Osteopenia/osteoporosis (O/O) has been associated with allogeneic stem cell transplantation (alloSCT). We retrospectively reviewed 102 patients undergoing a first alloSCT from 2000 to 2005 at our center to evaluate the prevalence of O/O p6 and 46 months post-alloSCT. Fifty-six patients did not have a dual energy X-ray absorptiometry (DXA) scan following alloSCT. Approximately half (n ¼ 13/27) of those with a first DXA scan p6 months post-alloSCT had O/O and a similar rate (n ¼ 9/19) was seen in those with a first DXA scan 46 months. There were no significant differences in patient characteristics between the normal and O/O groups. The dual femur (DF) appeared to be more vulnerable to alloSCTinduced bone mineral density (BMD) loss than the lumbar spine (LS), regardless of screening time. O/O patients were treated with bisphosphonates and 41% had a repeat DXA scan post-treatment. No patient developed jaw osteonecrosis and significant BMD improvement was seen at the LS (mean BMD, 1.03 ± 0.13 vs 1.08 ± 0.12, P ¼ 0.004) but not the DF (mean BMD, 0.84±0.06 vs 0.85 ± 0.08, P ¼ 0.29), indicating BMD loss at the DF is more resistant than the LS to antiresorptive therapy. Our results demonstrate that O/O is an early and late complication post-alloSCT and bisphosphonate treatment reverses BMD loss at the LS.

Allogeneic hematopoietic cell transplantation (alloHCT) is a curative therapy for hematologic disorders including acute lymphoblastic and myeloid leukemia, chronic lymphocytic and myeloid leukemia, Hodgkin's and non-Hodgkin lymphoma, multiple myeloma, and myelodysplastic syndrome. To determine the utilization of alloHCT from unrelated donors (URDs) in the United States, we calculated the number of patients diagnosed with hematologic disorders age 20 to 74 years based on 2004 to 2008 Surveillance, Epidemiology and End Results and 2007 US Census data, estimated the percentage of patients who would be eligible for URD alloHCT after discounting the mortality rate during induction therapy and the rate of severe comorbidities, and compared these with the actual 2007 alloHCTs facilitated by the National Marrow Donor Program. We found that the number of URD alloHCT as a percentage of the estimated potential transplantations ranged from 11% for multiple myeloma to 54% for chronic myeloid leukemia, with an average percentage of 26% for all the disorders considered. In an analysis stratified by age groups (20 to 44, 45 to 64, and 65 to 74 years), the utilization of URD alloHCT was higher in younger patients than in older patients for all disorders. Of acute lymphoblastic and myeloid leukemia patients, approximately 66% underwent URD alloHCT later in the course of their disease (in second or greater complete remission). URD alloHCT is likely underused for potentially curable hematologic disorders, particularly in older patients. Understanding the reasons for low use of alloHCT may lead to strategies to expand the use of this curative therapy for more patients with hematologic disorders.

Early recognition of gastrointestinal graft-versus-host disease (GI GVHD) after allogeneic hematopoietic stem cell transplantation (alloHSCT) is vital to initiation of therapy. However, the most common location, the small bowel (SB), is difficult to access with upper and lower endoscopy (UGE/LGE). Wireless capsule endoscopy (WCE) is a noninvasive technology allowing complete SB evaluation. The capsule location can also be tracked to identify motility derangements. From August 2006 to July 2007, 11 alloHSCT patients with GI symptoms underwent WCE, and visual grading was performed. UGE and LGE with biopsies were done when clinically indicated. All patients had evidence of probable acute GVHD (aGVHD) on WCE. WCE revealed lesions of greater severity than those seen by UGE or LGE in most patients. WCE demonstrated that 45% of patients had delayed gastric transit time. WCE is an excellent, noninvasive method for assessing GI GVHD, with the ability to more accurately assess the severity of GVHD, evaluate clinical symptoms, and follow response to treatment.

