Acute kidney injury during leukocyte engraftment after autologous stem cell transplantation in patients with light‐chain amyloidosis

Abstract

Engraftment syndrome (ES) is a complication of hematopoietic stem cell transplantation characterized by fever, rash, and non-cardiogenic pulmonary edema. Acute kidney injury (AKI) has been recognized but is considered a minor criterion in one and excluded another definition of ES. We have noted a high incidence of AKI in patients with immunoglobulin light-chain amyloidosis (AL) undergoing autologous stem cell transplant (ASCT) around the time of leukocyte engraftment. This study was conducted to further investigate the relationship between AKI and ES. Data were collected from 377 AL patients who underwent ASCT from 7/1997 to 10/2009. Patients who experienced an elevation of serum creatinine >0.5 mg/dL within 4 days of leukocyte engraftment and anyone who presented with signs associated with ES regardless of renal manifestations were included. Forty-one patients met criteria. Twelve were excluded for positive cultures (10), acute interstitial nephritis (1), and acute cellular rejection (1). In addition to AKI (93.1%), patients also exhibit fever (82.7%), hypotension (51.7%), rash (48.2%), edema (93.1%), diarrhea (69.0%), conjunctival hemorrhage (31.0%), pulmonary edema (31.0%), pulmonary hemorrhage (13.8%), and transient encephalopathy (17.2%). Patient with pulmonary involvement were more likely to require dialysis but was not statistically significant. AKI was very common during leukocyte engraftment in AL patients. While infectious etiology accounted for some of the AKI, most appeared to be associated with ES. After infection is ruled out, ES should be considered in the differential diagnosis when evaluating AKI in this population. Am. J. Hematol. 87:51-54, 2012. V V C 2011 Wiley Periodicals, Inc. IntroductionEngraftment syndrome (ES) is a complication of hematopoietic stem cell transplantation that occurs around the time of neutrophil recovery. It is characterized by fever, rash, diarrhea, weight gain, and non-cardiogenic pulmonary edema within days of leukocyte engraftment [1][2][3]. Currently, no standard diagnostic criteria have been agreed upon. The two more commonly used are the Spitzer and Maiolino criteria. The Spitzer criteria regard non-infectious fever, erythrodermatous rash, and noncardiogenic pulmonary edema as major criteria and hepatic dysfunction, renal insufficiency, weight gain, and transient encephalopathy as minor criteria [4]. A diagnosis is made when all three major criteria or two major and at least one minor criterion are present. The Maiolino criteria only include pulmonary infiltrates, diarrhea, fever, and rash [5]. A diagnosis of ES is made when fever and one of the other three features are present.Acute kidney injury (AKI) has been recognized in ES and is not uncommon. A recent study found 26% of the patients diagnosed with ES by either Maiolino or Spitzer criteria had AKI [6]. Despite that, renal impairment as defined by twice the normal serum creatinine (Scr) was regarded as a minor criterion in one and completely excluded by the other [4,5]. This is interesting since even mild AKI...

Engraftment Syndrome after Autologous Stem Cell Transplantation: An Update Unifying the Definition and Management Approach

“…Acute kidney injury, edema, fever, diarrhea, rash, and transient encephalopathy were observed in 93%, 93%, 83%, 69%, 48%, and 17% of patients, respectively 29 . Carerras et al reported a high incidence (12/25; 48%) of ES in patients with amyloidosis 2 .…”

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“… 58 Acute kidney injury can frequently occur in patients with AL amyloidosis who have other features associated with engraftment syndrome in the setting of ASCT. 59 This syndrome is characterized by rash, fever, weight gain, diarrhea, and noncardiogenic pulmonary edema within days of leukocyte engraftment. Other causes of acute kidney injury around the time of engraftment, particularly infection, need to be excluded.…”

Monoclonal Gammopathy of Renal Significance

“…in younger patients with myeloma, the standard procedure consists of consolidation with high-dose melphalan chemotherapy, followed by autologous stem cell transplantation. This treatment can be administrated to patients with severe kidney dysfunction caused by MGrS, but significant morbidity and mortality must be taken into account [37,38].…”