 cases). Of the patients with IFIs, four began prophylaxis with voriconazole, one with caspofungin, and one with fluconazole. Additionally, six were possible cases, one was proven (Candida parapsilosis), and 1/7 died.

Conclusion

There were no differences in the incidence of IFI between patients who received prophylaxis with voriconazole and other antifungal agents.

Renal Tubular Acidosis in the Postpartum Period: A Case Report and Literature Review

Case Presentation. Distal renal tubular acidosis (dRTA) is characterized by impaired hydrogen ion secretion in the distal nephron resulting either from decreased net activity of the proton pump or from increased luminal membrane hydrogen ion permeability. Typical complications of dRTA include severe hypokalemia, normal anion gap metabolic acidosis, nephrolithiasis, and nephrocalcinosis. The patient is a 25-year-old woman in immediate puerperium with hypokalemia leading to paralysis, and the laboratory findings in this patients were concerning for dRTA. It is rare to encounter this entity during pregnancy, and the impact of this pathology is unknown.

Outcomes in pediatrics patients diagnosed with bone marrow failure disorders treated in a tertiary care center

INTRODUCTION

Bone marrow failure (BMF) syndromes are rare disorders with an annual incidence of 2-4 cases per million. Treatment options include immunosuppressive therapy (IST) and hematopoietic stem cell transplantation (HSCT).

OBJECTIVE

To analyze the outcomes of pediatric patients diagnosed with BMF treated in a tertiary care center.

PATIENTS AND METHOD

Retrospective study of pediatric patients diagnosed with BMF who consulted at Fundación Valle de Lili, Cali. Descriptive statistical analysis was performed according to Acquired BMF (ABMF) and Inherited BMF (IBMF). The outcomes include treatment, complications, overall survival (OS) in transplant patients, calculated using the Kaplan Meier method.

RESULTS

We included 24 patients with BMF, average age 6.5 ± 4 years, and 50% were women. 58% presented IBMF, 9 with Fanconi anemia (FA), 2 dyskeratosis congenita, 2 congenital amegakaryocytic thrombocytopenia, and 1 presented Diamond-Blackfan anemia. 12 patients treated with HSCT had a 5-year OS of 83%. ABMF represented 42%. 6 patients received IST-HSCT, 3 received IST, and 1 received HSCT. The OS of the IST-HSCT group was 86%. Six patients died, four of them related to infection.

CONCLUSIONS

In this series, there was a higher number of cases with IBMF. The OS of patients treated with HSCT is similar to that reported in recent studies. The most frequent cause of death was of infectious origin which has also been previously reported. The treatment esta blished in the patients showed favorable results in a Latin American tertiary care center.

Hematopoietic Stem Cell Transplantation in Children with Inborn Errors of Immunity: a Multi-center Experience in Colombia

PURPOSE

To characterize the pediatric population with inborn errors of immunity (IEI) that was treated with hematopoietic stem cell transplantation (HSCT) in three reference centers in Colombia. What have been the characteristics and outcomes of hematopoietic stem cell transplantation in pediatric patients with inborn errors of immunity in three reference care centers in Colombia between 2007 and 2018?

METHODS

We conducted an observational, retrospective cohort study in children with a diagnosis of IEI who underwent HSCT between 2007 and 2018.

RESULTS

Forty-seven patients were identified, and 5 were re-transplanted. Sixty-eight percent were male. The median age at diagnosis was 0.6 years, and for HSCT was 1.4 years. The most common diseases were chronic granulomatous disease (38%) followed by severe combined immune deficiencies (19%) and hemophagocytic lymphohistiocytosis (15%). Cord blood donors were the most used source of HSCT (44%). T cell-replete grafts from haploidentical donors using post-transplantation cyclophosphamide represent 37% of the cohort. All patients received conditioning, 62% with a non-myeloablative regimen. Calcineurin inhibitors were the main graft-versus-host disease prophylaxis (63.8%). Acute graft-versus-host disease developed in 35% of the total patients. The most frequent post-transplant infections were viral and fungal infections. The 1-year overall survival rates for the patients who received HSCT from identical, haploidentical, and cord sources were 80%, 72%, and 63%, respectively. The 5-year overall survival was 63%.

CONCLUSIONS

HSCT is a curative treatment option for some IEI and can be performed with any donor type. Early and timely treatment in referral centers can improve survival.

