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Zhu XL, Wang JZ, Lyu M, Han TT, Zheng FM, Chen YY, Zhang YY, Chen H, Zhang XH, Xu LP, Huang XJ, Wang Y. [Clinical analysis of allogeneic hematopoietic cell transplantation in 9 patients with hematological malignancies complicated by Gilbert's syndrome]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2024; 45:851-855. [PMID: 39414610 PMCID: PMC11518900 DOI: 10.3760/cma.j.cn121090-20240311-00088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Indexed: 10/18/2024]
Abstract
From January 1, 2013, to March 1, 2024, nine patients with hematological malignancies complicated by Gilbert's syndrome in Peking University People's Hospital underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT). The patients comprised seven male and two female cases, with a median age of 38 (13-60) years old. Among them, three cases were acute myeloid leukemia, three cases were acute lymphocytic leukemia, two cases were myelodysplastic syndrome, and one case was chronic myelomonocytic leukemia. None of the patients had viral hepatitis. Of the nine cases, seven cases received the Bu-Cy+ATG regimen, while the other two cases received the TBI-Cy+ATG regimen (Bu, busulfan; Cy, cyclophosphamide; ATG, antithymocyte immunoglobulin; and TBI, total body irradiation). All patients achieved neutrophil engraftment, and eight received platelet engraftment. The median total bilirubin level was 45.4 (22.5-71.2) μmol/L before transplantation and 22.0 (18.0-37.2) μmol/L on -1d of preconditioning. The total bilirubin level on +20d after the transplantation of eight patients decreased compared with the baseline level before transplantation. Moreover, one patient had a transient increase in the total bilirubin level on +5d after transplantation, which was considered to be attributed to the toxicity of Bu. No patients were complicated by hepatic veno-occlusive disease. The median follow-up time was 739 (42-2 491) days. During the follow-up period, one patient died of recurrence, and the remaining eight patients had disease-free survival events.
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Affiliation(s)
- X L Zhu
- 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 100044, China
| | - J Z Wang
- 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 100044, China
| | - M Lyu
- 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 100044, China
| | - T T Han
- 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 100044, China
| | - F M Zheng
- 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 100044, China
| | - Y Y Chen
- 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 100044, China
| | - Y Y Zhang
- 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 100044, China
| | - H Chen
- 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 100044, China
| | - X H Zhang
- 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 100044, China
| | - L P Xu
- 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 100044, China
| | - X J Huang
- 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 100044, China
| | - Y Wang
- 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 100044, China
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Grupp SA, Corbacioglu S, Kang HJ, Teshima T, Khaw SL, Locatelli F, Maertens J, Stelljes M, Stepensky P, Lopez P, Amber V, Pagliuca A, Richardson PG, Mohty M. Defibrotide plus best standard of care compared with best standard of care alone for the prevention of sinusoidal obstruction syndrome (HARMONY): a randomised, multicentre, phase 3 trial. Lancet Haematol 2023; 10:e333-e345. [PMID: 37001534 DOI: 10.1016/s2352-3026(23)00011-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/21/2022] [Accepted: 01/10/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Sinusoidal obstruction syndrome, also known as veno-occlusive disease, is a potentially life-threatening complication of haematopoietic stem-cell transplantation (HSCT). We aimed to compare defibrotide prophylaxis plus best supportive care versus best supportive care alone for sinusoidal obstruction syndrome prevention after HSCT. METHODS This open-label, randomised, multicentre, phase 3 trial was done in 104 centres in 14 countries. Patients who were at least 1 month old, were scheduled to receive allogeneic HSCT (adult [aged >16 years] or paediatric [aged >1 month to ≤16 years] patients) or autologous HSCT (paediatric patients only), and were at high risk or very high risk of developing sinusoidal obstruction syndrome were eligible for inclusion. Patients were randomly assigned (1:1) by an interactive web response system to receive intravenous defibrotide 25 mg/kg per day (four equal doses [6·25 mg/kg per dose]) and best supportive care (determined by individual institutional guidelines; defibrotide prophylaxis group) or best supportive care only (best supportive care group). Randomisation was stratified by sinusoidal obstruction syndrome risk, age, and country. The primary endpoint, sinusoidal obstruction syndrome-free survival at day 30 after HSCT, was assessed by an independent Endpoint Adjudication Committee in the intention-to-treat (ITT) population. Safety was assessed in all patients who received protocol treatment. The trial is registered with ClinicalTrials.gov, NCT02851407. FINDINGS Between Jan 11, 2017, and Oct 20, 2020, 372 patients (172 [46%] women and 200 [54%] men; median age 14·0 years [IQR 4·0-41·0] were randomly assigned to the defibrotide prophylaxis group (n=190) or best supportive care group (n=182; ITT population). On the basis of recommendations from the Independent Data Monitoring Committee following completion of the planned interim analysis in the first 280 recruited patients on April 29, 2020, enrolment was prematurely stopped for presumed futility. At the final analysis, sinusoidal obstruction syndrome-free survival by day 30 after HSCT was 67% (95% CI 58-74) in the defibrotide prophylaxis group and 73% (62-80) in the best supportive care group (HR 1·27 [95% CI 0·84-1·93]; p=0·85). Treatment-emergent adverse events were similar between groups during the randomised prophylaxis phase; most treatment-emergent adverse events were related to the transplantation rather than to study drug. The most common grade 3 or 4 treatment-emergent adverse events were stomatitis (grade 3, 52 [29%] of 181 patients in the defibrotide prophylaxis group and 56 [32%] of 174 patients in the best supportive care group; grade 4, two [1%] in the defibrotide prophylaxis group and two [1%] in the best supportive care group) and febrile neutropaenia (grade 3, 51 [28%] in the defibrotide prophylaxis group and 52 [30%] in the best supportive care group; grade 4, no patients in the defibrotide prophylaxis group and three [2%] in the best supportive care group). Serious treatment-emergent adverse events occurred in 74 (41%) of 181 patients in the defibrotide prophylaxis group and 61 (35%) of 174 patients in the best supportive care group. In the rescue phase, when patients in both treatment groups received defibrotide as rescue treatment, fatal treatment-related adverse events occurred in one (4%) of 25 patients in the defibrotide prophylaxis group (intracranial haemorrhage) and one (3%) of 31 patients in the best supportive care group (sinusoidal obstruction syndrome). INTERPRETATION Defibrotide did not show a benefit in the prophylaxis of sinusoidal obstruction syndrome. Additional studies of carefully selected patients at high risk of sinusoidal obstruction syndrome after HSCT are warranted. FUNDING Jazz Pharmaceuticals.
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Affiliation(s)
- Stephan A Grupp
- Division of Oncology, Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
| | - Hyoung Jin Kang
- Department of Pediatrics, College of Medicine, Seoul National University Cancer Research Institute and Wide River Institute of Immunology, Seoul National University Children's Hospital, Seoul National University, Seoul, South Korea
| | - Takanori Teshima
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Seong Lin Khaw
- Children's Cancer Centre, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Franco Locatelli
- IRCCS, Bambino Gesù Children's Hospital, Catholic University of the Sacred Heart, Rome, Italy
| | - Johan Maertens
- Department of Microbiology, Immunology, and Transplantation, Catholic University Leuven, Leuven, Belgium; Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Matthias Stelljes
- Department of Medicine and Department of Hematology and Oncology, University of Münster, Münster, Germany
| | - Polina Stepensky
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah Hebrew University Medical Centre, Jerusalem, Israel
| | - Paty Lopez
- Jazz Pharmaceuticals, Palo Alto, CA, USA
| | | | - Antonio Pagliuca
- Department of Haematological Medicine, King's College Hospital NHS Foundation Trust and Kings College London, London, UK; Anthony Nolan, London, UK
| | - Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Mohamad Mohty
- Department of Haematology, Hôpital Saint-Antoine, Universite Pierre and Marie Curie, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche, Paris, France
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Coutsouvelis J, Kirkpatrick CM, Dooley M, Spencer A, Kennedy G, Chau M, Huang G, Doocey R, Copeland TS, Do L, Bardy P, Kerridge I, Cole T, Fraser C, Perera T, Larsen SR, Mason K, O'Brien TA, Shaw PJ, Teague L, Butler A, Watson AM, Ramachandran S, Marsh J, Khan Z, Hamad N. Incidence of sinusoidal obstruction syndrome/veno-occlusive disease and treatment with defibrotide in allogeneic transplant: A multicentre Australasian registry study. Transplant Cell Ther 2023:S2666-6367(23)01173-9. [PMID: 36934993 DOI: 10.1016/j.jtct.2023.03.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/03/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Sinusoidal obstruction syndrome/veno-occlusive disease (SOS/VOD) is an established complication in patients undergoing allogeneic haemopoietic stem cell transplantation. Defibrotide is an effective and safe pharmacological option for treating diagnosed SOS/VOD. OBJECTIVE By exploring data provided to the Australasian Bone Marrow Transplant Recipient Registry (ABMTRR) by centres from Australia and New Zealand, this study aimed to describe the incidence of SOS/VOD and patterns of defibrotide use from 2016 to 2020. STUDY DESIGN Patients who underwent allogeneic HSCT between 2016 and 2020 were identified from the ABMTRR. Data was extracted for a total of 3346 patients, 2692 from adult centres and 654 from paediatric centres, with a median follow up of 21.5 months and 33.3 months respectively. Descriptive statistics were used to describe the patient population, including the incidence of SOS/VOD and defibrotide use. Comparisons were made between patients not experiencing SOS/VOD, and those with the diagnosis, divided into defibrotide and no-defibrotide cohorts. Associations with overall survival and day 100 survival with variables such as gender, age, disease at transplant, source of stem cells, conditioning agents, SOS/VOD diagnosis and use of defibrotide were determined. RESULTS The reported incidence of SOS/VOD was 4.1% in adult centres and 11.5% in paediatric centres. Defibrotide was administered to 74.8% of adult patients with SOS/VOD and 97.3% of paediatric patients. Significant variability of use, dose and duration of defibrotide was seen across the adult centres. Day 100 survival rate and median overall survival (OS) for patients managed with defibrotide was 51.8% and 103 days respectively for adult patients, and 90.4% and not reached for paediatric patients. In adults, older age at transplant, an HLA matched donor who was a non-sibling relative, and a diagnosis of SOS/VOD treated with defibrotide, were all associated with reduced OS. In paediatrics, the patient and transplant characteristics that were associated with a reduced OS were a diagnosis of SOS/VOD and donor relation as 2 or more HLA mismatched relative. CONCLUSION A collaborative approach across Australasia to diagnose and manage SOS/VOD, in particular with respect to consistent defibrotide use, is recommended.
