Transplantation In Older Patients Research Articles

Reduced-toxicity conditioning regimen with low dose post-transplantation cyclophosphamide and low-dose anti-thymocyte globulin as graft-versus-host disease prophylaxis for haploidentical stem cell transplantation in older patients.

We retrospectively analyzed outcomes in 55 patients ≥ 55 years of age with hematologic malignancies treated with fludarabine, cytarabine, busulfan, and low-dose cyclophosphamide as the conditioning regimen between January 1, 2019, and November 30, 2023. Neutrophil engraftment was successful in all patients within 28 days, with 54 patients (98.2%) achieving complete donor chimerism. The cumulative incidence of non-relapse mortality was 0% at 30 days, 7.5% at 100 days, and 19% at 1 year. The cumulative incidence of grade II-IV acute graft-versus-host disease (aGVHD) was 25% (95%CI, 15-38%), whereas that of grade III-IV aGVHD was 9.1% (95% CI, 3.3-19%). The cumulative incidence of extensive chronic graft-versus-host disease at 1 year was 3.6% (95%CI, 0.66-11%). The cumulative incidences of relapse, overall survival, and GVHD-free/relapse-free survival at 1 year were 9.0%, 71.6%, and 67.1%, respectively. An RIC conditioning regimen, including a combination of lower PTCy/ATG as GVHD prophylaxis, followed by haplo-SCT, might be a promising option for appropriately selected older patients.

Improved Outcome of Allogeneic Transplantation in Older Patients Treated for Myeloid Malignancies Using Post-Transplantation Cyclophosphamide and Reduced Duration of Immune Suppression

BackgroundAllogeneic stem cell transplantation (alloSCT) offers curative potential for older patients with myeloid malignancies. We evaluated the efficacy and safety of alloSCT using post-transplantation cyclophosphamide (PTCy) in combination with a very short duration of immune suppression (IS) in this population. MethodsWe retrospectively analyzed 92 consecutive patients aged 65 years and older who underwent an alloSCT for myeloid malignancies between February 2018 and December 2022 at our institution. Data on patient characteristics, treatment modalities, and outcomes were collected. ResultsNinety-two patients received an alloSCT with PTCy-based GVHD prophylaxis. The majority had minimal comorbidities and were diagnosed with acute myeloid leukemia (AML). Patients mostly received conditioning regimens with low to intermediate TCI scores. In 43% of patients, IS could be permanently stopped at day +90, resulting in a median time of IS of 2.93 months in high-risk patients. At a median follow-up of 21.3 months, the 1- and 2-year overall survival rates were 89% and 87%, respectively. Relapse-free survival rates were 88% and 84% at 1 and 2 years, respectively. The 1- and 2-year cumulative incidences of relapse were 8% and 13%, while transplant-related mortality (TRM) estimates were 9% at both time points. Acute GVHD grade 3-4 occurred in 7% within the first 180 days and severe chronic GVHD in 6% of patients. This all resulted in a 1- and 2-year graft versus host and relapse free survival (GRFS) of 74% and 70%, respectively. ConclusionAlloSCT using PTCy in combination with a short duration of IS in older patients with myeloid malignancies demonstrates favorable survival outcomes due to low relapse rates and a low TRM. The low incidence of relapse and acceptable rates of graft-versus-host disease suggest the efficacy and safety of this approach. Further studies are warranted to validate these findings and optimize transplant strategies for older patients with myeloid malignancies.

A Comprehensive Model for Predicting 1-Year Survival after Allogeneic Hematopoietic Cell Transplantation in Older Patients

