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Kojima K, Takada J, Kamei M, Kubota M, Ibuka T, Shimizu M. Steroid refractory severe ulcerative colitis after kidney transplantation successfully treated with infliximab. Clin J Gastroenterol 2023; 16:848-853. [PMID: 37715899 DOI: 10.1007/s12328-023-01857-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/03/2023] [Indexed: 09/18/2023]
Abstract
A 54-year-old man underwent kidney transplantation at the age of 50 for end-stage renal failure owing to diabetic nephropathy. The patient was subsequently treated with three immunosuppressive drugs (tacrolimus, mycophenolate mofetil, and methylprednisolone) to prevent organ rejection, and no renal failure was noted. He visited our department with bloody stools and diarrhea, and a colonoscopy revealed mucosal edema and redness of the entire colon. After excluding infection and drug-induced enteritis based on the endoscopic and pathological findings, he was diagnosed with ulcerative colitis (UC). He was admitted and received a high dose of steroids, but did not demonstrate improvement. We initiated infliximab (IFX), and his symptoms improved within 3 days. After the second IFX treatment, the patient achieved clinical remission and was discharged. After the third IFX dose, the biomarker level became normal, and a colonoscopy after the fourth IFX dose revealed that all ulcers had become scarred and achieved endoscopic remission. The patient continued all medications to prevent organ rejection after the onset of UC and had no graft dysfunction or infection for 1 year.
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Affiliation(s)
- Kentaro Kojima
- Department of Gastroenterology and Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan.
| | - Jun Takada
- Department of Gastroenterology and Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Makoto Kamei
- Department of Gastroenterology and Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Masaya Kubota
- Department of Gastroenterology and Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Takashi Ibuka
- Department of Gastroenterology and Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Masahito Shimizu
- Department of Gastroenterology and Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan
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Pandeep K, Rakesh K, Mohitpreet S, Prabhjeet S. Therapeutic plasma exchange as a treatment modality for steroid refractory acute disseminated encephalomyelitis - A case report. Transfus Clin Biol 2023; 30:16-18. [PMID: 36007859 DOI: 10.1016/j.tracli.2022.08.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 02/07/2023]
Abstract
The epidemiology of Dengue fever in the Indian subcontinent has been substantially increased. Acute disseminating encephalomyelitis is a rare complication of dengue and is characterized by multifocal white matter involvement and encephalopathy with neurological deficits. Treatment is usually steroids, IVIG and therapeutic plasma exchange (TPE). We report a case of 46 year old female patient who was a non responder to steroid treatment and successfully treated by TPE.
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Chen J, Lu J, Hong X, Lu Q. Tocilizumab combined with ruxolitinib in the treatment of children with steroid resistant graft versus host disease after hematopoietic stem cell transplantation: report of 6 cases. Zhejiang Da Xue Xue Bao Yi Xue Ban 2022; 51:470-473. [PMID: 37202101 PMCID: PMC10264977 DOI: 10.3724/zdxbyxb-2022-0245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/20/2022] [Indexed: 05/20/2023]
Abstract
Six children with steroid resistant graft versus host disease (GVHD) after hematopoietic stem cell transplantation admitted in the hospital, including 4 cases of acute GVHD and 2 cases of chronic GVHD. Among the 4 acute GVHD cases, the main manifestations were large area rash and fever in 2 cases, and abdominal pain and diarrhea in 2 cases. In 2 chronic GVHD cases, one presented lichenoid dermatosis, and the other showed repeated oral ulcers with difficult mouth opening. Patients received tocilizumab (8 mg/kg per dose every 3 weeks) and ruxolitinib (5-10 mg/d, 28 d), at least 2 courses were completed. All patients had complete responses (100%), and 5 patients responded after completion of two treatment courses, with the median time of remission was 26.7 d. The median follow-up period was 11 (7-25) months, and no severe treatment-related adverse reactions were observed.
