ALBERT

Description: Acute graft-versus-host disease (aGVHD) is partly mediated by host antigen presenting cells (APCs) that activate donor T-cells. Extracorporeal photoimmune therapy with UVADEX® (ECP) has shown benefit in some patients (pts) with GVHD, which was associated with decreased host APCs. We report preliminary results of the first multi-institutional phase II study examining ECP with a standard myeloablative preparative regimen prior to allogeneic hematopoietic stem cell transplantation (ASCT). ECP was given on two consecutive days between D-10 and D-6, followed by cyclophosphamide 60 mg/kg/day for 2 days and TBI 1200 cGy over 3 days. GVHD prophylaxis was Cyclosporine 3–5 mg/kg IV daily beginning D-1, and latter switched to PO, adjusted to keep levels 200–600 ng/ml, and methotrexate 10 mg/m2 on D1, 3, 6, and 11 for pts who had matched unrelated donors (MUD) or HLA class 1 one-antigen mismatched related donors (MMRD), or 10 mg/m2 on D1 and 5 mg/m2 on D3, 6, and 11 for pts who had matched related donors (MRD). Enrollment has been completed and data are available on 61 of 65 pts. The median age was 39 (20–60) years and 40 (66%) pts were male. Diagnoses included AML/MDS (n=20), ALL (n=14), CML (n=16), lymphoma (n=5), CLL (n=3), and other (n=3). Pts who received bone marrow (n=28) engrafted at a median of 20 (9–30) days, and pts who received peripheral blood (n=33) engrafted at a median of 15 (10–32) days. Grade II–IV and III/IV aGVHD occurred in 11 (38%) and 2 (7%) pts, respectively, who received MRD transplants (n=29), and in 16 (52%) and 10 (32%) pts, respectively, who received MUD transplants (n=31). No aGVHD occurred in 1 pt who received a MMRD transplant. Mild reversible hypotension related to ECP occurred in 1 pt who was able to continue on study. Chronic GVHD occured in 23 (42%) of 54 evaluable pts; limited in 15, extensive in 6, and unknown in 2 pts. There are 49 (80%) pts alive at a median follow up of 272 (23–560) days. Actuarial estimates of survival at one year are 93% for pts who received MRD transplants and 69% for pts who received MUD or MMRD transplants. Causes of death include relapse (n=4), aGVHD (n=3), multi-organ-system-failure (n=2), and 1 each of infection, interstitial pneumonitis, and neurologic toxicity. Preliminary results of this study reveal no adverse affects of ECP in combination with conventional preparative regimens or on engraftment after a standard myeloablative ASCT. Data correlating measurement of APCs with the incidence and severity of acute and chronic GVHD is pending. The overall survival of pts in this trial is encouraging and warrants further study.

Description: Pulmonary hypertension (PH) is a risk factor for mortality in Sickle Cell Disease, but it is unclear whether pulmonary hypertension is a marker or a direct cause of mortality. To better understand the pathophysiology of pulmonary hypertension in patients with sickle cell disease we performed evaluations of cardiopulmonary function in sickle cell disease patients with pulmonary hypertension (n= 15, mean age = 41 ± 2.4 years, males = 7, HbSS = 15, mean Hb = 8.3 ± 0.2 g/dl, mean tricuspid regurgitant jet velocity = 3.2 ± 0.11 m/s) compared to matched controls with sickle cell disease without pulmonary hypertension (n=11, mean age=40.2 ± 2.5 years, males=4, HbSS=11, mean Hb=8.5 ± 0.3 g/dl, mean tricuspid regurgitant jet velocity = 2.28 ± 0.07 m/s). To evaluate if specific therapy for pulmonary hypertension has any impact on systolic pulmonary artery pressure (PAP), estimated by tricuspid regurgitant jet velocity (TRJ), and functional capacity, measured by six-minute walk test (a well validated surrogate of functional capacity and response to therapy in patients with other causes of pulmonary hypertension), we treated 14 patients with sickle cell disease and pulmonary hypertension (mean age = 40 ± 2.5 years, males = 3, HbSS = 14, mean Hb = 8.8 ± 0.6 g/dl, mean TRJ = 3.4 ± 0.1 m/s) with sildenafil for at least three months. When compared to controls pulmonary hypertension patients had lower maximal oxygen consumption (VO2 max (% predicted), +PH: 44 ± 4, −PH: 55 ± 4; P=0.41), walked shorter six-minute walk distance (meters, +PH: 308.5 ± 53.8, −PH: 427.1 ± 44.6; P=0.03), demonstrated greater degree of interstitial lung disease by chest CT (P 〈 0.05), and more perfusion impairments measured by ventilation perfusion scan (P 〈 0.05). Six-minute walk distance correlated directly with maximal oxygen consumption (R=0.6; P=0.01), and inversely with mean pulmonary arterial pressure (R= −0.5; P=0.03) and tricuspid regurgitant jet velocity (R= −0.6;P=0.002), suggesting that the test is an adequate surrogate of functional capacity and response to therapy in pulmonary hypertension patients with sickle cell disease. Chronic treatment with sildenafil (up to 100 mg TID) decreased pulmonary arterial pressure (PAP mmHg, baseline: 50 ± 4.4, sildenafil: 41 ± 2.5; P=0.04) and increased six-minute walk distance (meters, baseline: 394 ± 31, sildenafil: 476 ± 26: P= 0.02). Sildenafil was well tolerated with only 2 patients stopping the drug due to headaches. We also observed 3 episodes of transient eyelid edema not requiring discontinuation of drug. Priapism was not observed in the 3 males treated (2 on exchange transfusion therapy, 1 with erectile dysfunction). In conclusion, we find that in patients with sickle cell disease, 1) pulmonary hypertension, though relatively mild, is associated with severe impairments in cardiopulmonary function, 2) traditional markers of functional capacity such as six-minute walk test can be utilized in this population as a therapeutic endpoint for clinical trials, 3) and therapy with sildenafil seems to have a favorable impact on pulmonary pressures and functional capacity.

