Hemorrhagic Cystitis in Haploidentical Hematopoietic STEM CELL Trasplant: Retrospective Study and Comparison with a NON-Haploidentical DONOR Transplant Group

Abstract Introduction HLA-haploidentical hematopoietic stem cell transplant (Haplo HSCT) is a potentially curative strategy for patients lacking a HLA matched donor or a suitable unrelated donor. The use of post-transplant Cyclophosphamide (Cy) for GVHD prophylaxis and the particular characteristics of Haplo-HSCT can be linked to a higher risk of hemorrhagic cystitis (HC) and viral infections. In this context, our aim was to analyze HC in both haploidentical and conventional donor transplants in our center. Material and Methods We retrospective analyzed of 237 patients who received an HSCT in our center, between August-2012 and January-2016. We analyze the incidence of HC in the early post-HSCT period (6 months) and its characteristics in those patients receiving Haplo (n=36, 15%) and we compared it with a non-haploidentical donor transplant group from the same period (n=201, 85%). Results Patients' characteristics are summarized in table 1. Both groups are balanced, except for diagnosis due to the high proportion of Hodgkin lymphoma in Haplo group, conditioning regimen, and GVHD grade III-IV with a lower incidence in Haplo. Conditioning regimen in Haplo consisted of Fludarabine (30mg/m2x or 50mg/kg x 4days in RIC or MA regimen) and Busulfan (3.2 mg/kg x 2 in RIC or 3 days in MA). Post-HSCT Cy was used for GVHD prophylaxis in 94%. Median of days to reach more than 500x10^9 granulocytes and more than 20x10^9 platelets in Haplo group were 18 (13-30) and 23 (0-103) respectively. Hemorrhagic cystitis: Incidence of HC was 33% vs. 13% in conventional HSCT (p=0.03). Infectious etiology was documented in 84% of the Haplo recipients and 89% in conventional HSCT (p=0.87). In Haplo, HC was caused by BK/JC polyomavirus in 67% and adenovirus in 17%. Among conventional HSCT recipients, BK/JC was documented in 75% and adenovirus in 14% of HC. Viral infection was diagnosed by positive PCR in urine. HC appeared at a median of 65 days post-HSCT (5-557), without differences between Haplo and non-Haplo: 61 (5-423) vs. 67 (8-557). Treatment of HC consisted of hyper-hydration and spasmolytic drugs in 19 patients. Intravesical cidofovir was used in 7 and intravenous cidofovir was needed in 2 cases. Receiving an Haplo HSCT was associated with a higher risk of developing HC [OR 3.5 (95% CI 1.56-7.91); p=0.002]. We did not observed association between HC and conditioning regimen (p=0.18), receiving ATG (p=0.45) or presence of acute GVHD grade I-II (p=0.75) or grade III-IV (p=0.46). Haplo donor was the only variable with significant impact in multivariate analysis. Conclusions Incidence of HC is higher in Haplo HSCT, being viral infections and not Cy toxicity, the main cause (polyomavirus BK/JC as the first cause). Table 1 Table 1. Disclosures Mateos: Janssen, Celgene, Amgen, Takeda, BMS: Honoraria.

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Age-Adjusted Recipient Pre-Transplant Telomere Length and Treatment Related Mortality After Hematopoietic Stem Cell Transplantation

Blood ◽

10.1182/blood.v118.21.490.490 ◽

2011 ◽

Vol 118 (21) ◽

pp. 490-490

Author(s):

Régis Peffault de Latour ◽

Rodrigo T. Calado ◽

Marc Busson ◽

Jeffrey Abrams ◽

Marie Robin ◽

...

Keyword(s):