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Affiliation(s)
- John Coutsouvelis
- Pharmacy Department, Alfred Health, Commercial Road, Melbourne VIC 3004, Australia; Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville VIC 3052, Australia.
| | - Carl M Kirkpatrick
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville VIC 3052, Australia
| | - Michael Dooley
- Pharmacy Department, Alfred Health, Commercial Road, Melbourne VIC 3004, Australia; Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville VIC 3052, Australia; Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC 3004, Australia
| | - Andrew Spencer
- Department of Malignant Haematology and Stem Cell Transplantation, Alfred Health - Monash University, Commercial Road, Melbourne, VIC 3004, Australia
| | - Glen Kennedy
- Cancer Care Services, Royal Brisbane and Women's Hospital, Herston QLD 4029; University of Queensland Medical School, St Lucia QLD 4072, Australia
| | - Maggie Chau
- Pharmacy Department, Royal Melbourne Hospital, Grattan Street, Parkville VIC 3050, Australia
| | - Gillian Huang
- Blood Transplant and Cellular Therapies, Department of Clinical Haematology & BTCT, Westmead Hospital, Westmead NSW 2145, Australia
| | - Richard Doocey
- Auckland City and Starship Hospitals Stem Cell Transplant Programme, Park Road, Grafton Auckland 1023, New Zealand
| | - Tandy-Sue Copeland
- Pharmacy Department, Fiona Stanley Hospital, Level 7D, 11 Robyn Warren Drive, MURDOCH WA 6150, Australia
| | - Louis Do
- Haematology Department, St Vincent's Hospital & The Kinghorn Cancer Centre, 370 Victoria St, Darlinghurst NSW 2010, Australia
| | - Peter Bardy
- Department of Haematology and Bone Marrow Transplantation, Royal Adelaide Hospital, Adelaide SA 5000, Australia
| | - Ian Kerridge
- Haematology Department, Royal North Shore Hospital, St Leonards, NSW 2065; Northern Blood Research Centre, Kolling Institute, St Leonards, NSW 2065; Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, 2006
| | - Theresa Cole
- Children's Cancer Centre, Royal Children's Hospital, Parkville, VIC,3052; Murdoch Children's Research Institute, Melbourne, Parkville, VIC,3052; Dept of paediatrics, University of Melbourne, Melbourne VIC, Australia
| | - Chris Fraser
- Blood and Marrow Transplant Program, Queensland Children's Hospital, 501 Stanley Street, South Brisbane QLD 4101, Australia
| | - Travis Perera
- Wellington Blood and Cancer Centre, Wellington Hospital, Riddiford St, Newtown, Wellington 6022, New Zealand
| | - Stephen R Larsen
- Institute of Haematology, Royal Prince Alfred Hospital, 50 Missenden Rd, Camperdown NSW 2050, Australia; Sydney Medical School, University of Sydney, NSW, Australia
| | - Kate Mason
- Clinical Haematology, Austin Health, 145 Studley Rd, Heidelberg VIC 3084, Australia
| | - Tracey A O'Brien
- Kids Cancer Centre, Sydney Children's Hospital, High Street, Randwick NSW 2031, Australia;; School of Clinical Medicine, UNSW Medicine and Health, Randwick Clinical Campus, Discipline of Paediatrics, UNSW Sydney, Australia
| | - Peter J Shaw
- Blood Transplant and Cell Therapies Program, The Children's Hospital, Westmead NSW 2145, Australia; Clinical Professor, Child and Adolescent Health, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Lochie Teague
- Starship Blood and Cancer Centre, Starship Hospital, 2 Park Rd, Grafton Auckland 1023, New Zealand
| | - Andrew Butler
- Haematology Department, Christchurch Hospital, 2 Riccarton Avenue, Christchurch 8140, New Zealand
| | - Anne-Marie Watson
- Haematology Department, Liverpool Hospital, Elizabeth Street, Liverpool NSW 2170, Australia
| | - Shanti Ramachandran
- Department of Clinical Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital, Nedlands 6009, WA, Australia,; School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia
| | - Jodie Marsh
- Townsville University Hospital, Angus Smith Drive, Douglas QLD 4814, Australia
| | - Zulekha Khan
- Australasian Bone Marrow Transplant Recipient Registry, Level 6, The Kinghorn Cancer Centre, 370 Victoria St, Darlinghurst NSW 2010, Australia
| | - Nada Hamad
- Haematology Department, St Vincent's Hospital & The Kinghorn Cancer Centre, 370 Victoria St, Darlinghurst NSW 2010, Australia; Australasian Bone Marrow Transplant Recipient Registry, Level 6, The Kinghorn Cancer Centre, 370 Victoria St, Darlinghurst NSW 2010, Australia; University of New South Wales, Sydney, Australia; University of Notre Dame Australia, Sydney Australia
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Corbacioglu S, Topaloglu O, Aggarwal S. A Systematic Review and Meta-Analysis of Studies of Defibrotide Prophylaxis for Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome. Clin Drug Investig 2022; 42:465-476. [PMID: 35594010 PMCID: PMC9188533 DOI: 10.1007/s40261-022-01140-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Defibrotide is approved to treat severe veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) after haematopoietic cell transplantation in patients aged > 1 month in the European Union and for VOD/SOS with renal/pulmonary dysfunction post-haematopoietic cell transplantation in the United States. This meta-analysis estimated the incidence and risk of VOD/SOS after intravenous defibrotide prophylaxis using the published literature. METHODS PubMed, Embase and Web of Science were searched through 30 November 2021 for defibrotide studies in VOD/SOS "prevention" or "prophylaxis," excluding phase I studies, case reports, studies with fewer than ten patients and reviews. RESULTS The search identified 733 records; 24 met inclusion criteria, of which 20 (N = 3005) evaluated intravenous defibrotide for VOD/SOS prophylaxis. Overall VOD/SOS incidence with intravenous defibrotide was 5%, with incidences of 5% in adults and 8% in paediatric patients. In eight studies with data on intravenous defibrotide prophylaxis vs controls (e.g. heparin, no prophylaxis), VOD/SOS incidence in controls was 16%. The risk ratio for developing VOD/SOS with defibrotide prophylaxis vs controls was 0.30 (95% confidence interval 0.12-0.71; p = 0.006). CONCLUSIONS This analysis suggests a low incidence of VOD/SOS following intravenous defibrotide prophylaxis, regardless of age group, and a lower relative risk for VOD/SOS with defibrotide prophylaxis vs controls in patient populations at high risk of VOD/SOS.
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Affiliation(s)
- Selim Corbacioglu
- Department of Haematology, Oncology, and Stem Cell Transplantation, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
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[Chinese expert consensus on the diagnosis and management of sinusoidal obstruction syndrome after hematopoietic stem cell transplantation (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:177-183. [PMID: 35405774 PMCID: PMC9072071 DOI: 10.3760/cma.j.issn.0253-2727.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Indexed: 11/11/2022]
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Kloehn J, Brodt G, Ernst J, Gruhn B. Analysis of risk factors for hepatic sinusoidal obstruction syndrome following allogeneic hematopoietic stem cell transplantation in pediatric patients. J Cancer Res Clin Oncol 2021; 148:1447-1455. [PMID: 34255148 PMCID: PMC9114040 DOI: 10.1007/s00432-021-03732-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 07/07/2021] [Indexed: 01/19/2023]
Abstract
Purpose Hepatic sinusoidal obstruction syndrome (SOS) represents a serious complication following hematopoietic stem cell transplantation (HSCT). Our study aimed to investigate important risk factors of SOS in a pediatric population. Methods This retrospective study analyzed 105 children, adolescents and young adults who underwent allogeneic HSCT at our pediatric HSCT center in Jena. The observation period was 12 years and SOS was defined by the pediatric criteria of the European Society for Blood and Marrow Transplantation (EBMT). Results 15 out of all 105 patients developed SOS (14.3%). The median time from HSCT to SOS diagnosis was 12 days. The mortality rate of SOS was 20.0%. In univariate analyses, we identified the significant risk factors of patient age < 1 year [odds ratio (OR) = 7.25, p = 0.037], prior treatment with gemtuzumab ozogamicin (OR = 11.00, p = 0.020), high pretransplant ferritin levels above 1500 ng/mL (OR = 4.00, p = 0.033), 2000 ng/mL (OR = 4.69, p = 0.016), and 2400 ng/mL (OR = 5.29, p = 0.005) as well as international normalized ratio (INR) ≥ 1.3 (OR = 5.91, p = 0.009). The following risk factors could be confirmed in multivariate analysis: treatment with gemtuzumab ozogamicin (OR = 9.24, p = 0.048), ferritin > 2400 ng/mL (OR = 5.74, p = 0.023), and INR ≥ 1.3 (OR = 8.02, p = 0.007). Conclusion Our study confirms several risk factors from the current literature. Additionally, this is the first report on the risk factor of high pretransplant INR.
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Affiliation(s)
- Jaspar Kloehn
- Department of Pediatrics, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Grit Brodt
- Department of Pediatrics, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Jana Ernst
- Department of Pediatrics, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany
| | - Bernd Gruhn
- Department of Pediatrics, Jena University Hospital, Am Klinikum 1, 07747, Jena, Germany.
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Roy Moulik N, Johnson I, Van Bruggen L, Petterson T, Mycroft J, Vaidya SJ. Defibrotide treatment but not prophylaxis is useful in hepatic sinusoidal obstruction syndrome in children undergoing autologous stem cell transplant following high-dose chemotherapy: A single-center experience from the Royal Marsden Hospital, UK. Pediatr Blood Cancer 2020; 67:e28677. [PMID: 32865880 DOI: 10.1002/pbc.28677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/29/2020] [Accepted: 08/11/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Hepatic sinusoidal obstruction syndrome (SOS) is a serious complication of autologous stem cell transplant (ASCT) in children with historically high mortality rates. Defibrotide has shown proven benefit in its treatment and may have a modest role in prevention. We report our experience with SOS in children undergoing autologous transplant. METHODS Case records of 82 consecutive patients undergoing ASCT following high-dose chemotherapy between 2010 and 2017 were reviewed. Defibrotide was used for treatment of all with SOS and prophylactically in patients receiving busulfan-based conditioning until 2014. RESULTS Fourteen of the 82 children (17%) were diagnosed with SOS. The incidence was higher in those receiving busulfan-based conditioning (13/42 vs 1/40, P = 0.008). Mean (±SD) time to diagnosis of SOS was 19 (±5.6) days following stem cell rescue. Bilirubin levels and ultrasound were normal in 7/14 and 3/14 patients. Coagulopathy was noted in 10/14; one child developed multiorgan involvement. Nine children had mild SOS, whereas two and three had moderate and severe SOS, respectively. Intensive care was required for four of five non-mild cases. Patients with SOS had significantly delayed platelet recovery, higher transfusion requirement, and longer hospital stay. Unavailability of defibrotide prophylaxis for 17/42 receiving busulfan did not change the incidence of SOS (7/25 with defibrotide vs 6 /17 without defibrotide, P = 0.74). There was no significant difference in the severity of SOS between these groups. CONCLUSION Hepatic SOS was more commonly seen in children receiving busulfan-based conditioning. Stopping the use of prophylactic defibrotide did not increase incidence or severity of SOS. Overall outcome was excellent with supportive care and timely treatment with defibrotide.
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Affiliation(s)
- Nirmalya Roy Moulik
- Children and Young People's Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Indranee Johnson
- Children and Young People's Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Lucia Van Bruggen
- Department of Pharmacy, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Toni Petterson
- Children and Young People's Unit, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Julie Mycroft
- Department of Pharmacy, The Royal Marsden Hospital, Sutton, United Kingdom
| | - Sucheta J Vaidya
- Children and Young People's Unit, The Royal Marsden Hospital, Sutton, United Kingdom
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Roh YY, Hahn SM, Kim HS, Ahn WK, Han JH, Kwon S, Lyu CJ, Han JW. Efficacy of low dose and short duration defibrotide prophylaxis for hepatic veno-occlusive disease after autologous haematopoietic stem cell transplantation. Bone Marrow Transplant 2020; 56:411-418. [PMID: 32839533 DOI: 10.1038/s41409-020-01036-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 11/09/2022]
Abstract
Hepatic veno-occlusive disease (VOD) is a serious systemic endothelial complication after stem cell transplantation. Defibrotide is under investigation as a prophylactic agent for VOD; however, high costs limit its utility. We evaluated the prophylactic efficacy of a low-dose defibrotide regimen for VOD. We retrospectively enrolled 147 paediatric patients who underwent autologous haematopoietic stem cell transplantation (HSCT; 69 with defibrotide prophylaxis and 78 historical controls) at the Yonsei Cancer Center in Seoul, Korea, between March 2013 and Feb 2020. Low-dose defibrotide (12.5 mg/kg/day) was administered from D-3 to D+10 after HSCT. The most common diagnosis in the cohort was brain tumour (N = 86). VOD developed in 10 (12.8%) and 3 (4.3%) patients in the control and prophylaxis groups, respectively (P = 0.071). In the second HSCT group, VOD incidence was significantly lower in the prophylaxis group [2.9% (1/35)] than in the control group (28.6%, 6/21, P = 0.005). VOD severity was significantly higher in the control group than in the prophylaxis group (P = 0.006). Three VOD-related mortalities occurred in the control group, whereas no VOD-related mortality occurred in the prophylaxis group. In conclusion, low-dose defibrotide prophylaxis is a promising and economical strategy for preventing VOD, especially in second-round HSCT.
