Adult Transplant Patients Research Articles

Outcomes of Busulfan, Fludarabine, and 400 cGy Total Body Irradiation Compared With Busulfan and Fludarabine Reduced-Intensity Conditioning Regimens for Allogeneic Stem Cell Transplantation in Adult Patients With Hematologic Diseases: A Single-Center Experience

Reduced intensity conditioning (RIC) regimens decrease the risk for nonrelapse mortality (NRM) in adult patients undergoing allogeneic hematopoietic stem cell transplantation for hematologic malignancies but increase the risk for relapse. The aim of this study was to compare the outcomes of fludarabine-total body irradiation (TBI) with fludarabine among patients with hematologic diseases. This retrospective study of 137 patients with different hematologic malignancies compared the outcomes of 63 patients who received a conventional RIC regimen with 2 days of IV busulfan (3.2 mg/kg/d×2 days) and fludarabine with 74 patients who received the same regimen plus 400 cGy of fludarabine and busulfan (FB)-TBI divided in 2 doses over 1 day (200 cGy BID). Median follow-up was 4.62 years. The donors were either HLA-matched siblings (36%) or HLA-matched unrelated donors (64%). The FB-TBI showed trends toward improvement in progression-free survival (PFS) and overall survival (OS) over FB (5-year PFS rates 50% vs 34%, P=.06, and 5-year OS rate 53% vs 39%, P=.13). Acute graft-vs-host disease (aGVHD), relapse, and NRM were similar between the 2 groups. The 5-year cumulative incidence of chronic GVHD (cGVHD) was lower in the FB-TBI group compared with the FB group (29% vs 52%, P=.003). Multivariable analysis revealed that grade III-IV aGVHD was the only independent risk factor for worse OS (P=.001) in both groups. A high disease risk index was possibly associated with inferior OS (P=.07) in both groups. The FB-TBI is a safe and effective intensified RIC regimen for adult patients with hematologic malignancies. It predicted a lower risk for cGVHD and showed possibly improved PFS and OS compared with FB.

Long-term outcomes after heart transplantation in adult patients with congenital heart disease: Does initial defect and physiology impact survival?

Long-term outcomes after heart transplantation in adult patients with congenital heart disease: Does initial defect and physiology impact survival?

Гилтеритиниб как «мост»-терапия перед аллогенной трансплантацией костного мозга у пациентов с рефрактерным/рецидивирующим острым миелоидным лейкозом с мутацией в гене FLT3

Гилтеритиниб как «мост»-терапия перед аллогенной трансплантацией костного мозга у пациентов с рефрактерным/рецидивирующим острым миелоидным лейкозом с мутацией в гене FLT3Gilteritinib as a bridge to allogeneic hematopoietic stem cell transplantation in adult patients with refractory/relapsed acute myeloid leukemia with FLT3 mutations

450 USE OF A DOUBLE MITRACLIP FOR SEVERE MITRAL REGURGITATION IN A HEART TRANSPLANT PATIENT

Abstract Despite the progresses made over the recent years on heart transplantation, there are few data in literature about mitral regurgitation in transplated hearts. We report a case of a 62-year-old Italian man who presented dyspnea for mild exercise two years after orthotopic heart transplantation. He was found to have sever mitral regurgitation and underwent a successful implantation of a double MitraClip with the reduction of the mitral regurgitation and improvement of the symptoms. Two months later, he was still doing well and a repeted echocardiogram showed good results with only residual mild aortic insufficiency. We found few previously reported cases using the MitraClip to treat mitral regurgitation in adult cardiac transplant patients.

