Hematopoietic Stem-Cell Transplantation
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《新英格兰医药杂志》
To the Editor: Copelan (April 27 issue)1 provides a comprehensive review of hematopoietic stem-cell transplantation, including complications after transplantation. However, the review article does not describe a common complication that causes substantial excess mortality: renal injury.
During the first 2 weeks after transplantation, acute renal failure develops in up to 75% of patients receiving myeloablative regimens and approximately 33% of these patients require hemodialysis.2 The mortality rate among patients with acute renal failure is two to seven times that among patients without this complication.3
From 2 weeks to 3 months after transplantation, a spectrum of renal insults occurs secondary to acute graft-versus-host disease (GVHD). These insults range from prerenal azotemia to a thrombotic thrombocytopenic purpura-like microangiopathy that does not respond to pheresis and is accompanied by high mortality rates (50 to 60%).4
By 3 to 6 months after transplantation, the glomerular filtration rate decreases in most patients (65 to 100%).2 In some patients with chronic GVHD, the nephrotic syndrome, primarily membranous glomerulonephropathy, develops.5 A combination of radiation-induced nephritis and thrombotic microangiopathy may also occur.6
As more transplantations are performed, successful outcomes will depend on finding interventions that decrease the incidence and effects of renal injury.
Matthew J. Ellis, M.D.
Uptal D. Patel, M.D.
Duke University Medical Center
Durham, NC 27710
mje4@duke.edu
References
Copelan EA. Hematopoietic stem-cell transplantation. N Engl J Med 2006;354:1813-1826.
Parikh CR, Coca SG. Acute renal failure in hematopoietic cell transplantation. Kidney Int 2006;69:430-435.
Parikh CR, Sandmaier BM, Storb RF, et al. Acute renal failure after nonmyeloablative hematopoietic cell transplantation. J Am Soc Nephrol 2004;15:1868-1876.
George JN, Li X, McMinn JR, Terrell DR, Vesely SK, Selby GB. Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome following allogeneic HPC transplantation: a diagnostic dilemma. Transfusion 2004;44:294-304.
Rao PS. Nephrotic syndrome in patients with peripheral blood stem cell transplant. Am J Kidney Dis 2005;45:780-785.
Cohen EP, Lawton CA, Moulder JE, Becker CG, Ash RC. Clinical course of late-onset bone marrow transplant nephropathy. Nephron 1993;64:626-635.
To the Editor: With respect to the article on hematopoietic stem-cell transplantation, we would like to point out that we used cord blood to treat a patient with leukemia in the early 1970s.1
Mark Ende, M.D.
Frederick I. Ende, M.D.
121 S. Market St.
Petersburg, VA 23803
mende44430@aol.com
References
Ende M, Ende N. Hematopoietic transplantation by means of fetal (cord) blood. Va Med Mon (1918) 1972;99:276-80.
The author replies: Ellis and Patel accurately state that renal injury is a common complication of hematopoietic stem-cell transplantation. The frequencies described in their letter pertain only to allogeneic transplantation with myeloablative regimens; but even in that setting, the stated need for hemodialysis is higher than that reported in most studies.1,2 Renal failure often occurs in association with the sinusoidal obstruction syndrome, as stated in my review article, and it may be secondary to that condition or to other complications, particularly sepsis. Death in these settings is largely related to the underlying problems.
I respect the originality of Ende and Ende in using cord blood more than 15 years before Gluckman et al. first reported successful transplantation with the use of cord blood.3 Much of the preliminary work was not included in my review.
Edward A. Copelan, M.D.
Ohio State University Medical Center
Columbus, OH 43210
edward.copelan@osumc.edu
References
Parikh CR, Coca SG. Acute renal failure in hematopoietic cell transplantation. Kidney Int 2006;69:430-435.
Nash RA, Antin JH, Karanes C, et al. Phase 3 study comparing methotrexate and tacrolimus with methotrexate and cyclosporine for prophylaxis of acute graft-versus-host disease after marrow transplantation from unrelated donors. Blood 2000;96:2062-2068.
Gluckman E, Broxmeyer HE, Auerbauch AD, et al. Hematopoietic reconstitution in a patient with Fanconi's anemia by means of umbilical-cord blood from an HLA-identical sibling. N Engl J Med 1989;321:1174-1178.
