High-Dose Carboplatin/Etoposide/Melphalan Increases Risk of Thrombotic Microangiopathy and Organ Injury After Autologous Stem Ce

Bone Marrow Transplantation (2018) 53:1311–1318 https://doi.org/10.1038/s41409-018-0159-8

ARTICLE

High-dose Carboplatin/Etoposide/Melphalan increases risk of thrombotic microangiopathy and organ injury after autologous stem cell transplantation in patients with neuroblastoma

1 1 1 1 1 Sonata Jodele ● Christopher E. Dandoy ● Kasiani Myers ● Gregory Wallace ● Adam Lane ● 2 3 1 Ashley Teusink-Cross ● Brian Weiss ● Stella M. Davies

Received: 13 October 2017 / Revised: 3 January 2018 / Accepted: 30 January 2018 / Published online: 19 April 2018 © Macmillan Publishers Limited, part of Springer Nature 2018

Abstract Transplant-associated thrombotic microangiopathy (TA-TMA) is an increasingly recognized complication of hematopoietic cell transplant that can result in multi-organ failure (MOF). Patients undergoing high-dose chemotherapy with autologous stem cell transplant (aHCT) for neuroblastoma require good organ function to receive post-transplant radiation and immunotherapy. We examined TA-TMA incidence and transplant outcomes in patients with neuroblastoma receiving different transplant preparative regimens. Sixty patients underwent aHCT using high-dose chemotherapy: 41 patients 1234567890();,: 1234567890();,: received carboplatin/etoposide/melphalan (CEM), 13 patients busulfan/melphalan (Bu/Mel) and six patients received tandem transplant (cyclophosphamide/thiotepa and CEM). TA-TMA with MOF was diagnosed in 13 patients (21.7%) at a median of 18 days after aHCT. TA-TMA occurred in 12 patients receiving CEM and in 1 after cyclophosphamide/thiotepa. There were no incidences of TA-TMA after Bu/Mel regimen. Six of 13 patients with TA-TMA and MOF received terminal complement blocker eculizumab for therapy. They all recovered organ function and received planned post-transplant therapy. Out of seven patients who did not get eculizumab, two died from TA-TMA complications and four progressed to ESRD. We conclude that the CEM regimen is associated with a high incidence of clinically signiﬁcant TA-TMA after aHCT and eculizumab can be safe and effective treatment option to remediate TA-TMA associated MOF.

Introduction adequate organ function after aHCT is critical to be able to proceed with neuroblastoma-directed therapy, including Patients with high-risk neuroblastoma undergo multistep radiation, cis-retinoic acid (cis-RA) and Ch14.18 antibody complex therapy, including induction chemotherapy, sur- [4]. gical tumor removal, high-dose chemotherapy consolidation Transplant –associated thrombotic microangiopathy with autologous hematopoietic stem cell rescue (aHCT), (TA-TMA) is a signiﬁcant and increasingly recognized radiation and immunotherapy [1–3]. Therapy for high-risk complication of stem cell transplantation that can affect neuroblastoma does not end with aHCT as it does for organ function and overall outcomes [5–7]. TA-TMA pre- patients with some other diagnoses. Preservation of sents with systemic endothelial injury that can range from a mild and self-limiting disorder to a severe and lethal complication with multi-organ failure (MOF). TA-TMA can also result in severe hypertension and proteinuria that would * Sonata Jodele preclude timely initiation of cis-RA. In our recent pro- [email protected] spective study, we demostrated that patients with terminal complement activation and proteinuria at TA-TMA diag- 1 Division of Bone Marrow Transplantation and Immune Deﬁciency, Cincinnati Children’s Hospital Medical Center, nosis have high transplant related mortality. In subsequent Cincinnati, OH, USA work, we reported that terminal complement blocking agent 2 Department of Pharmacy, Cincinnati Children’s Hospital Medical eculizumab is effective therapy for complement-mediated Center, Cincinnati, OH, USA TA-TMA and improves transplant outcomes [8–10]. 3 Division of Oncology, Cincinnati Children’s Hospital Medical In this study, we aimed to examine TA-TMA incidence Center, Cincinnati, OH, USA and associated outcomes in patients with neuroblastoma 1312 S. Jodele et al.