Background: As the number of elderly patients referred to and undergoing allogeneic hematopoietic cell transplantation (alloHCT) continues to rise, there is a growing need for a comprehensive risk assessment model to accurately predict transplantation outcomes in this specific patient population. The widely used Hematopoietic Cell Transplantation-specific Comorbidity Index (HCT-CI) does not fully capture factors influencing transplant outcomes in elderly patients. This study aims to enhance risk stratification for elderly patients undergoing alloHCT by integrating additional functional, nutritional, and clinical indicators. Methods: This is a retrospective study utilizing the data registry of HCT patients who received their treatment at UF Health Cancer Center. The inclusion criteria included all patients age > 65 years, who underwent their first alloHSCT between January 2012 and December 2022, regardless of graft type, conditioning regimen, donor type, or graft source. Patient data were extracted through chart review. The primary endpoint was 1-year Overall Survival (OS). Prognostic significance of each variable was assessed using Cox proportional hazard models. We subsequently used all variables to build a comprehensive prediction model to assess 1-year survival outcomes in elderly patients undergoing alloHCT. The predictive model's performance was measured by the Concordance-statistic (c-statistic). Results: A total of 69 patients satisfied the inclusion criteria and were included in the analysis. Median age was 69 years (range 66-81) and 65.2% were male. Unrelated donors were used in 66.6% of patients, while the remainder received grafts from related donors. Most patients received peripheral blood stem cell grafts (91%). Myeloid malignancies comprised the most common indication for alloHCT in this group of patients (89.8%). 59.4% had abnormal cytogenetics. 35 variables were considered in the analysis. In the univariate analysis, variables with impact on 1-year OS post-transplant included creatinine (HR 3.35, CI 1.62-6.91, p=0.001), blood urea nitrogen (HR 1.03, CI 1.01-1.06, p=0.007), estimated glomerular filtration rate (HR 0.93, CI 0.89-0.93, p=0.001), hemoglobin (HR 0.8, CI 0.66-0.97, p=0.02), abnormal cytogenetics (HR 2.27, CI 1.20-4.31, p=0.012) and high and very high disease risk index (HR 0.51, CI 0.27-0.98, p=0.04). Notably, both hemoglobin and cytogenetics demonstrated a c-statistic greater than 0.6 in the univariate analysis. In the multivariate analysis, variables impacting 1-year OS included hemoglobin (HR 0.69, CI 0.48-0.99, p=0.04), remission status at the time of transplant i.e., not reached (NR) vs complete remission 1 (CR1) (HR 0.05, CI 0.00-0.71, p=0.027), and abnormal cytogenetics (HR 7.55, CI 2.32-24.58, p=0.001). Interestingly, the HCT-CI did not significantly impact 1-year OS in the univariate analysis (c-statistic 0.51, HR 0.99, CI 0.85-1.15, p=0.896). Our prediction model showed good performance with a mean area under the receiver operating characteristic curve of 0.82. Conclusion: We developed a comprehensive prediction model to assess 1-year OS in elderly patients undergoing alloHCT to overcome some of the limitations of the HCT-CI in this unique age group. This model holds potential to enhance decision-making regarding candidacy for elderly patients undergoing alloHCT.

Determinants of refined GvHD-free, relapse-free survival after reduced-intensity allogeneic hematopoietic cell transplantation in older patients with myeloid malignancies

BackgroundOlder patients with AML/MDS have a poor prognosis with alloHCT as the only curative option. However alloHCT is challenging given its high TRM. Recently, a composite endpoint of GRFS was proposed to define transplant success. A single centre retrospective analysis was performed to determine the main variables influencing GRFS. Patients and Methodsmethods91 consecutive patients≥ 60 years (median 64 years, range 60–74) with AML/MDS who received reduced-intensity alloHCT during 2001–2017 analysed. Disease risk index (DRI) at HCT was low/intermediate in 47pts (52%) and high in 44 pts (48%). ResultsAfter median follow-up for survivors of 56 months (range 7–144), 37 (40.6%) patients were alive. The OS, LFS and GRFS were 61.4%, 58.1%, 49.1% at 1 year and 35.5%, 32.3% and 23.1% at 5 years, respectively. The 1-year and 5-year incidences of NRM and relapse were 26.9%, 21.3% and 47.9% and 35.4%, respectively. In univariate analysis, high DRI was the strongest factor for worse OS (HR 2.121; p = 0.049), LFS (HR 1.924; p = 0.0123) and GRFS (HR 2.319; p = 0.0005). The donor age ≥ 62 years had a negative impact on OS (HR 2.110; p = 0.0345) and GRFS (HR 2.014; p = 0.0341). High DRI (HR 2.652; p = 0.0003) and donor age (HR 2.304; p = 0.0257) retained its significance in multivariate analysis for GRFS. ConclusionA significant portion of older patients with myeloid malignancies survive alloHCT without experiencing GRFS event with DRI as the main determinant of outcome. Negative impact of donor age≥ 62 years suggests preference of a young donor, regardless of being related or unrelated.

