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Mini-Review Erythropoietin in Stem Cell Transplantation

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Mini-Review Erythropoietin in Stem Cell Transplantation Bone Marrow Transplantation (2001) 27, 1011–1016 2001 Nature Publishing Group All rights reserved 0268–3369/01 $15.00 www.nature.com/bmt Mini-review Erythropoietin in stem cell transplantation CB Miller1 and HM Lazarus2 1Johns Hopkins Oncology Center, Baltimore, MD; and 2Department of Medicine, Ireland Cancer Centre, University Hospitals of Cleveland, Cleveland, OH, USA Summary: in patients after autologous stem cell transplant, but mark- edly depressed at the time of marrow recovery in allogeneic Anemia is universal after allogeneic and autologous transplant recipients. They also found that erythropoietin stem cell transplantation, with both increased red cell response to anemia was lower in patients who had acute utilization and decreased production playing a role. GVHD, while chronic GVHD did not appear to affect This anemia sometimes is associated with a relative erythropoietin response.1,2 Cytomegalovirus infection also erythropoietin deficiency. In allogeneic stem cell trans- was an independent predictor of an impaired erythropoietin plantation, randomized trials have demonstrated response to anemia. Nephrotoxicity was more common in improved erythropoiesis and a decrease in red cell the allogeneic stem cell transplant patients compared to the transfusions in recombinant human erythropoietin autologous stem cell transplant patients. There was not a (rHuEPO)-treated patients. Studies of rHuEPO in significant correlation, however, between renal function and patients undergoing autologous stem cell transplants, impairment in the erythropoietin response to anemia. Abedi however, have not shown a benefit. The role of rHuEPO et al3 found that erythropoietin blood concentrations were in stem cell mobilization and treatment of delayed lower in patients who had received cyclosporine as prophy- erythropoiesis has yet to be defined and further studies laxis for GVHD compared to patients receiving T cell- are needed. Bone Marrow Transplantation (2001) 27, depleted transplants. However, they did not find a corre- 1011–1016. lation between acute GVHD and a decreased erythropoietin Keywords: anemia; stem cell transplantation; erythro- level. While patients with nephrotoxicity had lower erythro- poietin poietin blood concentration than patients without nephro- toxicity, the decreased erythropoietin levels in the cyclo- sporin A-treated patients was seen in patients with and without renal impairment. On the other hand, investigators at Johns Hopkins found that for any given degree of ane- mia, erythropoietin concentrations were depressed in both Anemia in the course of hematopoietic stem cell allogeneic and autologous stem cell transplant patients transplantation compared to iron deficient controls (Figure 1).4 Anemia remains a universal problem after both autologous and allogeneic stem cell transplantation and red blood cell Table 1 Etiology of anemia during hematopoietic stem cell transplan- tation (RBC) transfusions usually are necessary in the post-trans- plant period. The anemia is multi-factorial and increased Increased RBC utilization/shortened RBC survival utilization, bleeding and inadequate production of RBCs fever play important roles for this condition (Table 1). hemolysis, eg ABO or Rh incompatibility,27,28 microangiopathy after cyclosporine,29 hemolytic-uremic syndrome30 Erythropoiesis and stem cell transplantation hepatic veno-occlusive disease31 The prolonged reticulocytopenia and resultant large trans- Hemorrhage thrombocytopenia, especially when protracted, eg chemically-purged fusion requirement after stem cell transplantation is, in part, autografts, immune mechanisms,32–34 or hepatic veno-occlusive related to a relative erythropoietin deficiency at the time of disease31 marrow recovery. A number of studies have demonstrated organ injury, eg hemorrhagic cystitis,35–39 gastritis an impaired erythropoietin response after stem cell trans- infection, eg adenovirus,40 BK virus38 41,42 plant. Shapira and co-workers1 and Beguin and colleagues2 GVHD of gastro-intestinal tract both found that the erythropoietin response was appropriate Inadequate production RBC impaired/inadequate erythropoietin response, drugs causing bone marrow suppression (ganciclovir, trimethoprim- Correspondence: Dr CB Miller, Oncology Center, Johns Hopkins Bunting- sulfamethoxazole) Blaustein Cancer Research Bldg, 1650 Orleans St 2M88, Baltimore, infection causing bone marrow suppression (cytomegalovirus, HHV6) MD21231–1000, USA Erythropoietin in stem cell transplantation CB Miller and HM Lazarus 1012 1000 Clinical studies of the use of rHuEPO after stem cell transplantation Allogeneic stem cell transplantation rHuEPO has been demonstrated to be well-tolerated and