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Sud S, Sachdeva S, Puri AS. Tacrolimus as rescue therapy for steroid-dependent/steroid-refractory ulcerative colitis: Experience from tertiary referral center in India. Indian J Gastroenterol 2021; 40:598-603. [PMID: 34971402 DOI: 10.1007/s12664-021-01185-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/19/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Between 20% and 40% of patients with severe ulcerative colitis (UC) are either steroid-refractory UC (SRUC) or steroid-dependent UC (SDUC). Tacrolimus is an oral and relatively inexpensive drug, which has been extensively used in Japan for steroid-refractory and steroid-dependent disease. METHODS Patients diagnosed with SDUC/SRUC were treated with tacrolimus 0.05-0.1 mg/kg in this prospective study. Clinical Mayo score (CMS) and UC Endoscopic Index of Severity (UCEIS) were evaluated prior to starting the drug and subsequently after 8 weeks. 5-Aminosalicylic acid agents (5-ASA) and immunomodulators were continued if the patients were previously on these drugs. Clinical response at 8 weeks was defined as decrease in CMS by at least 3 points. Clinical remission was defined as CMS ≤2 and combined remission as CMS≤2 with UCEIS <3. RESULTS Fifty-two patients (29 males) with a mean age of 35.1± 12.8 years with predominantly E3 disease (71%) were prospectively evaluated in this study. SDUC and SRUC were diagnosed in 31 and 21 patients, respectively. Seven failed treatment within 8 weeks, four were subjected to surgery, and 3 were switched to infliximab. Forty-two patients continued tacrolimus for 8 weeks. Mean CMS and UCEIS prior to starting tacrolimus were 6 ± 1.1 and 4.8 ± 1.1, respectively. At 8 weeks, median CMS and UCEIS decreased to 2.6 ± 1.7 and 2.7 ± 1.3, respectively. Clinical response was documented in 29 patients (56%) at week 8 whereas clinical remission was seen in 25 patients (48%). Combined clinical and endoscopic remissions were seen in 18 patients (35%). Except for a single patient who developed reversible renal dysfunction, no other adverse event was observed. CONCLUSION Our results show that tacrolimus is effective in inducing a clinical response in 56% of patients with SDUC and SRUC. In view of its low cost and safety profile, it may be considered first-line therapy for SDUC/SRUC.
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Affiliation(s)
- Sukrit Sud
- Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, New Delhi 110 002, India. .,Medanta -The Medicity Hospital, Gurugram, 122 006, India.
| | - Sanjeev Sachdeva
- Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, New Delhi 110 002, India.,Medanta -The Medicity Hospital, Gurugram, 122 006, India
| | - Amarender Singh Puri
- Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, New Delhi 110 002, India.,Medanta -The Medicity Hospital, Gurugram, 122 006, India
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Soder RP, Dawn B, Weiss ML, Dunavin N, Weir S, Mitchell J, Li M, Shune L, Singh AK, Ganguly S, Morrison M, Abdelhakim H, Godwin AK, Abhyankar S, McGuirk J. A Phase I Study to Evaluate Two Doses of Wharton's Jelly-Derived Mesenchymal Stromal Cells for the Treatment of De Novo High-Risk or Steroid-Refractory Acute Graft Versus Host Disease. Stem Cell Rev Rep 2021; 16:979-991. [PMID: 32740891 DOI: 10.1007/s12015-020-10015-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Because of their well-described immunosuppressive properties, allogeneic adult human mesenchymal stromal cells (MSC) derived from bone marrow have demonstrated safety and efficacy in steroid refractory acute graft versus host disease (SR aGVHD). Clinical trials have resulted in variable success and an optimal source of MSC has yet to be defined. Based on the importance of maternal-fetal interface immune tolerance, extraembryonic