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Affiliation(s)
- Yun Young Roh
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea.,Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Seung Min Hahn
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea.,Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Hyo Sun Kim
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea.,Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Won Kee Ahn
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea.,Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Jung Hwa Han
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea
| | - Seungyeon Kwon
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea.,Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Chuhl Joo Lyu
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea.,Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea
| | - Jung Woo Han
- Department of Pediatric Hematology-Oncology, Yonsei Cancer Center, Yonsei University Health System, Seoul, Korea. .,Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Korea.
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9
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Bonifazi F, Barbato F, Ravaioli F, Sessa M, Defrancesco I, Arpinati M, Cavo M, Colecchia A. Diagnosis and Treatment of VOD/SOS After Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2020; 11:489. [PMID: 32318059 PMCID: PMC7147118 DOI: 10.3389/fimmu.2020.00489] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 03/03/2020] [Indexed: 12/27/2022] Open
Abstract
Hepatic veno-occlusive disease (VOD) or sinusoidal obstruction syndrome (SOS) is a rare complication characterized by hepatomegaly, right-upper quadrant pain, jaundice, and ascites, occurring after high-dose chemotherapy, hematopoietic stem cell transplantation (HSCT) and, less commonly, other conditions. We review pathogenesis, clinical appearance and diagnostic criteria, risk factors, prophylaxis, and treatment of the VOD occurring post-HSCT. The injury of the sinusoidal endothelial cells with loss of wall integrity and sinusoidal obstruction is the basis of development of postsinusoidal portal hypertension responsible for clinical syndrome. Risk factors associated with the onset of VOD and diagnostic tools have been recently updated both in the pediatric and adult settings and here are reported. Treatment includes supportive care, intensive management, and specific drug therapy with defibrotide. Because of its severity, particularly in VOD with associated multiorgan disease, prophylaxis approaches are under investigation. During the last years, decreased mortality associated to VOD/SOS has been reported being it attributable to a better intensive and multidisciplinary approach.
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Affiliation(s)
- Francesca Bonifazi
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Francesco Barbato
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Mariarosaria Sessa
- Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum-Bologna University School of Medicine S. Orsola's University Hospital, Bologna, Italy
| | - Irene Defrancesco
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy.,Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Mario Arpinati
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Michele Cavo
- Institute of Hematology "L. and A. Seràgnoli", S. Orsola-Malpighi University Hospital, Bologna, Italy.,Institute of Hematology "L. and A. Seràgnoli", Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater Studiorum-Bologna University School of Medicine S. Orsola's University Hospital, Bologna, Italy
| | - Antonio Colecchia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.,Gastroenterology Unit, Borgo Trento University Hospital, Verona, Italy
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10
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Richardson P, Aggarwal S, Topaloglu O, Villa KF, Corbacioglu S. Systematic review of defibrotide studies in the treatment of veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS). Bone Marrow Transplant 2019; 54:1951-1962. [PMID: 30804485 PMCID: PMC6957462 DOI: 10.1038/s41409-019-0474-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 12/20/2018] [Accepted: 01/20/2019] [Indexed: 01/07/2023]
Abstract
Veno-occlusive disease (VOD), also called sinusoidal obstruction syndrome (SOS), is a potentially life-threatening complication of hematopoietic stem cell transplantation (HSCT) conditioning or high-dose nontransplant chemotherapy. VOD/SOS with multi-organ dysfunction (MOD) is associated with a mortality rate of > 80%. Defibrotide (25 mg/kg/day) is approved to treat hepatic VOD/SOS with renal or pulmonary dysfunction post HSCT in the United States and to treat severe hepatic VOD/SOS in patients > 1 month of age in the European Union. A random effects model was used for pooling data from 17 systematically chosen defibrotide studies. For patients in these reports (n = 2598), and those in the subset of 10 reports of patients treated with ~ 25 mg/kg/day (n = 1691), estimated Day + 100 survival rates were 54% and 56%, respectively. Among those patients treated with ~ 25 mg/kg/day, estimated Day + 100 survival was 44% among patients with MOD and 71% in patients without MOD; survival was 41% and 70%, respectively, for the population of patients receiving any dose of defibrotide. Safety results were not pooled owing to differences in reporting methodology but were generally consistent with the known tolerability profile of defibrotide. This analysis provides the largest assessment of survival in patients treated with defibrotide for VOD/SOS with or without MOD.
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Affiliation(s)
- Paul Richardson
- Jerome Lipper Multiple Myeloma Center, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
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11
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Picod A, Bonnin A, Battipaglia G, Giannotti F, Ruggeri A, Brissot E, Malard F, Médiavilla C, Belhocine R, Vekhoff A, Gueye MS, Lapusan S, Adaeva R, Isnard F, Legrand O, Baylatry MT, Joly AC, Labopin M, Duléry R, Mohty M. Defibrotide for Sinusoidal Obstruction Syndrome/Veno-Occlusive Disease Prophylaxis in High-Risk Adult Patients: A Single-Center Experience Study. Biol Blood Marrow Transplant 2018; 24:1471-1475. [PMID: 29477779 DOI: 10.1016/j.bbmt.2018.02.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 02/14/2018] [Indexed: 10/17/2022]
Abstract
Sinusoidal obstruction syndrome (SOS), also known as hepatic veno-occlusive disease (VOD), is a serious complication after hematopoietic stem cell transplantation (HSCT). SOS/VOD usually occurs within 3 weeks of HSCT, but the 2016 European Society for Blood and Marrow Transplantation diagnosis criteria have been revised to include late forms. Prophylactic use of defibrotide is recommended in the pediatric setting, but its value remains uncertain in the adult population. We report here a single-center series of 63 adult patients considered at high risk for SOS/VOD who received defibrotide prophylaxis in combination with ursodeoxycholic acid between May 2012 and August 2016. The median duration of defibrotide therapy was 23 days. Bleeding occurred in 14 patients (21.5%). Defibrotide prophylaxis was discontinued in 7 patients (10.8%): 4 cases (6.3%) due to bleeding and 3 cases (4.6%) because of the need for antithrombotic therapy. Overall, SOS/VOD occurred in 4 cases (6.3%) within 21 days after HSCT (days 13 and 14) in 2 cases and late-onset SOS/VOD (days 57 and 58) in the other 2 cases. SOS/VOD was moderate in 1 case, very severe in 3 cases, with 2 deaths related to SOS/VOD. Cumulative incidence of grades II to IV acute graft-versus-host disease and transplant-associated thrombotic microangiopathy were 22.2% and 3.2%, respectively. With a median follow-up of 31 months (range, 10.7 to 60.3), the rates of 2-year overall survival, progression-free survival, incidence of relapse, and nonrelapse mortality were 56.5%, 49%, 28.7%, and 22.3%, respectively. In our experience defibrotide prophylaxis is associated with a low incidence of SOS/VOD after allogeneic HSCT in a high-risk adult population with an acceptable safety profile.
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Affiliation(s)
- Adrien Picod
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Agnès Bonnin
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Giorgia Battipaglia
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France; Université Pierre et Marie Curie (UPMC), Sorbonne Universités, Paris, France
| | - Federica Giannotti
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Annalisa Ruggeri
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Eolia Brissot
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France; Université Pierre et Marie Curie (UPMC), Sorbonne Universités, Paris, France; INSERM, UMRs 938, Paris, France
| | - Florent Malard
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France; Université Pierre et Marie Curie (UPMC), Sorbonne Universités, Paris, France; INSERM, UMRs 938, Paris, France
| | - Clémence Médiavilla
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France; Université Pierre et Marie Curie (UPMC), Sorbonne Universités, Paris, France
| | - Ramdane Belhocine
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Anne Vekhoff
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Mor Sény Gueye
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Simona Lapusan
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Rosa Adaeva
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Françoise Isnard
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France
| | - Ollivier Legrand
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France; Université Pierre et Marie Curie (UPMC), Sorbonne Universités, Paris, France
| | - Minh-Tam Baylatry
- UPAC & C (Unité de préparation des anticancéreux et contrôle), Saint Antoine Hospital, AP-HP, Paris, France
| | - Anne-Christine Joly
- UPAC & C (Unité de préparation des anticancéreux et contrôle), Saint Antoine Hospital, AP-HP, Paris, France
| | - Myriam Labopin
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France; Université Pierre et Marie Curie (UPMC), Sorbonne Universités, Paris, France
| | - Rémy Duléry
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France; Université Pierre et Marie Curie (UPMC), Sorbonne Universités, Paris, France; INSERM, UMRs 938, Paris, France
| | - Mohamad Mohty
- Hematology and Cellular Therapy Service, Saint Antoine Hospital, AP-HP, Paris, France; Université Pierre et Marie Curie (UPMC), Sorbonne Universités, Paris, France; INSERM, UMRs 938, Paris, France.
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12
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Corbacioglu S, Richardson PG. Defibrotide for children and adults with hepatic veno-occlusive disease post hematopoietic cell transplantation. Expert Rev Gastroenterol Hepatol 2017; 11:885-898. [PMID: 28825848 DOI: 10.1080/17474124.2017.1370372] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is a complication that is typically associated with conditioning for hematopoietic stem cell transplantation (HSCT). In patients with concomitant multi-organ dysfunction, mortality may be >80%. Recently, the European Society for Blood and Marrow Transplantation established separate criteria for diagnosis and severity of VOD/SOS for adults and children, to better reflect current understanding of the disease. Areas covered: This review provides an overview of post-HSCT hepatic VOD/SOS and defibrotide, including its pharmacological, clinical, and regulatory profile. In children and adults following HSCT, defibrotide is approved for the treatment of hepatic VOD/SOS with concomitant renal or pulmonary dysfunction in the United States and for the treatment of severe hepatic VOD/SOS in the European Union. Day +100 survival rates with defibrotide are superior to those of historical controls receiving best supportive care only, and safety profiles are similar. Expert commentary: Defibrotide appears to act through multiple mechanisms to restore thrombo-fibrinolytic balance and protect endothelial cells, and there are promising data on the use of defibrotide for VOD/SOS prophylaxis in high-risk children undergoing HSCT. An ongoing randomized controlled trial in children and adults will better assess the clinical value of defibrotide as a preventive medication.