Stem Cell ◽

Telomere Length ◽

Hematopoietic Stem Cell ◽

Chronic Gvhd ◽

Conditioning Regimen ◽

Control Group ◽

Transplant Recipients ◽

Hematopoietic Stem ◽

Gvhd Prophylaxis ◽

Related Mortality

Abstract Abstract 490 Telomeres are highly conserved protective terminal chromosomal structures consisting of hundreds of repeated TTAGGG hexamers and associated shelterin proteins. Telomeres shorten with every cell cycle, and telomere attrition has a fundamental role in cell senescence. Telomeres of leukocytes are shorter in transplant recipients than in their donors. Dyskeratosis congenita, a congenital aplastic anemia caused by mutations in the telomerase complex genes, is associated with treatment related mortality (TRM) after hematopoietic stem cell transplantation (HSCT). We hypothesized that age-adjusted pre-transplant telomere length might generally predict TRM after HSCT. Between 2000 and 2005, 178 consecutive patients underwent HSCT from HLA-identical sibling donor after myeloablative conditioning regimen (including TBI in 57 patients), mainly for hematological malignancies (n= 153) in our center. The stem cell source was bone marrow (BM) in 128 cases and peripheral blood (PB) in 50 cases. Median age at transplant was 32 years (range 3–65). Graft-versus-host disease (GvHD) prophylaxis mostly consisted of cyclosporine and methotrexate (n=149, 84%). Before HSCT, blood lymphocytes were obtained from each of the donor-recipient pair. Telomere length was assessed by real time quantitative PCR. We first determined the normal age distribution of telomere length using a group of 173 healthy French hematopoietic stem cell donors (f=-0.00833*age+1.522) as a control group. We then calculated the pre-transplant recipient age-adjusted telomere length in comparison to controls. After age adjustment, we categorized the population in quartiles (shortest telomeres for quartile 1) and analyzed the outcome post HSCT using competing risk in univariate and multivariate analyses (Fine and Gray). The mean telomere length in transplant recipients (1.05) was shorter than in the control group (1.23, p= 0.0001). After age-adjustment, patients' distribution was similar among all four quartiles except for disease severity (more high risk disease was present among patients with the shortest telomeres). The median follow-up was 51 months (range, 1 – 121 months). All patients engrafted. The median time to achieve absolute neutrophils count >500/ul was 18 days (range 4–45) and median time to platelet count >20.000/ul was 17 days (range 7–58). Cumulative incidence (CI) of acute GvHD grade II-IV was 45% (95% confidence interval [95CI] 37%–53%) and of chronic GvHD was 41% at 36 months (95CI 33%–49%). Thirty-four patients relapsed: CI: 22% at 5 years (95CI 16%–28%). There was no correlation between telomere length and engraftment, acute or chronic GvHD or relapse. The overall survival was 62% at 5 years (95CI 54%–70%). During the study, 37 patients died due to TRM. TRM rate inversely correlated with telomere length. In the first quartile, the 5-year CI of TRM was 33% (95CI 2%–22%), 20% (95CI, 8%–32%) in the second quartile; 20% (95CI, 8%–32%) in the third quartile; and 12% in the fourth quartile (95CI, 2%–22%) (p=0.06). When quartiles 2, 3 and 4 were pooled, the increased TRM in first quartile was statistically significant (p = 0.017) (Figure 1). In multivariate analysis using competing risk regression, (including age-adjusted telomeres length, disease stage, age, TBI and source of stem cells), age of the recipients (HR: 1.1, 95% CI [.0–1.1, p=0.0001] and age-adjusted telomeres [HR: 0.4, 95% CI [0.2–0.8, p=0.01]) were independently associated with TRM. The same two factors remained significant in subset analysis of patients with malignant diseases (n=154) (p= 0.0004, HR: 1.1 and p=0.018, HR: 0.43, respectively). No association was found between donor telomere length and outcome post HSCT. In conclusion, age-adjusted recipient pre-transplant telomere length is an independent biological marker of TRM after HSCT from related donors using a myeloablative conditioning regimen and cyclosporine-based GvHD prophylaxis. Disclosures: Peffault de Latour: Alexion: Consultancy, Research Funding.

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Aetiology of hemorrhagic cystitis after allogeneic hematopoietic stem cell transplantation

Clinical Microbiology and Antimicrobial Chemotherapy ◽

10.36488/cmac.2018.3.232-238 ◽

2018 ◽

Vol 20 (3) ◽

pp. 232-238

Author(s):

Vera A. Vasilieva ◽

E.N. Parovichnikova ◽

M.Yu. Drokov ◽

L.A. Kuzmina ◽

Galina A. Klyasova ◽

...