570 - Geriatric Assessment and Outcomes of Allogeneic Hematopoietic Cell Transplantation in Older Patients

570 - Geriatric Assessment and Outcomes of Allogeneic Hematopoietic Cell Transplantation in Older Patients

Allogeneic Hematopoietic Stem Cell Transplantation in Older Patients with Acute Myeloid Leukemia: Analysis of Outcomes and Contemporary Trends Spanning 10 Years

Background: Allogeneic hematopoietic stem cell transplantation (SCT) is a highly effective consolidation strategy in acute myeloid leukemia (AML). Non-myeloablative and reduced-intensity (NMA/RIC) conditioning regimens have expanded the use of SCT to older patients (pts) (age ≥ 60 years). Age alone no longer appears to be a barrier for successful SCT, with reported 3-year overall survival (OS) rates in the 45-50% range (Maakaron 2022). Methods: We conducted a retrospective study spanning 10 years to evaluate SCT-related outcomes in older AML. All pts ≥ 60 years presenting to our institution with newly-diagnosed (ND) AML were included. Acute promyelocytic leukemia (APL) was excluded. Median OS and relapse-free survival (RFS) were calculated using the Kaplan Meier method. A landmark analysis was performed to evaluate time-to-event endpoints in pts who underwent SCT in first response compared to those who did not. Results: Between 7/19/2012 and 11/17/2021, we identified 1073 pts ≥ 60 years with ND-AML. The median age at diagnosis was 71 years (range 60-94), 622 (58%) were male, 189 (18%) had prior myelodysplastic/myeloproliferative neoplasm, and 220 (21%) had therapy-related AML. ELN 2017 risk was favorable in 215 (20%), intermediate in 234 (22%), and adverse in 538 (50%) pts (86 with data missing). Most pts (84%) were treated with low-intensity (LOW) regimens. Only 16% were treated with intensive (INT) chemotherapy (intermediate or higher dose cytarabine). Venetoclax (VEN) was included in 34% of the regimens. The CR/CRi rate was 60% in the overall cohort. The CR/CRi rate was 74%, 48%, and 72% in pts treated with INT, LOW, and LOW + VEN therapies, respectively. The median OS and RFS were 11.2 and 10.6 months for the full cohort, respectively. The rate of referral to the SCT service was 38% (413/1073) and increased over time (31% in 2012-2013, 52% by 2020-2021). This occurred in parallel to increasing rates of CR/CRi (53% in 2012-2013, 66% by 2020-2021), likely reflecting increased efficacy of VEN-containing regimens in the later years. We identified 198/1073 pts (18%) who underwent SCT at some point during therapy, 152/198 (77%) in first response (CR/CRi/MLFS) after frontline therapy, and 46/198 (23%) following one or more salvage regimens. Of all ND-AML pts, the SCT rate was 37%, 10%, and 22% in pts treated with INT, LOW, and LOW + VEN, respectively. The rate of undergoing SCT increased over time (15% in 2012-2013, 27% by 2020-2021). Clinical/SCT characteristics for the pts who underwent SCT are shown in table 1. The rate of grade 3/4 acute graft-vs-host disease (GVHD) was 11% and 19% of pts experienced chronic GVHD of any grade. Following SCT, 24% of pts experienced relapse of AML and 21% died without disease relapse. The 100-day mortality following SCT was 13%. We then performed a landmark analysis (using median time to SCT [4.3 months] as the landmark) comparing pts undergoing SCT in first response following frontline therapy at our institution (n=139) to responding pts who did not receive SCT in first response and who were alive and without relapse at the landmark (n=353). Both the median OS (31.0 vs 18.9 months, p=0.0208, figure 1) and median RFS (23.2 vs 10.0 months, p<0.0001) were superior in the pts who underwent SCT compared to those who did not. Pts undergoing SCT in first response were younger (median age 66 vs 72 yrs) and had better performance status (PS 2-4 in 10% vs 22%) compared to no-SCT pts. Distribution of ELN risk categories and best response (CR/CRi/MLFS) were similar in the SCT and no-SCT groups. In pts who responded to initial therapy and were referred for SCT, but ultimately did not undergo SCT in first response (n=161), the most common documented reasons for forgoing SCT were social reasons (pt preference, financial/insurance/caregiver issues) in 29%, disease relapse in 29%, being deemed unfit due to comorbidities in 22%, active uncontrolled infections in 11%, and other reasons in 11%. An adequate donor was documented in 66% of these pts. Conclusions: Our results support the use of SCT as a consolidative strategy in older AML pts. Pts who undergo SCT have superior OS and RFS compared to those who do not. However, fewer than 20% of pts undergo the procedure mostly due to inadequate disease control, comorbidities, and a variety of social reasons. Recent trends indicate higher rates of SCT referral and completion as more effective anti-leukemic therapies are allowing a greater proportion of older AML pts to undergo SCT. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