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Affiliation(s)
- Selim Corbacioglu
- a Department of Pediatric Hematology, Oncology and Stem Cell Transplantation , University of Regensburg , Regensburg , Germany
| | - Paul G Richardson
- b Harvard Medical School, Jerome Lipper Multiple Myeloma Center , Dana-Farber Cancer Institute , Boston , MA , USA
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13
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Bajwa RPS, Mahadeo KM, Taragin BH, Dvorak CC, McArthur J, Jeyapalan A, Duncan CN, Tamburro R, Gehred A, Lehmann L, Richardson P, Auletta JJ, Woolfrey AE. Consensus Report by Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplantation Consortium Joint Working Committees: Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents, Part 1: Focus on Investigations, Prophylaxis, and Specific Treatment. Biol Blood Marrow Transplant 2017; 23:1817-1825. [PMID: 28754544 DOI: 10.1016/j.bbmt.2017.07.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/20/2017] [Indexed: 12/13/2022]
Abstract
Veno-occlusive disease (VOD) is a common and potentially fatal complication in children undergoing hematopoietic cell transplantation (HCT). It occurs in about one-third of all patients undergoing transplantation and is fatal in 50% of patients with severe disease. Early intervention and specific treatment with defibrotide are associated with improved outcomes. However, there is a lack of supportive care guidelines for management of the multiorgan dysfunction seen in most cases. There is high variability in the management of VOD, which may contribute to the increased morbidity and mortality. Although there is ample research in the specific treatment of VOD, there is paucity of literature regarding the management of ascites, transfusions requirements, fluids and electrolyte dysfunction, delirium, and investigations in children with VOD. The joint working committees of the Pediatric Acute Lung Injury and Sepsis Investigators and the Pediatric Blood and Marrow Transplantation Consortium collaborated to develop a series of evidence-based supportive care guidelines for management of VOD. The quality of evidence was rated and recommendations were made using Grading of Recommendations, Assessment, Development and Evaluation criteria. This manuscript is part 1 of the series and focuses on the need to develop these guidelines; methodology used to establish the guidelines; and investigations needed for diagnosis, prophylaxis, and treatment of VOD in children.
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Affiliation(s)
- Rajinder P S Bajwa
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio.
| | - Kris M Mahadeo
- Division of Pediatric Blood and Marrow Transplantation, The University of Texas, MD Anderson Children's Cancer Hospital, Houston, Texas
| | - Benjamin H Taragin
- Department of Pediatric Radiology, Children's Hospital at Montefiore, Bronx, New York
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, and Bone Marrow Transplant, University of California San Francisco, Benioff Children's Hospital, San Francisco, California
| | - Jennifer McArthur
- Department of Pediatric Critical Care Medicine St Jude Children's Research Hospital, Memphis, Tennessee
| | - Asumthia Jeyapalan
- Division of Pediatric Critical Care Medicine, University of Miami- Miller School of Medicine, Miami, Florida
| | - Christine N Duncan
- Division of Pediatric Stem Cell Transplant, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Robert Tamburro
- Division of Pediatric Critical Care Medicine, Pennsylvania University, Penn State Hershey Children's Hospital, Hershey, PA
| | - Alison Gehred
- Medical Library division, Nationwide Children's Hospital, Columbus, Ohio
| | - Leslie Lehmann
- Division of Pediatric Stem Cell Transplant, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Paul Richardson
- Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jeffery J Auletta
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio; Division of Infectious Diseases, Nationwide Children's Hospital, Columbus
| | - Ann E Woolfrey
- Fred Hutchinson Cancer Research Center and University of Washington, Seattle, Washington
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14
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Defibrotide in Severe Sinusoidal Obstruction Syndrome: Medicine and Economic Issues. Biol Blood Marrow Transplant 2016; 23:347-356. [PMID: 27939616 DOI: 10.1016/j.bbmt.2016.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/28/2016] [Indexed: 11/23/2022]
Abstract
In Europe, Defitelio (defibrotide) has a Market Authorization in curative treatment of severe sinusoidal obstruction syndrome (SOS) but not in prophylaxis (2013). In France, defibrotide has had a compassionate-use program since 2009. Today, the high cost of defibrotide remains a major hurdle for hospital budgets. Medicine and economic issues were evaluated for the 39 hospitals of the French Public Assistance-Hospitals of Paris (AP-HP). We analyzed literature reviews, consumption, and expenditures through AP-HP data in 2014 and patient profiles with defibrotide in the corresponding diagnostic-related groups (DRGs) and consulted a board of hematologists. Finally, 18 publications were selected. Between 2011 and 2014 consumption increased to €5.2M. In 2014, 80 patients receiving defibrotide were mainly ascribed to the DRG "hematopoietic stem cell transplantation" levels 3 or 4. The tariffs attributed to drugs (€3544 to 4084) cover a small part of treatment costs (€97,524 for an adult). French experts thus recommended a harmonization of indications in prophylaxis (off-label use), improvement of pretransplant care, and optimization of the number of vials used. The economic impact led experts to change their practices. They recommended the restriction of defibrotide use to SOS curative treatment and to high-risk situations in prophylaxis.
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Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433. The November 2016 monograph topics are apaziquone, crisaborole, irinotecan liposome, plecanatide, and telotristat. The Safety MUE is on methylnaltrexone PO.
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16
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Defibrotide for the management of sinusoidal obstruction syndrome in patients who undergo haemopoietic stem cell transplantation. Cancer Treat Rev 2016; 50:200-204. [PMID: 27721142 DOI: 10.1016/j.ctrv.2016.09.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 09/16/2016] [Accepted: 09/20/2016] [Indexed: 11/23/2022]
Abstract
Sinusoidal obstruction syndrome, previously known as veno-occlusive disease (VOD/SOS), is a complication in patients undergoing haemopoietic stem cell transplantation (HSCT). Severe VOD/SOS, including progression to multi-organ failure, has resulted in a mortality of greater than 80%. Defibrotide's varying pharmacological actions, particularly on endothelial cells, make it is a useful agent to consider for prophylaxis and treatment of VOD/SOS. Barriers to its routine use include the high acquisition cost and the fact that neither the oral or parenteral formulations are licensed products in many countries at this time. This review summarises available literature on the use of defibrotide in the management of VOD/SOS. Publications consist predominantly of single centre cohort studies and case series. Available evidence indicates that defibrotide is effective in the management of VOD/SOS. Using defibrotide prophylaxis should also be considered, especially in the paediatric setting, where there are available results from a large, open label, randomized controlled trial. Patient outcome data from the larger studies and compassionate programs can inform consensus recommendations on dosing regimen and criteria for the treatment of VOD/SOS with defibrotide in the adult population. The reviewed literature indicates an effective and safe dose for treatment is 25mg/kg/day, continued for at least 14days or until complete response is achieved. Further studies are required to determine the optimal dose and duration of treatment in both paediatric patients and adults. Recent recommendations and a phase 3 trial using historical controls indicate that defibrotide should be included as a pharmacotherapy option in protocols guiding management of VOD/SOS.
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17
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Richardson PG, Riches ML, Kernan NA, Brochstein JA, Mineishi S, Termuhlen AM, Arai S, Grupp SA, Guinan EC, Martin PL, Steinbach G, Krishnan A, Nemecek ER, Giralt S, Rodriguez T, Duerst R, Doyle J, Antin JH, Smith A, Lehmann L, Champlin R, Gillio A, Bajwa R, D'Agostino RB, Massaro J, Warren D, Miloslavsky M, Hume RL, Iacobelli M, Nejadnik B, Hannah AL, Soiffer RJ. Phase 3 trial of defibrotide for the treatment of severe veno-occlusive disease and multi-organ failure. Blood 2016; 127:1656-65. [PMID: 26825712 PMCID: PMC4817309 DOI: 10.1182/blood-2015-10-676924] [Citation(s) in RCA: 227] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 01/22/2016] [Indexed: 11/20/2022] Open
Abstract
Hepatic veno-occlusive disease (VOD), also called sinusoidal obstruction syndrome (SOS), is a potentially life-threatening complication of hematopoietic stem cell transplantation (HSCT). Untreated hepatic VOD/SOS with multi-organ failure (MOF) is associated with >80% mortality. Defibrotide has shown promising efficacy treating hepatic VOD/SOS with MOF in phase 2 studies. This phase 3 study investigated safety and efficacy of defibrotide in patients with established hepatic VOD/SOS and advanced MOF. Patients (n = 102) given defibrotide 25 mg/kg per day were compared with 32 historical controls identified out of 6867 medical charts of HSCT patients by blinded independent reviewers. Baseline characteristics between groups were well balanced. The primary endpoint was survival at day +100 post-HSCT; observed rates equaled 38.2% in the defibrotide group and 25% in the controls (23% estimated difference; 95.1% confidence interval [CI], 5.2-40.8;P= .0109, using a propensity-adjusted analysis). Observed day +100 complete response (CR) rates equaled 25.5% for defibrotide and 12.5% for controls (19% difference using similar methodology; 95.1% CI, 3.5-34.6;P= .0160). Defibrotide was generally well tolerated with manageable toxicity. Related adverse events (AEs) included hemorrhage or hypotension; incidence of common hemorrhagic AEs (including pulmonary alveolar [11.8% and 15.6%] and gastrointestinal bleeding [7.8% and 9.4%]) was similar between the defibrotide and control groups, respectively. Defibrotide was associated with significant improvement in day +100 survival and CR rate. The historical-control methodology offers a novel, meaningful approach for phase 3 evaluation of orphan diseases associated with high mortality. This trial was registered at www.clinicaltrials.gov as #.