Autologous Versus Haploidentical Stem Cell Transplantation in Adult Patients with Intermediate Risk Actue Myelogenous Leukemia in First Complete Remission and Undetectable Minimal Residual Disease: A Global Preliminary Analysis of Chinese Data

Background: Stem cell transplantation (SCT) is a potentially curative post-remission therapy for intermediate-risk acute myeloid leukemia (AML) patients. For patients in first remission (CR1) with negative measurable residual disease (MRD) and without a HLA-matched donor, both autologous SCT (ASCT) and haploidentical donor SCT (haplo-SCT) were acceptable options, but it is controversial that which one is preferred. Methods: A retrospective study was conducted in 8 Chinese centers. The inclusion criteria were: 1) adult patients >18 years old; 2) diagnosis as AML with intermediate-risk according to ELN 2017; 3) ASCT or haplo-SCT underwent between 2010-2019; 4) in CR1 and MRD negative before transplant. The Primary endpoint was overall survival (OS). Secondary endpoints were progression-free survival (PFS), cumulative incidence of relapse (CIR), treatment-related mortality (TRM), and graft-versus-host disease-free and relapse-free survival (GRFS). Results: Totally 299 patients were enrolled in this study, including 97 recepients after ASCT and 202 recipients after haplo-SCT (Table 1). The median follow-up was 28 months in ASCT group versus 35 months in haplo-SCT group. Compared to haplo-SCT, patients after ASCT had increased 3-year CIR (27.0% ± 0.2% versus 13.5% ± 0.1%, p = 0.004) but reduced 3-year TRM (3.5% ± 0.0% versus 12.0% ± 0.0%, p = 0.013), which led to similar 3-year OS (80.8% ± 4.3% versus 79.2% ± 3.1%, p = 0.796) and PFS (69.5% ± 5.0% versus 73.7% ± 3.3%, p = 0.504). Moreover, the 3-year GRFS was remarkable better in ASCT group (69.5% ± 5.0% versus 55.9% ± 3.6%, p = 0.009) (Figure 1), which implied a survival with superior quality of life (QoL). In multivariate analysis, haplo-SCT independently related to an improved CIR, while increased TRM and reduced GRFS. Additionally, age more than 50 was associated with the worse OS, CIR and GRFS. Conclusions: We concluded that both ASCT and haplo-SCT were applicable for patients with intermediate-risk AML in MRD-negative CR1, but the absence of GVHD might potentially favor the QoL for patients receiving ASCT. Randomized trials are needed to confirm our conclusion. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Fludarabine, Busulfan and Melphalan Based Conditioning Reduced Relapse after Allogeneic Hematopoietic Stem Cell Transplantation in Adult Patients with Myeloid Malignancies: A Multicenter Retrospective Analysis

Fludarabine in combination with full dose of busulfan has become the most popular myeloablative conditioning regimen for allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with myeloid malignancies, while relapse was till the main obstacle for cure. We observed a particular low incidence of relapse in patients prepared with double alkylating agents of busulfan and melphalan in our previous single center phase II study. To further evaluate the efficacy of the regimen, we designed a multicenter retrospective study and tried to verify our previous results in large samples. The inclusion criteria were as follows: 1) adult patients (16 to 70 years old) with myeloid malignancies including acute myeloid leukemia(AML), myelodysplastic syndrome with excess blast-1 or -2(MDS-EB-1 or MDS-EB-2) and chronic myelomonocytic leukemia (CMML); 2) patients received first allo-HSCT from HLA matched sibling donors(MSDs), matched unrelated donor(MUDs), related haplo-identical donor(HIDs) or cord blood(CB); 3) conditioning regimen included busulfan (≥3.2mg/kg) and melphalan(≥100mg/m2); fludarabine, cladribine, cytarabine, etoposide or cyclophosphamide could be used in combination, while venetoclax, thiotepa and total body irradiation(TBI) were excluded. From Jan.2020 to Mar. 2022, a total of 202 patients from nine HSCT centers were enrolled in this study. Over ninety-five percent (193/202) patients received conditioning consisted of different dose of fludarabine, busulfan and melphalan. Post transplantation cyclophosphamide (PTCy) based graft-versus-host disease prophylaxis strategy was used in 167 out of all patients. The median follow-up time was 314 days (range, 8~841days) for the whole cohort and the baseline data were summarized in Table-1. Three patients developed primary engraft failure. The median time for neutrophil and platelet recovery were 13 days (range, 9~22 days) and 14 days (range, 9~121 days), respectively. The 100-day cumulative incidence of grade II-IV acute GVHD was 10.9±4.1% and the 2-year cumulative incidence of moderate/severe chronic GVHD was 17.4±5.2%. At last follow-up, eighteen patients died of non-relapse reasons and sixteen patients relapsed including eight patients were still alive. Thus the 2-year non-relapse mortality (NRM) was 8.9%±0.6% and cumulative incidence of relapse (CIR) at 2-year was 7.9±1.9%. The 2-year overall survival (OS) and disease free survival (DFS) were 79.9%±4.3% and 72.4±5.5%, respectively. Subgroup analysis showed no significant difference in OS and DFS when grouping by sex, age(＜50y vs. ≥50y), diagnosis (AML vs. MDS), disease risk index (DRI, low risk vs. intermediate risk vs high/very high risk) and transplantation conditioning intensity( TCI, low vs. intermediate vs. intensive). These results identified with our previous study and supported that busulfan and melphalan based conditioning was associated with low relapse rate and acceptable NRM in adult patients with myeloid malignancies. Randomized controlled clinical trial should be warranted to evaluate this regimen further. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Understanding the symptom experience and self-management strategies of adult hematopoietic stem cell transplantation patients during hospitalization: findings from a qualitative longitudinal study.