Keyword(s):

Stem Cell ◽

Hematopoietic Stem Cell Transplantation ◽

Stem Cell Transplantation ◽

Cell Transplantation ◽

Hematopoietic Stem Cell ◽

Clinical Symptoms ◽

Hemorrhagic Cystitis ◽

Conditioning Regimen ◽

Hematopoietic Stem ◽

Viral Aetiology

Incidence, severity, and risk factors for hemorrhagic cystitis (HC) were assessed in 267 patients undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). HC was diagnosed in 14.6% (39 patients) within 1-139 days after allo-HSCT (median duration – 39 days). Chemotherapy-related HC was diagnosed in 4 patients only. The majority (19⁄35) of patients developed late HC of viral aetiology. Median time from a day of HC diagnosis to clinical symptoms resolution was 25 days (range: 6 to 133 days). Using a multivariate analysis, allo-HSCT from mismatched unrelated/haploidentical donor was found to be a risk factor of HC (р=0.01). The analysis also showed that 82.1% of patients with HC received cyclophosphamide as a part of conditioning regimen or +3/+4 days after allo-HSCT.

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The association of conditioning regimen with cytomegalovirus reactivation after allogeneic hematopoietic stem cell transplantation

Iranian Journal of Microbiology ◽

10.18502/ijm.v12i6.5040 ◽

2020 ◽

Author(s):

Masoud Mardani ◽

Sara Abolghasemi ◽

Shiva Shabani ◽

Farzaneh Tavakoli ◽

Anahita Saeedi ◽

...

Keyword(s):

Stem Cell ◽

Hematopoietic Stem Cell Transplantation ◽

Stem Cell Transplantation ◽

Cell Transplantation ◽

Hematopoietic Stem Cell ◽

Viral Infections ◽

Opportunistic Infections ◽

Conditioning Regimen ◽

Hematopoietic Stem ◽

Cmv Reactivation

Background and Objectives: Infections is yet one of the life-threatening complications of the hematopoietic stem cell transplantation (HSCT). The myeloablative and immunosuppressive conditioning regimens, which are administered before HSCT, dampen the defense capacity of the recipients’ immune systems. In this condition, opportunistic infections, especially viral infections such as cytomegalovirus (CMV) can be reactivated and cause morbidity and mortality in HSCT patients. Here, we aimed to find out any possible relationship between types of conditioning regimen and CMV reactivation in allo- geneic HSCT patients. Materials and Methods: We retrospectively analyzed the data of 145 CMV-seropositive cases out of total 201 allo-HSCT patients, including age, gender, underlying disease, conditioning regimen, prophylaxis regimen and occurrence of acute graft-versus-host disease (aGVHD) to evaluate their roles in CMV reactivation. Results: Our result showed that conditioning regimen containing Busulfan and Fludarabine (P=0.003) or Cyclophospha- mide (P=0.02) significantly decrease the early CMV reactivation. Patients who developed aGVHD (P=0.003) and those who received anti-thymocyte globulin (ATG) as prophylaxis regimen (P=0.002), had 1.84 and 2.63 times higher risks of CMV reactivation, respectively. Conclusion: Our findings suggest the conditioning regimen, aGVHD and ATG as influencing factors for early CMV reacti- vation post-HSCT which should be considered in the future studies.

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Masp-2 Levels Following Allogeneic Hematopoietic Stem Cell Transplantation in Adults: Correlation with Development of a Thrombotic Microangiopathy and Implications for Therapy with Anti-Complement Agents

Blood ◽

10.1182/blood-2019-130919 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3305-3305

Author(s):

Jeffrey Laurence ◽

Koen Van Besien ◽

Jasimuddin Ahamed ◽

Sonia Elhadad

Keyword(s):