POS-068 NON-KIDNEY INFECTIONS ARE CRITICAL FACTORS IN 5-YEAR KIDNEY GRAFT LOSS IN A TRANSPLANT POPULATION AT LOW RISK FOR CARDIOVASCULAR DISEASE

Kidney transplantation is the World's most common renal replacement therapy (RRT). In under-resourced countries, few transplant patients are elderly or diabetic, and the risk of cardiovascular events is low. Nevertheless, graft survival closely resembles that of living donor transplants in developed countries, where cardiovascular disease (CVD) death is a major cause of graft loss. This study evaluates kidney transplants performed in the Sulaimania Governate of Iraq from 2015 through 2019 and followed-up through 2021. There were 656 patients. The average age was 39.2 ± 14.0 years, 75% were under 50 years old, 3.5% were ≥ 65 years old, 19.7% were diabetic, and 11.7% had a BMI ≥ 30. All donors were living, and 96% of recipients were first-time transplants. Outcomes consisted of return to HD (RHD) and death with a functional graft (DWFG), and all graft loss (RHD+DWFG). Identified infections were pyelonephritis, PCR+ BK viremia (BKV), biopsy+ BK nephropathy (BKN), PCR+ COVID-19, and non-kidney-deep infections (NK-deep infections), the latter consisting of non-COVID pneumonia, septicemia, gastrointestinal infections, and hepatitis. Logistic regression tested the relationships between clinical characteristics, infections, and graft loss. Graft failure consisted of 53 patients with RHD and 50 with DWFG. Sixty-eight patients died, 41 of infection, 14 of CVD, and 13 of other or undetermined causes. NK-deep infections consisted mainly of bacterial pneumonia and septicemia. Septicemia followed implantation wound infections in 4 patients and intensified immunotherapy for recurrent disease in 3 patients (Table). Pyelonephritis affected 79 patients, and 37 patients had BKV with BKN in five. One pyelonephritis and 3 BKN progressed to dialysis. Two BKN resolved, but both patients DWFG, one of fungal sepsis, and one of CVD. COVID infected 211 patients, with 11 deaths (5.2%), 2 DOD and 9 DWFG. DWFG was attributed to infections in 26 patients (17 NK-deep infections and 9 COVID), CVD in 11 patients, and other causes in 13 patients. NK-deep infections were all fatal and were the most significant variable affecting all graft loss (NK-deep infection, OR=233.1, 30.4-1786.6, p<0.001; age, p=0.85; BMI, p=0.24; diabetes, p=0.16; pyelonephritis, p=0.21; BKV, p=0.38; COVID, p=0.28).Tabled 1Table: Non-kidney deep infections.InfectionNumberOutcomeTime post-transplant, months, median (interquartile range)Bacterial pneumonia96 DWFB, 3 DOD10 (2.5-15.7)Septicemia, all136 DWFG, 6 DOD3 (1.6-21.0)Septicemia, wound infections42 DWFG, 2 DOD1.1 (0.2-2.5)Septicemia, intensive therapy33 DOD2.0 (0.7-2.8)Viral pneumonia, non-COVID21 Cytomegalovirus, 1 herpes10, 40Pulmonary tuberculosis21 DWFG, 1 DOD4, 5HCV+ liver failure22 DWFG6, 17Intestinal infarction, peritonitis1DOD34Gastroenteritis1DWFG8 Open table in a new tab BKN was associated with graft loss in part indirectly by DWFG. COVID was responsible for 18% of DWFG, but it was NK-deep infections causing pneumonia and septicemia that had the most significant influence on graft loss. COVID and NK-deep infections caused 52% of DWFG and exceeded CVD by 2.4:1. The 5-year rate of graft loss was 18.6%. Currently, this rate does not seem excessive and is probably an unavoidable complication of immunosuppression. The transplantation of older patients with more CVD risk factors will assuredly increase rates of DWFG.