The aim of this study was to explore the symptom experience and self-management strategies of adult hematopoietic stem cell transplantation patients during hospitalization. This was a qualitative descriptive study. A heterogeneous sample of 19 patients who underwent hematopoietic stem cell transplantation from May to October 2021 were enrolled in the study. Semi-structured interviews were conducted at four time points during hospitalization, providing a total of 64 interview datasets. Four themes and 11 subthemes reflecting the symptom experience and self-management strategies of adult hematopoietic stem cell transplantation patients during hospitalization were observed. The four themes were (1) unexpected symptom burden: dynamic, disturbing, co-occurring, and correlative; (2) emotional complexity at different periods; (3) internal predicament: ineffectiveness of symptom management; and (4) external strength: desire for support from multiple sources. Hematopoietic stem cell transplantation patients experienced a complex and dynamic array of symptoms from admission to discharge, and they experienced the dual forces of internal predicament and external strength in symptom self-management during hospitalization. The findings of this study emphasize the need for a deeper understanding and precise management of the symptom experience of adult hematopoietic stem cell transplantation patients during hospitalization. Hematopoietic stem cell transplantation nurses need to assess symptoms on an ongoing basis; educate patients on ways to perceive, express, and self-manage multiple symptoms; and develop patients' self-symptom management skills to enhance their symptom relief and quality of life.

Impact of a change in universal gloving protocol on rates of central line-related bloodstream infection, Clostridioides difficile, and vancomycin-resistant Enterococcus

In this retrospective cohort of adult hematology-oncology and transplant patients, discontinuation of universal gloving did not result in significant changes in rates of central line-associated bloodstream infection, Clostridioides difficile infection, or vancomycin-resistant Enterococcus colonization. Active surveillance and subsequent isolation may be a viable alternative strategy to universal precautions.

Pneumocystis jirovecii Pneumonia Prophylaxis with Intravenous Pentamidine in Adult Allogeneic Hematopoietic Stem Cell Transplant Patients.

The purpose of this single-center retrospective case series was to evaluate the efficacy and safety of 300-mg once-monthly intravenous (IV) pentamidine prophylaxis in 702 adult allogeneic hematopoietic stem cell transplant (HSCT) patients. We observed no cases of Pneumocystis jirovecii pneumonia (PJP) following IV pentamidine administration. Breakthrough Nocardia and Toxoplasma infections were observed in 7 (1%) and 5 (0.7%) patients, respectively. The most commonly reported adverse event was nausea. Monthly IV pentamidine is a reasonable alternative to trimethoprim-sulfamethoxazole (TMP-SMX).

Infectious complications after second allogeneic hematopoietic cell transplant in adult patients with hematological malignancies.