Stem Cell ◽

Hematopoietic Stem Cell ◽

Complement Activation ◽

Thrombotic Microangiopathy ◽

Conditioning Regimen ◽

Clinical Manifestations ◽

Hematopoietic Stem ◽

Post Transplant ◽

Gvhd Prophylaxis ◽

The Impact

Introduction: 8500 adult allogeneic hematopoietic stem cell transplants (alloHSCT) are performed annually in the U.S. and 17,000 in Europe. HSCT-associated thrombotic microangiopathy (TMA), defined by thrombocytopenia, microangiopathic hemolytic anemia, and organ dysfunction in the absence of disseminated intravascular coagulation, complicates some 20% of these procedures. About half of post-alloHSCT TMAs may resolve when GvHD immunoprophylaxis is modified, but three year survival rates for those with severe HSCT-TMAs are a dismal 11%. Clinical manifestations are similar to other TMAs, but their pathophysiology may be distinct. Damage to vascular endothelium, independent of loss of ADAMTS13 activity, is thought to be critical. Fibrin-rich microthrombi, often accompanied by C4d and C5b-9 (membrane attack complex) deposition, occur in the microvasculature of multiple organs (Clin Adv Hematol Oncol 2014;12:565-573; Transplantation. 2013;96:217-223). This supports a role for complement activation in HSCT-TMA, but the importance of the various complement activation pathways is unclear. Recently, narsoplimab (OMS721), a monoclonal antibody inhibitor of MBL-associated serine protease-2 (MASP-2), a principal component of lectin-dependent complement activation, received Breakthrough Therapy Designation for HSCT-TMA, based on improved survival compared to historical controls in a phase 2 study. A phase 3 program is ongoing. Chemotherapy in association with autologous HSCT is linked to a marked increase in serum MASP-2 levels, persisting for about 4 weeks post-transplant (Front Immunol 2018;9:2153). However, TMAs are rare in autologous transplants, and circulating levels of MASP-2 following alloHSCT, and the impact of TMA development on those levels, are unknown. Methods: All individuals >18 years of age scheduled to undergo alloHSCT for hematologic malignancy at New York Presbyterian Hospital-Cornell were approached to participate in this study (NCT02604420). 100 of the first 101 subjects, age 58.3 +14 yrs, were enrolled and followed for >1.5 years post-transplant. This interval is consistent with the median time to HSCT-TMA diagnosis in adults of 90 days (range 32-733 days). Plasma was obtained at baseline (defined as between the time of consent and beginning of conditioning regimen), and at each regularly scheduled visit post-transplant-day 28 +5 days; day 100 +28 days; day 180 +28 days; and day 365 +28 days-as well as at the time of TMA diagnosis, based on the Consensus Criteria of Cho et al. (Transplantation 2010;90:918-926). A commercial ELISA (MyBioSource) was used to assess MASP-2 concentrations. Results: 20 subjects met study criteria for a HSCT-TMA diagnosis, occurring a median of 69 days (range 33-289) post-transplant. Three resolved following discontinuation of GvHD prophylaxis (mTOR or calcineurin inhibitor) and switch to mycophenolate and increased corticosteroid doses, and 7 had an intercurrent infection, 6 of whom expired with ongoing severe TMA despite a change in GvHD prophylaxis (Figure). TMAs persisted in the remaining 10 subjects. Median MASP-2 levels were significantly elevated in all subjects post-transplant, assessed at the time of TMA development or, in those not developing a TMA, at day 100 + 28 days post-transplant vs. controls (n=36, 86.2ng/ml (23.3-210.9): persistent TMA (n=9 (one plasma unavailable), 154ng/ml (range 82-209)); alloHSCT subjects who did not experience a TMA (n=40 evaluated to date, 113.5ng/ml (56-430.3)). (Figure). Lack of a significant rise in MASP-2 levels in patients with persistent TMAs vs. those who did not develop a TMA, combined with a significant decrease in variance of MASP-2 levels in the former group (p=0.005), may reflect consumption of product at sites of disease activity, i.e., the microvasculature. Conclusions: There is a significant increase in MASP-2 levels, with a wide variance, in post-alloHSCT patients evaluated at a time post-transplant typical of HSCT-TMA development. At time of development of a HSCT-TMA that persists despite withdrawal of GvHD prophylaxis, MASP-2 levels remain elevated over controls, but with a significantly lower variance vs. those not developing TMA. A study of additional samples, including longitudinal specimens, from this cohort is underway to determine if a change in MASP-2 levels correlates with HSCT-TMA development post-alloHSCT. Disclosures Van Besien: Miltenyi Biotec: Research Funding.

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Hematopoietic Stem Cell Therapy In Eight Patients with Metachromatic Leukodystrophy – Relevance of Post-Transplant Medication.

Blood ◽

10.1182/blood.v116.21.3727.3727 ◽

2010 ◽

Vol 116 (21) ◽

pp. 3727-3727

Author(s):

Judith Böhringer ◽

Birgit Kustermann-Kuhn ◽

Friederike Gieseke ◽

Annika Erbacher ◽

Michaela Döring ◽

...

