Allogeneic hematopoietic cell transplantation is indicated for refractory hematologic cancer and some nonmalignant disorders. Survival is limited by recurrent cancer and organ toxicity.
To determine ...whether survival has improved over the past decade and note impediments to better outcomes.
The authors compared cohorts that had transplants during 2003 to 2007 versus 2013 to 2017. Survival outcome measures were analyzed, along with transplant-related complications.
A center performing allogeneic transplant procedures.
All recipients of a first allogeneic transplant during 2003 to 2007 and 2013 to 2017.
Patients received a conditioning regimen, infusion of donor hematopoietic cells, then immunosuppressive drugs and antimicrobial approaches to infection control.
Day-200 nonrelapse mortality (NRM), recurrence or progression of cancer, relapse-related mortality, and overall mortality, adjusted for comorbidity scores, source of donor cells, donor type, patient age, disease severity, conditioning regimen, patient and donor sex, and cytomegalovirus serostatus.
During the 2003-to-2007 and 2013-to-2017 periods, 1148 and 1131 patients, respectively, received their first transplant. Over the decade, decreases were seen in the adjusted hazards of day-200 NRM (hazard ratio HR, 0.66 95% CI, 0.48 to 0.89), relapse of cancer (HR, 0.76 CI, 0.61 to 0.94), relapse-related mortality (HR, 0.69 CI, 0.54 to 0.87), and overall mortality (HR, 0.66 CI, 0.56 to 0.78). The degree of reduction in overall mortality was similar for patients who received myeloablative versus reduced-intensity conditioning, as well as for patients whose allograft came from a matched sibling versus an unrelated donor. Reductions were also seen in the frequency of jaundice, renal insufficiency, mechanical ventilation, high-level cytomegalovirus viremia, gram-negative bacteremia, invasive mold infection, acute and chronic graft-versus-host disease, and prednisone exposure.
Cohort studies cannot determine causality, and current disease severity criteria were not available for patients in the 2003-to-2007 cohort.
Improvement in survival and reduction in complications were substantial after allogeneic transplant. Relapse of cancer remains the largest obstacle to better survival outcomes.
National Institutes of Health.
Coronavirus disease 2019 (COVID‐19) due to infection with severe acute respiratory syndrome coronavirus 2 causes substantial morbidity. Tocilizumab, an interleukin‐6 receptor antagonist, might ...improve outcomes by mitigating inflammation. We conducted a retrospective study of patients admitted to the University of Washington Hospital system with COVID‐19 and requiring supplemental oxygen. Outcomes included clinical improvement, defined as a two‐point reduction in severity on a six‐point ordinal scale or discharge, and mortality within 28 days. We used Cox proportional‐hazards models with propensity score inverse probability weighting to compare outcomes in patients who did and did not receive tocilizumab. We evaluated 43 patients who received tocilizumab and 45 who did not. Patients receiving tocilizumab were younger with fewer comorbidities but higher baseline oxygen requirements. Tocilizumab treatment was associated with reduced C‐reactive protein, fibrinogen, and temperature, but there were no meaningful differences in time to clinical improvement (adjusted hazard ratio aHR, 0.92; 95% confidence interval CI, 0.38–2.22) or mortality (aHR, 0.57; 95% CI, 0.21–1.52). A numerically higher proportion of tocilizumab‐treated patients had subsequent infections, transaminitis, and cytopenias. Tocilizumab did not improve outcomes in hospitalized patients with COVID‐19. However, this study was not powered to detect small differences, and there remains the possibility for a survival benefit.
As more individuals survive their hematologic malignancies after allogeneic hematopoietic stem cell transplantation (HSCT), there is growing appreciation of the late organ complications of this ...curative procedure for malignant and nonmalignant hematologic disorders. Late noninfectious pulmonary complications encompass all aspects of the bronchopulmonary anatomy. There have been recent advances in the diagnostic recognition and management of bronchiolitis obliterans syndrome, which is recognized as a pulmonary manifestation of chronic graft-versus-host disease. Organizing pneumonia and other interstitial lung diseases are increasingly recognized. This article provides an update on these entities as well as pleural and pulmonary vascular disease after allogeneic HSCT.