Haploidentical stem cell transplant with post-transplantation cyclophosphamide and mini-dose methotrexate in children

BACKGROUND

Haploidentical stem cell transplantation (haplo-SCT) is an option for patients without human leukocyte antigen-matched related or unrelated donor. Post-transplantation cyclophosphamide (PTCy) is an effective method of graft versus host disease (GVHD) prophylaxis and permits the use of T-cell replete grafts in settings were ex vivo manipulation is not feasible.

METHODS

A retrospective study among patients younger than 18 years, with a history of hematologic malignancies who underwent haplo-SCT between 2012 and 2016. All patients received a preparative regimen of fludarabine, busulfan, and 400 cGy total body irradiation or melphalan. Post-transplant GvHD prophylaxis consisted either of PTCy (50 mg/kg on Days + 3 and + 4) and cyclosporine (CSA) plus mycophenolate (MMF) (15 mg/kg/dose, thrice daily, per os), or mini-dose methotrexate (MTX; 5 mg/m² dose) on Days + 5, +7, +10, and + 15.

RESULTS

A total of 52 children were included, whose median age was 9 years (interquartile range, 4.9-14; range, 1.2-17 years), and 63% were males. The most common complications were cytomegalovirus reactivation (57%) and hemorrhagic cystitis (36%). The acute GVHD prophylaxis was PTCy, CSA, and mini-dose MTX in 42 (81%) patients, and 10 (19%) patients received PTCy, CSA, and MMF. The cumulative incidence of acute GvHD II-IV, acute GvHD III-IV, and chronic GvHD were 42%, 8.5%, and 19%, respectively. Grades I-IV acute GvHD occurred in 100% of the patients who received prophylaxis with CSA and MMF, and 62% who received CSA and mini-dose MTX (p = .055). The transplant-related mortality at 100 days was 18%. The 5-year overall and event-free survival were 59% and 57%, respectively.

CONCLUSIONS

Haplo-SCT with PT/Cy can be an available, safe, and feasible option for children with hematologic malignancies; meanwhile, the use of mini-dose of MTX was associated with lower rates of acute GVHD. However, our results require further support from prospective randomized studies to improve the efficacy of this prophylactic strategy.

Bacteremia in pediatric patients with hematopoietic stem cell transplantation

BACKGROUND

This study aimed to describe the incidence, microbiological profile, and risk factors associated with bacteremia in pediatric patients with hematopoietic stem cell transplantation (HSCT).

METHODS

A retrospective cohort study was performed on patients under 18 years old who underwent HSCT due to any indication, between January 2012 and January 2017. The patient data were collected from the first 100 days post-HSCT. Bacteremia was defined as the isolation of bacteria from at least one blood culture. The relation between bacteremia and associated risk factors was evaluated using univariate and multivariate analysis.

RESULTS

We enrolled a total of 111 pediatric patients who received HSCT during the period of study. The total number of patients who developed at least one episode of bacteremia was 46 (41.4%), and the total number of bacteremia episodes was 62. Rectal swabs were performed in 44 patients to detect prior colonization and this showed that 25% of them were positive, the main pathogen isolated being carbapenem-resistant enterobacteriaceae. The Gram-negative bacteria cases accounted for 60% of 62 events. The main Gram-negative bacteria isolated were Klebsiella pneumoniae and Escherichia coli and the majority were resistant strains. The mortality rate on day +100 for the whole cohort was 18% (n=20). Regarding the patients with bacteremia, the mortality rate on day +100 was 30% (n=14), and the cause of death was related to infection in 10 of them. We did not find any statistically significant risk factor for the development of bacteremia.

CONCLUSION

Bacteremia is common after HSCT, and there is a high frequency of resistant Gram-negative infections which is related to high mortality.

1734. Antifungal Prophylaxis in Allogeneic Hematopoietic Stem Cell Transplantation: A Single-Center Experience in Colombia

Background

Invasive fungal infections (IFI) are significant causes of morbidity and mortality among patients with hematopoietic stem cell transplantation (HSCT). Primary antifungal prophylaxis has lowered the IFI cases however there is no clear guidance regarding which mold active agent is most useful if mold-active prophylaxis. We aim to present the incidence of IFI in patients with allogeneic HSCT, and the impact of primary antifungal prophylaxis regimen.

Methods

Retrospective cohort study. We included patients older than 18 years, with allogeneic HSCT from Fundación Valle del Lili, between January 2008 and April 2017. The patients received antifungal prophylaxis with fluconazole, itraconazole, or posaconazole from conditioning day to +100 post-transplant day. The prophylactic antifungal agent was selected according to the initial diagnosis, transplant type, conditioning regimen and the risk of developing GVHD. All patients received myeloablative conditioning regimens and were hospitalized in laminar airflow rooms during their period with neutropenia. The cases were defined according to the EORTC/MSG Consensus Group. We analyzed patients with probable or confirmed IFI, in the first 120 post-transplant days.