Keyword(s):

Gene Therapy ◽

Stem Cell ◽

Hematopoietic Stem Cell ◽

Metachromatic Leukodystrophy ◽

Chronic Gvhd ◽

Conditioning Regimen ◽

Unrelated Donor ◽

Hematopoietic Stem ◽

Post Transplant ◽

Gvhd Prophylaxis

Abstract Abstract 3727 The lysosomal storage disease metachromatic leukodystrophy (MLD) is caused by mutations in the arylsulfatase A (ASA) gene leading to demyelination in the central nervous system (CNS). Children often present impaired motor skills and progress to an inability to walk, paresis and cognitive deterioration. Therapeutic options are limited and currently focus on enzyme replacement, gene therapy and hematopoietic stem cell transplantation (HSCT). Both, gene therapy and HSCT aim to establish a continuous endogenous supply of ASA, which can be taken up by somatic cells of the recipient to correct their own lysosomal metabolism. We analyzed 8 patients with MLD, who underwent HSCT between 7 months and 15 years of age, regarding toxicity of a reduced intensity condition regimen and GvHD prophylaxis. The mean follow up was 2.8 years (range 8 months to 9.5 years). All patients received conditioning with treosulfan (3 × 14 g/m2), fludarabin (4 × 40 mg/m2) and thiotepa (10 mg/kg). Six patients received bone marrow from a 10/10 matched unrelated donor, one patient from her brother and one patient with late infantile MLD was transplanted from her haploidentical mother. Patients received a mean dose of 7.74 × 106 CD34+ cells/kg BW and engrafted at day 12 (range d11 to d22) with permanent full donor chimerism. Organ toxicity reached mucositis grade III and skin grade I. Three patients developed transient acute graft-versus-host disease (GvHD) of the skin grade II, which responded well to steroids. There was no case of transplant-related mortality and no chronic GvHD. The relative ASA activity in peripheral blood mononuclear cells (PBMCs) pre-transplantation was between 0 and 0.11 A514nm/106 cells and after transplantation between 0.52 and 2.24 A514nm/106 cells. Patients who were asymptomatic prior to transplantation stayed asymptomatic, but those who presented with neurological symptoms showed various degrees of progression. As the conditioning regimen showed no immediate neurotoxicity, we asked if other drugs may account for the disease progression early after transplantation. Cyclosporine A (CsA) is commonly used as post-transplant GvHD prophylaxis and is known for neurotoxic side effects. Thus, we analyzed effects of CsA on the activity of ASA in comparison to tacrolimus or mycophenolic acid (MPA). PBMCs were cultured with and without 75 or 150 ng/ml CsA (pharmacological level) for 8 days. During this time period, the ASA activity decreased to 70% of the activity of PBMC without CsA treatment. By contrast, the ASA activity of PBMCs did not decrease under treatment with pharmacological levels of tacrolimus (7,5 or 15 ng/ml) and MPA (3 or 7,5 μg/ml). Cell viability and metabolic activity were comparable in the presence of CsA and tacrolismus as assessed by MTS assays. This implies that the decrease of the ASA activity was not due to direct cell toxicity of CsA. Taken together, the conditioning regimen was well tolerated with low toxicity and good engraftment. HSCT is an option for treatment of asymptomatic MLD patients, whereas further studies are needed to identify symptomatic patients who may still benefit from the procedure. Here, the choice of GvHD prophylaxis may be an important factor. In vitro data suggested that CsA should be reconsidered with regimens including tacrolimus or mycophenolate mofetil as an alternative. Disclosures: No relevant conflicts of interest to declare.

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TLR4 Asp299Gly Variant Confers Strong Protection against BK Virus-Associated Hemorrhagic Cystitis After Hematopoietic Stem Cell Transplantation in Children.

Blood ◽

10.1182/blood.v114.22.344.344 ◽

2009 ◽

Vol 114 (22) ◽

pp. 344-344 ◽

Cited By ~ 1

Author(s):

Bernd Gruhn ◽

Norman Kloeppner ◽

Nadine Pfaffendorf ◽

Ilona Wolff ◽

Daniel Steinbach ◽

...