Induction dosing Maintenance dosing

<10 kg 300 mg IV every 7 days Eculizumab trough level

10-39 kg 600 mg IV every 7 days ≥ 40 kg 900 mg IV every 7 days < 100μg/mL ≥ 100μg/mL

Monitor CH50 daily Give additional eculizumab dose No active TMA: Patients ≥10kg reduce if CH50 >10% normal and/or - continue same dosing eculizumab dose Eculizumab trough level eculizumab trough serum Active TMA: by 300mg/dose weekly concentration <100μg/mL, -resume induction dosing sC5b-9 three times per week but no later than every 7 days STOP eculizumab if Patients <10kg advance trough level remains eculizumab dose to Continue current dosing till blood sC5b-9 normalizes >100μg/mL × 2 300mg/dose Q14 days

Fig. 1 Eculizumab dosing algorithm undergoing aHCT and to identify most effective clinical complex (sC5b-9, normal value <244 ng/mL) at the time of interventions for TA-TMA. TA-TMA diagnosis. Chronic kidney disease (CKD) was defined as impaired kidney function for >3 months. For study purposes, we classified patients as CKD if they had Methods stage 3 or higher CKD (nucGFR <59 ml/min/1.73sq. m) [14, 15]. Hypertension was defined as systolic and diastolic Cincinnati Children’s Hospital Medical Center (CCHMC) blood pressure above 99th percentile value for age, sex, and institutional review board approved this retrospective study. height in subjects ≤18 of age [16]. We reviewed all consecutive patients who underwent aHCT Rituximab for TA-TMA was administered as an intra- for high-risk neuroblastoma at our institution from January venous infusion at 375 mg/m2 per dose weekly. Therapeutic 2005 to December 2015. Patients who were clinically plasma exchange (TPE) was performed after placing an diagnosed with TA-TMA were assigned to the “TMA apheresis compatible line and using a single-volume plasma group”, and those without to the “non-TMA group”.Aspart exchange. Daily TPE was performed until hematologic TA- of routine transplant clinical care at our institution, all TMA signs resolved and then was tapered using previously patients had prospective monitoring of organ function and described strategy [17, 18]. TA-TMA markers that included the following: (1) lactate Eculizumab was administered using pharmacokinetic/ dehydrogenase (LDH) elevated above the upper limit of pharmacodynamics drug monitoring with personalized dose normal for age; (2) de novo thrombocytopenia with a pla- adjustment to provide adequate serum drug concentration telet count <50 × 109/L or a >50% decrease in the platelet required for complement blockade based on TA-TMA count; (3) de novo anemia with a hemoglobin below the activity as previously reported [10]. The first dose of ecu- lower limit of normal or anemia requiring transfusion sup- lizumab was given according to standard recommendations port; (4) microangiopathic changes defined as the presence for children with aHUS [19, 20]. Patients weighing 10–40 of schistocytes in the peripheral blood or histologic evi- kg started with 600 mg IV, and patients weighing >40 kg dence of microangiopathy on a tissue specimen; and (5) no started with 900 mg IV as a first dose. Subsequent drug evidence of a coagulopathy and a negative Coombs test. dosing was performed as summarized in eculizumab dosing The date of TA-TMA diagnosis was defined as the first date algorithm in Fig. 1. All patients receiving eculizumab were when all diagnostic criteria were fulfilled [11]. ADAMTS13 given antimicrobial prophylaxis adequate to cover menin- activity was measured to exclude diagnosis of thrombotic gococcal infection during complement blockade and for at thrombocytopenic purpura (TTP). Nuclear glomerular fil- least eight weeks after eculizumab therapy was dis- tration rate (nucGFR) studies were done pre-transplant and continued, since they were not able to receive meningo- on day +30 after HCT. Weekly Cystatin C-based GFR coccal vaccine due to severely immunocompromised status (CystC GFR) was used for dynamic renal function mon- early post-transplant [21, 22]. itoring [12, 13]. Proteinuria was defined as a random urinalysis protein concentration of >30 mg/dL on two Statistical analyses consecutive studies. Nephrotic range proteinuria was defined as random urine protein/creatinine ratio >2 mg/mg. Categorical and continuous data are summarized as fre- Terminal complement activation was determined by mea- quency (percent) and median (interquartile range) and dif- suring plasma concentration of the soluble membrane attack ferences were assessed using Fisher exact tests or Wilcoxon High-dose Carboplatin/Etoposide/Melphalan increases risk of thrombotic microangiopathy and organ injury. . . 1313

