Engraftment-associated hypophosphatemia – the role of cytokine release and steep leukocyte rise post stem cell transplantation

Abstract

Summary:Hypophosphatemia associated with bone marrow transplantation has been infrequently reported. The suggested mechanism is phosphate uptake by the replicating cells. Various cytokines are associated with the development of hypophosphatemia. The present study evaluated the interrelationship between cytokine release, the rise in WBC and the development of hypophosphatemia during the engraftment period. Blood samples were obtained from 60 patients undergoing peripheral blood stem cell transplant, on the day of admission and then daily from the day of transplant until discharge. Hypophosphatemia developed in 62% of the patients. The median day of minimal phosphorus level was +8 and it antedated engraftment by 2 days. There was a significant correlation between the day of minimal phosphorus level and the day of maximal WBC and a significant correlation between the fall in phosphorus level and WBC rise. IL-6 and IL-8 showed similar kinetics. Higher IL-6 and IL-8 levels were directly associated with lower phosphorus levels. In conclusion, hypophosphatemia commonly occurs in the post-transplant period. We assume that both a direct effect of cytokine release and an increased consumption by the dividing WBCs contribute to its appearance. As its occurrence usually antedates engraftment it can be used as a forerunner for WBC recovery. Bone Marrow Transplantation (2001) 27, 311-317. Keywords: hypophosphatemia; cytokines; engraftment; transplantation; WBC Several conditions are known to induce moderate to severe hypophosphatemia (HP). They include low dietary intake, conditions associated with decreased absorption or increased urinary phosphate excretion and conditions associated with shifts of phosphate from the extracellular into the intracellular fluid. The latter include various cellular

Recovery from neutropenia can be predicted by the immature reticulocyte fraction several days before neutrophil recovery in autologous stem cell transplant recipients

“…Other predictors of marrow recovery, AMoCX100/ml and hypophosphatemia 6 were not as predictive of marrow recovery as IRF-D or IRF-N. We therefore recommend the use of IRF-D or IRF-N for an earlier prediction of marrow recovery and have adopted the use of the IRF in our daily clinical practice. Red blood cell transfusion did not appear to affect the IRF values.…”

“…Other predictive tests of marrow recovery include hypophosphatemia 6 and hypouricemia, 7 both of which develop in approximately 60% of patients upon marrow recovery 6,7 but precede ANCX500/ml by only 2-3 days and can be altered by phosphate replacement, renal failure and/or allopurinol therapy.…”

Severe metabolic abnormalities after allogeneic hematopoietic cell transplantation

“…Increased phosphate uptake by replicating neutrophils during the peri-engraftment period is thought to play a role in the occurrence of hypophosphatemia in HCT recipients. [27][28][29] Hypokalemia was also frequently encountered after HCT. This condition may be due to renal potassium wasting, which may result from long-term use of aminoglycoside antibiotics and amphotericin B, concomitant hypomagnesemia, and vomiting.…”

Successful mobilization and transplantation of filgrastim mobilized hematopoietic stem cells in sickle cell-hemoglobin C disease

“…Reduced 2-3 DPG levels has been demonstrated in patients with hypophosphatemia. 11 This patient had hypophosphatemia related to engraftment 12 that may have contributed to the crisis at that time. We conclude that a modified filgrastim schedule, along with exchange transfusion successfully mobilized stem cells in a patient with HbSC disease and, given that such patients may be at risk of sickle crisis during engraftment, vigilant phosphate monitoring is prudent.…”