title: Audit of peripheral stem cell transplantation for aplastic anemia in multitransfused infected patients.
abstract: BACKGROUND
  Allogeneic hematopoietic stem cell transplantation is a curative modality for aplastic anemia; the preferred stem cell source is bone marrow. However, allogeneic peripheral blood stem cell transplantation (PBSCT) used in high-risk patients is associated with higher risk of chronic graft-versus-host disease (GVHD). Our center receives multitransfused, alloimmunized, infected, late referrals for transplant.
  
  
  METHODS
  Forty-one patients of median age 22 years (range 8-37) received allogeneic-PBSCT from human leukocyte antigen (HLA)-matched sibling donors. The median time since diagnosis was 12 months (range 4-65) and median pretransplant transfusions were 37 (range 6-160). Six patients were platelet refractory and one alloimmunized for pan-red blood cell (RBC) antigens. Several patients had pretransplant icterus or renal dysfunction and 26 (63.4%) had unresponsive bacterial/fungal infections. Our conditioning regimen included fludarabine 30 mg/m(2) for 6 days (days -10 to -5), cyclophosphamide 60 mg/kg/d for 2 days (days -6 to -5), and antithymocyte globulin (ATGAM) 30 mg/kg/d for 4 days (day -4 to -1), which was reduced to 2 days in 2 patients. We used standard GVHD prophylaxis with cyclosporine and methotrexate on days 1, 3, 6, 11.
  
  
  RESULTS
  The median follow-up period was 29 months (range 6-78) and median engraftment time 10 days (range 8-17). Thirty-one patients (75.6%) were treated for infections, with 20 of these on antifungals for preexisting infections. There were two graft rejections and 10 (24.4%) deaths, with three intracranial hemorrhages, two rejections with infection, three cases of refractory GVHD (acute/overlap syndrome) with cytomegalovirus reactivation, and two invasive fungal infections. Overall incidence of acute GVHD was 39% with 2 grade IV cases. Ten (25%) cases developed chronic GVHD, with extensive GVHD in four.
  
  
  CONCLUSIONS
  With more experience using shortened course of ATGAM, HLA-matched donor transfusions, and availability of newer antifungals, we have been able to decrease PBSCT-related mortality. Further improvement will be possible with early referrals.
authors.affiliation: Department of Hematology, All India Institute of Medical Sciences, New Delhi, India. tuliseth@yahoo.com
authors.forename: T
authors.initials: T
authors.lastname: Seth
authors.forename: U
authors.initials: U
authors.lastname: Kanga
authors.forename: P
authors.initials: P
authors.lastname: Sood
authors.forename: V
authors.initials: V
authors.lastname: Sharma
authors.forename: P
authors.initials: P
authors.lastname: Mishra
authors.forename: M
authors.initials: M
authors.lastname: Mahapatra
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000741:Anemia, Aplastic / Q000150:complications / Q000276:immunology / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000935:Antifungal Agents / Q000627:therapeutic use; D001424:Bacterial Infections / Q000150:complications* / Q000188:drug therapy / Q000276:immunology / Q000401:mortality; D001803:Blood Transfusion / Q000401:mortality; D002648:Child; D002908:Chronic Disease; D004359:Drug Therapy, Combination; D005260:Female; D006086:Graft vs Host Disease / Q000276:immunology / Q000401:mortality / Q000517:prevention & control; D006680:HLA Antigens / Q000276:immunology; D006648:Histocompatibility; D006650:Histocompatibility Testing; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use; D015994:Incidence; D007194:India; D053208:Kaplan-Meier Estimate; D008297:Male; D008485:Medical Audit; D009181:Mycoses / Q000150:complications* / Q000188:drug therapy / Q000276:immunology / Q000401:mortality; D036102:Peripheral Blood Stem Cell Transplantation / Q000009:adverse effects / Q000401:mortality; D012720:Severity of Illness Index; D013997:Time Factors; D065227:Transfusion Reaction; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D000935:Antifungal Agents; D006680:HLA Antigens; D007166:Immunosuppressive Agents