ALBERT

Description: Cancer patients have historically had a very poor outcome following ICU admission. Outcome has however improved over the last decade. We aim to identify factors that predict survival for critically ill patients with hematological malignancy and which can be readily identified prior to admission. This would improve selection of patients suitable for ICU admission, which represents a limited resource. We also assessed the ability of the APACHE II score to predict prognosis in these patients. Since the ICU admission case mix will vary between hospitals, one non-surgical admission within +/− 1 week of each hematological admission acted as a control group. Factors which might affect outcome were assessed by multivariate regression analysis. Factors included were age, hematological diagnosis (acute or chronic leukemia, myeloma, lymphoma), time from hematological diagnosis to ICU admission (0–6 months, 6–12 months, 〉12 months), degree of prior treatment (admission prior to diagnosis, during first line therapy, after first line), remission status, prior stem cell transplant, documented infection and length of neutropenia (none, 1–10 days, 〉10 days). For hematology patients, predicted hospital mortality was calculated from the APACHE II score by the formula of Knaus et al (Critical Care Medicine 1985). The APACHE scores of hematology patients were compared to controls by a two-sample t test. Predicted and actual mortalities were compared using a one sample test of proportion. The impact of mechanical ventilation (MV) on mortality was assessed by risk ratios. We identified 111 patients with hematological malignancy (acute leukemia n=42, chronic leukemia n=11, myeloma n=19 and lymphoma n=39) admitted to ICU in one teaching and three district general hospitals (November 2000 - January 2006). Median age of hematological patients was 59 years (range 17–84) and M: F ratio 1.22:1. Control patients (n=111) were similar with median age 63 years (range 17–86) and M: F ratio 1.09:1. For control patients, overall ICU and hospital survival rates were 70% and 55% respectively while survival for hematology patients was approximately half at 44% and 24% respectively. In multivariate regression analysis, only increasing age predicted poor outcome (p=0.016). There was a trend to poor outcome if patients were not in complete remission (p=0.066) or had documented infection (p=0.06). All other variables were not significant. APACHE scores were significantly higher in hematology patients (median 27) compared to controls (median 19) p

Description: Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired clonal stem cell disorder characterized by the expansion of a population of blood cells deficient in glycosylphosphatidylinositol (GPI) linked proteins. This results in the classical clinical features of intravascular hemolysis and thrombosis. PNH is known to be a rare disorder, but its incidence and prevalence have so far been poorly defined with very few studies. In order to better define the incidence and prevalence of PNH, survival data was collected on all patients diagnosed with PNH in the strategic health authorities of North and East Yorkshire, Northern Lincolnshire and West Yorkshire between January 1991 and July 2006. All patients were diagnosed by flow cytometry for GPI-linked antigens on red cells and neutrophils at a single reference laboratory (HMDS). The population of the study region is 3,742,835 (based on the 2001 census of Britain). 76 PNH patients were diagnosed during this time period giving an incidence of 0.13/100,000/year. Based on incidence and survival rates, the estimated 15 year prevalence of PNH is 1.59 per 100,000 resulting in a predicted prevalence of 59 patients in the study region. We have previously demonstrated that a neutrophil clone size 〉50% is a predictor of increased thrombotic risk; the current study predicts that 25% of patients will have 〉50% PNH neutrophil clone size, 43% with 〉10%, and 82% with 〉1%. Platelet count 〉100 x 109/L has been used as a criteria to consider primary prophylactic anticoagulation in PNH patients with substantial hemolysis if the neutrophil clone size is 〉50%. In the current study, the platelet count is 〉100 x 109/L in 32% of patients and

Description: Heme oxygenase-1 (HO-1) is an intracellular enzyme that degrades heme and inhibits immune responses and inflammation in vivo. In most cell types, HO-1 is inducible by inflammatory stimuli and oxidative stress. Here we demonstrate that human monocyte-derived immature dendritic cells (iDCs) and several but not all freshly isolated rat splenic DC subsets and rat bone marrow-derived iDCs, spontaneously express HO-1. HO-1 expression drastically decreases during human and rat DC maturation induced in vitro. In human tissues, iDCs also express HO-1, whereas mature DCs do not. Induction of HO-1 expression with cobalt protoporphyrin (CoPP) in human and rat DCs inhibits lipopolysaccharide (LPS)-induced phenotypic maturation and secretion of proinflammatory cytokines, resulting in the inhibition of alloreactive T-cell proliferation. CoPP-treated DCs, however, retain the ability to produce the anti-inflammatory cytokine interleukin 10 (IL-10). Reactive oxygen species induced by LPS in DCs were inhibited by induction of HO-1. In conclusion, we identify, for the first time, the capacity of HO-1 to block maturation of DCs and to inhibit proinflammatory and allogeneic immune responses while preserving IL-10 production. This novel immune function for HO-1 may be of interest for the inhibition of immune responses in autoimmune diseases, transplantation, and other conditions involving activation of the immune system. (Blood. 2005;106:1694-1702)