fetal tissues, such as the umbilical cord, may provide an superior tissue source of MSC to mediate immunomodulation in aGVHD. METHODS A two-dose cohort trial allogeneic Wharton's Jelly-derived mesenchymal stromal cells (WJMSC, referred to as MSCTC-0010, here) were tested in 10 patients with de novo high risk (HR) or SR aGVHD post allogeneic hematopoietic stem cell transplantation (allo-HCT). Following Good Manufacturing Practices isolation, expansion and cryostorage, WJMSC were thawed and administered via intravenous infusions on days 0 and 7 at one of two doses (low dose cohort, 2 × 106/kg, n = 5; high dose cohort, 10 × 106/kg, n = 5). To evaluate safety, patients were monitored for infusion related toxicity, Treatment Related Adverse Events (TRAE) til day 42, or ectopic tissue formation at day 90. Clinical responses were monitored at time points up to 180 days post infusion. Serum biomarkers ST2 and REG3α were acquired 1 day prior to first MSCTC-0010 infusion and on day 14. RESULTS Safety was indicated, e.g., no infusion-related toxicity, no development of TRAE, nor ectopic tissue formation in either low or high dose cohort was observed. Clinical response was suggested at day 28: the overall response rate (ORR) was 70%, 4 of 10 patients had a complete response (CR) and 3 had a partial response (PR). By study day 90, the addition of escalated immunosuppressive therapy was necessary in 2 of 9 surviving patients. Day 100 and 180 post infusion survival was 90% and 60%, respectively. Serum biomarker REG3α decreased, particularly in the high dose cohort, and with REG3α decrease correlated with clinical response. CONCLUSIONS Treatment of patients with de novo HR or SR aGVHD with low or high dose MSCTC-0010 was safe: the infusion was well-tolerated, and no TRAEs or ectopic tissue formation was observed. A clinical improvement was seen in about 70% patients, with 4 of 10 showing a complete response that may have been attributable to MSCTC-0010 infusions. These observations indicate safety of two different doses of MSCTC-0010, and suggest that the 10 × 106 cells/ kg dose be tested in an expanded randomized, controlled Phase 2 trial. Graphical abstract.
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Affiliation(s)
- Rupal P Soder
- Midwest Stem Cell Therapy Center, University of Kansas Medical Center, Kansas City, KS, USA
| | - Buddhadeb Dawn
- University of Nevada, Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Mark L Weiss
- Midwest Institute of Comparative Stem Cell Biotechnology and Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, USA
| | - Neil Dunavin
- University of California, San Francisco, CA, USA
| | - Scott Weir
- Institute for Advancing Medical Innovation Medical Center, University of Kansas, Kansas City, USA
| | - James Mitchell
- Midwest Stem Cell Therapy Center, University of Kansas Medical Center, Kansas City, KS, USA
| | - Meizhang Li
- Pathology & Laboratory Medicine, Univeristy of Kansas Medical Center, Kansas City, USA
| | - Leyla Shune
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Anurag K Singh
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Siddhartha Ganguly
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Marc Morrison
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Haitham Abdelhakim
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Andrew K Godwin
- Pathology & Laboratory Medicine, Univeristy of Kansas Medical Center, Kansas City, USA
| | - Sunil Abhyankar
- Midwest Stem Cell Therapy Center, University of Kansas Medical Center, Kansas City, KS, USA
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA
| | - Joseph McGuirk
- Blood and Marrow Transplant Program, Division of Hematologic Malignancies and Cellular Therapeutics, University of Kansas Medical Center, 2330 Shawnee Mission Parkway, Suite 210, Westwood, KS, 66205, USA.