Results

We enrolled a total of 101 patients who received HSCT over the course of the study. The median age was 32 (23–43). Posaconazole prophylaxis was used in 73%, fluconazole in 18% and itraconazole 10% of the patients. The IFI incidence was 3.9% (4 cases) and the median time from HSCT to the diagnosis of IFI was 60 days. The percentages of patients who experienced probable IFI in the itraconazole arm was 22% (2/9 patients) and in the fluconazole arm 11.1% (2/18), there was no infection in the posaconazole group (P = 0.001). Donor sources were HLA-matched sibling (42%), Haploidentical (48%), and cord blood (10%). The cumulative incidence of grade I–IV aGVHD was 63.4% and that of grade III–IV aGVHD was 37.5%.

Conclusion

In patients undergoing HSCT posaconazole prevented invasive fungal infections more effectively than did either fluconazole or itraconazole.

Disclosures

All authors: No reported disclosures.

Cytomegalovirus disease in patients with hematopoietic stem cell transplantation, experience over 8 years

Objective

Cytomegalovirus infection and disease are significant causes of morbidity and mortality among patients with hematopoietic stem cell transplantation. The aim of this study was to assess the frequency of cytomegalovirus infection and characterize the patients who developed the disease.

Methods

A retrospective cohort study was performed among adult patients, recipients of allogeneic HSTC between 2008 and 2015. Taking into account the institutional protocol of prophylaxis infections in hematopoietic stem cell transplantation, patients received either preemptive therapy or prophylaxis with valganciclovir. Infection was defined as a positive pp65 antigenemia assay or PCR higher than 500 copies/mL. Disease was defined as viremia with evidence of end organ damage.

Results

Seventy patients were included, the median age was 36 years old (IQR 17–62). A total of 93% of the recipients had a positive serology. The Cytomegalovirus infection occurred in 59% of the patients. Eleven patients developed disease (16%), the most frequent manifestation being colitis, followed by pneumonitis and a single case of retinitis. There were no differences between the preemptive therapy or prophylaxis groups. The mean time of onset of the disease was day 94 post-transplant. Three patients developed disease with a viral load lower than 1000 copies/mL.

Conclusion

The incidence of cytomegalovirus infection after transplantation at our institution is high. It was found that the disease can occur with any level of viral load and is associated with high mortality.

1188. Could Chlorehexidine (CHX) Bathing Decrease the Incidence of Carbapenem-Resistant Enterobacteria (CRE) Bacteremia in Previously Colonized CRE Hematopoietic Stem Cell Transplant Recipients (HSCT)?

Background

CRE colonized patients that undergo HSCT have a higher incidence of CRE bacteremia, especially during the initial neutropenic period, with a high mortality rate. This situation is critical in countries highly endemic for CRE such as Colombia. It is necessary to find measures that decrease the occurrence of this infection, permitting a safer transplant. Daily CHX bathing could be effective reducing this risk.

Methods

Since March 2014 in our hospital in Cali, Colombia, all adult patients admitted to the HSCT unit were peri-rectal screened for CRE colonization, and then CHX daily bathing (CHX 4% soap or CHX 2% pads) was used regardless of the screening results. Prospectively all type of microorganism bacteremia were recorded from 2014 to 2017. We compare bacteremia, and CRE bacteremia rates between CRE colonized vs. non-colonized patients. We compared the annual proportion of CRE bacteremia in this two groups. Nonparametrical statistic χ² for trend was used to compare the difference.

Results

We analyzed data collected from 155 patients from July 2014 to June 2017. There were 39.5% females, and the average age was 42 years, 60% were autologous, and 40% were allogeneic. The total of CRE colonized patients was 25/155 (16%), and the overall of bacteremia was 54/155 (34%). All type of microorganism bacteremia and CRE bacteremia were more frequent in CRE Colonized patients. (52% vs. 31% and 24% vs. 3,8%, RR: 6.24, 95% CI 2.06–18.8, P = 0.002). With the increase in compliance with CHX bathing, there was a decreasing trend in CRE bacteremia in the colonized patient, dropping from 50% during 2014, to 14% in 2017 (OR 0.167; P = 0.21).

Conclusion

Daily CHX bathing in the CRE colonized patient reduce the incidence of CRE bacteremia in HSCT patients. We propose this intervention as a significant protective measure in CRE colonized hospitalized patients.

Disclosures

All authors: No reported disclosures.