We conducted a retrospective review of the infectious complications and outcomes over a 2-year follow-up period of adult patients who received a second allogeneic hematopoietic cell transplant (2nd allo-HCT) during a five-year period at two cancer centers in Michigan. Sixty patients, of whom 44 (73%) had acute leukemia or myelodysplastic syndrome, were studied. The majority (n = 37,62%) received a 2nd allo-HCT because of relapsed leukemia. Infection episodes after the 2nd allo-HCT totaled 112. Bacteria were identified in 76 episodes, the majority of which occurred pre-engraftment. The most common infecting organisms were Enterococcus species and Clostridioides difficile. Viral infections, predominantly cytomegalovirus, accounted for 59 infection episodes and occurred mostly in pre-engraftment and early post-engraftment periods. There were 16 proven/probable fungal infections, of which 9 were invasive aspergillosis or candidiasis. Mortality was 45% (n = 27) at one year and 65% (n = 39) at 2 years after transplant, and 16 deaths (41%) were due to infection. Of those 16 infection deaths, 8 were bacterial, 4 fungal, 2 both bacterial and fungal, and 2 viral. Failure to engraft neutrophils or platelets was significantly associated with decreased survival, p < 0.0001 and p < 0.001, respectively. Infections are common after a 2nd allo-HCT and are associated with a high mortality rate.

P8.152: Clinical Characteristics and Factors Related to Recurrent Cytomegalovirus Infection Post-kidney Transplant in Adult Patients at Cho Ray Hospital

Introduction: Cytomegalovirus (CMV) is one of the main causes of opportunistic infections after kidney transplantation. Manifestations of CMV disease in post renal transplantation patients are quite discreet, non-specific and difficult to diagnose early. Asymptomatic recurrent CMV infection has been reported remarkably to increase mortality rate and rejection incidence, and effect on graft survival. The recently follow-up and treatment procedures’ changes make it urgent to re-evaluate the incidence and the factors related to the risk of CMV recurrence as well as the clinical characteristics of CMV infection in postkidney transplantation patients. This helps to control the recurrence of CMV infection as well as to diagnose CMV disease early and treat it promptly and appropriately to reduce the mortality rate of patients after transplantation. Method: Objective 1: Retrospective cohort study of adult renal transplant recipients between January 1, 2015 and December 31, 2018. Objective 2: A cross - sectional descriptive study on 22 cases of CMV disease in post kidney transplant patients to present a review of the main clinical aspects of cytomegalovirus infection in renal transplants with a focus on clinical approach and its future perspectives. Results: Objective 1: A total of 365 patients who received a renal transplant at Cho Ray hospital in the study time period were reviewed for the presence of CMV infection occurring less than 540 days after transplant. The recurrent CMV infection was observed in 254 cases (69,6%), but only 3 patients (0,8%) developed CMV disease. Independent risk factors of CMV infection were HLA >80 (HR = 2,309, 95% CI 1,021 – 4,071, p = 0,044), daily oral Prednisone doses used <0,5 mg/kg/day (HR = 0,178, 95% CI 0,084 – 0,374, p <0,001), Tacrolimus whole blood trough concentration ≤10 µg/L (HR = 0,445, 95% CI 0,243 – 0,816, p = 0,009), Cyclosporine wole blood trough concentration >150 µg/L (HR = 4,25, 95% CI 1,97 – 9,2, p < 0,001). Objective 2: Male majority (2/3), with average age of 47,5 ± 4,5. Rate of symptomic recurrence CMV infection in the first 6 months, 6 - 12 months, 1 - 5 years, 5 - 10 years after transplant were 45,4%, 9,1%, 27,3% and 18,2% respectively. Common clinical manifestations are fever 59,1%, respiratory, renal and gastrointestinal manifestations 31,8%, 27,3% and 13,6%, respectively. Two cases of CMV retinitis with typical fundus lesions were treated with intraocular Ganciclovir, however, vision was not fully recovered. Lymphopenia <1.000 cells/mm3 was observed in most cases of CMV disease after kidney transplantation. Quantitative PCR of CMV DNA in plasma ranged from 375 – 6.533.850 copies/mL. 6 of 22 cases of PCR CMV DNA in plasma >4.000 copies/mL, of which 5 severe cases developed rapidlly progressive respiratory failure and 2 deaths. Conclusion: Recurrent CMV infection has a high rate in adult patients after kidney transplantation, so it is necessary to take initiactive for screening, monitoring and treating early to reduce mortality and protect the transplanted kidney. The appropriate dose of immunosuppressants plays an important role in the prevention of recurrent CMV infection and the successful treatment of disease due to it. Key words: Cytomegalovirus, Kidney transplantation, Post-transplant infection. * Deparment of Tropical diseases– Cho Ray Hospital ** Nephrology Surgery – Cho Ray Hospital Coresponding author: Tho A. N. Vo, Deparment of Tropical diseases– Cho Ray Hospital. Email: [email protected]. Mobile: 0983888841.