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Lorenz G, Schul L, Schraml F, Riedhammer KM, Einwächter H, Verbeek M, Slotta-Huspenina J, Schmaderer C, Küchle C, Heemann U, Moog P. Adult macrophage activation syndrome-haemophagocytic lymphohistiocytosis: 'of plasma exchange and immunosuppressive escalation strategies' - a single centre reflection. Lupus 2020; 29:324-333. [PMID: 32013725 DOI: 10.1177/0961203320901594] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE In the context of systemic autoimmunity, that is systemic lupus erythematosus (SLE) or adult-onset Still's disease (AOSD), secondary haemophagocytic lymphohistiocytosis (HLH; also referred to as macrophage activation syndrome (MAS) or more recently MAS-HLH) is a rare and potentially life-threatening complication. Pathophysiological hallmarks are aberrant macrophage and T cell hyperactivation and a systemic cytokine flare, which generate a sepsis-like, tissue-damaging, cytopenic phenotype. Unfortunately, for adult MAS-HLH we lack standardized treatment protocols that go beyond high-dose corticosteroids. Consequently, outcome data are scarce on steroid refractory cases. Aside from protocols based on treatment with calcineurin inhibitors, etoposide, cyclophosphamide and anti-IL-1, favourable outcomes have been reported with the use of intravenous immunoglobulin (IvIG) and plasma exchange (PE). METHODS Here we report a retrospective series of steroid refractory MAS-HLH, the associated therapeutic regimes and outcomes. RESULTS In this single-centre experience, 6/8 steroid refractory patients survived (median follow-up: 54.4 (interquartile range: 23.3-113.3) weeks). All were initially treated with PE, which induced partial response in 5/8 patients. Yet, all patients required escalation of immunosuppressive therapies. One case of MAS-HLH in new-onset AOSD had to be escalated to etoposide, whereas most SLE-associated MAS-HLH patients responded well to cyclophosphamide. Relapses occurred in 2/8 cases. CONCLUSION Together, early use of PE is at most a supportive measure, not a promising monotherapy of adult MAS-HLH. In refractory cases, conventional cytoreductive therapies (i.e. cyclophosphamide and etoposide) constitute potent and reliable rescue approaches, whereas IvIG, anti-thymoglobulin, and biologic agents appear to be less effective.
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Affiliation(s)
- G Lorenz
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - L Schul
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - F Schraml
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - K M Riedhammer
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - H Einwächter
- II Medizinische Klinik, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - M Verbeek
- III Medizinische Klinik, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - J Slotta-Huspenina
- Institute of Pathology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - C Schmaderer
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - C Küchle
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - U Heemann
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - P Moog
- Department of Nephrology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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Tang FF, Cheng YF, Xu LP, Zhang XH, Yan CH, Han W, Chen YH, Huang XJ, Wang Y. Basiliximab as Treatment for Steroid-Refractory Acute Graft-versus-Host Disease in Pediatric Patients after Haploidentical Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 26:351-357. [PMID: 31704470 DOI: 10.1016/j.bbmt.2019.10.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 11/25/2022]
Abstract
Basiliximab has been used successfully as a second-line treatment for steroid-refractory (SR) acute graft-versus-host disease (aGVHD) in adult patients after haploidentical hematopoietic stem cell transplant (haplo-HSCT) but has not been studied separately in the pediatric setting. We retrospectively reviewed 100 pediatric patients after haplo-HSCT receiving basiliximab for grades II (57%), III (27%), and IV (16%) SR aGVHD between January 2015 and December 2017. The median number of basiliximab doses was 4 (range, 2 to 9). The day 28 overall response rate was 85%, with complete response in 74% of patients, partial response in 11% of patients, and no response in 15% of patients. The day 28 overall response rates were 94.6% in skin SR aGVHD, 81.6% in gut SR aGVHD, and 66.7% in liver SR aGVHD. Infectious complications included bacterial infection (11%), presumed or documented fungal infections (7%), cytomegalovirus viremia (53%), Epstein-Barr virus viremia (11%), human herpesvirus-6 viremia (7%), and herpes simplex virus viremia (1%). The 3-year overall survival, disease-free survival, nonrelapse mortality, and relapse rates between responders and nonresponders were 81.3% versus 46.7% (P < .001), 79.0% versus 46.7% (P = .001), 6.1% versus 33.3% (P < .001), and 14.9% versus 20.0% (P = .46), respectively. We conclude that basiliximab is an effective second-line agent for pediatric patients with SR aGVHD after haplo-HSCT, particularly for skin SR aGVHD.