Table 1 Study demographics and disease characteristics TMA n = 13 No TMA n = 47 p value

Age at HSCT 4.0 [3.5–4.8] 3.9 [3.2–6.1] 0.95 Male gender 6 (46.2%) 35 (74.5%) 0.09 Caucasian race 10 (76.9%) 42 (89.4%) 0.35 BMT high-dose chemotherapy plan 0.03 Carboplatin/etoposide/melphalan (CEM) 10 (77%) 31(65.9%) Busulfan/melphalan (Bu/Mel) 0 (0%) 13(27.7) Tandem (Cy/Thio and CEM) 3 (23%) 3 (6.4%) TMA diagnosis day after BMT day 0 18 (7–52) n/a n/a Pre-transplant nucGFR (ml/min/1.73sq.m) 137 (121–167) 135 (116–160) 0.87 Post-transplant nucGFR GFR (ml/min/1.73sq.m) 46 (30–65) 116 (101–130) <0.0001 Proteinuria pre-transplant 0 (0%) 0 (0%) Proteinuria post-transplant 13 (100%) 4 (8.7%) <0.0001 Hypertension pre-transplant 0 (0%) 0 (0%) Hypertension post-transplant 13 (100%) 3 (6.3%) <0.0001 Hospital stay (days) 43 (34–70) 33.5 (26–45) 0.03 Veno-occlusive disease of liver (VOD) 1 (7.7%) 8 (17.0%) 0.67 Relapse time after BMT (month) 28 (23–29) 11.0 (6–16) 0.10 CEM carboplatin/etoposide/melphalan, Bu/Mel busulfan/melphalan, Cy/Thio cyclophosphamide and thiotepa The data are presented as median [IQR] or n (%) rank sum tests, respectively. The Kaplan–Meier method was all patients (ADAMTS13 activity 42–95%). Patients’ age at used to produce overall survival (OS), transplant related transplantation, gender and race was similar in both groups. mortality (TRM) and relapse percentages and figures. Dif- There was no TA-TMA diagnosed in patients receiving ferences in OS by group were assessed using the log rank busulfan/melphalan. Out of 13 patients in the TMA group, test. Cumulative incidences of TRM and relapse were 12 developed TA-TMA after CEM regimen (2 of those assessed using Gray’s test. For TRM, relapse was treated as were receiving CEM as their second transplant in tandem a competing risk. For relapse, death from without relapse regimen) and 1 patient developed TA-TMA after cyclo- was treated as a competing risk. Statistical significance was phosphamide/thiotepa (first transplant in tandem regimen) assessed at 0.05. R software (Vienna, Austria) was used for (p = 0.03). TA-TMA was diagnosed a median of 18 days all computations. after aHCT (range 7–52 days). All 60 patients with neuroblastoma had normal kidney function, without proteinuria or hypertension before pro- Results ceeding to transplant, with a median nucGFR of 137 ml/ min/1.73sq.m (range 121–167 ml/min/1.73 sq.m) vs 135 ml/ Study subjects min/1.73 sq.m (range 116–160 ml/min/1.73 sq.m), p = 0.87 in the TMA and no-TMA groups, respectively. Thirty days Sixty patients underwent aHCT during the study period. after transplantation, the nucGFR was significantly lower in Study demographics and transplant characteristics are out- the TMA group as compared with the non-TMA group lined in Table 1. Forty-one patients received a single (median 46 ml/min/1.73 sq.m (range 30–65 ml/min/1.73 sq. transplant using carboplatin/etoposide/melphalan (CEM), m) vs 116 ml/min/1.73 sq.m (range: 101–130 ml/min/1.73 thirteen patients received a single transplant after busulfan/ sq.m), p < 0.0001). Persistent proteinuria and severe melphalan (Bu/Mel), and six patients received tandem hypertension requiring medical interventions occurred transplant (cyclophosphamide/thiotepa followed by CEM). almost exclusively in patients with TA-TMA (100% vs. 8.7 Thirteen of the 60 patients (21.7%) were diagnosed with and 100% vs. 6.3%, respectively, p < 0.0001). Pulmonary TA-TMA (TMA group) and 47 (78.3%) patients had no hypertension was documented only in patients with TA- evidence of microangiopathy (no-TMA group). Six of the TMA after a CEM regimen (n = 3). 13 patients had TMA documented on renal tissue biopsy in All patients diagnosed with TA-TMA had systemic dis- addition to the clinical TA-TMA diagnosis. One patient had ease, presenting with multi-organ involvement. All patients TMA in multiple organs on autopsy. TTP was ruled out in had severe hypertension requiring 3–6 antihypertensive 1314 S. Jodele et al.

