[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Comprehensive Geriatric Assessment (CGA) is frequently used in oncology to measure the health status of older adults with cancer, but has not been studied in allogeneic hematopoietic cell transplantation (HCT). We conducted a prospective pilot study of CGA in allogeneic HCT recipients ≥50 years old, in order to examine the prevalence of vulnerabilities in this population. METHODS: Patients ≥50 years and eligible for HCT were enrolled. CGA consisted mainly of self-report, performance-based, and chart extracted measures evaluating domains of comorbidity, physical and mental function, frailty, disability, and nutrition. RESULTS: Of 238 eligible,166 completed CGA and underwent transplant. Only 1% had a Zubrod performance status (PS) >1; 44% and 66% had high comorbidity defined by the hematopoietic cell transplant-comorbidity index (HCT-CI) and cumulative illness rating scale-geriatrics (CIRS-G), respectively. The presence of additional vulnerability was frequent: disability was present in 40% by instrumental activities of daily living (IADL), self-reported physical and mental function were significantly lower than population age-group norms, 58% were pre-frail, and 25% were frail. Among those with Zubrod PS of 0, 28% demonstrated disability, 58% were pre-frail, 15% were frail; 35% and 55% reported low physical and mental function, respectively. CONCLUSION: CGA uncovers a substantial prevalence of undocumented impairments in functional status, frailty, disability, and mental health in older allogeneic transplant recipients.
Preview · Article · Nov 2012 · Biology of blood and marrow transplantation: journal of the American Society for Blood and Marrow Transplantation
[Show abstract][Hide abstract] ABSTRACT: Background: Hemorrhagic cystitis manifesting as gross hematuria (GH) is a well described BK virus associated syndrome after HSCT. Other BK virus associated syndromes, such as polyoma virus associated nephropathy (PVAN), are reported as cases in the HSCT literature. Data regarding the spectrum, incidence, treatment, and treatment response of BK virus associated syndromes in a large patient cohort are few. The primary aim of this study was to describe these features in a large cohort of allogeneic HSCT recipients.
Methods: Charts of 115 allogeneic HSCT recipients were reviewed. Continuous variables were compared using the t-test.
Results: 11 patients had gross hematuria (GH). In 6/11 cases, GH resolved without intervention. 2/11 cases required urologic procedures and the remaining 3 were treated with cidofovir. Mean urinary BK viral load (VL) was 17,349,496 copies/mL (c/mL) in GH cases and 5,615,542 c/mL in those without GH (p = 0.001). Mean blood BK VL was 9689 c/mL in GH cases and 78,208 c/mL in patients without GH (p = 0.18).
9 patients had cystitis symptoms other than GH (uncomplicated cystitis, UC). None required directed therapy. Mean urinary BK VL was 19,817,151 c/mL in UC cases and 5,055,767c/mL in those without UC (p < 0.0001). Mean blood BK VL was 11,380 c/mL in UC cases and 77,119 c/mL in patients those without UC (p = 0.20). 2 patients developed PVAN. Both were treated with leflunomide, required dialysis, and had urinary BK VLs greater than 25,000,000 c/mL and blood BK VLs greater than 100,000 c/mL persistently for over 6 months.
Discussion: Our understanding of clinical syndromes associated with BK virus continues to evolve. Urinary BK VL was associated with all BK associated syndromes reported. In patients with UC, symptoms resolved without anti-viral treatment. PVAN was seen in 2.7% of the present cohort and may represent an emerging BK virus associated syndrome.
[Show abstract][Hide abstract] ABSTRACT: BK virus (BKV) is an important pathogen and cause of nephropathy in renal transplant recipients, but its significance following hematopoetic stem cell transplantation (HSCT) is less well described. We measured blood and urine BKV in 124 allogeneic HSCT patients (67 had undergone prior HSCT [surveillance cohort]; 57 were monitored from transplant day 0 [prospective cohort]). BK viruria was manifest in 64.8% of the patients; 16.9% developed viremia. In the prospective cohort, the median time from transplantation to BK viremia development (128 days) was longer than for viruria (24 days; P < .0001). Among clinical factors (sex, disease, transplant type, alemtuzumab use, cytomegalovirus [CMV] viremia, graft-versus-host disease [GVHD], donor HLA C7 allele), only CMV viremia was more common in patients with BKV infection (P < or = .04). There was a direct relationship between blood and urine BKV levels and the occurrence, and degree, of hematuria (P < or = .03). Finally, BKV infection was analyzed along with other clinical factors in relation to the development of post-HSCT renal impairment. On multivariate analysis, only BK viremia (P=.000002) and alternative-donor transplantation (P=.002) were independent predictors of development of post-HSCT renal impairment, with BK viremia associated with a median 1.62mg/dL rise in creatinine from the pretransplant baseline. Among 8 patients in the surveillance cohort with BK viremia, 2 developed biopsy-proven BKV nephropathy requiring hemodialysis. Investigation of whether prophylaxis against, or treatment of, BKV in the post-HSCT setting mitigates the associated morbidities, especially kidney injury, warrants prospective evaluation.
Preview · Article · Sep 2009 · Biology of blood and marrow transplantation: journal of the American Society for Blood and Marrow Transplantation
[Show abstract][Hide abstract] ABSTRACT: Identification of an HLA identical donor/recipient pair using high-resolution techniques at HLA A, B, C, and DRB1 optimizes survival after adult unrelated hematopoietic stem cell transplant. It has been estimated that roughly 50% of African-Americans have suitable unrelated donors based on serologic typing, but there is little information on the likelihood of identifying an HLA-identical unrelated donor using molecular techniques. From February 2002 to May 2007, we performed 51 unrelated donor searches for African-American patients using the National Marrow Donor Program and found HLA identical unrelated donors for only 3. By contrast, 50 (98%) had at least 1, and often multiple, appropriately matched cord blood units available. Very few African-American recipients have HLA-identical unrelated donors. To allow more African-American patients to proceed to transplant, innovative donor strategies, including adult cord blood transplantation, haploidentical transplant, or the identification of permissive mismatches should be investigated.
Preview · Article · Aug 2008 · Biology of blood and marrow transplantation: journal of the American Society for Blood and Marrow Transplantation