Article

The Mexican approach to conduct nonmyeloablative stem cell transplantation should not be overlooked.

International Journal of Hematology (Impact Factor: 1.68). 07/2003; 77(5):526-7. DOI: 10.1007/BF02986624
Source: PubMed
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    ABSTRACT: RESuMEN Durante mucho tiempo se consideró, de manera equívoca, que la razón por la que los trasplantes de médula ósea podían curar a los pacientes con hemopatías malignas era porque permitían la administración de cantidades elevadas de quimioterapia o radiote-rapia y porque la función de las células trasplantadas era sólo la de restablecer la hematopoyesis del paciente después de recibir el tratamiento mieloablativo. Ahora está claro que la razón principal por la que los trasplantes de células hematopoyéticas alogénicas pueden curar a los pacientes con neoplasias es por la inducción del efecto de injerto contra tumor, que es parte del efecto de injerto contra huésped. En el año de 1999 se diseñó en México un método para realizar trasplantes hematopoyéticos, conocido como método mexicano de acondicionamiento no mieloablativo, que utiliza fármacos accesibles y baratos, como la ciclofosfamida, el bu-sulfano y la fludarabina. Con este método se han hecho trasplantes hematopoyéticos en más de 300 pacientes. Cerca de una cuarta parte de los pacientes no necesitó trasfusiones de glóbulos rojos y un tercio de éstos no necesitó trasfusión de plaquetas. En más del 80% de los casos el procedimiento del trasplante pudo completarse de manera extrahospitalaria. La mediana de supervivencia post-trasplante no se ha alcanzado y la supervivencia a 2,000 días es del 54%. La mortalidad a 100 días es del 16% y la mortalidad relacionada con el trasplante del 20%. Los mejores resultados se obtuvieron en la leucemia granulocítica crónica en primera fase crónica (92% de supervivencia a 750 días) y los menos halagüeños en la leucemia aguda linfoblástica (22% de supervivencia a 1,600 días), con cifras intermedias para la leucemia aguda mieloblástica (66% de supervivencia a 860 días) y la anemia aplástica (91% de supervivencia a 1,500 días). El costo promedio de cada trasplante es de 20 mil dólares americanos. Sin embargo, el método mexicano para realizar los trasplantes alogénicos no mieloablativos no se ha escapado del efecto Mateo. Dicho método, que se ha usado en varios países y que ha demostrado tener varias ventajas sobre otros, lo han ignorado de forma deliberada investigadores nacionales e internacionales y también lo han criticado de manera negativa algunos médicos nacionales. Se espera que con el paso del tiempo y con los resultados obtenidos se le pueda ubicar en el lugar que se merece. Palabras clave: trasplante de médula ósea. ABSTRACT Several dogmas have been broken as a consequence of the evolution of knowledge in the area of allogeneic hematopoietic stem cell transplantation. It is now clear that: a) for the successful engraftment of hematopoietic stem cell transplantation bone marrow ablation of the recipient is not required, b) hematopoietic stem cell transplantation create its own space through graft versus host reactions, c) several malignancies can be eradicated by the graft versus tumor effect, d) hematopoietic stem cell allografting can be conducted on an outpatient basis, e) hematopoietic stem cell allografting can be done in aged or debilitated individuals, f) hematopoi-etic stem cell allografting can be achieved without transfusion of blood products, and g) the costs of the allografting procedures can be substantially diminished. The use of non-myeloablative conditioning for stem cell allografting has been the main reason to break these dogmas: using the "Mexican" non-ablative conditioning regimen, we have allografted over 300 individuals in five different Latin American countries. With a median cost of 20,000 US dollars, we have allografted individuals with malignant and benign hematologi-cal diseases. The best results have been obtained in chronic myelogenous leukemia in chronic phase (92% survival at 750 days), whereas the worse results were obtained in relapsed acute lymphoblastic leukemia (22% survival at 1,600 days), with intermediate results for aplastic anemia (91% survival at 1,500 days) and acute myelogenous leukemia (66% survival at 860 days). Despite the fact that hematopoietic stem cell allografting with reduced intensity conditioning may be related with several disadvantages, such as mixed chimerism and relapse of the malignancy, breaking these dogmas has resulted in availability of hematopoietic stem cell allografting to a larger number of individuals worldwide, thus offering true curative therapeutic options to patients who otherwise would not qualify to be given these opportunities. Interestingly, the "Mexican method" to conduct bone marrow transplantation has not escaped the "Matthew effect"; our method, which has been used in several countries, and is endowed with several advantages over other procedures is frequently overlooked in reviews or papers dealing with the topic.
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    ABSTRACT: BACKGROUND: The impact of obesity on hematopoietic stem cell transplantation (HSCT) outcome remains controversial and has been considered a relative contraindication for the procedure. We investigated the influence of Body Mass Index (BMI) on the clinical course of adults undergoing an ambulatory HSCT after a non-myeloablative conditioning regimen. METHODS: Adults with hematologic diseases undergoing an autologous or allogeneic HSCT after reduced intensity conditioning (RIC) and supported exclusively with enteral nutrition (EN) were studied. BMI and body fat were sequentially determined. Patients were divided into three BMI subgroups: underweight; normal, and overweight/obese. RESULTS: Seventy-seven patients with a median follow-up of 21months were evaluated. Fourteen (18.2%) were underweight, 21 (27.3%) had a normal weight, and 42 (54.5%) were overweight/obese. A significant weight loss was observed among all three weight groups after HSCT (P=0.014). No correlation was found between time to engraftment and BMI (P=0.91), serum albumin (P=0.387), and fasting glucose (P=0.64), nor between BMI and acute (P=0.456) or chronic (P=0.209) graft versus host disease (GVHD). On multivariate analysis a higher overall survival (OS) was documented for obese patients (P=0.037). DISCUSSION: A BMI >30/kg/m(2) was independently associated with a higher survival rate after HSCT. Obese patients should not be excluded as transplant candidates based only on this parameter.
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