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Affiliation(s)
- Fei-Fei Tang
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yi-Fei Cheng
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Lan-Ping Xu
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Hui Zhang
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Chen-Hua Yan
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Wei Han
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Yu-Hong Chen
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
| | - Xiao-Jun Huang
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Yu Wang
- Department of Hematology, Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China; Collaborative Innovation Center of Hematology, Suzhou, China.
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8
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Yu J, Judy JT, Parasuraman S, Sinha M, Weisdorf D. Inpatient Healthcare Resource Utilization, Costs, and Mortality in Adult Patients with Acute Graft-versus-Host Disease, Including Steroid-Refractory or High-Risk Disease, following Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2019; 26:600-605. [PMID: 31678539 DOI: 10.1016/j.bbmt.2019.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 11/29/2022]
Abstract
Acute graft-versus-host disease (GVHD) contributes to poor outcomes following allogeneic hematopoietic cell transplantation (HCT). Data are limited regarding the economic burden of acute GVHD, particularly steroid-refractory or high-risk (SR/HR) disease. This retrospective analysis of the Premier Healthcare Database reports inpatient healthcare resource utilization (HCRU), costs, and mortality during initial hospitalization for allogeneic HCT and through 100 days post-HCT among patients who developed acute GVHD, including a subgroup with SR/HR disease, compared with patients without GVHD. The analysis included adults discharged for first HCT between January 1, 2011, and June 30, 2016 (acute GVHD, n = 906; SR/HR acute GVHD, n = 158; no GVHD, n = 1529). During the initial hospitalization for HCT, patients with acute GVHD and SR/HR acute GVHD (n = 455 and 125, respectively) had significantly longer median lengths of stay (31 and 46 days versus 24 days) and higher median total costs ($153,849 and $205,880 versus $97,417) versus patients with no GVHD (n = 1529; P < .0001 for all). During the 100-day post-HCT period, patients with acute GVHD and SR/HR acute GVHD had higher readmission rates (78.3% and 77.2% versus 28.3%; P < .0001) and inpatient mortality rates (20.2% and 35.4% versus 8.9%; P < .0001) versus patients with no GVHD. In summary, acute GVHD, especially SR/HR disease, is associated with longer inpatient stays, higher readmission rates, and higher inpatient mortality compared with no GVHD.
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Affiliation(s)
- Jingbo Yu
- Incyte Corporation, Wilmington, Delaware.
| | | | | | | | - Daniel Weisdorf
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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Li J, Wei MM, Fei GJ, Feng YL, Yang H, Li Y, Lyu G, Shu HJ, Qian JM. [The efficacy of cyclosporine A as salvage therapy for severe active ulcerative colitis refractory to glucocorticoid]. Zhonghua Nei Ke Za Zhi 2017; 56:279-283. [PMID: 28355721 DOI: 10.3760/cma.j.issn.0578-1426.2017.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To clarify the efficacy and safety of cyclosporine A (CsA) as salvage therapy in patients with severe active ulcerative colitis (UC) and refractory to steroids. Methods: A total of 24 severe active UC patients refractory to steroids and hospitalized from 2006 to 2012, were retrospectively enrolled.Data including demographic features, clinical manifestations, laboratory tests and medications were collected. Results: CsA was effective in 15(62.5%) patients, who did not receive colectomy during 12-week administration. This regimen was tolerable in most patients.Twelve (50.0%) patients reported 16 adverse events, but only one patient withdrew CsA due to intolerance.The rates of adverse events in initial intravenous CsA including 4 mg·kg(-1)·d(-1,) 3 mg·kg(-1)·d(-1) and 2 mg·kg(-1)·d(-1) were 2/2, 9/17 and 1/5 respectively.Responders had higher white blood cell count compared with non-responders (P= 0.045). Conclusions: CsA could be an effective alternative regimen to colectomy in severe active UC patients who are refractory to steroids.