Outcomes of Autologous Hematopoietic Cell Transplantation in Older Patients with Diffuse Large B-Cell Lymphoma

Data for outcomes after autologous hematopoietic cell transplantation (auto-HCT) in diffuse large B-cell lymphoma (DLBCL) patients ≥70 years are limited. Auto-HCT is feasible in older DLBCL patients. Using the Center for International Blood and Marrow Transplant Research database, we compared outcomes of auto-HCT in DLBCL patients aged 60 to 69 years (n = 363) versus ≥70 years (n = 103) between 2008 and 2019. Non-relapse mortality (NRM), relapse/progression (REL), progression-free survival (PFS), and overall survival (OS) were modeled using Cox proportional hazards models. All patients received BEAM conditioning (carmustine, etoposide, cytosine arabinoside and melphalan). On univariate analysis, in the 60 to 69 years versus ≥70 years cohorts, 100-day NRM was 3% versus 4%, 5-year REL was 47% versus 45%, 5-year PFS 40% versus 38% and 5-year OS 55% versus 41%, respectively. On multivariate analysis, patients ≥70 had no significant difference in NRM (hazard ratio [HR] 1.43, 95% confidence interval [CI] 0.85-2.39), REL (HR 1.11, 95% CI 0.79-1.56), PFS (HR 1.23, 95% CI 0.92-1.63) compared to patients 60 to 69 years. Patients ≥70 years had a higher mortality (HR 1.39, 95% CI 1.05-1.85, p=0.02), likely because of inferior post-relapse OS in this cohort (HR 1.82, 95% CI 1.27-2.61, P = .001). DLBCL was the major cause of death in both cohorts (62% versus 59%). Older patients should not be denied auto-HCT solely on the basis of chronological age.

Heart Failure in Older Adults: Medical Management and Advanced Therapies.

As the population ages and the prevalence of heart failure increases, cardiologists and geriatricians can expect to see more elderly patients with heart failure in their everyday practice. With the advancement of medical care and technology, the options for heart failure management have expanded, though current guidelines are based on studies of younger populations, and the evidence in older populations is not as robust. Pharmacologic therapy remains the cornerstone of heart failure management and has improved long-term mortality. Prevention of sudden cardiac death with implantable devices is being more readily utilized in older patients. Advanced therapies have provided more options for end-stage heart failure, though its use is still limited in older patients. In this review, we discuss the current guidelines for medical management of heart failure in older adults, as well as the expanding literature on advanced therapies, such as heart transplantation in older patients with end-stage heart failure. We also discuss the importance of a multidisciplinary care approach including consideration of non-medical co-morbidities such as frailty and cognitive decline.

142 - Allogenic Transplantation in Older Patients with Acute Myeloid Leukemia and Myelodysplastic Syndrome

142 - Allogenic Transplantation in Older Patients with Acute Myeloid Leukemia and Myelodysplastic Syndrome

Good Long-term Results Following Simultaneous Pancreas-kidney Transplantation in a 69-y-old Recipient: A Case Report.

In contrast to well-published data with acceptable long-term results in large cohorts of single renal transplant recipients aged >65 y (lit.), combined pancreas-kidney transplantation in recipients >50 y is discussed controversially. Some groups have identified older recipients as a high-risk group, demonstrating decreased patient and graft survival in this population.1-4 Nevertheless, several centers have reported results for pancreatic transplantation in older patients as being comparable to those for younger recipients with the age cutoff ranging from 50 to 60 y.5-10 At our center, we have long-term experience with a total of 655 pancreas transplants performed between 1979 and August 2020, whereby 21 recipients were over 60 y of age; the oldest was age 69 and in remarkably good general condition with good mental adherence and a strong wish to undergo simultaneous kidney-pancreas transplantation (SPK). We retrospectively analyzed patient, pancreas, and kidney graft survival, graft function, and complications at month 38 posttransplant.

SY12-3 Hematopoietic transplantation for AML

Hematopoeitic stem cell transplantation (HSCT) has been an important modality for the treatment and cure of patients with high risk acute myeloid leukemia (AML). Improved stratification of AML patients with genetic markers (e.g. FLT3, CEBPA, NPM1 and others) has allowed better selection of patients for HSCT. Outstanding results from cord blood and haploidentical transplants have also increased the availability of donors for transplantation. Novel drugs like hypomethylating agents, BCL-2 inhibitors and various FLT 3 inhibitors have also improved the remission status of patients before transplant while also facilitating post-transplant consolidation and maintenance to improve disease control. Transplantation of older patients has also been made possible by the reduction of transplant-related mortality and morbidity through improved pre-transplant conditioning regimens and better management of post-transplant complications. Cellular engineering has also made possible the expansion of hematopoietic stem and progenitor cells to improve the results of HSCT while genetic engineering and expansion of cellular subsets has facilitated targeted therapy against viruses and leukemia. The outcomes of HSCT for the treatment of AML has improved significantly due to the above measures and HSCT remains a mainstay in the treatment of this disease.

