Twenty years of unrelated donor hematopoietic cell transplantation for adult recipients facilitated by the National Marrow Donor Program.
ABSTRACT For more than 20 years the National Marrow Donor Program has facilitated unrelated donor hematopoietic cell transplants for adult recipients. In this time period, the volunteer donor pool has expanded to nearly 12 million adult donors worldwide, improvements have occurred in the understanding and technology of HLA matching, there have been many changes in clinical practice and supportive care, and the more common graft source has shifted from bone marrow (BM) to peripheral blood stem cells (PBSCs). The percentage of older patients who are receiving unrelated donor transplants is increasing; currently over 1 in 10 adult transplant recipients is over the age of 60 years. Chronic myelogenous leukemia (CML) was previously the most common diagnosis for unrelated donor transplantation, but it now comprises less than 10% of transplants for adult recipients. Transplants for acute myelogenous leukemia (AML), acute lymphoblastic leukemia (ALL), non-Hodgkin lymphoma (NHL), and myelodysplastic syndromes (MDS) all outnumber CML. Treatment-related mortality (TRM) has declined significantly over the years, particularly in association with myeloablative transplant preparative regimens. Correspondingly, survival within each disease category has improved. Particularly gratifying are the results in severe aplastic anemia (AA) where 2-year survival has doubled in just 10 years.
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ABSTRACT: Problem Identification: Many patients undergoing hematopoietic cell transplantation (HCT) for hematologic malignancies experience hyperglycemic events during treatment, leading to adverse outcomes. Understanding how hyperglycemia during the acute HCT treatment phase impacts outcomes is vital for preventing and mitigating adverse events. This integrative review evaluates the impact of hyperglycemia on adult patients undergoing HCT.Literature Search: PubMed, MEDLINE®, and CINAHL® electronic databases were used to identify relevant articles.Data Evaluation: The final sample for this integrative review included 12 empirical quantitative reports of clinical patient outcomes. Of the 12, 10 are retrospective, 1 is case-control, and 1 is prospective.Data Analysis: Content analysis was used to synthesize and summarize findings.Presentation of Findings: A review of published literature found associations between hyperglycemia and infection, time to engraftment, development of acute graft-versus-host disease, length of stay, and overall survival. Patient-related risk factors for hyperglycemia included older age, preexisting diabetes, and insulin resistance (i.e., prediabetes). Patients of normal weight experiencing hyperglycemia had worse outcomes than patients who were overweight or obese. Treatment-related risk factors for hyperglycemia include dose and duration of immunosuppressants, specifically corticosteroids, treatment with antihyperglycemic medications, and use of total parenteral nutrition.Implications for Nursing Practice: HCT is one of the most complex treatments for hematologic disorders. The transplantation nurse, as part of an interdisciplinary team, plays an essential role in glycemic control during the acute phase of HCT. Understanding the effects of hyperglycemia, as well as factors that place the patient at risk for hyperglycemia, allows the nurse to make well-informed, proactive interventions aimed at glycemic control.Oncology nursing forum 09/2014; 41(5):E302-E312. · 2.83 Impact Factor
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ABSTRACT: Adoptive transfer of cultured bone marrow stromal cells (mesenchymal stem cells also known as MSCs) is a promising new way to aid tissue regeneration and treat a wide variety of diseases where regulation of inflammatory responses is derailed. Although significant advances have been made in the field, pinpointing important mechanistic details about how MSCs function in vitro and in vivo, there are still many unanswered questions that need to be addressed before welcoming MSCs in the therapeutic arsenal of immune mediated diseases. In this Viewpoint we highlight and discuss a few factors that we believe are critical in terms of therapeutic success employing cultured MSCs. Selecting the right donor population, choosing the best culture conditions and picking the patient population that's most likely to give a favorable therapeutic response is just as important as considering interactions between MSCs and the combination of drugs in the recipient's body. Given the complexity of MSC-host interactions it is also imperative to develop screening tools that account for as many variables as possible and predict precisely the in vivo response rates before MSCs enter the body. In order to achieve this, a multidisciplinary approach is required with comprehensive knowledge of basic MSC biology, immunology, pharmacology and good clinical practice.This article is protected by copyright. All rights reserved.Experimental Dermatology 05/2014; · 4.12 Impact Factor
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ABSTRACT: Background Reduced intensity conditioning (RIC) protocols for allogeneic haematopoietic cell transplants (HCT) have become commonplace treatments for patients with haematological disease, extending allogeneic HCT to older and less fit patients. There is a perception that centres treating larger numbers of patients have improved outcomes.AimsWe wanted to examine whether outcomes for adult allogeneic HCT patients from our smaller centre were equivalent to those expected at larger centres internationally.Methods Clinical and laboratory data were collected on all patients who received allogeneic HCT during 2000—2012. Outcomes including overall survival (OS) and progression free survival (PFS) were compared between patients receiving myeloablative conditioning (MAC) and RIC protocols.Results118 adult patients underwent allogeneic HCT with MAC (n=51) or RIC (n=67). The mean age of patients receiving MAC (35.8 years, range 18—56) was lower than those receiving RIC (48.4 years, range 19—64). Two year OS was similar for MAC and RIC patients (66% vs 62%, P = 0.17), whereas two year PFS was superior in MAC patients (63% vs 50%, P = 0.01) due to fewer relapses. Overall survival was reduced in older patients irrespective of conditioning. Patients with chronic graft-versus-host disease had improved survival due to fewer relapses. Overall survival was unaffected by HCT comorbidity index, donor, cell source or patient/donor cytomegalovirus status.ConclusionRIC protocols have resulted in long-term survival in many patients ineligible for MAC protocols. In our smaller centre, patient age but not conditioning intensity influenced survival, which was equivalent to reports from larger centres.Internal Medicine Journal 04/2014; · 1.70 Impact Factor