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Affiliation(s)
- J Li
- Department of Gastroenterology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100730, China
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Mohammadi S, Malek Mohammadi A, Norooznezhad AH, Heshmati F, Alimoghaddam K, Ghavamzadeh A. Extra corporeal photochemotherapy in steroid refractory graft versus host disease: A review of guidelines and recommendations. Transfus Apher Sci 2017; 56:376-384. [PMID: 28359604 DOI: 10.1016/j.transci.2017.01.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 12/04/2016] [Accepted: 01/29/2017] [Indexed: 12/18/2022]
Abstract
Regardless of remarkable progresses in prevention and treatment approaches, graft versus host disease (GVHD) remains a major impediment for successful allogeneic hematopoietic stem cells transplantation (HSCT) and leads to morbidity and mortality in transplanted patients. Corticosteroids are the standard therapy for GVHD; however, a great number of patients will not respond sufficiently and others will be significantly affected by adverse effects of steroids. Extracorporeal photochemotherapy (ECP), as one of the numerous second line therapies, through modulation of immune cells may improves GVHD affected organ function in steroid-refractory forms. Considering to widespread utilization of ECP as a therapeutic strategy, we performed review on current literature of ECP, regarding the treatment strategies, monitoring protocols and technical aspects in chronic and acute GVHD.
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Affiliation(s)
- Saeed Mohammadi
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ashraf Malek Mohammadi
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Norooznezhad
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Kamran Alimoghaddam
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ardeshir Ghavamzadeh
- Hematology, Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Fløisand Y, Lundin KEA, Lazarevic V, Kristiansen JD, Osnes LTN, Tjønnfjord GE, Reims HM, Gedde-Dahl T. Targeting Integrin α4β7 in Steroid-Refractory Intestinal Graft-versus-Host Disease. Biol Blood Marrow Transplant 2016; 23:172-175. [PMID: 27777142 DOI: 10.1016/j.bbmt.2016.10.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022]
Abstract
Steroid refractory acute graft-versus-host-disease of the gut is a serious complication associated with high mortality after allogeneic stem cell transplantation. Treatment options are limited and not predictably effective. We describe the treatment of steroid-refractory acute graft-versus-host-disease with vedolizumab, an antibody directed against integrin α4β7, in 6 patients. All patients responded, and 4 of 6 patients are alive with a median follow-up of 10 months.
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Affiliation(s)
- Yngvar Fløisand
- Department of Hematology, Oslo University Hospital, Rikshospitalet, Oslo, Norway.
| | - Knut E A Lundin
- Department of Hematology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Gastroenterology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Centre for Immune Regulation, University of Oslo, Oslo, Norway
| | - Vladimir Lazarevic
- Department of Hematology and Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Liv T N Osnes
- Department of Immunology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Geir E Tjønnfjord
- Department of Hematology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Henrik Mikael Reims
- Department of Pathology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Tobias Gedde-Dahl
- Department of Hematology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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van Groningen LFJ, Liefferink AM, de Haan AFJ, Schaap NPM, Donnelly JP, Blijlevens NMA, van der Velden WJFM. Combination Therapy with Inolimomab and Etanercept for Severe Steroid-Refractory Acute Graft-versus-Host Disease. Biol Blood Marrow Transplant 2015; 22:179-82. [PMID: 26386320 DOI: 10.1016/j.bbmt.2015.08.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 08/31/2015] [Indexed: 11/26/2022]
Abstract
Steroid-refractory acute graft-versus-host disease (aGVHD) remains an important cause of morbidity and mortality after allogeneic stem cell transplantation (SCT). A protocol on the management of aGVHD was introduced in our center that incorporated a prospective study on combination therapy with inolimomab (anti-IL-2Rα) and etanercept (anti-tumor necrosis factor-α) for steroid-refractory aGVHD. We evaluated the efficacy and safety in 21 consecutively treated patients. The patients had developed refractory aGVHD after SCT (n = 16) or donor lymphocyte infusion (n = 5), and aGVHD was classified as severe in all patients, mostly due to gastrointestinal involvement stages 2 to 4. No drug-related side effects were observed apart from the infections expected to occur in these severely immunocompromised patients. Overall response at day 28 of second-line therapy was 48% (10/21), with 6 and 4 patients achieving a complete and partial response, respectively. Eventually, 19 patients died (90%), with early mortality (<6 months) predominantly resulting from refractory aGVHD and secondary infections and late mortality resulting from relapse of the underlying disease. With a median follow-up of 55 days, the estimated rates of 6-month and 2-year overall survival were dismal, 29% and 10%, respectively. In conclusion, the combination of inolimomab and etanercept for steroid-refractory aGVHD failed to improve the dismal prognosis of severe steroid-refractory aGVHD.
