Effect of IgM‐enriched intravenous immunoglobulin (Pentaglobin) on endotoxaemia and anti‐endotoxin antibodies in bone marrow transplantation

Summary:A five-agent GVHD prophylaxis programme consisting of cyclosporin A, methotrexate, anti-thymocyte-globulin, pentaglobin and metronidazol was given to 48 recipients of unrelated donor marrow with chronic myelogenous leukemia, acute leukemia, myelodysplastic syndromes, and familiar lymphocytic hemophagocytosis of an average age of 33.5 (0.6-56) years. GVHD grades II-IV occurred in 18 patients (39%) and grades III-IV in five patients (11%). Chronic GVHD developed in nine patients (23%), three limited and six extensive. Fifteen patients died. Clinical relapse was detected in eight patients. Four patients died as a consequence of the underlying disease and subsequent treatment, 11 patients died of transplant-related causes. After a median follow-up of 19 months, the overall and diseasefree survival are 67% and 62%, respectively. Survival by age is as follows: 0-19 years: 12/13 patients; 20-39 years: 14/25 patients; 40-59 years: 7/10 patients. The five-agent GVHD prophylaxis regimen is effective. Matched-unrelated donor transplants can be carried out safely in patients younger than 50 years of age. The results in patients younger than 20 years of age should encourage matched-unrelated donor transplants at earlier stages of the disease.

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Use of a five-agent GVHD prevention regimen in recipients of unrelated donor marrow

Zander

Zabelina²,

Kröger

et al. 1999

“…52 Higher levels of circulating endotoxin are obtained after giving intensive TBI containing regimens 13 suggesting that persistent low-grade endotoxaemia or the inflammation associated with MBI induce fever of unknown origin since endotoxaemia and gut mucosal damage occurred in 44 (70%) of 63 HSC transplant recipients (both allogeneic and autologous) all of whom developed fever that could not be explained by infection. 53 Peptidoglycan (the major component of the cell wall of Gram-positive bacteria) may play a similar role as endotoxin as it is also biologically active in tissues and may induce a pro-inflammatory response. 54 Although much less potent than endotoxin gram-for-gram, large amounts of peptidoglycan may well be released into the circulation when gut MBI is present simply because there are many more Gram-positive than Gram-negative bacteria in the gut.…”

Section: The Epithelial Phasementioning

confidence: 99%

Mucosal barrier injury: biology, pathology, clinical counterparts and consequences of intensive treatment for haematological malignancy: an overview

Blijlevens¹,

Donnelly²,

Pauw³

2000

234

153

Summary:Mucositis is an inevitable side-effect of the conditioning regimens used for haematopoietic stem cell transplantation. The condition is better referred to as mucosal barrier injury (MBI) since it is primarily the result of toxicity and is a complex and dynamic pathobiological process manifested not only in the mouth but also throughout the entire digestive tract. A model has been proposed for oral MBI and consists of four phases, namely inflammatory, epithelial, ulcerative and healing phases. A variety of factors are involved in causing and modulating MBI including the nature of the conditioning regimen, the elaboration of pro-inflammatory and other cytokines, translocation of the resident microflora and their products, for example, endotoxins across the mucosal barrier, exposure to antimicrobial agents and whether or not the haematopoietic stem cell graft is from a donor. Neutropenic typhlitis is the most severe gastrointestinal manifestation of MBI, but it also influences the occurrence of other major transplant-related complications including acute GVHD, veno-occlusive disease and systemic infections. The pathobiology, clinical counterparts and the means of measuring MBI are discussed together with potential approaches for prevention, amelioration and, perhaps, even cure. Bone Marrow Transplantation (2000) 25, 1269-1278. Keywords: mucositis; mucosal barrier injury; diagnosis; risk factors; treatment Mucositis is an inevitable side-effect of the intensive conditioning therapy used for haematopoietic stem cell transplantation 1 and usually refers to the mucosal ulceration of mouth and throat. However, it is generally accepted that oral mucositis is in reality the most obvious manifestation of damage or injury elsewhere particularly that of the gut. Hence, mucosal barrier injury (MBI) may be a more appropriate term for this biological process. There exists no clear definition of MBI which is defined by a constellation of signs and symptoms that vary in their clinical expression. Oral MBI is reported to affect 60% to 100% of transplant recipients 2,3 and is characterised by pain, oedema, erythema, lesions, pseudomembrane formation, excessive mucous production, reduced saliva and bleeding, all of which reduce the patient's ability to eat and drink. In contrast, there are no reliable data on the incidence of gut MBI although intestinal symptoms affect almost every transplant recipient to some extent and include nausea, vomiting, abdominal cramping and watery diarrhoea occasionally accompanied by macroscopic blood loss. The exact course and severity of bowel symptoms of MBI are also difficult to ascertain because many patients are in such pain due to oral MBI that they only gain relief from narcotic analgesia which induces constipation as a result of reduced gut motility. There are also a number of scoring systems for oral MBI 4 although none is universally accepted and all lack standardisation. As yet, there is no system for registering gut MBI although there are published definitions for grading toxicity o...

“…[69][70][71] Recent work has also demonstrated that LPS is an important effector molecule in the development of acute GVHD; translocation of LPS across a gut mucosa damaged early in the post transplant period provides access to the systemic circulation where it stimulates leukocytes to release inflammatory mediators that subsequently contribute to GVHD target organ damage and dysfunction. 60,61,[72][73][74][75][76] LPS levels are elevated in the BAL fluid of mice with IPS, and LPS stimulates the release of inflammatory cytokines that directly contribute to lung damage: intravenous LPS injection 6 weeks after allogeneic SCT significantly amplifies lung injury. 41 This amplification is only seen in mice with advanced GVHD and is associated with large increases in BAL fluid levels of TNFa and LPS, and the development of alveolar hemorrhage.…”

Section: The Pathogenesis Of Ipsmentioning

confidence: 99%

Acute lung injury after allogeneic stem cell transplantation: is the lung a target of acute graft-versus-host disease?

Cooke

Yanik

2004

103

Summary:Allogeneic hematopoietic stem cell transplantation (SCT) is an important therapeutic option for a number of malignant and nonmalignant conditions but the broader application of this treatment strategy is limited by several side effects. In particular, diffuse lung injury is a major complication of SCT that responds poorly to standard therapeutic approaches and significantly contributes to transplant-related morbidity and mortality. Historically, approximately 50% of all pneumonias seen after SCT have been secondary to infection, but the judicious use of broad-spectrum antimicrobial prophylaxis in recent years has tipped the balance of pulmonary complications from infectious to noninfectious causes. This mini review will discuss the definition, risk factors and pathogeneses of noninfectious lung injury that occurs early after allogeneic SCT.