P14.11: Lung Transplantation in Adult Patients With Bronchiectasis

P14.11: Lung Transplantation in Adult Patients With Bronchiectasis

P9.41: Outcomes of Live Donor Liver Transplantation in Adult Patients With HPS – 10-Year Experience From a Single Centre: A Retrospective Analysis

Introduction: Hepatopulmonary syndrome (HPS) is characterised by hypoxia and is associated with a worse prognosis in patients with cirrhosis. Liver transplantation is the only definitive treatment. We report our 10 year experience of live donor liver transplant in adult patients with HPS. Methods: Seventeen patients with HPS (age ≥ 18 years) and cirrhosis who underwent LDLT during the period 2012 – 2022 were retrospectively analysed. HPS was defined as PaO2 < 80 mmHg in presence of demonstrable macro-aggregated albumin (MAA) scan shunt fraction >6%. Results: The study group composed of 15 male and 2 female patients, mean age 51.05 ± 7.67 years. The most common presentations was dyspnoea, seen in 82.35% patients followed by ascites (76.47%) and gastrointestinal bleed (41.18%). Mean Child Pugh score was 10.52 ± 1.77, model for end-stage liver disease (MELD) score was 20.35 ± 7.38. One patient had very severe HPS (PaO2 <50 mmHg), four had severe HPS (PaO2 50 - 60 mmHg) and twelve had moderate HPS (PaO2 60 - 80 mmHg). The mean MAA shunt fraction was 24.05 ± 18.52% and mean PaO2 was 66.77 ± 10.63 mmHg. All patients underwent right lobe LDLT. The overall time to extubation was 1.23 ± 0.83 days and for ICU stay8.66 ± 0.55 days. Patients received oxygen for a median of 3 [2 – 5] days post-transplant. The main complications in post-LT course were sepsis and neurological, both seen in 3 patients each (17.64%). Overall survival at a median follow up of 54.5 [17 – 76] months was 82.35%. Conclusion: LDLT in HPS is feasible and is associated with good outcomes.

P16.40: Physicians’ Opinions Regarding Low-Level Epstein-Barr Virus DNA Levels From PCR Testing