Description: In paroxysmal nocturnal hemoglobinuria (PNH), lack of the GPI-anchored terminal complement inhibitor CD59 from erythrocytes renders them susceptible to chronic hemolysis, which is central to the signs and symptoms of PNH. Patients are at elevated risk for thrombosis, experience anemia that may require transfusion support, and suffer from fatigue that can be severe. Patients often have a poor quality of life resulting from PNH related symptoms including pain, dyspnea, dysphagia and erectile dysfunction, which negatively impact quality of life. The prevalence and severity of symptoms were explored in the context of a multi-national content validation study, of patients not receiving eculizumab therapy, employing the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue and the European Organization for Research and Treatment of Cancer Quality of Life Core 30 (EORTC QLQ-C30) instruments. Symptom questions were asked of 29 PNH patients (19 men, 10 women, mean age 41.2±13.2 years) from the United Kingdom, United States, France and Spain. More than half (52%) had PNH for over 5 years. Most (76%) reported never having had a blood clot, 31% reported not receiving any medication for their PNH, and 59% reported either that they had never been transfused or had not received transfusion within the last year for PNH. Patients viewed overall quality of life, global health, functioning, fatigue, pain, and shortness of breath as important PNH-related signs/symptoms. Both the FACIT-Fatigue and EORTC instruments were relevant and adequate in assessing the level of fatigue and other quality of life measures in PNH. The burden of disease in this multicultural and diverse cohort of patients was significant: 76% were forced to modify their daily activities to manage their PNH and 17% were unemployed due to PNH. Nearly all (96%) complained of fatigue and more than half reported abdominal pain, headache and shortness of breath (Table). Patients also commonly reported dysphagia (41%) and erectile dysfunction (47% in males). Most patients reported these PNH-related symptoms as moderate to very severe, and a substantial majority reported distress associated with the symptoms. Significant disease burden was identified in a diverse population of PNH patients, most of which had minimal or no transfusion requirements and a low incidence of thrombosis. Therapy that controls hemolysis and thereby improves fatigue, pain, shortness of breath, dysphagia and erectile dysfunction may prove beneficial for PNH patients with these disease characteristics.

Description: Life-threatening thromboembolism (TE) is the most feared complication in patients with paroxysmal nocturnal hemoglobinuria (PNH). Thrombophilia in PNH likely involves a hypercoagulable state, possibly due to intravascular hemolysis with scavenging of the coagulation regulator nitric oxide, and platelet activation. Approximately 45% of PNH deaths result from TE. Thrombosis is more frequent in patients with larger PNH clones, but can occur in patients with smaller clones. Primary prophylactic anti-coagulation may reduce the thrombotic risk in PNH patients, although controlled studies have not been performed and there is a known serious hemorrhage risk. A randomized, placebo-controlled, 26-week phase 3 study of the terminal complement inhibitor eculizumab in 87 PNH patients (TRIUMPH) recently demonstrated dramatic reductions in intravascular hemolysis and RBC transfusions; 1 TE was reported with placebo and 0 with eculizumab. This single study was not powered to examine the effect of eculizumab on TE, and we prospectively examined the aggregate TE event rate in eculizumab-treated patients from TRIUMPH, the two other PNH trials, and the subsequent phase 3 extension study as compared to each patient’s pre-treatment event rate. Before receiving eculizumab, examination of patient records identified 126 TE events in 195 patients, and 103 were on anticoagulants. While pre-treatment TE event rates were variable in the 3 individual PNH studies, eculizumab reduced TE in each study. The TE event rate with eculizumab treatment was 1.22 per 100 patient years, compared to 7.49 (p

Description: G-CSF mobilized peripheral blood has emerged as the dominant source of stem cells for allogeneic stem cell transplantation. G-CSF modulates T cell function and Suppressor of Cytokine Signaling-3 (SOCS3) is the major regulator of signaling by this cytokine, although the downstream effects in vivo remain unclear. We have therefore examined the effect of SOCS3 in the well established B6 → B6D2F1 murine model of acute GVHD directed to major histocompatibility antigens. Using SOCS3−/Δvav mice in which SOCS3 deficiency is restricted to the haematopoietic compartment we transplanted splenocytes from G-CSF mobilized wild-type (WT) or SOCS3−/Δvav donors and demonstrated that the absence of SOCS3 within the graft accelerated GVHD (median survival 23 vs. 39 days, P=0.04). By using SOCS3−/ΔLysM and SOCS3−/Δlck donors in which SOCS3 deficiency was restricted to the myeloid or T cell lineage respectively we confirmed SOCS3 deficiency enhanced GVHD via effects only within the donor T cell (median survival 19 vs. 35 and 39 days in SOCS3−/Δlck vs. WT and SOCS3−/ΔLysM, P