Keyword(s):

Stem Cell ◽

Hematopoietic Stem Cell Transplantation ◽

Stem Cell Transplantation ◽

Cell Transplantation ◽

Hematopoietic Stem Cell ◽

Myeloid Leukemia ◽

Hemorrhagic Cystitis ◽

Conditioning Regimen ◽

Bk Virus ◽

Hematopoietic Stem

Abstract Abstract 344 Hemorrhagic cystitis is a serious complication after hematopoietic stem cell transplantation (HSCT). The pathogenesis of hemorrhagic cystitis is not fully understood and is influenced by BK virus infection, type of transplant, conditioning regimen, stem cell source, and graft-versus-host disease. Nothing is known about human genetic factors and the development of BK virus-associated hemorrhagic cystitis in patients after HSCT. Toll-like receptors (TLR) are essential components of the innate immune system. TLR have been discovered as the most important class of pattern recognition receptors, involved in the host defense against bacteria, viruses, fungi, and protozoa. C3H/HeJ mice that lack functional TLR4 receptors did not develop cystitis after intravesical instillation of E. coli. Individuals with the Asp299Gly polymorphism of the TLR4 gene showed a diminished inflammatory responsiveness to endotoxin. Because of the requirement of TLR4 in inflammatory response we hypothesized that TLR4 Asp299Gly reduces the risk of BK virus-associated hemorrhagic cystitis after hematopoietic stem cell transplantation (HSCT). 166 children (median age, 13 years) with acute lymphoblastic leukemia (n=72), acute myeloid leukemia (n=38), myelodysplastic syndrome (n=21), chronic myeloid leukemia (n=12), genetic disease (n=12) or severe aplastic anemia (n=11) who underwent allogeneic bone marrow (n=105) or peripheral blood stem cell transplantation (n=61; T-cell depleted: n=31) in a single center and their respective donors were genotyped of TLR4 for rs4986790 (A896G, Asp299Gly) using TaqMan real-time polymerase chain reaction. The donor was HLA-matched unrelated in 57% of transplants or HLA-identical related in 33% of transplants. Conditioning regimen was myeloablative in all cases and based on total body irradiation in 48% of transplants or busulfan in 47% of transplants. Two forms of post-transplant immunosuppression predominated, cyclosporine A and methotrexate in 64% of transplants and cyclosporine A alone in 25% of transplants. The Asp299Gly variant was present in 21 of the 166 patients (12.6%) and in 24 of the 166 donors (14.4%). Interestingly, we found a significantly reduced incidence of BK virus-associated hemorrhagic cystitis in patients with the Asp299Gly variant (0% versus 22.8%, p=0.009). In addition, we observed a significantly reduced incidence of BK virus-associated hemorrhagic cystitis in patients who were transplanted from a donor with this specific variant (4.2% versus 22.5%; p=0.05). In ten of the donor-patient pairs the variant was present in both individuals and no hemorrhagic cystitis was observed. The occurrence of the TLR4 Asp299Gly variant, in either recipients or donors, had no significant impact on acute and chronic GVHD, relapse rate, bacterial and fungal infectious complications, transplant related mortality, and overall survival. In conclusion, the TLR4 Asp299Gly variant in the recipient and/or the donor confers strong protection against BK virus-associated hemorrhagic cystitis after HSCT in children. This study provides the first evidence that the innate immune system through TLR4 signaling pathway seems to play an important role in the pathogenesis of BK virus-associated hemorrhagic cystitis after HSCT. Disclosures: No relevant conflicts of interest to declare.

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Sulfolane (a metabolite of busulfan) Levels Could Predict Occurrence Of Hemorrhagic Cystitis In Children Receiving Busulfan Based Myeloablative Conditioning Before Hematopoietic Stem Cell Transplantation

Blood ◽

10.1182/blood.v122.21.4574.4574 ◽

2013 ◽

Vol 122 (21) ◽

pp. 4574-4574

Author(s):

Chakradhara Rao S Uppugunduri ◽

Mohamed Aziz Rezgui ◽

Yves Theoret ◽

Patricia Huezo Diaz ◽

Anuj Kumar Tyagi ◽

...