Introduction: Epstein Barr virus (EBV) DNA measurement supports diagnosis and management of EBV-associated complications in transplant recipients. Laboratory-developed EBV DNA tests can be variable between laboratories and relatively insensitive. The availability of more sensitive, consistent and accurate tests, with results that are traceable to the WHO International Standard and are reported IU/mL of plasma, raises questions regarding the clinical importance of results in lower titer ranges that are newly detectable. Commercially available EBV DNA tests now exhibit sensitivity and even linearity near or below 100 IU/mL in plasma. With the advancement of more sensitive diagnostics, the clinical significance of low-level EBV DNA test results should be considered, however, no clear clinical consensus is currently available to help interpret these results, and it is unclear what actions clinicians may take when presented with them. We undertook a survey of practicing adult and pediatric transplantation clinicians in order to characterize their likely therapeutic and diagnostic decisions in response to theoretical scenarios involving low-level EBV DNA test results. Methods: Fifty-one clinicians who manage transplant recipients in the US, UK and Australia responded to a questionnaire presenting two hypothetical clinical scenarios involving low-level EBV DNA test results in adult and pediatric transplant patients. Scenario 1 included a detectable DNA level that was below the limit of quantitation. Scenario 2 involved low-level DNA results (150 vs. 400 IU/mL of plasma) from two different laboratories. Results: Almost a quarter (24%) of clinicians would change treatment based on a single detectable EBV DNA result as presented in scenario 1 (Figure 1). Before changing treatment or ordering imaging studies in anticipation of possible core biopsy, the overwhelming majority would repeat EBV testing, mostly on a weekly basis. Most clinicians (59%) were likely to act based on the apparent increase in EBV DNA in scenario 2, with most intending to confirm the results through repeat testing to confirm the trend in viral load (Figure 2). Conclusions: Adequate use and uptake of diagnostic testing in clinical medicine is often suboptimal leading to misinterpretation by clinicians and unnecessary diagnostic errors. Our findings reveal the impact that low-level EBV DNA plasma results may have on potential patient management approaches. In addition, the survey also showed marked differences in how clinicians would interpret and act on these results. This highlights that, in our theoretical clinical scenarios, there is no clear consensus regarding these potential and diverse interventions based on the different diagnostic and therapeutic approaches triggered by low EBV DNA plasma levels. These observed differences underline the need for more interpretive guidance to support the wider availability of more accurate, sensitive and standardized EBV DNA level monitoring assays.

Liver transplantation for NAFLD cirrhosis: Age and recent coronary angioplasty are major determinants of survival.

Liver transplantation (LT) is the treatment of end-stage non-alcoholic liver disease (NAFLD), that is decompensated cirrhosis and/or complicated by hepatocellular carcinoma (HCC). Few data on long-term outcome are available. The aim of this study was to evaluate overall patient and graft survivals and associated predictive factors. This retrospective multicentre study included adult transplant patients for NAFLD cirrhosis between 2000 and 2019 in participating French-speaking centres. A total of 361 patients (69.8% of male) were included in 20 centres. The median age at LT was 62.3 years [57.4-65.9] and the median MELD score was 13.9 [9.1-21.3]; 51.8% of patients had HCC on liver explant. Between 2004 and 2018, the number of LT for NAFLD cirrhosis increased by 720%. A quarter of the patients had cardiovascular history before LT. Median follow-up after LT was 39.1months [15.8-72.3]. Patient survival at 1, 5 and 10 years after LT was 89.3%, 79.8% and 68.1% respectively. The main causes of death were sepsis (37.5%), malignancies (29.2%) and cardiovascular events (22.2%). In multivariate analysis, three risk factors for overall mortality after LT were recipient pre-LT BMI < 32 kg/m2 at LT time (OR: 2.272; p=.012), pre-LT angioplasty during CV check-up (OR: 2.916; p=.016), a combined donor and recipient age over 135 years (OR: 2.020; 95%CI: p=.035). Survival after LT for NAFLD cirrhosis is good at 5 years. Donor and recipient age, and cardiovascular history, are major prognostic factors to consider.

Early Change in Lower Limb Strength and Function in Lung Transplant Patients After Center-Based and Telerehabilitation.