Description: TNF is a key cytokine in the effector phase of both graft-versus-host disease (GVHD) and the graft-versus leukemia (GVL) effect after bone marrow transplantation (BMT). TNF neutralizing antibodies are now established as effective therapeutic adjuncts for the treatment of severe acute GVHD. TNF signals through the p55 and p75 TNF receptors (TNFR), which are also receptors for the soluble lymphotoxin homotrimer (LTα3). The membrane-bound lymphotoxin heterotrimeric molecule (LTα1β2) signals through the LTβ receptor. The function of these molecules in GVHD remains unknown. Pharmacological agents are available which block either TNF alone, or both TNF and LTα3 and elucidating the roles of these molecules in GVHD is essential for the design of rational therapeutic strategies. We have employed multiple well established preclinical models of GVHD to investigate the roles of these molecules. We first used a functional bioassay to confirm that a human TNFR:Fc construct was capable of preventing physiological activity of both recombinant murine TNF and LTα3. Irradiated B6D2F1 recipients were then transplanted with allogeneic B6.TNF−/− bone marrow and T cells, then treated with control Ig or the TNFR:Fc. Suprisingly, the TNFR:Fc provided significant protection from GVHD mortality in the absence of donor derived TNF (median survival 25.5 vs 35 days, P 3 logs more LTα than LTβ). We subsequently developed the first reported ELISA to assess murine LTα3 protein and were able to clearly demonstrate LTα3 production by wild-type (WT) CD4 T cells seven days after BMT. To further examine this molecule, we performed experiments using WT, LTα−/− or LTβ−/− donor grafts in two BMT systems (B6 → B6D2F1 and B6 → BALB/c). Recipients of LTα−/− grafts were protected from GVHD (P

Description: Abstract 4316 Chimerism defines the amount of donor versus recipient hematopoiesis following allogeneic stem cell transplant (SCT). PCR-based analyses of short tandem repeats (STRs) are commonly used and are accurate and applicable to allogeneic transplant recipients. These analyses are performed on peripheral blood and marrow aspirates, but it is not known if it is necessary to analyze both. We performed a retrospective analysis of 42 consecutive adult allogeneic SCT recipients at our institution with available chimerism studies. PCR and capillary electropheresis of microsatellite loci were performed at 30, 60, and 90 days after SCT on both unfractionated blood and unfractionated marrow aspirate. Full donor chimerism (FDC) was defined as 95% or greater donor chimerism. PCR analyses of STRs for chimerism performed on unfractionated blood did not differ from results obtained on unfractionated marrow aspirate at 30, 60, or 90 days post transplant (P

Description: Abstract 4193 Introduction The management of red cell disorders especially Thalassaemias is a fine balance between adequate transfusion and maintainence of Ferritin levels within a threshold. To achieve this, UK thalassaemia guidelines advice : Study Is a retrospective audit to check if the above standards are met. The study period was 1 year (Jan –Dec 2008) ;the cohort being 12 patients(ages ranging from 22 to 46),10 with Beta thalassaemia major, 1 thalassaemia intermedia and 1 with erythropoietic porphyria. Data 1.pretransfusion Hb 64%transfusions had a mean pretransfusion Hb〉10. 2. Mean Ferritin levels : Treatment allocation 3 patients: had cardiac + liver iron overload & ferritin〉5000, were initially on Deferasirox, but later swapped to desferol and deferiprone combination based on MR T2*results. 3 patient s : had cardic and liver iron overload -2 had associated endocrine dysfunction with Ferritins 〉2000;the first was already on Desferol, Deferiprone was added to this. The second was on Desferol +Deferiprone combination with little response, was changed to Deferasirox increased upto 30 mg/kg, however the Ferritin levels showed a progressive rise and patient was considered for trial (Deferasirox40 mg/kg Vs Desferol). 1 patient had a Ferritin330 mls/kg/year) and pancytopenia on Desferol was considered for Splenectomy. 1patient: with clostrophobia was reluctant to undergo MR scanning, was commenced on Desferol + Deferoprone combination based on ferritin levels〉4000. Monitoring: All patients had monthly complete blood count,liver, kidney and endocrine function tests; and annual MR T2* imaging of heart / liver and ophthalmology and audiology assesments. Those with cardiac iron overload had cardiology followup .Those with liver iron overload had annual alphafetoprotein levels and Liver ultrasound. 3.Splenectomy : 42%(5/12)patients had a transfusion requirement of 〉200mls/kg/year. DISCUSSION Of the 12 patients:1 had regular 3 weekly transfusions,regardless of the Hb;3 patients were transfused on prewritten regimes designed at least 2 years earlier and lacked modification to current iron status.8 patients were transfused on a symptomatic basis-the most common symptom being ‘tiredness’-2 had left ventricular ejection fraction1500 in 75% of the patients could be improved by :strictly adhering to pretransfusion Hbs 9 to 10.5,reviewing prewritten transfusion regimes in the context of current iron overload,careful exclusion of other causes of symptoms ;avoiding transfusing patients purely on a 3 / 4 weekly basis .Lastly Splenectomy needs consideration in those with transfusion requirments〉200mls/kg/yr. Disclosures: No relevant conflicts of interest to declare.

