PD or Not PD? Optimal Management of Dialysis-Dependent Patients Undergoing Autologous Peripheral Blood Stem Cell Transplantation

PD or Not PD? Optimal Management of Dialysis-Dependent Patients Undergoing Autologous Peripheral Blood Stem Cell Transplantation

Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391 receiving LM and support preliminary data that lenalidomide may augment vaccine responses...

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Abstracts / Biol Blood Marrow Transplant 23 (2017) S18–S391

receiving LM and support preliminary data that lenalidomide may augment vaccine responses. Conclusions: Re-immunization with inactivated vaccines in patients on LM is both safe and effective, offering this population immunity to vaccine preventable diseases.

298 PD or Not PD? Optimal Management of DialysisDependent Patients Undergoing Autologous Peripheral Blood Stem Cell Transplantation Soyoung Park 1, Kamron Saleem 2, Amy Sussman 2, Andrew Yeager 3. 1 Hematology-Oncology, University of Arizona Cancer Center, Tucson, AZ; 2 Nephrology, University of Arizona, Tucson, AZ; 3 Blood and Marrow Transplant Program, Arizona Cancer Center/University of Arizona, Tucson, AZ Introduction: Renal impairment occurs in 20-40% of patients with multiple myeloma (MM), and about 2-3% require chronic hemodialysis (HD) or peritoneal dialysis (PD). Autologous stem cell transplant (ASCT) is a mainstay of treatment for MM, and renal failure (RF) is not in itself a contraindication to ASCT. Successful ASCT in HD-dependent MM patients has been reported. To our knowledge, however, there are no comparable published experiences using PD. The absence of established guidelines and “best practices” for management of ASCT in PD-dependent MM patients is problematic. Methods: A 43-year-old woman was diagnosed with ISS stage 3 lambda light chain MM; at diagnosis, serum creatinine (Cr) was 7.3, BUN 92, albumin 3.4, beta-2 microglobulin 13.63, serum lambda free light chains (FLC) 6310 mg/L, and absolute FLC difference 6289 mg/L. Cr decreased to 1.9 without dialysis following treatment with cyclophosphamide (Cy)/ dexamethasone (D). After 5 cycles of Cy/bortezomib (Bor)/D and 5 cycles of lenalidomide (Len)/Bor/D, she had ASC collection and cryopreservation and continued Bor/prednisone (Pred). At 26 months after diagnosis (dx), the patient developed acute RF (creatinine 5.0) without MM progression (lambda FLC 216 mg/L; absolute FLC difference 148.5 mg/L); renal biopsy showed collapsing glomerulopathy and global glomerulosclerosis. She started PD and resumed Len/Bor/Pred. At 33 months post-dx, with MM in first VGPR (absolute FLC difference 242.5 mg/L), the patient proceeded to ASCT. Given the lack of published reports on outcomes of ASCT in PD-dependent patients, we changed this patient’s regimen from daily PD to thrice-weekly HD for the immediate peri-ASCT period. Results: The patient had placement of an HD catheter; the PD catheter was not removed. She received intravenous melphalan 140 mg/m2 on day −2 and HD on day −1; day zero CD34+ cell dose was 5.28 × 106/kg. She received dose-adjusted prophylactic acyclovir and ciprofloxacin, and therapeutic oral fluconazole for pulmonary coccidioidomycosis. On day +5 she developed febrile neutropenia and received empiric cefepime and vancomycin. All cultures remained negative; antibiotics were discontinued on day +11 when absolute neutrophil count was >.5 × 10 9 /L. The patient remained on thriceweekly HD until day +46 and then resumed PD. At 6 months post-ASCT, MM remained in VGPR with absolute FLC difference 6.68 mg/L on Bor maintenance. Conclusion: In a PD-dependent patient undergoing ASCT for MM, transition to HD in the immediate peri-transplant period was safe and well tolerated, and resumption of PD was uneventful. Both this single-center experience and the absence of publications on continuation of PD throughout ASCT justify a multi-institution survey of management of PD-dependent patients undergoing ASCT. Information thus obtained could lead to data-driven guidelines of use to both nephrology and transplant practitioners.


299 Low Plasma Vitamin C Levels in Patients Undergoing Stem Cell Transplantation Mahmood Rasheed 1, Catherine H. Roberts 2, Gaurav Gupta 3, Bernard J. Fisher 1, Kevin Leslie 4, Gary Lee Simmons 2, Christina M. Wiedl 5, John Michael McCarty 2, William B. Clark 2, Harold M. Chung 2, Jason C. Reed 4, Alpha A. Fowler 1, Amir A. Toor 2, Ramesh Natarajan 1. 1 Internal Medicine, Virginia Commonwealth University, Richmond, VA; 2 Bone Marrow Transplant, VCU Massey Cancer Center, Richmond, VA; 3 School of Medicine, Virginia Commonwealth University, Richmond, VA; 4 Physics, Virginia Commonwealth University, Richmond, VA; 5 Pediatric Bone Marrow Transplant, Virginia Commonwealth University, Richmond, VA Patients undergoing high dose therapy and stem cell transplantation (SCT) develop mucosal toxicity with declining oral intake and nutrient absorption. Vitamin C (VitC) is critical in regulating the inflammatory response. Low vitamin C levels have been associated with poor outcomes in patients with systemic inflammatory state, such as is commonly observed in patients undergoing myeloablative conditioning and SCT. This study was performed to determine plasma VitC steady state levels in these patients. In this single institution IRB-approved prospective study, patients were enrolled prior to SCT and plasma VitC levels were measured at baseline and on days 0, 14, 30, and 60 post-transplant. Thus far, 15 patients have been studied, 4 underwent an autologous and 11 an allogeneic SCT (3 HLA matched related donors and 8 unrelated donors): median age was 50 years (range 31, 65) at the time of transplant. Primary diagnoses included myelofibrosis (2), AML (2), ALL (2), MDS (3) non-Hodgkin lymphoma (3), Hodgkin’s lymphoma (1), Myeloma (1) and CML (1). Preparatory regimens were all myeloablative; Flu/ Mel/ATG (2), Bu/Cy/ATG (5), BEAM (3), Bu/Flu/ATG (2), TBI/ Cy/ATG (1), Mel 200 (1), Bu/Flu (1). Mucositis was observed in 12 patients, grades 1 (3), 2 (5) and 3 (4) with grades 2 and 3 possibly associated with Busulfan in the conditioning regimen. GVHD prophylaxis included tacrolimus with Mycophenolate (3) or Methotrexate (5) or cyclosporine with Mycophenolate (1) or Methotrxate (2). (Mean plasma VitC levels was 40.8 μmol/l (±18.4) (normal range: 50-80 μmol/ L) at baseline, before falling to 27.3 μmol/l (±14.1) at day 0 (P < .05, c/w baseline) and reaching nadir at 21.5 μmol/l (±13.8) on day 14 (P < .05 c/w baseline) post-SCT (Figure 1). Plasma

Figure 1. Vitamin C levels during stem cell transplantation.