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Affiliation(s)
- Lenneke F J van Groningen
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Aleida M Liefferink
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anton F J de Haan
- Department for Health Evidence, Biostatistics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nicolaas P M Schaap
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - J Peter Donnelly
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nicole M A Blijlevens
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Walter J F M van der Velden
- Department of Hematology, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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Seagrove AC, Alam MF, Alrubaiy L, Cheung WY, Clement C, Cohen D, Grey M, Hilton M, Hutchings H, Morgan J, Rapport F, Roberts SE, Russell D, Russell I, Thomas L, Thorne K, Watkins A, Williams JG. Randomised controlled trial. Comparison Of iNfliximab and ciclosporin in STeroid Resistant Ulcerative Colitis: Trial design and protocol (CONSTRUCT). BMJ Open 2014; 4:e005091. [PMID: 24785401 PMCID: PMC4010821 DOI: 10.1136/bmjopen-2014-005091] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 03/14/2014] [Accepted: 03/17/2014] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Many patients with ulcerative colitis (UC) present with acute exacerbations needing hospital admission. Treatment includes intravenous steroids but up to 40% of patients do not respond and require emergency colectomy. Mortality following emergency colectomy has fallen, but 10% of patients still die within 3 months of surgery. Infliximab and ciclosporin, both immunosuppressive drugs, offer hope for treating steroid-resistant UC as there is evidence of their short-term effectiveness. As there is little long-term evidence, this pragmatic randomised trial, known as Comparison Of iNfliximab and ciclosporin in STeroid Resistant Ulcerative Colitis: a Trial (CONSTRUCT), aims to compare the clinical and cost-effectiveness of infliximab and ciclosporin for steroid-resistant UC. METHODS AND ANALYSIS Between May 2010 and February 2013, 52 UK centres recruited 270 patients admitted with acute severe UC who failed to respond to intravenous steroids but did not need surgery. We allocated them at random in equal proportions between infliximab and ciclosporin.The primary clinical outcome measure is quality-adjusted survival, that is survival weighted by Crohn's and Colitis Questionnaire (CCQ) participants' scores, analysed by Cox regression. Secondary outcome measures include: the CCQ-an extension of the validated but community-focused UK Inflammatory Bowel Disease Questionnaire (IBDQ) to include patients with acute severe colitis and stoma; two general quality of life measures-EQ-5D and SF-12; mortality; survival weighted by EQ-5D; emergency and planned colectomies; readmissions; incidence of adverse events including malignancies, serious infections and renal disorders; disease activity; National Health Service (NHS) costs and patient-borne costs. Interviews investigate participants' views on therapies for acute severe UC and healthcare professionals' views on the two drugs and their administration. ETHICS AND DISSEMINATION The Research Ethics Committee for Wales has given ethical approval (Ref. 08/MRE09/42); each participating Trust or Health Board has given NHS Reseach & Development approval. We plan to present trial findings at international and national conferences and publish in high-impact peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN 22663589; EudraCT number: 2008-001968-36.