Parametric response mapping (PRM) is a novel computed tomography (CT) technology that has shown potential for assessment of bronchiolitis obliterans syndrome (BOS) after hematopoietic stem cell ...transplantation (HCT). The primary aim of this study was to evaluate whether variations in image acquisition under real‐world conditions affect the PRM measurements of clinically diagnosed BOS. CT scans were obtained retrospectively from 72 HCT recipients with BOS and graft‐versus‐host disease from Fred Hutchinson Cancer Research Center, Karolinska Institute, and the University of Michigan. Whole lung volumetric scans were performed at inspiration and expiration using site‐specific acquisition and reconstruction protocols. PRM and pulmonary function measurements were assessed. Patients with moderately severe BOS at diagnosis (median forced expiratory volume at 1 second FEV1 53.5% predicted) had similar characteristics between sites. Variations in site‐specific CT acquisition protocols had a negligible effect on the PRM‐derived small airways disease (SAD), that is, BOS measurements. PRM‐derived SAD was found to correlate with FEV1% predicted and FEV1/ forced vital capacity (R = −0.236, P = .046; and R = −0.689, P < .0001, respectively), which suggests that elevated levels in the PRM measurements are primarily affected by BOS airflow obstruction and not CT scan acquisition parameters. Based on these results, PRM may be applied broadly for post‐HCT diagnosis and monitoring of BOS.
Parametric response mapping, a potential indicator of bronchiolitis obliterans syndrome following hematopoietic cell transplant, was examined in a multicenter setting and is shown to be applicable using a variety of high resolution CT scan techniques.
For millions of people, taking immunosuppressive medication to control or prevent disease is a daily reality 1. Rheumatological disease, inflammatory lung disease, organ transplantation and graft-
...versus
-host disease are but a few of the immune dysregulation syndromes that may require short- or long-term immunosuppressive therapy (IST). Patients taking ISTs are frequently regarded as immunocompromised, sharing risks of increased infection susceptibility with cancer patients receiving chemotherapy, those with profound neutropenia from haematological malignancies, and individuals living with HIV. In the context of the immune-mediated respiratory failure associated with coronavirus disease 2019 (COVID-19), an apparent paradox arises: can ISTs both promote and protect against severe COVID-19?
Lessons learned from a large registry analysis show worse COVID-19 outcomes for patients previously exposed to glucocorticoids
https://bit.ly/306rNrk
Acute respiratory distress syndrome and coagulopathy played an important role in morbidity and mortality of severe COVID‐19 patients. A higher frequency of pulmonary embolism (PE) than expected in ...COVID‐19 patients was recently reported. The presenting symptoms for PE were untypical including dyspnea, which is one of the major symptoms in severe COVID‐19, especially in those patients with acute respiratory distress syndrome (ARDS). We reported two COVID‐19 cases with coexisting complications of PE and ARDS, aiming to consolidate the emerging knowledge of this global health emergency and raise the awareness that the hypoxemia or severe dyspnea in COVID‐19 may be related to PE and not necessarily always due to the parenchymal disease.
Highlights
Acute severe COVID‐19 infection can trigger pulmonary embolism. The exact incidence of pulmonary embolism in COVID‐19 patients is still unknown and is likely to be underestimated by the nonspecific presenting symptoms. For COVID‐19 patients, the hypoxemia or severe dyspnea symptoms may be related to PE and not necessarily always due to the parenchymal disease. The patients with persistent dyspnea or hypoxemia later in the course of the disease should prompt an investigation for PE.
Pretransplant pulmonary function tests provide baseline data by which to reference subsequent respiratory impairment, as well as important prognostic information, for the hematopoietic cell ...transplant (HCT) recipient. Abnormalities in forced expiratory volume in 1 second and diffusing capacity of carbon monoxide are associated with early respiratory failure and increased all-cause mortality after allogeneic HCT. These parameters have been incorporated into risk assessment calculators that may aid in clinical decision making. This article discusses the clinical implications of pulmonary function parameters and other risk factors for pulmonary complications in the context of evolving allogeneic HCT practice.
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