Allogeneic Hematopoietic Stem Cell Transplantation in Older Patients Aged 50 Years or Older with Severe Aplastic Anaemia: Results from the European Society for Blood and Marrow Transplant and the Center for International Blood and Marrow Transplant Research

Treatment guidelines for older patients with severe aplastic anaemia (SAA) are incompletely developed. In particular, there is a paucity of data relating to outcomes among older patients with SAA who receive hematopoietic stem cell transplantation (SCT) from HLA-matched sibling (MSD) or unrelated donors (MUD). SCT is usually performed as second line treatment and it has been postulated that with improvements in conditioning protocols and supportive care, results in older patients would have improved over time. We analysed transplant outcomes in 538 patients aged 50 years and older with SAA who were transplanted between 2005 and 2016.275 patients (51%) received grafts from MSD, 224 (42%) from 8/8 HLA-matched MUD and 39 (7%) from 7/8 HLA-matched MUD. Median age at SCT was 58 years (range 50-77yrs,), of whom 347 were aged 50-59 years, 174 were aged 60-69yrs and 17 were aged ≥70yrs. 205 patients (38%) reported a performance score less than 90% and the median time from diagnosis to SCT was 10 months. Cyclophosphamide (Cy) with ATG or Cy with fludarabine and ATG were the predominant conditioning regimens for MSD SCT, whereas for MUD SCT, Cy with TBI 200 cGy and ATG or Cy, TBI 200 cGy, fludarabine with ATG were mostly used. 53% of the patients received bone marrow graft and 75% received calcineurin inhibitor (CNI) containing GVHD prophylaxis; 9% received alemtuzumab as part of GVHD prophylaxis.The day-28 cumulative incidence of neutrophil recovery was 84% (95% CI 81-87) and did not differ by patient age. Overall survival (OS) at 3 years for the entire cohort at 3 years was 56% (95% CI 51-60%) (Figure 1). Multivariate analysis confirmed higher mortality for patients with performance score less than 90% (HR 1.37, 95% CI 1.02-1.82; p=0.04) or who received a MUD SCT (HR 1.48, 95% CI 1.02-2.13, p=0.04). No other patient, disease or transplant characteristic was associated with survival. There were no significant differences in mortality risks for patients aged 65-78 versus those aged 50-64 years (HR1.20, 95% CI 0.08-1.74, p=0.36). However, age was significantly associated with grade II-IV acute GVHD; patients aged 65-78 years were at higher risk (HR 1.80, 95% CI 1.18-2.77, p=0.007). On univariate analysis, stem cell source (bone marrow versus peripheral blood) had no impact on acute (p=0.47) or chronic GVHD (p=0.12). Chronic GVHD risks were lower with CNI plus methotrexate (MTX) (HR 0.52, 95% CI 0.34-0.79, p =0.002) and alemtuzumab containing regimens (HR 0.25, 95% CI 0.13-0.48, p,0.001) than with CNI plus mycophenolate (MMF) GVHD prophylaxis. The group of patients who received alemtuzumab had the lowest rate of acute GVHD: 4% (95% CI: 0-10%) compared with 33% (95% CI: 25-42%) with CNI+MMF, 24% (95% CI: 19-30%) with CNI+MTX and 16% (95% CI:8-25%) with other GVHD prophylaxis (non-CNI containing regimens) (p=0.001). The corresponding 2-year rates of chronic GVHD were 11% (95% CI: 1-21%) with alemtuzumab, 50% (95% CI: 40-60%) with CNI+MMF, 32% (95% CI: 26-39%) with CNI+MTX and 21% (95% CI:10-33%) with other GVHD prophylaxis (p<0.001) (Figure 2). Infection was the predominant cause of death accountiing for 40% of deaths.These data support the feasibility of MSD or MUD SCT in SAA patients aged 50 years and older. However, the data need to be interpreted with caution since the selection of patients very likely has been biased. The importance of the performance status for outcome only underscores that concern. Acute and chronic GVHD adds to the burden of morbidity. Alemtuzumab-containing regimens deserve further study in this patient population. [Display omitted] DisclosuresPetersen:Sanofi: Membership on an entity's Board of Directors or advisory committees. Hallek:Mundipharma: Consultancy, Honoraria, Research Funding; F. Hoffmann-LaRoche: Consultancy, Honoraria, Research Funding; Janssen-Cilag: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Gilead: Consultancy, Honoraria, Research Funding; Amgen: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria, Research Funding. Potter:Jazz: Honoraria; Pfizer: Other: Advisory board. Peffault De Latour:Alexion Pharmaceuticals, Inc.: Consultancy, Honoraria, Research Funding; Amgen: Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; Novartis: Consultancy, Honoraria, Research Funding.