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Affiliation(s)
- Paul G Richardson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Marcie L Riches
- Division of Hematology/Oncology, University of North Carolina Hospitals, Bone Marrow and Stem Cell Transplant Clinic, University of North Carolina Cancer Hospital, Chapel Hill, NC
| | - Nancy A Kernan
- Pediatric Bone Marrow Transplant Service, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Joel A Brochstein
- Department of Pediatrics, Stem Cell Transplant Program, Cohen Children's Medical Center, New Hyde Park, NY
| | - Shin Mineishi
- Division of Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Amanda M Termuhlen
- Division of Pediatric Hematology, Oncology, Blood and Marrow Transplantation, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sally Arai
- Blood and Marrow Transplantation, Stanford University Medical Center, Stanford, CA
| | - Stephan A Grupp
- Pediatric Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Eva C Guinan
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Hematology/Oncology, Children's Hospital, Boston, MA
| | - Paul L Martin
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, NC
| | - Gideon Steinbach
- Gastroenterology Division, University of Washington School of Medicine and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Amrita Krishnan
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Eneida R Nemecek
- Pediatric Bone Marrow Transplant Program, Oregon Health and Science University, Portland, OR
| | - Sergio Giralt
- Adult Bone Marrow Transplant Service, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Tulio Rodriguez
- Hematology/Oncology, Loyola University Medical Center, Chicago, IL
| | - Reggie Duerst
- Stem Cell Transplant Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - John Doyle
- Pediatric Hematology/Oncology, CancerCare Manitoba and the University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joseph H Antin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Angela Smith
- Division of Blood and Marrow Transplantation, University of Minnesota, Minneapolis, MN
| | - Leslie Lehmann
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA; Department of Hematology/Oncology, Children's Hospital, Boston, MA
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, The University of Texas, Houston, TX
| | - Alfred Gillio
- Department of Pediatrics, Hackensack University Medical Center, Hackensack, NJ
| | - Rajinder Bajwa
- Department of Hematology/Oncology/BMT, The Ohio State University/Nationwide Children's Hospital, Columbus, OH
| | | | - Joseph Massaro
- Department of Mathematics and Statistics, Boston University, Boston, MA
| | - Diane Warren
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Robin L Hume
- Regulatory Affairs, Jazz Pharmaceuticals, Palo Alto, CA
| | | | - Bijan Nejadnik
- Research and Clinical Development, Galena Biopharma, San Ramon, CA; and
| | | | - Robert J Soiffer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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18
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Cheuk DKL, Chiang AKS, Ha SY, Chan GCF, Cochrane Haematological Malignancies Group. Interventions for prophylaxis of hepatic veno-occlusive disease in people undergoing haematopoietic stem cell transplantation. Cochrane Database Syst Rev 2015; 2015:CD009311. [PMID: 26017019 PMCID: PMC10891422 DOI: 10.1002/14651858.cd009311.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hepatic veno-occlusive disease (VOD) is a severe complication after haematopoietic stem cell transplantation (HSCT). Different drugs with different mechanisms of action have been tried in HSCT recipients to prevent hepatic VOD. However, it is uncertain whether high-quality evidence exists to support any prophylactic therapy. OBJECTIVES We aimed to determine the effects of various prophylactic therapies on the incidence of hepatic VOD, overall survival, mortality, quality of life (QOL), and the safety of these therapies in people undergoing HSCT. SEARCH METHODS We searched the Cochrane Central Registe of Controlled Trials (CENTRAL), MEDLINE, EMBASE, conference proceedings of three international haematology-oncology societies and two trial registries in January 2015, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing prophylactic therapies with placebo or no treatment, or comparing different therapies for hepatic VOD in people undergoing HSCT. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 14 RCTs. Four trials (612 participants) compared ursodeoxycholic acid with or without additional treatment versus placebo or no treatment or same additional treatment. Two trials (259 participants) compared heparin with no treatment. Two trials (106 participants) compared low molecular weight heparin (LMWH) with placebo or no treatment. One trial (360 participants) compared defibrotide with no treatment. One trial (34 participants) compared glutamine with placebo. Two trials (383 participants) compared fresh frozen plasma (FFP) with or without additional treatment versus no treatment or same additional treatment. One trial (30 participants) compared antithrombin III with heparin versus heparin. One trial compared heparin (47 participants) with LMWH (46 participants) and prostaglandin E1 (PGE1) (47 participants). No trial investigated the effects of danaparoid. The RCTs included participants of both genders with wide age range and disease spectrum undergoing autologous or allogeneic HSCT. Funding was provided by government sources (two studies), research fund (one study), pharmaceutical companies that manufactured defibrotide and ursodeoxycholic acid (two studies), or unclear source (nine studies). All RCTs had high risk of bias because of lack of blinding of participants and study personnel, or other risks of bias (mainly differences in baseline characteristics of comparison groups).Results showed that ursodeoxycholic acid may reduce the incidence of hepatic VOD (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.40 to 0.88; number needed to treat for an additional beneficial outcome (NNTB) 15, 95% CI 7 to 50, low quality of evidence), but there was no evidence of difference in overall survival (hazard ratio (HR) 0.83, 95% CI 0.59 to 1.18, low quality of evidence). It may reduce all-cause mortality (RR 0.70, 95% CI 0.50 to 0.99; NNTB 17, 95% CI 8 to 431, low quality of evidence) and mortality due to hepatic VOD (RR 0.27, 95% CI 0.09 to 0.87; NNTB 34, 95% CI 16 to 220, very low quality of evidence). There was no evidence of difference in the incidence of hepatic VOD between treatment and control groups for heparin (RR 0.47, 95% CI 0.18 to 1.26, very low quality of evidence), LMWH (RR 0.27, 95% CI 0.06 to 1.18, very low quality of evidence), defibrotide (RR 0.62, 95% CI 0.38 to 1.02, low quality of evidence), glutamine (no hepatic VOD in either group, very low quality of evidence), FFP (RR 0.66, 95% CI 0.20 to 2.17, very low quality of evidence), antithrombin III (RR 0.13, 95% CI 0.01 to 2.15, very low quality of evidence), between heparin and LMWH (RR 1.96, 95% CI 0.80 to 4.77, very low quality of evidence), between heparin and PGE1 (RR 1.20, 95% CI 0.58 to 2.50, very low quality of evidence), and between LMWH and PGE1 (RR 0.61, 95% CI 0.24 to 1.55, very low quality of evidence). There was no evidence of difference in survival between treatment and control groups for heparin (92.6% vs. 88.7%) and defibrotide (HR 1.04, 95% CI 0.54 to 2.02, low quality of evidence). There were no data on survival for trials of LMWH, glutamine, FFP, antithrombin III, between heparin and LMWH, between heparin and PGE1, and between LMWH and PGE1. There were no data on quality of life (QoL) for any trials. Eleven trials reported adverse events. There was no evidence of difference in the frequency of adverse events between treatment and control groups except for one trial showing that defibrotide resulted in more adverse events compared with no treatment (RR 18.79, 95% CI 1.10 to 320.45). These adverse events included coagulopathy, gastrointestinal disorders, haemorrhage and microangiopathy. The quality of evidence was low or very low due to bias of study design, and inconsistent and imprecise results. AUTHORS' CONCLUSIONS There is low or very low quality evidence that ursodeoxycholic acid may reduce the incidence of hepatic VOD, all-cause mortality and mortality due to VOD in HSCT recipients. However, the optimal regimen is not well-defined. There is insufficient evidence to support the use of heparin, LMWH, defibrotide, glutamine, FFP, antithrombin III, and PGE1. Further high-quality RCTs are needed.
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Affiliation(s)
- Daniel KL Cheuk
- The University of Hong Kong, Queen Mary HospitalDepartment of Pediatrics and Adolescent MedicinePokfulam RoadHong Kong SARChina
| | - Alan KS Chiang
- The University of Hong Kong, Queen Mary HospitalDepartment of Pediatrics and Adolescent MedicinePokfulam RoadHong Kong SARChina
| | - Shau Yin Ha
- The University of Hong Kong, Queen Mary HospitalDepartment of Pediatrics and Adolescent MedicinePokfulam RoadHong Kong SARChina
| | - Godfrey CF Chan
- The University of Hong Kong, Queen Mary HospitalDepartment of Pediatrics and Adolescent MedicinePokfulam RoadHong Kong SARChina
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19
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Seifert C, Wittig S, Arndt C, Gruhn B. Heparanase polymorphisms: influence on incidence of hepatic sinusoidal obstruction syndrome in children undergoing allogeneic hematopoietic stem cell transplantation. J Cancer Res Clin Oncol 2015; 141:877-85. [PMID: 25335953 DOI: 10.1007/s00432-014-1857-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/11/2014] [Indexed: 12/29/2022]
Abstract
PURPOSE Sinusoidal obstruction syndrome (SOS) is a life-threatening early complication after hematopoietic stem cell transplantation (HSCT), and until now, examinations about the influence of genetic risk factors are extremely rare. The purpose of this study was to identify an association between heparanase (HPSE) single nucleotide polymorphisms (SNPs) and SOS in children undergoing allogeneic HSCT. METHODS We retrospectively analyzed the distribution of the both HPSE SNPs rs4693608 and rs4364254 and the occurrence of SOS after allogeneic HSCT in 160 children with malignant and non-malignant diseases. RESULTS Patients with HPSE genotypes GG or AG of rs4693608 (G>A) had a significantly reduced incidence of SOS on day 100 after HSCT compared to patients with genotype AA (4.7 vs. 14.3 %, P = 0.038). In addition, incidence of SOS in patients with genotype CC or CT of rs4364254 (C>T) was significantly decreased in comparison with patients with genotype TT (2.3 vs. 14.7 %, P = 0.004). Interestingly, no patient with genotype CC developed SOS. Because both SNPs co-occur in vivo, we generated subsets: AA-TT, GG-CC, and a group with remaining SNP combinations. We found significant differences between all three patient groups (P = 0.035). Patients with AA-TT showed the highest incidence of SOS (16.7 %), while SOS did not appear in patients with GG-CC (0 %) and residual combinations were numerically in-between (4.9 %). An impact caused by main patient and donor characteristics, established risk factors for SOS, and conditioning regimen could be excluded in multivariate analyses. CONCLUSIONS HPSE polymorphisms turned out to be significant independent risk factors (P = 0.030) for development of SOS and should be evaluated in further trials.
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Affiliation(s)
- Claudia Seifert
- Section for Hematology and Oncology, Department of Pediatrics, Jena University Hospital, Kochstraße 2, 07740, Jena, Germany
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20
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Smith FO, Reaman GH, Racadio JM. Pulmonary and Hepatic Complications of Hematopoietic Cell Transplantation. ACTA ACUST UNITED AC 2013. [PMCID: PMC7123560 DOI: 10.1007/978-3-642-39920-6_5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
| | | | - Judy M. Racadio
- Division of Hematology/Oncology, Dept. of Internal Medicine, University of Cincinnati College of Medicine, Madeira, Ohio USA
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21
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Mateos MK, O’Brien TA, Oswald C, Gabriel M, Ziegler DS, Cohn RJ, Russell SJ, Barbaric D, Marshall GM, Trahair TN. Transplant-related mortality following allogeneic hematopoeitic stem cell transplantation for pediatric acute lymphoblastic leukemia: 25-year retrospective review. Pediatr Blood Cancer 2013; 60:1520-7. [PMID: 23733511 PMCID: PMC3798104 DOI: 10.1002/pbc.24559] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 03/15/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Over the last 25 years, donor source, conditioning, graft-versus-host disease prevention and supportive care for children undergoing hematopoeitic stem cell transplantation (HSCT) have changed dramatically. HSCT indications for acute lymphoblastic leukemia (ALL) now include high-risk patients in first and subsequent remission. There is a large burden of infectious and pre-HSCT morbidities, due to myelosuppressive therapy required for remission induction. We hypothesized that, despite these trends, overall survival (OS) had increased. PROCEDURE A retrospective audit of allogeneic pediatric HSCT for ALL was performed in our institution over 25 years. Outcomes for 136 HSCTs were analyzed in three consecutive 8-year periods (Period 1: 1/1/1984-31/8/1992, Period 2: 1/9/1992-30/4/2001, Period 3: 1/5/2001-31/12/2009). RESULTS Despite a significant increase in unrelated donor HSCT, event-free and OS over 25 years improved significantly. (EFS 31.6-64.8%, P = 0.0027; OS 41.8-78.9%, P < 0.0001) Concurrently, TRM dropped from 33% to 5% (P = 0.0004) whilst relapse rate was static (P = 0.07). TRM reduced significantly for matched sibling and unrelated cord blood transplantation (UCT) in Period 3 compared with earlier periods (P = 0.036, P = 0.0098, respectively). Factors leading to improved survival in patients undergoing UCT include better matching, higher total nucleated cell doses, and significantly faster neutrophil engraftment. Length of initial HSCT admission was similar over time. CONCLUSION EFS and OS have increased significantly despite heightened HSCT complexity. This survival gain was due to TRM reduction. Contemporary patients have benefited from refined donor selection and improved supportive care. Overall rates of leukemic relapse post-HSCT are unchanged, and remain the focus for improvement.
