Fungal and viral infections after allogeneic hematopoietic transplantation from unrelated donors in adults: improving outcomes over time

Abstract

Umbilical cord blood (CB) is increasingly used as an alternative source of stem cells in adult unrelated transplantation. Although registry studies report similar overall outcomes in comparison with BM/PB, comparative studies focusing on severe infections and infection-RM (IRM) with a long follow-up are scarce. A total of 434 consecutive unrelated transplants (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009) were retrospectively analyzed to compare overall outcomes, incidence and risk factors of severe viral and invasive fungal infections in CB (n = 65) vs BM/PB recipients (n = 369). The 5-year OS was 38 vs 43%, respectively (P = 0.2). CB transplantation (CBT) was associated with a higher risk of invasive aspergillosis (100-days-cumulative incidence 16 vs 6%, P = 0.04) and CMV infection without differences in RM. No statistically significant differences were found regarding NRM (NRM of 38% in CB vs 37% in BM/PB at 1 year) nor IRM (30% in CB vs 27% in BM/PB at 1 year). In the overall population, NRM and IRM improved in more recent years. In adults who receive a single CBT, the risk of severe infections is increased when compared with unrelated BM/PB recipients, but mortality from infections is similar, leading to similar NRM and survival. INTRODUCTIONInfections are a major concern after allo-HSCT, and the main cause of mortality in at least 35-45% of deaths.1-7 The use of unrelated donors (UD) in adults increases the risk of severe infectious complications, although recent reports have found similar survival with matched sibling and UD allo-HSCT in the setting of specific diseases, such as AML. 8,9 Moreover, the use of cord blood (CB) as an alternative source of HSC in adults who lack an HLA-matched UD BM or PB has shown to be a valid alternative for an allo-HSCT. Recent studies have shown that similar NRM and OS can be achieved with CB if an accurate choice of the CB unit(s) is made, in comparison with other alternative donor sources.10-15 However, slow hematologic and immune recovery after CB transplantation (CBT) still remains a concern, and a high rate of serious pre and post-engraftment infections has been reported. However, few studies have actually compared the incidence of severe infections and infection-RM (IRM) of adult CBT recipients as opposed to UD BMT/PBT.For this purpose, and as a continuation of a previously published study by our group, 16 we performed a multicenter 12-year retrospective study to analyze the impact of the source of HSC for UD transplantation, including single CBT and BM/PBT on overall transplantation outcomes, especially. We also analyzed the

Sequential systematic anti‐mold prophylaxis with micafungin and voriconazole results in very low incidence of invasive mold infections in patients undergoing allogeneic hematopoietic stem cell transplantation

“…However, other transplant‐related factors as the incidence of GVHD (not addressed in this study) could also play a role in the incidence of IMI in this population. Contrary to other studies, we did not observe a higher incidence of IMI in patients receiving more immunosuppressive transplant modalities such as CD34+ selection or cord blood . While it is possible that the more aggressive prophylactic approach used at our center may overcome a higher risk for mold infections in patients receiving highly immunosuppressive transplant modalities, this would need to be confirmed in comparative studies.…”

Infection Rates among Acute Leukemia Patients Receiving Alternative Donor Hematopoietic Cell Transplantation

“…In contrast, a study from Massachusetts General Hospital did not show a correlation between prior fungal infection and invasive fungal disease 14 . Parody and colleagues reported a higher incidence of invasive aspergillosis after UCBT but no difference in mortality compared to MUD 36 .…”

Control of Cytomegalovirus Viremia after Allogeneic Stem Cell Transplantation: A Review on CMV-Specific T Cell Reconstitution

“…Multiple trials have demonstrated the safety and efficacy of pre-emptive strategies using oral valganciclovir [15]. However, despite the use of a preemptive strategy, the incidence of CMV disease is still 10% at 1 year following alloSCT in CMV-seropositive patients [16,17], illustrating the need for effective CMV-specific T cell immunity.…”