Toxicities of high-dose chemotherapy and autologous hematopoietic cell transplantation in older patients with lymphoma

High-dose chemotherapy and autologous hematopoietic cell transplantation is an effective consolidation therapy in lymphoma; however, its use in elderly patients has been limited because of concerns for greater toxicity in this group. We investigated the toxicities of carmustine, etoposide, cytarabine, and melphalan (BEAM) and autologous hematopoietic cell transplantation (AHCT) in 346 patients in 2 age groups: 279 patients aged 60 to 69 years and 67 patients aged ≥70 years. The majority developed severe toxicities; the most common were febrile neutropenia, gastrointestinal, infections, and cardiovascular. Older patients were at higher risk for grade ≥3 cardiovascular toxicities (hazard ratio [HR], 3.36; 95% confidence interval [CI], 2.25-5.00; P < .001) and skin toxicities (HR, 2.45; 95% CI, 1.08-5.54, P = .032). In the older group, nonrelapse mortality at 100 days and at 2 years was 2.99% (95% CI, 0.55-9.32) and 6.2% (95% CI, 1.97-13.95), respectively, vs 1.79% (95% CI, 0.68-3.92) and 2.91% (95% CI, 1.37-5.42), respectively, in the younger group. When adjusting for the number of grade ≥3 toxicities within the first 100 days, older patients had a 1.71-fold (95% CI, 1.08-2.71) increased risk for progression or death relative to younger patients. Although BEAM followed by AHCT is effective, it is associated with significant organ toxicities, especially in patients aged ≥70 years. Interventions to mitigate toxicities while maintaining efficacy are much needed.

Understanding the Impact of Pneumonia and Other Complications in Elderly Liver Transplant Recipients: An Analysis of NSQIP Transplant.

Background.Despite an increasing demand for liver transplantation in older patients, our understanding of posttransplant outcomes in older recipients is limited to basic recipient and graft survival. Using National Surgical Quality Improvement Program Transplant, we tracked early outcomes after liver transplantation for patients >65.Methods.We conducted a retrospective analysis of patients in National Surgical Quality Improvement Program Transplant between March 1, 2017 and March 31, 2019. Recipients were followed for 1 y after transplant with follow-up at 30, 90, and 365 d. Data were prospectively gathered using standard definitions across all sites.Results.One thousand seven hundred thirty-one adult liver transplants were enrolled; 387 (22.4%) were >65 y old. The majority of older recipients were transplanted for hepatocellular carcinoma. The older cohort had a lower lab Model for End-Stage Liver Disease and was less likely to be hospitalized at time of transplant. Overall, older recipients had higher rates of pneumonia but no difference in intensive care unit length of stay (LOS), total LOS, surgical site infection, or 30-d readmission. Subgroup analysis of patients with poor functional status revealed a significant difference in intensive care unit and total LOS. Pneumonia was even more common in older patients and had a significant impact on overall survival.Conclusions.By targeting patients with hepatocellular carcinoma and lower Model for End-Stage Liver Diseases, transplant centers can achieve nearly equivalent outcomes in older recipients. However, older recipients with poor functional status require greater resources and are more likely to develop pneumonia. Pneumonia was strongly associated with posttransplant survival and represents an opportunity for improvement. By truly understanding the outcomes of elderly and frail recipients, transplant centers can improve outcomes for these higher-risk recipients.