Table 2 Chronic organ injury and eligibility for post-transplant second had combined heterozygous CFHR3 c.786 A > T(p. therapy P262P) and CFHR5, c.1067 G > A(p.R356H) variants, and Rituximab + /− TPE Eculizumab n = 6 third had heterozygous CFHR3-CFHR1 deletion and het- n = 6 erozygous CFI, c.1322 A > G (p.K441R) variant. Number of treatment sessions Review of clinical interventions for patients with TA- TPE: 31 sessions Eculizumab: 9 TMA showed that TA-TMA management options included (23–69) doses (4–18) the following: (1) supportive care only (n = 1), (2) ritux- Rituximab: 4 doses imab with or without concurrent therapeutic plasma – (2 10) exchange (Ritux +/−TPE) (n = 6) and (3) eculizumab Post-transplant therapy (n = 6). Radiation therapy 6/6 (100%) 6/6 (100%) One patient with TA-TMA received only supportive a Cis-Retinoic acid 3/6 (50%) 4/6 (67%) care. Six patients received rituximab (median of 4 doses Immunotherapy 0/6 (0%) 4/6 (67%)a (range: 2–10 doses), and three of those patients also (Ch14.18 ab) received concurrent therapeutic plasma exchange (median Chronic organ injury of 31 sessions (range 23–69 sessions). Other six patients ≥ CKD (stage 3) 3/6 (50%) 1/6 (16.7%) received the terminal complement blocker eculizumab as ESRD 1/6 (17%) 0/6 (0%) first line therapy (median 9 doses (range 4–18 doses). Nephrotic range 3/6 (50%) 0/6 (0%) Patients in all three intervention groups had severe hyper- proteinuria tension, similar acute organ injury at TA-TMA diagnosis, Hypertension 3/6 (50%) 1/6 (16.7%) and anemia/thrombocytopenia requiring transfusion sup- b Pulmonary n/a 0/2 (0%) port. (Table 2 and Fig. 1). hypertension The patient who did not receive any TA-TMA targeted Chronic heart failure 1/6 (17%) 0/6(0%) therapy died in the intensive care unit from severe systemic Death from TA-TMA 1/6 (17%) 0/6 (0%) TA-TMA with multi-organ failure while on mechanical TPE therapeutic plasma exchange, CKD (stage ≥3) chronic kidney ventilation, hemodialysis and while receiving continuous – disease, stage 3 (nucGFR 30 59 ml/min/1.73sq.m), ESRD end-stage antihypertensive medication infusion for severe hyperten- renal disease sion and PRES and nitric oxide for pulmonary hyperten- a Two patients received other chemotherapy for neuroblastoma control based on oncology MD decision sion. Autopsy showed extensive lung, kidney, and bowel involvement with microangiopathy and CNS bleed. b Pulmonary hypertension diagnosed in 2 patients treated with eculizumab completely resolved, patients are of medical therapy Of the six patients who received Rituximab +/−TPE one patient died with active microangiopathy and end-stage renal disease (ESRD) while on hemodialysis after a pro- medications, or continuous medication infusions to control longed TPE course. Three of the other 5 patients developed blood pressure. Two patients had intracranial bleeding chronic kidney disease (stage 3b, nucGFR 30–44 ml/min/ associated with hypertension and posterior reversible 1.73 sq.m) and one developed chronic heart failure. All 6 encephalopathy syndrome (PRES). All patients had patients in this treatment group were able to receive post- nephrotic range proteinuria after TA-TMA diagnosis and transplant radiation therapy (XRT) with delay. XRT was had at least a 50% drop in renal function from pre-transplant started at median 63 days after transplant (range baseline. Three patients required hemodialysis at TA-TMA 40–112 days). Cis-retinoic acid (cis-RA) therapy was diagnosis. Twelve of 13 patients (92.3%) had moderate to initiated in 3 of 6 patients with the delay at 123, 157 and large pericardial or pleural effusions during the course of 196 days after aHCT. Cis-RA was started at 25% of TA-TMA, 4 of them with cardiac tamponade requiring recommended dose and escalated to tolerance. None of urgent pericardiocentesis. Three patients were diagnosed these patients were eligible to start immunotherapy with with pulmonary hypertension requiring therapy with Ch14.18 antibody to due organ function impairment [6]. inhaled nitric oxide or sildenafil. Two of them required All six patients who received eculizumab are all alive mechanical ventilation. TA-TMA diagnosis preceded all and well despite presenting with multi-organ injury at TA- listed clinical complications. TMA diagnosis. Eculizumab was well tolerated and there Nine of 13 patients with TA-TMA had