Description: Secondary pulmonary hypertension (PHT), defined as a tricuspid regurgitant jet velocity (TRV) 〉 2.4 meters/second at rest, has been identified as an emerging complication in patients with sickle cell disease, with 32% prevalence. Patients with sickle cell pulmonary hypertension tend to have a higher mortality rate than patients with primary PHT at comparable pulmonary artery pressures (PAP). We analyzed prospectively obtained Doppler echocardiography measurements from 11 patients in steady-state and during vaso-occlusive crisis episodes or during exercise to determine whether pulmonary pressures became further elevated during stress. We found that tricuspid regurgitant jet velocity is significantly further elevated during vaso-occlusive crisis (2.61 ± 0.03 vs. 2.81 ± 0.06 m/sec (mean ± SEM), p = 0.01)(Fig. A). We assessed other laboratory parameters and found associated significant decreases in hemoglobin concentration (9.3 ± 0.3 vs. 8.4 ± 0.3 gm/dL, p = 0.02)(Fig. B), and significant elevations in lactate dehydrogenase (381 ± 39 vs. 442 ± 49 IU/L, p = 0.02)(Fig. C). These data are consistent with increased hemolysis during vaso-occlusive crisis, and the association of increased hemolysis with acute exacerbation of PHT in patients with SCD. In three patients at steady state, exercise echocardiograms were performed, showing acute marked rise in TRV during exercise (2.80 ± 0.12 vs. 3.37 ± 0.17 m/sec, p = 0.02)(Fig. D). These data bring to light several important points in the clinical assessment of tricuspid regurgitant jet velocity in patients with sickle cell disease. First, the relatively mild steady state PHT in patients with SCD is associated with previously unappreciated acute increases in PAP that may explain the high mortality rate in this population. This might be responsible for sudden death occurring during vaso-occlusive crisis or physical exertion. Second, this acute rise is associated with markers of increased hemolysis, further implicating hemolysis-associated derangement of nitric oxide homeostasis, endothelial function and PHT. Third, exercise measurements of TRV may be indicated in the clinical evaluation of patients with SCD and dyspnea on exertion, since it may unmask otherwise unappreciated PHT. Figure Figure

Description: We and others have published biochemical and physiological evidence supporting a model in which intravascular hemolysis and oxidant stress in patients with sickle cell disease (SCD) results in impaired nitric oxide (NO) bioavailability, with an associated reduction in NO-dependent blood flow. This reduced bioavailability is characterized by NO destruction and thus a resistance to both endogenous and exogenous (nitroprusside, nitroglycerin, NONOates) NO. A crucial regulator of endothelial cell homeostasis, NO regulates basal vasodilation, inhibits platelet aggregation, and tonically inhibits expression of cell adhesion molecules by endothelial cells, including vascular cell adhesion molecule (VCAM-1). Statins have been reported to both improve NO-dependent blood flow and reduce oxidant stress in patients with hypercholesterolemia and in normal subjects. We therefore investigated whether atorvastatin has similar effects in patients with SCD. Five patients have completed the study (targeted enrollment will be 15 patients); patients were selected for suspected NO-dependent vascular dysfunction as determined by higher than median plasma levels of soluble VCAM-1 or pulmonary hypertension (tricuspid regurgitant jet velocity 〉 2.4 meters/second). Baseline vascular reactivity to arterial infusions of sodium nitroprusside (SNP), acetylcholine (ACh), and the inhibitor of endothelial NO synthesis, L-NG-monomethyl-L-arginine (L-NMMA) at increasing doses was assessed by forearm venous occlusion plethysmography. Patients took atorvastatin 10 mg daily for two weeks, then 20 mg daily for another two weeks, and forearm studies were repeated. All patients tolerated the drug without adverse effects. Plasma total cholesterol levels decreased in all patients, (baseline 115 ± 5 mg/dL, post-treatment 93 ± 5 mg/dL (mean ± SEM), p=0.002). Serum creatine kinase increased slightly, but remained in the normal range (55 ± 9 vs. 73 ± 18 IU/L, p=0.15). All patients had markedly impaired responses at baseline to SNP, ACh and L-NMMA compared to healthy control subjects, validating our screening methodology to identify subjects with NO resistance. After four weeks of oral atorvastatin therapy, responsiveness to both SNP and ACh significantly improved in each group compared to baseline by ANOVA with repeated measures (p 〈 0.05). Response to L-NMMA was not significantly affected. These data provide a non-invasive strategy for identifying patients with NO-resistance (endothelial dysfunction) by screening soluble VCAM-1 levels and tricuspid regurgitant jet velocities, and further suggest that high pulmonary artery systolic pressures in this population are associated with reduced NO bioavailability. Additionally, we show that short term use of the FDA approved medication atorvastatin, is safe in this population. Our data are consistent with statin-mediated improvement in vascular responsiveness to NO that is independent of improved endothelial NO production, and support consideration of statins in clinical trials to reduce vascular occlusion in patients with SCD. Figure Figure