Keyword(s):

Stem Cell ◽

Hematopoietic Stem Cell Transplantation ◽

Stem Cell Transplantation ◽

Cell Transplantation ◽

Hematopoietic Stem Cell ◽

Hemorrhagic Cystitis ◽

Conditioning Regimen ◽

Myeloablative Conditioning ◽

Hematopoietic Stem ◽

Post Transplant

Background One of the complications of myeloablative conditioning regimen with busulfan (BU) and cyclophosphamide (CY) in children undergoing hematopoietic stem cell transplantation (HSCT) is the occurrence of hemorrhagic cystitis (HC). Pathophysiology of HC involves multiple factors, such as damage to the bladder's transitional epithelium and the endothelium of blood vessels by BU, CY and their metabolites, viruses, bacterial infections, or other disease processes. It is well established fact that damage to the urothelium is the initial step during pathogenesis of HC. Though it is known about acrolein (metabolite of CY) contribution to HC development, the role of BU or its metabolites is not yet known completely. We recently developed an analytical method for sulfolane (Su) quantification, a water soluble metabolite of BU. Using this method we explored the relation of Su levels in plasma with HC before day 30 post-transplant, in 39 children (20 females, 19 males) receiving BU-CY conditioning prior to HSCT. Methods Hospital ethics committee approved the study, and all patients or their parents have signed the informed consent. Out of 39 patients 16 were diagnosed with nonmalignant disease. BU was administered in 16 dose infusions, with each infusion lasting two hours for every six hours. Bone marrow and cord blood were graft sources in 18 and 21 patients, respectively. Twenty patients had HLA–matched donor. HC was defined as the presence of hematuria (both microscopic and macroscopic) for more than a week from the initiation of the conditioning regimen up to 30 days post-transplant. All patients received MESNA as prophylaxis for HC. Plasma from patients collected before dose 7 and after dose 9 infusions of BU was used for measuring Su levels using gas-chromatography. Plasma levels of Su adjusted to cumulative BU dose up to Su level measurements (upto dose 6 for before dose 7 levels, upto dose 9 for after dose 9 levels) in mg/kg were used in the analysis. Mann-Whitney U test was used to analyze the relation of Su levels (ng/mL//mg/kg) and HC. A receiver–operator characteristic curve (ROC) for Su levels was plotted to show the trade-off in sensitivity versus 1- specificity rates for HC, as the cut-off of the test was shifted from low to high. Two sided p values were represented and probability at 0.05 was considered as statistically significant. Cumulative incidences of HC were estimated using Kaplan-Meier curves and log-rank test was used to compare the difference between groups divided based on cutoff defined in ROC curves, in univariate analysis. Univariate cox-regression was used to estimate hazard ratios with 95% confidence intervals. Results The overall cumulative incidence of HC was 20.5 %. We observed higher Su levels before dose 7 (mean±SD; 48.3±11.2 vs. 35.1±15.3 – p=0.02) and after dose 9 (40.5±9.6 vs. 30.9±14.4 – p=0.03) in patients diagnosed with early HC (n=8) compared to those with no HC (n=31-Figure 1A, Figure 1B), respectively. Cutoff values of 49.44 and 36.28 were chosen in ROC analysis for Su levels before dose 7 and after dose 9, respectively with better sensitivity and specificity to diagnose HC (Figure 1C). Patients with Su levels above the cutoff value defined (before dose 7, 41.7 %; after dose 9 42.9 %) had higher incidence of HC compared to those below the cutoff (before dose 7, 11.0 %; after dose 9, 8.0 %) at both dose levels (Figure 2A, Figure 2B). Age and Weight were also correlated with the incidence of HC, with higher incidence in patients older than 10 years, and weighed above 30 kg. Higher levels of Su correlated with the weight and age of the patients. Out of 8 individuals diagnosed with HC, 6 were detected positive for BK virus and one patient was positive for JC virus. Conclusion Higher plasma Su levels might also explain availability of Su and its hydroxyl metabolite in bladder to cause damaging effect similar to that of acrolein. We hypothesize that formation of Su is related to the volume of liver and enzyme activity which is usually correlated with weight and age of the patient. These levels might also predict the extent for acrolein formation, and might serve as surrogate marker to identify patients predisposed to HC. A functional study to elucidate the effect of Su on bladder urothelium is underway at our laboratory to understand its role in pathogenesis of HC. Disclosures: No relevant conflicts of interest to declare.

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