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Affiliation(s)
- Marion K Mateos
- Kids Cancer Centre, Sydney Children’s HospitalRandwick, NSW, Australia,School of Women and Children’s Health, University of New South WalesNSW, Australia
| | - Tracey A O’Brien
- Kids Cancer Centre, Sydney Children’s HospitalRandwick, NSW, Australia,School of Women and Children’s Health, University of New South WalesNSW, Australia
| | - Cecilia Oswald
- Kids Cancer Centre, Sydney Children’s HospitalRandwick, NSW, Australia
| | | | - David S Ziegler
- Kids Cancer Centre, Sydney Children’s HospitalRandwick, NSW, Australia,School of Women and Children’s Health, University of New South WalesNSW, Australia
| | - Richard J Cohn
- Kids Cancer Centre, Sydney Children’s HospitalRandwick, NSW, Australia,School of Women and Children’s Health, University of New South WalesNSW, Australia
| | - Susan J Russell
- Kids Cancer Centre, Sydney Children’s HospitalRandwick, NSW, Australia,School of Women and Children’s Health, University of New South WalesNSW, Australia
| | - Draga Barbaric
- Kids Cancer Centre, Sydney Children’s HospitalRandwick, NSW, Australia
| | - Glenn M Marshall
- Kids Cancer Centre, Sydney Children’s HospitalRandwick, NSW, Australia,School of Women and Children’s Health, University of New South WalesNSW, Australia
| | - Toby N Trahair
- Kids Cancer Centre, Sydney Children’s HospitalRandwick, NSW, Australia,School of Women and Children’s Health, University of New South WalesNSW, Australia,* Correspondence to: Toby N. Trahair, Pediatric Hematologist/Oncologist Sydney Children’s Hospital, Randwick, NSW, Australia 2031., E-mail:
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22
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Corbacioglu S, Kernan N, Lehmann L, Brochstein J, Revta C, Grupp S, Martin P, Richardson PG. Defibrotide for the treatment of hepatic veno-occlusive disease in children after hematopoietic stem cell transplantation. Expert Rev Hematol 2012; 5:291-302. [PMID: 22780209 DOI: 10.1586/ehm.12.18] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hepatic veno-occlusive disease (VOD) is a serious complication of stem cell transplantation in children. VOD is characterized by rapid weight gain, hepatomegaly, hyperbilirubinemia and ascites. The pathogenesis of VOD is thought to involve chemotherapy and radiation-induced damage to the sinusoidal endothelium, resulting in endothelial injury, microthrombosis, subendothelial damage and cytokine activation. These processes lead to concomitant progressive hepatocellular dysfunction and subsequent fluid retention and renal impairment. Severe VOD is typically associated with multiorgan failure and high mortality. A number of possible strategies for the prevention and/or treatment of VOD in children have been investigated. The most promising agent to date is defibrotide, a novel polydeoxyribonucleotide with fibrinolytic properties but no major bleeding risk. Numerous studies, including Phase II/III trials, have shown clinical benefit in pediatric patients with the use of defibrotide treatment and prophylaxis. This review discusses VOD in children and focuses on therapeutic options, including defibrotide, in this patient population.
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23
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Richardson PG, Ho VT, Cutler C, Glotzbecker B, Antin JH, Soiffer R. Hepatic veno-occlusive disease after hematopoietic stem cell transplantation: novel insights to pathogenesis, current status of treatment, and future directions. Biol Blood Marrow Transplant 2012; 19:S88-90. [PMID: 23089567 DOI: 10.1016/j.bbmt.2012.10.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- P G Richardson
- Division of Hematologic Malignancy, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA.
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Hepatic veno-occlusive disease with immunodeficiency (VODI): first reported case in the U.S. and identification of a unique mutation in Sp110. Clin Immunol 2012; 145:102-7. [PMID: 22982295 DOI: 10.1016/j.clim.2012.07.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Revised: 07/26/2012] [Accepted: 07/28/2012] [Indexed: 11/21/2022]
Abstract
Familial hepatic veno-occlusive disease with immunodeficiency (VODI, OMIM: 235550), a rare form of severe combined immune deficiency, was first described in Australian Lebanese patients as being associated with homozygous mutations in SP110, a gene encoding a PML nuclear body-associated protein. We present the first case of confirmed VODI in the United States, and identify the first novel missense mutation in SP110. The 3-year-old daughter of Hispanic parents without known consanguinity presented at age 5 months with fever, hepatomegaly, and pancytopenia. Her brother died at age 3 months from hepatic failure of undetermined etiology. Initial T- and B-cell counts were low, but eventually normalized. Serum IgG and IgM levels were low for age. Lymphoproliferation to mitogens and allogenic B-cells was normal, but absent to tetanus and candida antigens. Serum antibody levels against pneumococcal, Hib and tetanus antigens were low. Liver biopsies at ages 5 and 9 months were consistent with hepatic veno-occlusive disease or hVOD (also known as sinusoidal obstruction syndrome or SOS) and broncho-alveolar lavage detected Pneumocystis jiroveci. The patient recovered from her acute disease and has been clinically stable on immunoglobulin replacement therapy and trimethoprim-sulfamethoxazole prophylaxis. T-Cell receptor excision circle (TREC) analysis suggests that VODI will not be detected by newborn screening for severe combined immunodeficiency that relies on this assay. DNA was obtained from the patient, 4 siblings, and both parents, and SP110 was sequenced. The first missense mutation, a homozygous deletion/insertion variation in exon 2 (NM_080424.2 (SP110):c.78_79delinsAT) was detected in the patient. This novel mutation segregated in the heterozygous state in other living unaffected family members. The mechanism by which this SP110 mutation associates with VODI is consistent with the normal length mutated SP110 protein being subject to enhanced proteosome degradation resulting in marked reductions in SP110 protein.
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25
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Richardson PG, Ho VT, Giralt S, Arai S, Mineishi S, Cutler C, Antin JH, Stavitzski N, Niederwieser D, Holler E, Carreras E, Soiffer R. Safety and efficacy of defibrotide for the treatment of severe hepatic veno-occlusive disease. Ther Adv Hematol 2012; 3:253-65. [PMID: 23606935 PMCID: PMC3627330 DOI: 10.1177/2040620712441943] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome, is a potentially life-threatening complication of chemotherapeutic conditioning used in preparation for hematopoietic stem-cell transplantation (SCT). VOD may occur in up to 62% of patients undergoing SCT, with onset generally within the first month after SCT. In severe cases, 100-day mortality is in excess of 80%. Current management consists of best supportive care, with no agents to date approved for treatment in the USA or the EU. Defibrotide, a polydisperse oligonucleotide, has been shown in phase II and III trials to improve complete response and survival in patients undergoing SCT with severe VOD. This article reviews our current understanding of VOD, and examines recent clinical findings on defibrotide for the treatment and prophylaxis of VOD.
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Affiliation(s)
- Paul G Richardson
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02115, USA
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26
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Cheuk DK. Hepatic veno-occlusive disease after hematopoietic stem cell transplantation: Prophylaxis and treatment controversies. World J Transplant 2012; 2:27-34. [PMID: 24175193 PMCID: PMC3782230 DOI: 10.5500/wjt.v2.i2.27] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Revised: 10/18/2011] [Accepted: 03/20/2012] [Indexed: 02/05/2023] Open
Abstract
Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome, is a major complication of hematopoietic stem cell transplantation and it carries a high mortality. Prophylaxis for hepatic VOD is commonly given to transplant recipients from the start of conditioning through the early weeks of transplant. However, high quality evidence from randomized controlled trials is scarce with small sample sizes and the trials yielded conflicting results. Although various treatment options for hepatic VOD are available, most have not undergone stringent evaluation with randomized controlled trial and therefore it remains uncertain which treatment offers real benefit. It remains controversial whether VOD prophylaxis should be given, which prophylactic therapy should be given, who should receive prophylaxis, and what treatment should be offered once VOD is established.
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Affiliation(s)
- Daniel Kl Cheuk
- Daniel KL Cheuk, Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, China
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27
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Wong KM, Atenafu EG, Kim D, Kuruvilla J, Lipton JH, Messner H, Gupta V. Incidence and risk factors for early hepatotoxicity and its impact on survival in patients with myelofibrosis undergoing allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 2012; 18:1589-99. [PMID: 22531490 DOI: 10.1016/j.bbmt.2012.04.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 04/17/2012] [Indexed: 11/30/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is commonly associated with hepatic complications. Patients with myelofibrosis (MF) often develop liver dysfunction in the early posttransplantation period; however, this has not yet been studied in a systematic fashion. We retrospectively evaluated 53 patients with MF who underwent HCT to assess the prevalence of acute liver toxicity and risk factors and the impact on survival. We compared the prevalence of acute hepatic complications in that group and a matched control group of 53 patients with myelodysplastic syndrome (MDS). In the MF group, during the first 6 weeks after HCT, the incidence of mild (34.2-102.6 μM), moderate (102.6-342 μM), and severe (>342 μM) hyperbilirubinemia was 34%, 40%, and 4%, respectively (normal, <22 μM). The incidence of mild/moderate transaminitis (2-10 times the upper limit of normal) was 23%, and that of severe transaminitis (>10 times the upper limit of normal) was 6%. Veno-occlusive disease as defined by the Baltimore criteria was observed in 19 patients (36%) in the MF group. Compared with MDS, MF was associated with a significantly higher incidence of moderate/severe hyperbilirubinemia (44% versus 21%; P = .02) and veno-occlusive disease (36% versus 19%; P = .05). A history of portal hypertension, biopsy-proven hepatic iron overload, or splanchnic vein thrombosis was a strong predictor of moderate/severe hyperbilirubinemia (P = .02). Acute hepatocellular injury with moderate/severe hyperbilirubinemia or transaminitis was associated with inferior survival at 12 months (P = .02) in the MF group. We conclude that patients with MF are at significant risk of early hepatotoxicity after HCT, which is associated with an adverse impact on survival.
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Affiliation(s)
- Kit Man Wong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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28
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Corbacioglu S, Cesaro S, Faraci M, Valteau-Couanet D, Gruhn B, Rovelli A, Boelens JJ, Hewitt A, Schrum J, Schulz AS, Müller I, Stein J, Wynn R, Greil J, Sykora KW, Matthes-Martin S, Führer M, O'Meara A, Toporski J, Sedlacek P, Schlegel PG, Ehlert K, Fasth A, Winiarski J, Arvidson J, Mauz-Körholz C, Ozsahin H, Schrauder A, Bader P, Massaro J, D'Agostino R, Hoyle M, Iacobelli M, Debatin KM, Peters C, Dini G. Defibrotide for prophylaxis of hepatic veno-occlusive disease in paediatric haemopoietic stem-cell transplantation: an open-label, phase 3, randomised controlled trial. Lancet 2012; 379:1301-9. [PMID: 22364685 DOI: 10.1016/s0140-6736(11)61938-7] [Citation(s) in RCA: 265] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hepatic veno-occlusive disease is a leading cause of morbidity and mortality after haemopoietic stem-cell transplantation (HSCT). We aimed to assess whether defibrotide can reduce the incidence of veno-occlusive disease in this setting. METHODS In our phase 3 open-label, randomised controlled trial, we enrolled patients at 28 European university hospitals or academic medical centres. Eligible patients were younger than 18 years, had undergone myeloablative conditioning before allogeneic or autologous HSCT, and had one or more risk factor for veno-occlusive disease based on modified Seattle criteria. We centrally assigned eligible participants on the basis of a computer-generated randomisation sequence (1:1), stratified by centre and presence of osteopetrosis, to receive intravenous defibrotide prophylaxis (treatment group) or not (control group). The primary endpoint was incidence of veno-occlusive disease by 30 days after HSCT, adjudicated by a masked, independent review committee, in eligible patients who consented to randomisation (intention-to-treat population), and was assessed with a competing risk approach. Patients in either group who developed veno-occlusive disease received defibrotide for treatment. We assessed adverse events to 180 days after HSCT in all patients who received allocated prophylaxis. This trial is registered with ClinicalTrials.gov, number NCT00272948. FINDINGS Between Jan 25, 2006, and Jan 29, 2009, we enrolled 356 eligible patients to the intention-to-treat population. 22 (12%) of 180 patients randomly allocated to the defibrotide group had veno-occlusive disease by 30 days after HSCT compared with 35 (20%) of 176 controls (risk difference -7·7%, 95% CI -15·3 to -0·1; Z test for competing risk analysis p=0·0488; log-rank test p=0·0507). 154 (87%) of 177 patients in the defibrotide group had adverse events by day 180 compared with 155 (88%) of 176 controls. INTERPRETATION Defibrotide prophylaxis seems to reduce incidence of veno-occlusive disease and is well tolerated. Thus, such prophylaxis could present a useful clinical option for this serious complication of HSCT. FUNDING Gentium SpA, European Group for Blood and Marrow Transplantation.