complement were no toxicities attributed to this drug. All patients genetic testing done and 7 had abnormal results. Four of recovered from acute organ injury, including a 3-year-old these patients had single heterozygous deletion in CFHR3- boy who had acute renal failure requiring hemodialysis, CFHR1 (n = 3) and CFHR4-CFHR1 (n = 1). Three patients respiratory failure on mechanical ventilation, cardiac tam- had more than one variant identified: one had heterozygous ponade and CNS bleeding, resulting in cortical blindness, CFHR3-CFHR1 deletion and vWF c.4135 C > T variant, which all resolved on eculizumab therapy. Patients High-dose Carboplatin/Etoposide/Melphalan increases risk of thrombotic microangiopathy and organ injury. . . 1315 receiving eculizumab recovered platelet count >20 × 109/L microangiopathy. This patient received high-dose methyl- without transfusion support at median of 31 days from the prednisolone and defibrotide therapy for VOD and devel- start of eculizumab therapy (IQR range 30.3–55.8), while oped TA-TMA while still on defibrotide after resolution of patients who received rituximab +/− TPE recovered pla- VOD. Eculizumab was started for TA-TMA with good telets later, a median of 92.5 days from the start of TA- control of microangiopathy. This patient was not able to TMA therapy (IQR range 54.5–120.0), (p = 0.04). Two proceed to the second transplant with CEM due to inade- patients with pulmonary hypertension who received eculi- quate renal function, but later was able to initiate Cis-RA zumab and sildenafil therapy recovered fully from this and Ch14.18 antibody therapy when renal function recov- complication. Both patients are currently doing well with ered on eculizumab. In the no-TMA group VOD occurred normal cardiac function without any medical therapy. Five after busulfan/melphalan regimen in 4 of 8 patients (50%), patients recovered from TA-TMA-associated acute kidney and in 2 patients in each regimen using cyclophosphamide/ injury and resolved nephrotic range proteinuria by the end thiotepa and CEM (25 % each) [23, 24]. of eculizumab therapy. One patient remains with stage 3a Taken together, patients in the TMA group had much CKD (nuc GFR 45–59 ml/min/1.73 sq.m) and is receiving longer hospital stay then those without TMA (median of salvage therapy for neuroblastoma relapse. Eculizumab was 43 days after HCT (range 34–70 days) vs. 33.5 days after successfully discontinued in all patients after resolution of HCT (26–45 days), p = 0.03). Transplant related mortality acute TA-TMA symptoms. There were no microangiopathy (TRM) was higher in the TMA group with 2 of 13 (15.4%) relapsed documented in this group. patients dying from TA-TMA compared with 1 of 47 (2%) All six patients treated with eculizumab were able to patients in the non-TMA group, who died from VOD prior receive XRT with delay a median of 61 days (range to the availability of defibrotide (p = 0.06) (Fig. 2a). Neu- 45–193) after HCT. Four of six patients were started on cis- roblastoma relapses occurred at similar frequency in the two RA and Ch14.18 therapy at median of 131 days after HCT groups (28 month after HCT (range 23–29 month) in the (range 90–158). One patient was still receiving eculizumab TMA group and 11 month after HCT range 6–16 month) in during the first two courses of Ch14.18, while the remainder the no-TMA group (p = 0.1) (Fig. 2b). Overall survival of patients were already off eculizumab when Ch14.18 was (OS) was not statistically different between clinical groups, initiated. There were no Ch14.18 dose modifications for although follow-up is ongoing (Fig. 2c). history of TA-TMA and there were no TA-TMA relapsed noted during antibody therapy. Cis-RA was started at 25% of recommended dose and escalated to tolerance. The other Discussion two patients received other chemotherapy treatment approaches due to neuroblastoma disease status, based on We documented a high incidence (21.7%) of clinically their primary oncology attending discretion. significant TA-TMA in patients with neuroblastoma Veno-occlusive disease of liver (VOD) occurred in one receiving a carboplatin/etoposide/melphalan (CEM) high- patient in the TMA group after cyclophosphamide/thiotepa dose chemotherapy regimen for autologous stem cell chemotherapy and preceded the diagnosis of transplantation, while there was no TA-TMA observed in