During the first 2 weeks after transplantation, acute renal failure develops in up to 75% of patients receiving myeloablative regimens and approximately 33% of these patients require hemodialysis.2 The mortality rate among patients with acute renal failure is two to seven times that among patients without this complication.3
From 2 weeks to 3 months after transplantation, a spectrum of renal insults occurs secondary to acute graft-versus-host disease (GVHD). These insults range from prerenal azotemia to a thrombotic thrombocytopenic purpura-like microangiopathy that does not respond to pheresis and is accompanied by high mortality rates (50 to 60%).4
By 3 to 6 months after transplantation, the glomerular filtration rate decreases in most patients (65 to 100%).2 In some patients with chronic GVHD, the nephrotic syndrome, primarily membranous glomerulonephropathy, develops.5 A combination of radiation-induced nephritis and thrombotic microangiopathy may also occur.6
As more transplantations are performed, successful outcomes will depend on finding interventions that decrease the incidence and effects of renal injury.
Matthew J. Ellis, M.D.
Uptal D. Patel, M.D.
Duke University Medical Center
Durham, NC 27710
mje4@duke.edu
References
Copelan EA. Hematopoietic stem-cell transplantation. N Engl J Med 2006;354:1813-1826.
Parikh CR, Coca SG. Acute renal failure in hematopoietic cell transplantation. Kidney Int 2006;69:430-435.
Parikh CR, Sandmaier BM, Storb RF, et al. Acute renal failure after nonmyeloablative hematopoietic cell transplantation. J Am Soc Nephrol 2004;15:1868-1876.
George JN, Li X, McMinn JR, Terrell DR, Vesely SK, Selby GB. Thrombotic thrombocytopenic purpura-hemolytic uremic syndrome following allogeneic HPC transplantation: a diagnostic dilemma. Transfusion 2004;44:294-304.
Rao PS. Nephrotic syndrome in patients with peripheral blood stem cell transplant. Am J Kidney Dis 2005;45:780-785.
Cohen EP, Lawton CA, Moulder JE, Becker CG, Ash RC. Clinical course of late-onset bone marrow transplant nephropathy. Nephron 1993;64:626-635.
To the Editor: With respect to the article on hematopoietic stem-cell transplantation, we would like to point out that we used cord blood to treat a patient with leukemia in the early 1970s.1
Mark Ende, M.D.
Frederick I. Ende, M.D.
121 S. Market St.
Petersburg, VA 23803
mende44430@aol.com
References
Ende M, Ende N. Hematopoietic transplantation by means of fetal (cord) blood. Va Med Mon (1918) 1972;99:276-80.
The author replies: Ellis and Patel accurately state that renal injury is a common complication of hematopoietic stem-cell transplantation. The frequencies described in their letter pertain only to allogeneic transplantation with myeloablative regimens; but even in that setting, the stated need for hemodialysis is higher than that reported in most studies.1,2 Renal failure often occurs in association with the sinusoidal obstruction syndrome, as stated in my review article, and it may be secondary to that condition or to other complications, particularly sepsis. Death in these settings is largely related to the underlying problems.
I respect the originality of Ende and Ende in using cord blood more than 15 years before Gluckman et al. first reported successful transplantation with the use of cord blood.3 Much of the preliminary work was not included in my review.
Edward A. Copelan, M.D.
Ohio State University Medical Center
Columbus, OH 43210
edward.copelan@osumc.edu
References
Parikh CR, Coca SG. Acute renal failure in hematopoietic cell transplantation. Kidney Int 2006;69:430-435.
Nash RA, Antin JH, Karanes C, et al. Phase 3 study comparing methotrexate and tacrolimus with methotrexate and cyclosporine for prophylaxis of acute graft-versus-host disease after marrow transplantation from unrelated donors. Blood 2000;96:2062-2068.
Gluckman E, Broxmeyer HE, Auerbauch AD, et al. Hematopoietic reconstitution in a patient with Fanconi's anemia by means of umbilical-cord blood from an HLA-identical sibling. N Engl J Med 1989;321:1174-1178.