The aim of this study was to examine the change and relationship among quadriceps torque (QT) and physical function in adult lung transplant (LTx) patients undergoing rehabilitation. A prospective study assessed 6-min walk test (6MWT) distance, QT, and Short Physical Performance Battery (SPPB) at the start of pre-habilitation and 10-12 wk post-LTx. Functional outcomes were examined for within-group differences for participants who completed center-based rehabilitation between September 2019 and March 2020 and participants who completed telerehabilitation ("telerehab") between March 2020 and June 2021 during COVID-19. Relationships between QT, SPPB, and 6MWT were examined pre- and post-LTx. A total of 49 LTx recipients were included (30 men, 61 [56-67] yr, 26 center-based rehab, and 23 telerehab). The 6MWT increased (median 75 m: 95% CI, 35 - 117, P < .0001), and the telerehab group showed an LTx decrease in QT (-9.6 Nm: 95% CI, -29 to -2.3, P = .02) and an increased gait speed (0.21 m/sec: 95% CI, 0.11 - 0.47, P < .0001). Pre-LTx QT showed a moderate correlation to pre-LTx SPPB ( r = 0.41, P = .004) and weak correlations to gait speed and 6MWT ( r ranging from 0.21 to 0.35, P < .05). Post-LTx QT showed moderate correlations to post-LTx SPPB ( r = 0.43, P = .002), gait speed ( r = 0.54, P < .001), five-time sit-to-stand ( r =-0.57, P < .0001), and 6MWT ( r = 0.62, P < .0001). Early post-LTx 6MWT and gait speed increased with no improvement in QT or other SPPB components. Correlations between QT and measures of exercise capacity and lower limb function were stronger post-LTx. Serial measurements may further inform functional trajectories and rehabilitation models.

Palliative care pilot initiative for transplant patients: The Westchester Medical Center experience.

e19050 Background: It is well known HCT recipients experience multiple symptoms affecting quality of life. Emerging data supports the role palliative care can play in mitigating these issues. Our cellular therapy team collaborated with the Palliative Care team on a pilot project incorporating their expertise into the management of our new allogeneic transplant patients. We chose this group of patients given their increased needs relative to other cellular therapy recipients (i.e. autologous, CTL) and our institution’s available resources. Methods: Patients admitted to the HCT unit for allogenic stem cell transplant underwent palliative care consult during their conditioning regimen. During the initial palliative care visit, performed by a specialist palliative care nurse practitioner, patients underwent comprehensive assessment of physical symptoms, psychosocial distress, and overall quality of life. Patients were then followed during hospitalization by members of the palliative care team including Nurse Practitioner, Social Worker and Chaplain, to address identified needs and support both the patient and their family. The palliative care team provided daily communication and recommendations to our inpatient HCT team. Results: Patient one was a 61-year-old man with intermediate risk MDS who underwent a reduced intensity conditioning regimen of busulfan, fludarabine, and alemtuzumab. His transplant was complicated by delirium and anorexia. Patient two was a 63-year-old man with AML who underwent a reduced conditioning regimen of the same combination. His transplant was complicated by bone pain and insomnia. Patient three was a 70-year-old woman with AML who also underwent a reduced conditioning regimen. Her transplant was complicated by severe mucositis and gastric reflux. Conclusions: Allogeneic stem cell transplant patients experience a multitude of symptoms and psychosocial distress. With the help of a dedicated palliative care assessment, we can improve patients’ quality of life during their admission for the transplant. Considering the positive feedback from patients, we plan to conduct a formal prospective study evaluating the impact of palliative care on adult stem cell transplant patients at our institution. By addressing the patient’s whole person rather than just their disease, we also hope to decrease number of admissions as well as length of stay. Ultimately, we look forward to expanding this to other malignancies as well.

Lung Transplant Outcomes in Adults in the United States: Retrospective Cohort Study Using Real-world Evidence from the SRTR.