a b c 1.0 P-value =0.06 1.0 P-value =0.28 1.0

TMA (n=13) 0.8 0.8 0.8 No TMA (n=47)

0.6 0.6 0.6

No TMA (n=47) 0.4 0.4 0.4 TMA (n=13) Survival probability 0.2 TMA (n=13) 0.2 0.2 Transplant related mortality Transplant Cumulative incidence of relapse Cumulative No TMA (n=47) 0 0 0 P-value =0.18 010203040 0102030405060 0102030405060 Months post HSCT Months post HSCT Months post HSCT Fig. 2 Transplant outcomes in patients with TA-TMA and without patients that developed TMA and did not develop TMA (29.0 vs TA-TMA. a Displays cumulative incidence of transplant related 44.5%, p = 0.28). c Shows Kaplan–Meier overall survival curves mortality at 1 year after HCT in neuroblastoma patients that developed starting at HCT time (day 0) in neuroblastoma patients that developed TMA and did not develop TMA (7.7 vs. 2.1%, p = 0.06). b Displays TMA and did not develop TMA (83.1 vs. 59.3%, p = 0.18) cumulative incidence of relapse at 5 year after HCT in neuroblastoma 1316 S. Jodele et al.

Confirm TMA: A or B Treat with Functional assessment Screen for TMA during HCT Both present complement blocker • CH50 Daily CBC with differential (eculizumab) • sC5b-9 Twice weekly LDH Quantitative tests Weekly urinalysis A. TMA by tissue histology • Factor H autoantibody Blood pressure assessment • Complement panel • MCP/CD46 by flow cytometry B. TMA by laboratory and Additional clinical markers evaluation (>4 present strongly suggest TMA) TMA complement gene panel CFH, CFHR1, CFHR3, CFHR4, CFHR5, Suspected TMA 1. LDH above normal for age CD55, CD59, CD46, CFI, CFB, CFP, C5, LDH above normal 2. Schistocytes on blood smear ADAMTS13, CFD, C3, C4BPA.THBD, DGKE Proteinuria 3. De novo thrombocytopenia or Case by case Hypertension (>99% for age) increased transfusion requirements TMA-associated organ injury One present decision based on 4. De novo anemia or severity of TMA Evaluate symptomatic patient increased transfusion requirements 5. Hypertension >99% for age (<18 years) • Hypoxemia: cardiac echo for ≥18 or >140/90 ( years of age) pulmonary hypertension and ≥ Rule out TTP 6. Proteinuria 30mg/dl × 2 or pericardial effusion ADAMTS13 activity random urine prot/creat ratio ≥ 2mg/mg Both absent Continue monitoring 7. Terminal complement activation • GI bleeding: intestinal biopsy for (elevated plasma sC5b-9 above normal) histologic evidence of TMA