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29
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Zhang L, Wang Y, Huang H. Defibrotide for the prevention of hepatic veno-occlusive disease after hematopoietic stem cell transplantation: a systematic review. Clin Transplant 2012; 26:511-9. [PMID: 22428954 DOI: 10.1111/j.1399-0012.2012.01604.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2012] [Indexed: 12/12/2022]
Abstract
Prophylactic use of defibrotide (DF) to prevent veno-occlusive disease (VOD), a relatively common and high-risk complication of hematopoietic stem cell transplantation (HSCT), may be an encouraging modality to reduce morbidity and mortality from VOD. However, conclusions remain unclear. We carried out a systematic review to summarize the state of knowledge. One randomized controlled trial (RCT), four cohort studies and eight case series studies were found, including a total of 1230 patients. The overall mean incidence of VOD in patients using DF was 4.7% (95% CI, 3.3-6.1) which was significantly lower than the data 13.7% (95% CI, 13.3-14.1) across 135 studies using no VOD prophylaxis (p < 0.005). The meta-analysis of the incidence of VOD in controlled trials revealed a statistical reduction in VOD incidence in the DF group (RR = 0.47, 95% CI, 0.31-0.73). The overall mean incidence of severe VOD was 0.8% (95% CI, 0.2-1.4). The RR was 0.31 (95% CI, 0.09-1.06). However, the lack of RCTs and the methodological weaknesses of the studies may preclude making generalizable conclusions. Our review described that DF appears promising for VOD prevention and large RCT is needed for further confirmation.
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Affiliation(s)
- Lifei Zhang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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30
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Barba P, Martino R, Perez-Simón JA, Fernández-Avilés F, Piñana JL, Valcárcel D, Campos-Varela I, Lopez-Anglada L, Rovira M, Novelli S, Lopez-Corral L, Carreras E, Sierra J. Incidence, characteristics and risk factors of marked hyperbilirubinemia after allogeneic hematopoietic cell transplantation with reduced-intensity conditioning. Bone Marrow Transplant 2012; 47:1343-9. [PMID: 22388280 DOI: 10.1038/bmt.2012.25] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To analyze the incidence, characteristics and risk factors of hyperbilirubinemia after allogeneic hematopoietic cell transplantation with reduced-intensity conditioning (allo-RIC), we conducted a retrospective study in three Spanish centers. We analyzed 452 consecutive patients receiving allo-RIC. Of these, 92 patients (20%) developed marked hyperbilirubinemia (>4 mg/day or >68.4 μM) after allo-RIC. The main causes of marked hyperbilirubinemia after transplant were cholestasis due to GVHD or sepsis (n=57, 62%) and drug-induced cholestasis (n=13, 14%). A total of 22 patients with marked hyperbilirubinemia (24%) underwent liver biopsy. The most frequent histological finding was iron overload alone (n=6) or in combination with other features (n=6). In multivariate analysis, the risk factors for marked hyperbilirubinemia after allo-RIC were non-HLA-identical sibling donors (hazard ratio (HR) 2.2 (95% confidence interval (CI) 1.4-3.6) P=0.001), female donors to male recipients (HR 2.1 (95% CI 1.3-3.3) P=0.003) and high levels of bilirubin and γ-glutamyl transpeptidase before transplant (HR 4.5 (95% CI 2.5-8.4) P<0.001 and HR 4.6 (95% CI 2.6-8.1) P<0.001, respectively). Patients with marked hyperbilirubinemia showed higher 4-year nonrelapse mortality (HR 1.3 (95% CI 1-1.7), P=0.02) and lower 4-year OS (HR 1.4 (95%CI 1.3-1.7), P<0.001) than patients without. In conclusion, we confirm that marked hyperbilirubinemia is frequent and diverse after allo-RIC. Development of marked hyperbilirubinemia after allo-RIC is associated with worse outcome of the procedure.
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Affiliation(s)
- P Barba
- Department of Hematology, Hospital de la Santa Creu i Sant Pau de Barcelona, Barcelona, Spain.
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Abstract
INTRODUCTION Defibrotide is a polydisperse oligonucleotide obtained from porcine intestinal mucosa and prepared by controlled depolymerization of DNA. It is a nucleic acid polymer, predominantly single-stranded, which has anti-ischemic and anti-thrombotic properties. AREAS COVERED The efficacy and safety of defibrotide in the treatment of veno-occlusive disease (VOD) occurring after high-dose chemotherapy and hematopoietic stem-cell transplantation is now well established in Phase II - III trials. A recent randomized, Phase III trial in pediatric patients has also demonstrated its role in the prevention of VOD. Preclinical studies reported the inhibitory effects of defibrotide on myeloma cells' growth through an antiangiogenic action and a regulation of the tumor-microenvironment interactions. A recent Phase II trial underlines the efficacy and safety of defibrotide-thalidomide-melphalan combination in the treatment of relapsed/refractory multiple myeloma. EXPERT OPINION Defibrotide may be effective in the prophylaxis and the treatment of veno-occlusive disease. Recent experimental results suggest that defibrotide may belong to the new generation of anti-cancer drugs that can prevent tumor angiogenesis. In multiple myeloma, defibrotide may overcome the prothrombotic effect of thalidomide on endothelial cells. Further preclinical and clinical investigations are needed to assess the precise role of defibrotide in the treatment of patients with multiple myeloma.
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Cheuk DKL, Chiang AKS, Ha SY, Chan GCF. Interventions for prophylaxis of hepatic veno-occlusive disease in patients undergoing hematopoietic stem cell transplantation. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [DOI: 10.1002/14651858.cd009311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Munchel A, Chen A, Symons H. Emergent Complications in the Pediatric Hematopoietic Stem Cell Transplant Patient. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2011; 12:233-244. [PMID: 25411564 PMCID: PMC4234095 DOI: 10.1016/j.cpem.2011.07.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Hematopoietic cell transplantation is the only potentially curative option for a variety of pediatric malignant and nonmalignant disorders. Despite advances in transplantation biology and immunology as well as in posttransplant management that have contributed to improved survival and decreased transplant-related mortality, hematopoietic cell transplantation does not come without significant risk of complications. When patients who have undergone hematopoietic cell transplantation present to the emergency department, it is important to consider a variety of therapy-related complications to optimize management and outcome. In this article, we use clinical cases to highlight some of the more common emergent complications after hematopoietic cell transplantation.
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Affiliation(s)
- Ashley Munchel
- Pediatric Hematology/Oncology, The Johns Hopkins Hospital, Baltimore, MD
- Pediatric Oncology Branch at the National Institutes of Health, Bethesda, MD
| | - Allen Chen
- Division of Oncology, Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital, Baltimore, MD
- Division of Pediatrics, Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital, Baltimore, MD
| | - Heather Symons
- Division of Oncology, Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital, Baltimore, MD
- Division of Pediatrics, Sidney Kimmel Comprehensive Cancer Center at The Johns Hopkins Hospital, Baltimore, MD
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Cefalo MG, Maurizi P, Arlotta A, Scalzone M, Attinà G, Ruggiero A, Riccardi R. Hepatic veno-occlusive disease: a chemotherapy-related toxicity in children with malignancies. Paediatr Drugs 2010; 12:277-284. [PMID: 20799757 DOI: 10.2165/11531840-000000000-00000] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Hepatic veno-occlusive disease (VOD) is a major manifestation of liver toxicity associated with conventional and high-dose chemotherapy in children affected by hematologic malignancies and certain solid tumors. Clinically, patients present with jaundice, painful hepatomegaly, and fluid retention, which may evolve into multi-organ failure, a hallmark of severe disease. The pathogenesis is complex and not completely understood, but the damage to sinusoidal endothelium, typically caused by toxic metabolites released from antineoplastic drugs, is thought to play a crucial role, together with cytokine activation, immune deregulation, and coagulopathy. Diagnosis is based on clinical criteria supported by characteristic ultrasound findings, with the gold standard investigation being hepatic-venous pressure gradient measurement and biopsy. Several treatment options have been tested; the most convincing approach to date is the use of defibrotide, a novel oligonucleotide with antithrombotic and antiplatelet aggregating properties, as well as endothelial-stabilizing effects. This agent, together with other specific forms of supportive care, has shown efficacy in the treatment of established VOD and promising results in the prevention of VOD in pediatric patients receiving chemotherapy.
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Lakshminarayanan S, Sahdev I, Goyal M, Vlachos A, Atlas M, Lipton JM. Low incidence of hepatic veno-occlusive disease in pediatric patients undergoing hematopoietic stem cell transplantation attributed to a combination of intravenous heparin, oral glutamine, and ursodiol at a single transplant institution. Pediatr Transplant 2010; 14:618-21. [PMID: 20051023 DOI: 10.1111/j.1399-3046.2009.01285.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
We report the low incidence of hepatic VOD in pediatric patients with various diagnoses including hematologic malignancies and non-malignant conditions transplanted at our institution. Retrospective review of 188 patients who underwent HSCT and received a combined prophylactic regimen of intravenous heparin, oral glutamine, and ursodiol was undertaken. Analysis of the outcome of VOD revealed only one clinical case with acute myeloid leukemia; the patient developed hepatic VOD 10 days after receiving myeloablative chemotherapy with busulfan and CTX followed by HLA-matched related peripheral blood stem cell transplantation. The low incidence of hepatic VOD in an otherwise high-risk pediatric transplant population is an important observation, which may be partly attributed to this prophylactic regimen, and warrants further randomized clinical trials for confirmation.
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Affiliation(s)
- Sonali Lakshminarayanan
- Division of Pediatric Hematology/Oncology and Stem Cell Transplantation, Schneider Children's Hospital, North Shore-Long Island Jewish Health System, New Hyde Park, NY 11040, USA
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Richardson PG, Soiffer RJ, Antin JH, Uno H, Jin Z, Kurtzberg J, Martin PL, Steinbach G, Murray KF, Vogelsang GB, Chen AR, Krishnan A, Kernan NA, Avigan DE, Spitzer TR, Shulman HM, Di Salvo DN, Revta C, Warren D, Momtaz P, Bradwin G, Wei LJ, Iacobelli M, McDonald GB, Guinan EC. Defibrotide for the treatment of severe hepatic veno-occlusive disease and multiorgan failure after stem cell transplantation: a multicenter, randomized, dose-finding trial. Biol Blood Marrow Transplant 2010; 16:1005-17. [PMID: 20167278 PMCID: PMC2956581 DOI: 10.1016/j.bbmt.2010.02.009] [Citation(s) in RCA: 175] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2009] [Accepted: 02/09/2010] [Indexed: 12/12/2022]
Abstract
Therapeutic options for severe hepatic veno-occlusive disease (VOD) are limited and outcomes are dismal, but early phase I/II studies have suggested promising activity and acceptable toxicity using the novel polydisperse oligonucleotide defibrotide. This randomized phase II dose-finding trial determined the efficacy of defibrotide in patients with severe VOD following hematopoietic stem cell transplantation (HSCT) and identified an appropriate dose for future trials. Adult and pediatric patients received either lower-dose (arm A: 25 mg/kg/day; n = 75) or higher-dose (arm B: 40 mg/kg/day; n = 74) i.v. defibrotide administered in divided doses every 6 hours for > or =14 days or until complete response, VOD progression, or any unacceptable toxicity occurred. Overall complete response and day +100 post-HSCT survival rates were 46% and 42%, respectively, with no significant difference between treatment arms. The incidence of treatment-related adverse events was low (8% overall; 7% in arm A, 10% in arm B); there was no significant difference in the overall rate of adverse events between treatment arms. Early stabilization or decreased bilirubin was associated with better response and day +100 survival, and decreased plasminogen activator inhibitor type 1 (PAI-1) during treatment was associated with better outcome; changes were similar in both treatment arms. Defibrotide 25 or 40 mg/kg/day also appears effective in treating severe VOD following HSCT. In the absence of any differences in activity, toxicity or changes in PAI-1 level, defibrotide 25 mg/kg/day was selected for ongoing phase III trials in VOD.