489 - Trends and Outcomes in Australia and New Zealand in Autologous Stem Cell Transplantation in Older Patients with Multiple Myeloma: An Australasian Bone Marrow Transplant Recipient Registry Study

489 - Trends and Outcomes in Australia and New Zealand in Autologous Stem Cell Transplantation in Older Patients with Multiple Myeloma: An Australasian Bone Marrow Transplant Recipient Registry Study

Transplantation for Older Patients with Hematologic Malignancies in 2021: Uncertainty and Ethics in Decision-Making

Hematological malignancies such as acute myeloid leukemia or myelodysplastic syndrome occur predominantly in older individuals. For many of these patients, hematopoietic cell transplantation is currently the only treatment modality with curative potential. However, older age tends to be associated with increasing co-morbidities, rendering patients more susceptible to toxicities associated with the transplantation procedure. Further, transplantation carries the risk of inducing graft-versus-host disease, the clinical result of the immunological attack of donor cells against the patient's body, even if the donor is matched (for human leukocyte antigen) with the patient. These complications affect quality of life and may prove fatal. More conventional chemotherapy does not carry the risk of these complications; however, in most patients, it does not cure the disease. Therefore, multiple patient and disease characteristics are being considered in the decision-making process regarding the two treatment strategies, and the decision is generally based on statistics from previous studies. Of course, those statistics do not consider individual patient personalities nor physician attitudes, which clearly affect patient decisions. Thus, these discussions involve considerable uncertainty and ethical considerations as to the greatest benefit at the lowest "cost" for the patient.

Outcomes of ABO-incompatible kidney transplantation in older patients: a national cohort study.

Outcomes of ABO-incompatible living donor kidney transplantation (ABOi LDKT) in older individuals have not been established. This multicentric observational study, using data from the Korean Organ Transplantation Registry database, included 634 older patients (≥60years) undergoing kidney transplantation. We compared clinical outcomes of ABOi LDKT (n=80) with those of ABO-compatible LDKT (ABOc LDKT, n=222) and deceased donor kidney transplantation (DDKT, n=332) in older patients. Death-censored graft survival was similar between the three groups (P=0.141). Patient survival after ABOi LDKT was similar to that after ABOc LDKT (P=0.489) but higher than that after DDKT (P=0.038). In multivariable analysis, ABOi LDKT was not risk factor (hazard ratio [HR] 1.73, 95% confidence interval [CI] 0.29-10.38, P=0.548), while DDKT was significant risk factor (HR 3.49, 95% CI 1.01-12.23, P=0.049) for patient survival. Although ABOi LDKT showed higher biopsy-proven acute rejection than ABOc LDKT, the difference was not significant after adjustment with covariates. However, ABOi LDKT was significant risk factor for infection (HR 1.66, 95% CI 1.12-2.45, P=0.012). In older patients, ABOi LDKT was not inferior to ABOc LDKT and was superior to DDKT for patient survival. ABOi LDKT can be recommended for older patients, rather than waiting for DDKT.

Trends in Outcomes in Australia and New Zealand in Autologous Stem Cell Transplantation in Older Patients with Multiple Myeloma: An Australasian Bone Marrow Transplant Recipient Registry Study

Trends in Outcomes in Australia and New Zealand in Autologous Stem Cell Transplantation in Older Patients with Multiple Myeloma: An Australasian Bone Marrow Transplant Recipient Registry Study

Skeletal Muscle Index as a Prognostic Marker for Kidney Transplantation in Older Patients

Low skeletal muscle mass has emerged as a risk factor for mortality after liver transplantation. We evaluated the prognostic value of muscle mass on length of hospitalization and adverse outcomes after kidney transplantation in aging end-stage renal disease patients. One hundred twenty-two patients aged 60years or older at the time of transplantation were retrospectively analyzed. Skeletal muscle index (SMI), evaluated by computed tomography scan, was calculated from total muscle surface area at L3 vertebral level divided by body height squared. Outcomes were compared according to SMI (namely, length of hospitalization, wound complications, combined endpoint comprising all-cause mortality, and graft failure within 1year). In male patients, by multivariate analysis, a low SMI (<42cm2/m2) was associated with longer immediate post-transplantation hospitalization (β=17.03±4.3; P=.0002), longer total hospitalization during the first year (β=34.3±10.7; P=.002), higher rate of wound complications (odds ratio=12.1 [1.9-77.0]; P=.008), and higher rate of the combined endpoint of graft loss or death (odds ratio=3.4 [3.0-399.5]; P=.004). In female patients, low SMI was not associated with length of hospitalization or adverse outcomes after transplantation. SMI is an independent marker of morbidity and mortality after kidney transplantation in older men and could help thereby nephrologists better select aging candidates for kidney transplantation with a view to improving post-transplant outcomes.