Description: Paroxysmal nocturnal hemoglobinuria (PNH) is characterized by a lack of the terminal complement inhibitor CD59 on erythrocytes that renders these cells susceptible to chronic hemolysis. Eculizumab blocks terminal complement resulting in reductions in hemolysis, thrombotic events, renal impairment and transfusion requirement, as well as improvement in quality of life. The standard dosing regimen for eculizumab is 600 mg/week for 4 weeks (induction); 900 mg one week later; and then 900 mg every 14 ± 2 days (maintenance). This regimen maintains eculizumab levels 〉35 μg/mL, which is sufficient to completely and consistently block complement-mediated hemolysis in patients with PNH. In PNH clinical trials, 900 mg of eculizumab every 14 ± 2 days effectively and consistently blocked complement-mediated hemolysis in 98% of patients (n=195). During the studies, 10–15% of patients experienced an increase in hemolysis (elevation of LDH) near the end of the 14-day dosing interval with a return of pre-eculizumab symptoms such as hemoglobinuria, dysphagia, abdominal pain, or fatigue. The dosing interval was reduced to 12 days, as specified by label, resulting in sustained complement blockade, control of hemolysis and resolution of symptoms in nearly all patients. Three of the original 195 patients (2%) were not consistently blocked with the approved dosing regimen. Alternative eculizumab dosing regimens were investigated in these patients to assess their effectiveness and safety. Two different dosing regimens were employed; both included a maintenance phase with 1200 mg every 14 days. One regimen also included an induction period of 900 mg weekly for 5 doses. LDH, pharmacokinetics (PK), and clinical signs of complement breakthrough were monitored. The time from first eculizumab treatment to initial breakthrough on the 900 mg every 14 days ranged from 2 to 19 mo., and the reduction in the dosing interval to 900 mg every 12 days, as specified in the label, did not adequately control hemolysis in each of these 4 patients. Patient 1 was managed for 6 mo. with 900 mg every 12 days before experiencing additional complement breakthrough episodes (Figure, panel A). LDH levels (closed diamonds) reached 9234 U/L (ULN, 430-450 U/L) and breakthrough symptoms occurred 2 days prior to the next dose. The patient was re-induced with 900 mg eculizumab every 7 days for 5 weeks followed by 1200 mg every 14 days. Trough levels of eculizumab increased (open circles) each week during the induction phase (42.7 – 81.8 μg/ml) resulting in an immediate reduction in LDH to near normal levels. A maintenance dose of 1200 mg every 14 days in this patient resulted in sustained complement blockade. Patient 2 experienced breakthrough hemolysis after 19 mo. of standard dosing. Complement breakthrough occurred during a post-cholecystectomy infective endocarditis. After an adjustment to 900 mg every 12 days did not control complement breakthrough (Figure, panel B), the dose was changed to 1200 mg every 14 days without re-induction. This regimen resulted in sufficient levels of eculizumab to consistently reduce hemolysis to near normal levels. Further episodes of hemoglobinuria and other symptoms of hemolysis were not observed. Two additional patients received 1200 mg every 14 days without re-induction, one following complement breakthrough on the approved dose and the other due to the convenience of the 14 day interval with the 1200 mg dose. Complete complement blockade has been maintained in these patients for 8 mo. and 12 mo. to date, respectively. After 1 year of sustained complement blockade with the 1200 mg maintenance dose, patient 1 again demonstrated a breakthrough. Complement inhibition is now being maintained in this patient by a 1200 mg dose every 14 days with an additional 1200 mg dose in between the 14 day dosing interval every 4–5 doses. There were no reported adverse events in any of the four patients in which the 1200 mg dosing regimens were administered. In summary, these data demonstrate good correlation between eculizumab and LDH levels, suggesting that a breakthrough in complement activity due to insufficient drug levels can be monitored by levels of LDH near the end of the dosing interval. These results illustrate that two alternative-dosing regimens are well tolerated and can be effectively employed in the small percentage of PNH patients in which complement inhibition is not consistently maintained using the standard dose. Figure Figure