Common blood and marrow transplantation (BMT) eligibility criteria include a minimum glomerular filtration rate (GFR) that may vary by regimen intensity. GFR is often estimated by measurement of creatinine clearance in a 24-hour urine collection (24-hr CrCl), an inconvenient and error-prone method that overestimates GFR. The study objectives were to determine which of 6 GFR calculations: Cockroft-Gault (CG), modified CG (mCG), Modification of Diet in Renal Disease 1 (MDRD1), MDRD2, Jelliffe, and Wright, consistently underestimated measured 24-hr CrCl pre-BMT. We retrospectively analyzed 98 consecutive allogeneic (n = 48) or autologous (n = 50) adult BMT patients from January 2006 to April 2007. All 6 formulas were significantly (P < .001) correlated with 24-hr CrCl with R = 0.64 (Wright), 0.63 (CG), 0.61 (mCG), 0.61 (Jelliffe), 0.54 (MDRD2), and 0.50 (MDRD1). When compared to the measured 24-hr CrCl, MDRD2 consistently underestimated it in the highest proportion of patients (66%, P < .001), compared with MDRD1 (65%, P < .001), Jelliffe (61%, P = NS), mCG (55%, P = NS), Wright (34%, P < .001), and CG (34%, P = .001). Measured 24-hr CrCl, pre-BMT serum Cr, and all 6 equations were not predictive of renal regimen-related toxicity (RRT) post-BMT. The Wright and CG formulas are closest to, but overestimate 24-hr CrCl in 66% of patients. In comparison, MDRD2 consistently underestimates 24-hr CrCl in 66%. Although MDRD2 is the most conservative formula, all 6 formulas gave reasonable estimates of GFR and any of the 6 equations can replace the measured 24-hr CrCl. Larger analyses and transplantation of patients with GFR <50 mL/min may better define subgroups at risk for renal RRT.

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Bone mineral density (BMD) loss has been recently associated with allogeneic stem cell transplantation (alloSCT). It is not certain whether BMD loss in alloSCT patients (pts) occurs primarily within the first six months, since some reports cite continuing BMD loss up to six years post-transplant. Furthermore, it has been suggested that alloSCT-BMD loss is more likely to manifest in the femoral neck (FN), as opposed to the lumbar spine (LS). There are no studies that have detailed the incidence of alloSCT-BMD loss. We retrospectively reviewed 90 alloSCT pts who underwent a single alloSCT between 7/1/2001 and 2/26/2005 to assess the frequency of DEXA scan use and alloSCT-BMD loss. 7/1/2001 was chosen as the start date since this was when DEXA scans were first available at RPCI. 50 patients did not have DEXA scans following BMT: 15/50 pts died before day 130, 21/50 pts died after day 130 post BMT, and 14/50 pts are alive post day 130 without DEXA scans (median 1.1 yrs, range 0.34–3.0 yrs). Clinical criteria for obtaining DEXA scans were a medically stable condition with a good KPS and alive at day 130. 37 pts met this criteria. The median survival of the non-DEXA scan pts was 180 (7–1296) days and 571 (110–1282) days for the DEXA scan pts. DEXA scan pt characteristics in this sample included: Median age 39 years (range 7–66); AML (n=12), Lymphoma (n=12), CML (n=5), MDS/MPD (n=5), ALL (n=2), or Aplastic Anemia (n=1); Flu+Mel (n=14), Bu+Cy (n=8), Cy+TBI (n=7), non-myeloablative regimen (n=6), or other regimens (n=2); FK+Mt (n=28), FK+/− other (n=4), Mt (n=2), Cs+Mt (n=2), or Cs+FK+Mt (n=1). Approximately half (n=18/37) of alloSCT pts were found to have BMD loss at day 130 post-transplant. Results were stratified by year, and no trends regarding the frequency of DEXA scans in the population or the frequency of abnormal results over time were noted. There were no differences in terms of conditioning regimens or GVHD prophylaxis between the normal and low BMD groups. Contrary to previously published reports, we did not find a marked difference between the LS and FN T scores of the 18 pts with BMD loss at baseline (LS median T score = −1.4, FN median T score = −1.55). Also, BMD improvement following oral bisphosphonates was seen in six pts with available follow-up scans (LS median T score improved from −1.15 to −0.55, FN median T score improved from −1.45 to −1.1). The day 130 incidence of BMD loss in our alloSCT population was higher than we expected. Therefore, we recommend that all future alloSCT pts undergo DEXA scans as part of the day 100 workup. Further study may elucidate risk factors for BDM loss post BMT. Bisphosphonate use may reverse alloSCT BDM loss.