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Affiliation(s)
- Paul G Richardson
- Department of Adult Oncology, Harvard Medical School, Boston, MA, USA.
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Cecinati V, Giordano P, De Leonardis F, Grassi M, Arcamone G, De Mattia D, Santoro N. Hepatic veno-occlusive disease during chemotherapy for nephroblastoma: successful and safe treatment with defibrotide. Report of a clinical case. Immunopharmacol Immunotoxicol 2010; 31:702-5. [PMID: 19874245 DOI: 10.3109/08923970903095322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Here we report a case of administration of defibrotide in an 11 months old infant with hepatic veno-occlusive disease during chemotherapy for nephroblastoma. He presented with abdominal distension, a weight gain of 15%, ascites, hepatomegaly with right upper quadrant pain, thrombocytopenia and hypertransaminasemia. Despite therapy, his clinical conditions aggravated, and, therefore intravenous administration of defibrotide on a compassionate-use basis was started. The dosage was 15 mg/kg/day in 4 divided doses, which was increased gradually (in 3 days) to 40 mg/kg/day in 4 divided doses. Defibrotide proved safe and effective in resolving clinical symptoms and normalizing serological findings in the syndrome.
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Affiliation(s)
- Valerio Cecinati
- Division of Pediatric Oncology-Hematology, Department of Biomedicine in Childhood, University of Bari, Bari, Italy
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Ozyilmaz E, Aydogdu M, Sucak G, Aki SZ, Ozkurt ZN, Yegin ZA, Kokturk N. Risk factors for fungal pulmonary infections in hematopoietic stem cell transplantation recipients: the role of iron overload. Bone Marrow Transplant 2010; 45:1528-33. [DOI: 10.1038/bmt.2009.383] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Lee SH, Yoo KH, Sung KW, Koo HH, Kwon YJ, Kwon MM, Park HJ, Park BK, Kim YY, Park JA, Im HJ, Seo JJ, Kang HJ, Shin HY, Ahn HS. Hepatic veno-occlusive disease in children after hematopoietic stem cell transplantation: incidence, risk factors, and outcome. Bone Marrow Transplant 2009; 45:1287-93. [PMID: 20010866 DOI: 10.1038/bmt.2009.349] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Four hundred and sixty-seven hematopoietic stem cell transplantations (HSCTs) (217 autologous and 250 allogeneic HSCT) were performed in 374 children at four pediatric HSCT centers in Korea from January 2005 to December 2007. Among 467 transplants, veno-occlusive disease (VOD) developed in 72 transplants (15.4%) at a median of 10 days after HSCT. Multivariate analysis showed that BU or TBI-containing regimen (P=0.002), VOD prophylaxis without lipo-prostaglandin E1 (PGE1) (P=0.012), number of previous HSCT (P=0.014), and pretransplant serum ferritin (P=0.018) were independent risk factors for developing VOD. Mean serum ferritin levels were significantly higher in HSCT with VOD (2109.6+/-2842.5 ng/ml) than in HSCT without VOD (1315.9+/-1094.4 ng/ml) (P<0.001). The relative risk of death within 100 days of HSCT in transplants with VOD compared with transplants without VOD was 3.39 (confidence interval: 1.78-6.45). Our results suggest that lipo-PGE1 might have a protective effect against the development of VOD, and pretransplant serum ferritin could act as a risk factor for VOD. A larger prospective study is needed to confirm a possible role of lipo-PGE1 and iron chelation therapy in reducing the incidence of VOD.
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Affiliation(s)
- S H Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Cappelli B, Chiesa R, Evangelio C, Biffi A, Roccia T, Frugnoli I, Biral E, Noè A, Fossati M, Finizio V, Miniero R, Napolitano S, Ferrua F, Soliman C, Ciceri F, Roncarolo MG, Marktel S. Absence of VOD in paediatric thalassaemic HSCT recipients using defibrotide prophylaxis and intravenous Busulphan. Br J Haematol 2009; 147:554-60. [PMID: 19747363 DOI: 10.1111/j.1365-2141.2009.07871.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Hepatic veno-occlusive disease (VOD) is a common complication of haematopoietic stem cell transplantation (HSCT), with reported incidences of 5-40% in children. Recently, defibrotide (DF) has been successfully used as prophylaxis and treatment of VOD. This study reports data on 63 human leucocyte antigen-matched HSCT performed in 57 children affected by beta thalassemia at very high risk for developing VOD (liver fibrosis, iron overload, hepatitis C virus infections, busulphan-based conditioning, methotraexate + ciclosporine). All patients received a busulphan-based conditioning regimen, either orally (four HSCT) or intravenously (59 HSCT). All patients received oral DF (40 mg/kg per day, final dose) as VOD prophylaxis from median day -9 to median day +29. In order to overcome the lack of oral paediatric formulations, a galenic formulation was administered. DF was well tolerated. Only one patient fulfilled Seattle Criteria for VOD diagnosis. This patient had discontinued DF 6 d prior to VOD onset, due to high risk of haemorrhage. We concluded that oral defibrotide prophylaxis and i.v. busulphan safely abated VOD incidence in high-risk patients who had undergone HSCT. A galenic preparation of oral DF also permits this treatment in low-weight patients. Costs of DF prophylaxis are acceptable considering the reduced incidence of VOD.
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Affiliation(s)
- Barbara Cappelli
- Pediatric Immunohematology and Bone Marrow Transplantation Unit, San Raffaele Scientific Institute, Milan, Italy
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Morabito F, Gentile M, Gay F, Bringhen S, Mazzone C, Vigna E, Musto P, Di Raimondo F, Palumbo A. Insights into defibrotide: an updated review. Expert Opin Biol Ther 2009; 9:763-72. [PMID: 19456210 DOI: 10.1517/14712590903008507] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Defibrotide is a polydisperse oligonucleotide with antiatherosclerotic, anti-inflammatory, anti-ischaemic, pro-fibrinolytic and antithrombotic actions without significant systemic anticoagulant effects. It has been used in the treatment of various cardiovascular disorders, and especially in endothelial complications of allogeneic stem-cell transplantation. We reviewed the published work for the mechanism of action and clinical use of defibrotide to consolidate data and to describe new applications of this drug. We reviewed the most relevant papers on defibrotide published from November 1982 to January 2008. (selected through PubMed), and used recent meeting abstracts as sources for this review. Reports have suggested that defibrotide has clinical efficacy for treatment and prophylaxis of hepatic sinusoidal obstruction syndrome occurring after stem-cell transplantation. Animal models have clearly shown the potential antineoplastic effect of this drug. Further clinical investigations are needed to clarify this new application.
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Affiliation(s)
- F Morabito
- Unità Operativa Complessa di Ematologia, Dipartimento di Medicina Interna, Azienda Ospedaliera di Cosenza, Viale della Repubblica, Cosenza 87100, Italy.
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Cutler C, Stevenson K, Kim HT, Richardson P, Ho VT, Linden E, Revta C, Ebert R, Warren D, Choi S, Koreth J, Armand P, Alyea E, Carter S, Horowitz M, Antin JH, Soiffer R. Sirolimus is associated with veno-occlusive disease of the liver after myeloablative allogeneic stem cell transplantation. Blood 2008; 112:4425-31. [PMID: 18776081 PMCID: PMC2597119 DOI: 10.1182/blood-2008-07-169342] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Accepted: 08/23/2008] [Indexed: 12/19/2022] Open
Abstract
Sirolimus is an effective agent used in graft-versus-host disease (GVHD) prophylaxis after allogeneic transplantation. It also has antiproliferative effects on vascular endothelium when used to coat coronary artery stents. We noted an excess of veno-occlusive disease (VOD) in a clinical trial, and retrospectively reviewed the records of 488 patients to determine the association between sirolimus and VOD. When used with cyclophosphamide/total body irradiation (Cy/TBI) conditioning, sirolimus is associated with an increased incidence of VOD (OR 2.35, P = .005). The concomitant use of methotrexate further increased this rate (OR 3.23, P < .001), while sirolimus without methotrexate was not associated with an increased risk of VOD (OR 1.55, P = .33). Mortality after VOD diagnosis was unaffected, and overall treatment-related mortality was lowest when sirolimus was used without methotrexate. Similar findings were noted in matched, related, and unrelated as well as mismatched donor subgroups. When used with busulfan-based conditioning, sirolimus use was associated with an even higher rate of VOD (OR 8.8, P = .008). Our findings suggest that sirolimus use is associated with VOD after TBI-based transplantation when used with methotrexate after transplantation. Sirolimus-based GVHD prophylaxis without methotrexate is associated with the greatest overall survival. Myeloablative doses of busulfan should not be used with sirolimus-based immunosuppression.
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Affiliation(s)
- Corey Cutler
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA 02115, USA.
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Larocca A, Cavallo F, Magarotto V, Rossi D, Patriarca F, Boccadoro M, Palumbo A. Defibrotide: a review on clinical use and future development. Expert Opin Biol Ther 2008; 8:1201-12. [PMID: 18613771 DOI: 10.1517/14712598.8.8.1201] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Defibrotide is a deoxyribonucleic acid derivative that has been developed for the treatment of different vascular disorders. OBJECTIVE The authors reviewed the literature to give due representation to the spectrum of pharmacological properties and clinical application of this drug, evaluating consolidate and innovative application. METHODS The authors used PubMed from November 1982 to December 2007 and meeting abstracts (form American Society of Hematology Annual Meeting) with updated data as the sources for this review and selecting the most relevant papers when two or more articles covered the same point of interest. CONCLUSIONS Defibrotide has been used effectively in the treatment of endothelial complications of allogeneic stem cell transplantation and recent preclinical evidences suggest an antiangiogenic effect and an anticancer activity. Further in vivo and in vitro investigations are needed.
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Affiliation(s)
- A Larocca
- Divisione di Ematologia dell'Università di Torino, Azienda Ospedaliero Universitaria San Giovanni Battista, Torino, Italy
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Del Toro G. Defibrotide in sinusoidal obstruction syndrome: mounting evidence in pediatric patients (Commentary on Qureshi et al., page 831). Pediatr Blood Cancer 2008; 50:735-6. [PMID: 18286500 DOI: 10.1002/pbc.21470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Gustavo Del Toro
- Jack Martin Division of Pediatric Hematology/Oncology, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1208, New York, New York 10029, USA.
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