Background.The Scientific Registry of Transplant Recipients was retrospectively analyzed to provide real-world evidence of the efficacy and safety of tacrolimus-based immunosuppressive regimens in adult lung transplant recipients in the United States.Methods.Adult recipients (N = 25 355; ≥18 y) of a primary deceased-donor lung transplant between January 1, 1999, and December 31, 2017, were followed for 3 y posttransplant based on immunosuppressive regimen at discharge: immediate-release tacrolimus (TAC) + mycophenolate mofetil (MMF), TAC + azathioprine (AZA), cyclosporine (CsA) + MMF, or CsA + AZA. The primary outcome was the composite endpoint of graft failure or death (all-cause) at 1 y posttransplant (calculated via a modified Kaplan–Meier method).Results.Discharge immunosuppressive regimens in lung transplant recipients changed over time, with a substantial increase in the use of TAC + MMF. TAC + MMF was the most common immunosuppressive regimen (received by 61.0% of individuals at discharge). The cumulative incidence of graft failure or death at 1 y posttransplant in adult lung transplant patients receiving TAC + MMF was 8.6% (95% confidence interval 8.1-9.1). Risk of graft failure or death was significantly higher in adults receiving CsA + MMF or CsA + AZA compared with TAC + MMF, with no significant difference seen between TAC + MMF and TAC + AZA. TAC + MMF had the highest continued use at 1 y posttransplant (72.0% versus 35.4%–51.5% for the other regimens). There was no increase in the rate of infection or malignancy in the TAC + MMF group.Conclusions.Real-world evidence from the most comprehensive database of transplant recipients in the United States supports the use of TAC in combination with MMF or AZA as maintenance immunosuppression in adult lung transplant recipients.

Successful neutrophil engraftment supported by granulocyte transfusion in adult allogeneic transplant patients with peri-transplant active infection

Active infection at the time of allogeneic hematopoietic stem cell transplantation (HSCT) is a risk for non-relapse mortality (NRM) after HSCT. Granulocyte transfusion (GTX) has been used to prevent or treat life-threatening infections in patients with severe neutropenia. However, data are limited on the clinical benefits of GTX during HSCT. We retrospectively analyzed the transplant outcomes of HSCT patients who had undergone GTX between 2012 and 2020. Altogether, 20 patients with documented infection had received 55 GTXs during HSCT. No adverse events were observed during the GTX infusion. The average number of granulocytes was 0.40 (range, 0.10–1.59) × 109/kg. The median neutrophil increment one day after GTX was 515 (range, −6 to 6630)/μl, which was significantly correlated with the infused granulocyte dose (p = 0.0007). A total of 17 of 20 patients achieved neutrophil engraftment. The number of infused granulocytes tended to higher in clinical responders (p = 0.12), and patients receiving ≥ 0.5 × 109/kg showed trend toward to better transplant outcomes (GTX-high vs. GTX-low, 1-year OS; 33% vs. 11%, p = 0.19. 1-year NRM; 44% vs.77%, p = 0.11). The type of red blood sedimenting agents was significantly correlated with the amounts of granulocyte collection. In conclusion, GTX, especially with a high amount of containing granulocytes, could be a safe bridging therapy for neutrophil engraftment after HSCT in patients with active infection.

Neurological complications in adult allogeneic hematopoietic stem cell transplant patients: Incidence, characteristics and long-term follow-up in a multicenter series.

Neurological complications (NCs) represent a diagnostic and clinical challenge in allogeneic hematopoietic stem cell transplant (alloHSCT) patients. We retrospectively analyzed NC incidence, etiology, timing, characteristics, outcome, and long-term effects in 2384 adult patients transplanted in seven Italian institutions between January 2007 and December 2019. Ninety-three (3.9%) patients were affected by 96 NCs that were infectious (29.2%), immune/inflammatory (26%), drug-related (12.5%), cerebrovascular (5.2%), metabolic (3.1%), related to central nervous system disease relapse (11.5%) and malignancy (3.1%), or undefined (9.4%). Six patients (6.4%) had neurological manifestations of chronic graft-versus-host disease (GVHD). NCs occurred on average at day +128 (from -5 to +4063). Early (< day +120) and late NCs had similar frequencies (46.9% vs 53.1%, p = 0.39). Thirty-one patients (33.3%) were affected by acute or chronic GVHD at the NC onset. With a median follow-up of 25.4 (0.4-163) months, the overall mortality due to NCs was 22.6%. The median time between NC onset and death was 36 (1-269) days. Infectious NCs were the main cause (61.9%) of NC-related mortality. A persistent neurological impairment occurred in 20.4% patients, 57.9% of whom being affected by immune/inflammatory NCs. This study highlights the rare, yet severe impact of alloHSCT-associated NCs on patient survival and long-term functional ability.