effective in the allogeneic stem cell transplant setting 9–11 11 100 (Table 2). Steegman and co-workers randomly assigned patients to receive daily rHuEPO (100 units per kg days 0 to 7, then 150 units per kg days 7 to 30) or placebo. Thirteen subjects received rHuEPO and 11 patients received placebo for a period of more than 14 days and were considered evaluable. In the rHuEPO-treated group, times to reach reticulocyte counts of 1%, 5% and Log erythropoietin level (mU/ml) 20% were shorter and bone marrow erythroid cellularity 10 was increased. Importantly, RBC transfusion requirement was decreased from a mean of 12 units to 4 units (P Ͻ 5 0.05) during the first 30 days after transplant. Additionally, 8 9 10 11 time to platelet transfusion (Ͼ25 000/␮l) independence (19 Hemoglobin (g/dl) days vs 31 days, P Ͻ 0.05) and a decrease in platelet units transfused (36 vs 138, P Ͻ 0.05) were significantly better Figure 1 Erythropoietin:hemoglobin relationship week 4 after stem cell b in the rHuEPO-treated patients. transplant ( ) compared to iron deficiency controls (mean plus standard 9 deviation depicted by shaded area). Reproduced with permission. Klaesson and colleagues prospectively compared rHuEPO (200 units per kg per day for 4 weeks followed by twice weekly for 4 weeks) or placebo in 50 hematologic malignancy patients undergoing stem cell transplant. rHuEPO dose was decreased to 100 units per kilogram when hemoglobin exceeded 10 g/dl and was discontinued The etiology for the inadequate erythropoietin response when hemoglobin was greater than 12 g/dl. Five patients to anemia is unknown but may reflect toxic effects exerted (three rHuEPO and two controls) died before day 28 and upon erythropoietin-producing cells by drugs or infectious were not considered evaluable. RBCs were transfused to agents, or may be a result of direct suppression of erythro- maintain a hemoglobin of greater than 7.0 g/dl and platelets poietin production by cytokines. Tumor necrosis factor con- were transfused to maintain a count of greater than centrations, elevated after stem cell transplant,5 can sup- 30 000/mm3. At the 2 month evaluation, mean hemoglobin press erythropoietin production in Hep3B cell lines.6 Both in the rHuEPO-treated patients was higher compared to pla- cyclosporin A7 as well as amphotericin B8 can suppress cebo-treated patients (10.0 g/dl vs 9.0 g/dl, P = 0.02) and erythropoietin production in model systems. Regardless of RBC transfusion requirement was decreased 50% from 10 the etiology, the inadequate erythropoietin response to ane- units to 5 units. mia after stem cell transplantation suggests that exogenous Biggs and co-workers10 assigned 91 patients receiving recombinant human erythropoietin (rHuEPO) treatment matched-related allogeneic stem cell transplants for leuke- may be beneficial. mia or aplastic anemia to either placebo or rHuEPO (300 Table 2 Use of exogenous recombinant human erythropoietin in allogeneic transplant recipients Author/Ref. Steegman et al11 Klaesson et al9 Biggs et al10 Link et al12 Type of trial randomized, placebo-control randomized, placebo-control randomized, placebo-control randomized, placebo-control Total No. patients entered 28 50 91 215 No. evaluable patients 13/11 22/23 43/48 106/109 rHuEPO/controls rHuEPO dose/duration 100 U/kg d1–7, 150 U/kg 200 U/kg d1–28, then 2 300 U/kg 3×/week d1–42 150 U/kg by continuous i.v. d7–30 ×/week d29–56 infusion up to d42 Mean or median No. RBC units 4/12 5.5/10.9 5/6 8.0/8.7 txn: rHuEPO/control P value Ͻ0.05 0.03 NS NS Faster reticulocyte recovery yes yes yes yes Shorter time to RBC txn yes yes yes yes independence RBC = red blood cell; txn = transfusion; rHuEPO = recombinant human erythropoietin; NS = not significant. Bone Marrow Transplantation Erythropoietin in stem cell transplantation CB Miller and HM Lazarus 1013 units per kg) intravenously three times a week from day 0 reported by Link and associates,12 57 patients received to day 42. Study drug was withheld if the hemoglobin rose rHuEPO (150 units/kg/day) and 57 patients received pla- higher than 12 g/dl but was re-instituted at a 50% lower cebo, given by continuous infusion from the day of stem dose when hemoglobin fell below 12 g/dl. Four patients cell infusion (day 0) until RBC recovery or day 41. Treat- died prior to day 28 and were not evaluable for ment with rHuEPO did not affect the time to RBC trans- engraftment. Median hemoglobin levels and reticulocyte fusion independence, reticulocyte recovery or RBC counts did not differ between the two groups before day utilization during any time period. 14; however, at all other subsequent time points, hemoglo- Based on an increase in erythroid response in myelo- bin and reticulocyte counts were significantly higher in the dysplastic syndrome patients, Vannucchi et al7 studied the rHuEPO-treated group. On the other hand, RBC transfusion
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