• Hypertension:monitor for posterior ≤ 10% >10% reversible encephalopathy syndrome (PRES) TMA risk stratification • Acute kidney injury (AKI): monitor TTP 1. Proteinuria cystatin C GFR, proteinuria and 2. sC5b-9 above normal hematuria

Fig. 3 Recommended TA-TMA evaluation for patients undergoing HCT patients receiving high-dose busulfan/melphalan (Bu/Mel) ratio) and hypertension (>99% for age) requiring medical regimen. In contrast, we saw a high frequency of VOD, interventions with one or more antihypertensive agents in another disorder associated with endothelial injury, in addition to commonly used diuretics is nearly universally recipients of busulfan/melphalan [25]. Our study data sug- associated with TA-TMA in patients with neuroblastoma gest that specific chemotherapeutic agents or chemotherapy undergoing aHCT. If TA-TMA is suspected, we would agent combinations may have a potential to target the advise a more detailed complement system analysis, in endothelium of different organs. These observations warrant particular, measurement of plasma sC5b-9 as a marker of further investigation of pathogenesis of endothelial injury- terminal complement activation, indicating high-risk dis- associated multi-organ impairment after stem cell trans- ease [11]. Since TA-TMA is strongly associated with plantation. It is important that treating clinicians are aware pericardial effusion and pulmonary hypertension, we also of the increased risk of TA-TMA with CEM regimen and recommend that patients with suspected TA-TMA are clo- recognize this complication before severe organ injury sely monitored with echocardiography [29, 30]. occurs. Further studies are required to examine occurrence The only patient with TA-TMA in this cohort who did of TA-TMA and VOD with different chemotherapy regi- not receive any targeted therapy died from severe micro- mens as our study statistical value is limited by small angiopathy affecting multiple organs. The autopsy per- sample size. formed in this patient highlighted that TA-TMA can present We recently demonstrated that complement system as systemic disease after aHCT, and can be associated with activation plays significant role in development and severity complement-mediated endothelial injury. Rituximab/TPE of TA-TMA in HCT recipients and these patients benefit combination was used in some patients based on responses from complement blockade [26–28]. Sixty-nine percent of reported documenting antibody formation against comple- patient with TA-TMA in this current study had complement ment Factor H (CFH ab) in subjects with CHFR1/R3 gene gene variants identified that is similar to our prior obser- defects [31]. We previuosly demonstrated CFHR1/R3 gene vations. We propose that all patients with neuroblastoma abnormalities in HCT recipients with severe TA-TMA, receiving high-dose chemotherapy for aHCT should be some of them in association with CFH ab [32]. While in this prospectively monitored for TA-TMA (Fig. 3). Readily current cohort 5 of 6 patients receiving rituximab +/− TPE available and inexpensive laboratory tests like LDH and therapy survived, the majority remained with chronic organ urinalysis with random urine protein/random urine creati- injury, preventing them from receiving planned post- nine ratio and good attention to age appropriate blood transplant therapy. pressure parameters and transfusion needs can aid in early In previous work, we have demonstrated that eculizumab TA-TMA detection. In our experience, nephrotic range is very easy to administer in inpatient and outpatient set- proteinuria (>2 mg/mg random urine protein/creatinine tings, and has a low toxicity profile in HCT recipients, but High-dose Carboplatin/Etoposide/Melphalan increases risk of thrombotic microangiopathy and organ injury. . . 1317

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