Bone marrow transplant‐associated thrombotic microangiopathy (BMT‐TM) ranges in severity from a self‐limited to a fatal disorder. There has been no specific therapy for this condition. We have previously described a clinical grading system for BMT‐TM, based upon lactate dehydrogenase level (LDH) and percentage fragmented cells (FC) as follows: grade 0, normal or ↑ LDH and % FC ≤ 1.2%; grade 1, normal LDH and FC ≥ 1.3%; grade 2, ↑ LDH and FC = 1.3–4.8%; grade 3, ↑ LDH and FC = 4.9–9.6%; and grade 4, ↑ LDH and FC ≥ 9.7%. Patients with grade 4 BMT‐TM usually have fulminant disease and generally succumb. This study summarizes results using a variety of apheresis procedures in a series of 16 patients with grade 4 BMT‐TM. The apheresis procedures consisted of plasma exchange (with replacement with fresh frozen plasma or cryo‐poor plasma), and protein A immunoadsorption (PAI). The PAI exchanges were not done concurrently with plasma exchange procedures. Fifteen patients had undergone an allogeneic BMT and the 16th patient had undergone an autologous peripheral blood stem cell transplant. Half showed hematologic improvement with a downstaging of their TM to grades 1–3. All non‐responders died a median of 11 days following the onset of grade 4 BMT‐TM. The median survival in the responders was significantly (P = 0.001) increased to 218 days with three responders surviving more than 400 days following the onset of this severe complication. These results suggest a role for apheresis in the treatment of this lethal complication. Nevertheless grade 4 BMT‐TM represents a major complication of BMT; the median survival in this group of 16 patients with grade 4 BMT‐TM was only 31 days. © 1996 Wiley‐Liss, Inc.

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Background: Elevation in cardiac enzymes after percutaneous coronary intervention (PCI) is common and is associated with adverse clinical outcomes. Hypothesis: Administration of intracoronary nicardipine-a calcium channel blocker will reduce cardiac enzyme levels in patients undergoing elective PCI. Methods: In a single center, prospective, double-blind placebo-controlled trial, 193 patients undergoing elective PCI (with or without stenting) for chronic stable angina and/or an abnormal stress test were randomized to receive 200 mcg of intracoronary nicardipine (n = 93) or saline solution (n = 100) prior to intervention. Cardiac enzyme levels were measured immediately and at 8 and 16 hours after the procedure. Major adverse clinical events (MACE) were assessed at 30 days and at 6 months. Results: Incidence of periprocedural myonecrosis defined as elevation of troponin I levels >1× the upper limit of normal was similar in both groups (placebo 15.4% vs drug 10.6%; P = 0.47). There was no significant difference in peak troponin I levels after PCI between the 2 groups (placebo 0.58 ng/mL ± 1.08 ng/mL vs drug 0.97 ng/mL ± 3.6 ng/mL; P = 0.35). Major adverse clinical events at 6 months were infrequent and not statistically different in the 2 groups (placebo 3.4% vs drug 1.2%; P = 0.52). Multivariate analysis revealed that pretreatment with nicardipine was not associated with reduction in the incidence of troponin I elevation (odds ratio [OR]: 0.54; 95% confidence interval [CI]: 0.18-1.6; P = 0.28). Conclusions: In low-risk patients undergoing elective PCI, intracoronary nicardipine administration did not produce a significant cardioprotective effect in reducing postprocedural cardiac enzymes leakage.