Description: Pulmonary hypertension (PHTN) occurs in 32% of adult patients with sickle cell disease (SCD) and carries a high mortality risk. PHTN is also a complication of HIV infection in non-SCD patients, with a prevalence of 0.5%, which is about 2500 times greater than that of primary PHTN in the general population. Of 201 SCD patients tested at Howard Sickle Cell Center, 15 were HIV positive. The association of PHTN and HIV infection has never been reported in SCD patients. We recently identified two patients with severe PHTN (PAs 90 mm Hg or higher) and HIV infection among the 240 adult SCD patients prospectively screened for pulmonary hypertension. One is a 50-year-old male with HbSS, PHTN, supraventricular tachycardia, leg ulcer, transfusional hemosiderosis, hypertension, and mild renal insufficiency. The patient prior to cardiac catheterization was on chronic blood transfusion program for PHTN and frequent vaso-occlusive episodes. His HIV infection screen prior to cardiac catheterization in July of 2003 was positive. His serology had been negative for HIV infection in 1992. The second patient is a 39-year-old female with HbSC, splenectomy secondary to sequestration/hypersplenism, GERD, and chronic pulmonary disease, who was diagnosed with HIV infection in 2000. She has been on antiretroviral medications. Her echocardiogram in June of 2004 revealed a PAs pressure of 85–90 mm Hg. Both patients had cardiac catheterization and the results are shown in the table. A review of Howard Sickle Cell Center’s records identified a third patient: A 35 year-old male with HBSS, and sickle retinopathy with retinal detachment. His HIV infection was diagnosed in 1986, an ECHO in 1993 showed a PAs of 64 mm Hg, and he died suddenly while hospitalized for a painful event in 1994. These observations suggest that HIV infection potentiates the risk for PHTN in patients with SCD. Our published studies have indicated that the risk of PHTN in patients with SCD is associated with high LDH, low hemoglobin and high direct bilirubin levels, and is rare in HbSC disease. The first two SCD patients described above stand in contrast to this risk profile, suggesting that HIV infection may add significant risk for PHTN. We recommend that HIV testing be performed in all patients with SCD diagnosed with PHTN, in order to provide appropriate antiretroviral therapy, which might improve control of PHTN. Clinical data and pulmonary hemodynamics in 2 SCD patients with HIV infection and PHTN, and in 16 sickle patients with PHTN but without HIV infection HIV Pt. 1 HIV Pt. 2 No HIV N=16 Mean +/− SD PAs, PAd, and PAm are pulmonary artery systolic, diastolic, and mean pressures. PCWP is pulmonary capillary wedge pressure. C.O. is cardiac output. Hemoglobin concentration (g/dl) 8.2 8.6 8.56+/− 23 PAs (mmHg) 65 66 48.75 +/− 12.41 PAd (mmHg) 35 34 24.13 +/− 6.38 PAm (mm Hg) 46 44 32.19 +/− 6.93 PCWP (mm Hg) 14 10 18.13 +/− 4.47 C.O. (L/min) 6.0 7.9 9.63 +/− 2.46 Lactate dehydrogenase (IU/L) 307 211 456 +/− 213 Total bilirubin (mg/dL) 1.3 0.4 3.3 +/− 3.1 Direct bilirubin (mg/dL) 0.4 0.1 0.9 +/− 1.7

Description: In 1997, a measles outbreak was identified in São Paulo. Between February and December, 20 185 cases were confirmed. From April to July 1997, a seroepidemiologic survey was conducted to identify the recipients of bone marrow (BM) transplants who were susceptible to measles and the occurrence of measles in this population. A total of 156 patients were screened by enzyme immunoassay (EIA). Patients with IgG titers more than 100 mIU/mL were considered immune. Measles reimmunization records were also reviewed. Thirty-two vaccinated patients underwent serologic evaluation. Six of 22 patients (27.3%) within 3 years after vaccination lost measles immunity, in contrast to 7 of 10 patients (70%) vaccinated longer than 3 years previously (P = .049). Among the 122 nonvaccinated patients, 41 (33.6%) were susceptible to measles: 4 of 47 patients (8.5%) within the first year after BM transplantation (BMT), and 37 of the 75 patients (49.3%) after the first year after BMT (P