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Affiliation(s)
- Anne C Seagrove
- College of Medicine, Swansea University, Singleton Park, Swansea, UK
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14
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Kurtzberg J, Prockop S, Teira P, Bittencourt H, Lewis V, Chan KW, Horn B, Yu L, Talano JA, Nemecek E, Mills CR, Chaudhury S. Allogeneic human mesenchymal stem cell therapy (remestemcel-L, Prochymal) as a rescue agent for severe refractory acute graft-versus-host disease in pediatric patients. Biol Blood Marrow Transplant 2013; 20:229-35. [PMID: 24216185 DOI: 10.1016/j.bbmt.2013.11.001] [Citation(s) in RCA: 158] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 11/01/2013] [Indexed: 12/31/2022]
Abstract
Severe steroid-refractory acute graft-versus-host disease (aGVHD) is related to significant mortality and morbidity after allogeneic stem cell transplantation. Early clinical trials of therapy with human mesenchymal stem cells (hMSCs) in pediatric patients with severe aGVHD resistant to multiple immunosuppressive agents showed promising results. In this study, we evaluated the risk/benefit profile of remestemcel-L (Prochymal), a third-party, off-the-shelf source of hMSCs, as a rescue agent for treatment-resistant aGVHD in pediatric patients. Children with grade B-D aGVHD failing steroids and, in most cases, other immunosuppressive agents were eligible for enrollment. Patients received 8 biweekly i.v. infusions of 2 × 10(6) hMSCs/kg for 4 weeks, with an additional 4 weekly infusions after day +28 for patients who achieved either a partial or mixed response. The enrolled patients compose a very challenging population with severe disease that was nonresponsive to the standard of care, with 88% of the patients experiencing severe aGVHD (grade C or D). Seventy-five patients (median age, 8 yr; 58.7% male; and 61.3% Caucasian) were treated in this study. Sixty-four patients (85.3%) had received an unrelated hematopoietic stem cell graft, and 28 patients (37.3%) had received a cord blood graft. At baseline, the distribution of aGVHD grades B, C, and D was 12.0%, 28.0%, and 60.0%, respectively. The median duration of aGVHD before enrollment was 30 d (range, 2 to 1639 d), and patients failed a median of 3 immunosuppressive agents. Organ involvement at baseline was 86.7% gastrointestinal, 54.7% skin, and 36.0% liver. Thirty-six patients (48.0%) had 2 organs involved, and 11 patients (14.7%) had all 3 organs involved. When stratified by aGVHD grade at baseline, the rate of overall response (complete and partial response) at day +28 was 66.7% for aGVHD grade B, 76.2% for grade C, and 53.3% for grade D. Overall response for individual organs at day +28 was 58.5% for the gastrointestinal system, 75.6% for skin, and 44.4% for liver. Collectively, overall response at day +28 for patients treated for severe refractory aGVHD was 61.3%, and this response was correlated with statistically significant improved survival at day +100 after hMSC infusion. Patients who responded to therapy by day +28 had a higher Kaplan-Meier estimated probability of 100-d survival compared with patients who did not respond (78.1% versus 31.0%; P < .001). Prochymal infusions were generally well tolerated, with no evidence of ectopic tissue formation.
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Affiliation(s)
- Joanne Kurtzberg
- Pediatric Blood and Bone Marrow Transplant Program, Duke University Medical Center, Durham, North Carolina
| | - Susan Prockop
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Pierre Teira
- Hematology-Oncology Division, Charles Bruneau Cancer Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Henrique Bittencourt
- Hematology-Oncology Division, Charles Bruneau Cancer Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Victor Lewis
- Pediatric Oncology, Blood and Marrow Transplantation, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Ka Wah Chan
- Pediatric Blood and Marrow Transplant Program, Texas Transplant Institute, Methodist Children's Hospital of South Texas, San Antonio, Texas
| | - Biljana Horn
- Blood and Marrow Transplant Program, Benioff Children's Hospital, University of California, San Francisco, California
| | - Lolie Yu
- Bone Marrow Transplant Program, Children's Hospital, Louisiana State University Health Science Center, New Orleans, Louisiana
| | - Julie-An Talano
- Department of Pediatric Hematology Oncology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Eneida Nemecek
- Pediatric BMT Program, Oregon Health & Science University, Portland, Oregon
| | | | - Sonali Chaudhury
- Division of Pediatric Hematology, Oncology, Stem Cell Transplantation, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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