Quantification of minimal residual disease levels by flow cytometry at time of transplant predicts outcome after myeloablative allogeneic transplantation in ALL.

The potential impact on patient outcome of different Minimal residual disease (MRD) levels at time of transplant in patients with lymphoblastic leukemia undergoing allogeneic hematopoietic SCT (HSCT) remains uncertain. In this study, we quantified MRD levels at time of transplant using multiparameter flow cytometry (MFC). Mononuclear cells from marrow aspirates were obtained from 102 adult and child patients before their conditioning regimen. Quantification of MRD levels was carried out by detecting patient-specific leukemia-associated immunophenotypes using four-color MFC. Thirty patients exhibited measurable levels of MRD at the time of transplant, with low levels (0.01 to 0.1%) in 12 cases, intermediate levels (>0.1 to 1%) in 8 cases and high levels (>1%) in 10 cases. The leukemia-free survival (LFS) rates were 65.9±7.0%, 42.9±15.7% and 0% for negative, low levels 0.1% and intermediate-high levels >0.1%, respectively (P<0.001, log-rank test). Overall survival (OS) was 52.3±7.6%, 28.6±13.8% and 0% for MRD-negative, low levels 0.1% and intermediate-high levels >0.1%, respectively (P<0.001, log-rank test). Multivariate Cox analysis confirmed that detection of leukemia cells by flow cytometry at transplant was the most significantly adverse factor for OS, LFS and EFS after transplant.

Unidades preoperatorias de alta resolución para pacientes de CMA / Preoperative units for patients undergoing ambulatory surgery

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Un hospital de apoyo al servicio de la sociedad. Nuevas realidades la unidad de preoperatorios de alta resolución / A support hospital at the service of society. New realities: high resolution pre-operative unit (UPAR in Spanish)

El Hospital de la Cruz Roja San José y Santa Adela es un hospital de apoyo, los pacientes provienen de las poblaciones periféricas y la gran mayoría deben repetir su preoperatorio. Dado que nuestras actividades tienen como finalidad la satisfacción de las necesidades del paciente/ usuario, nos preguntamos: ¿podemos mejorar nuestro proceso de lista de espera, y beneficiar al paciente? Hemos revisado nuestro proceso, y la respuesta ha sido "la unidad de preoperatorios de alta resolución" (UPAR) nos ha permitido obtener: disminución de los procesos burocráticos; disminuir consultas sucesivas del preoperatorio; confortabilidad, y trato personalizado, y ahorros al paciente, a la familia y a la organización (AU)

[Atypical presentation of acute myeloblastic leukemia in two pediatric patients]. / Presentación inusual de leucemia mieloblástica aguda en dos pacientes pediátricos.

Acute myeloblastic leukemia (MLA) is an uncommon disease in childhood and its prognosis is worse than that of lymphoblastic leukemia. Severe hemorrhage, infections and perfusion disorders secondary to leukostasis are the main complications leading to its high mortality rate. Two pediatric patients with MLA (M5a and M2) are presented. Both patients were admitted to the pediatric intensive care unit with acute respiratory distress syndrome and intracranial hemorrhage respectively, secondary to leukostasis. The first patient showed favorable clinical course and underwent bone marrow transplantation four months later; in contrast, the second patient died a few hours after admission. The physiopathology of each case, the therapeutic approach and the use of leukopheresis as a therapeutic alternative in patients with hyperleukocytosis and leukostasis are discussed. A high degree of suspicion is required to make a diagnosis as early as possible in order to avoid the death of a large percentage of patients before cytostatic treatment begins.

Presentación inusual de leucemia mieloblástica aguda en dos pacientes pediátricos / Atypical presentation of acute myeloblastic leukemia in two pediatric patients

La leucemia mieloide aguda (LMA) es poco frecuente en la infancia, pero cuando se presenta suele revestir mayor gravedad que las formas linfoides. Las principales complicaciones, íntimamente relacionadas con su peor pronóstico, son la hemorragia aguda, la infección y las secundarias a leucostasis. Se presentan 2 pacientes pediátricos con LMA tipo M5a y M2 en los que la enfermedad se manifestó con un proceso agudo grave (distrés respiratorio agudo y hemorragia cerebral, respectivamente), secundario a leucostasis y que motivó su ingreso en la unidad de cuidados intensivos pediátricos. Mientras que la evolución fue favorable en el primer paciente, permitiendo con posterioridad el trasplante de medula ósea, el segundo falleció a las pocas horas de su ingreso. Se discute la fisiopatología de cada caso, el tratamiento y el uso de leucoferesis como alternativa terapéutica en pacientes con hiperleucocitosis y leucostasis. Se insiste en la necesidad de mantener un alto grado de sospecha para realizar un diagnóstico lo más precoz posible que impida que un porcentaje elevado de pacientes fallezca aun antes de iniciar el tratamiento citostático (AU)

[Effect of cyclosporine on plasma levels of uric acid in patients treated with bone marrow transplantation]. / Efecto de la ciclosporina sobre los niveles plasmáticos de ácido úrico en pacientes trasplantados de médula ósea.

In patients treated with cyclosporine, an increase in the incidence of goiter has been demonstrated. This agent produces changes in the lipidic metabolisms, among which the increase in VLDL stands put. Given that the hyperlipemia more frequently associated to hyperuricemia is the increase of such lipoprotein, we decided to study the behaviour of plasmatic uric acid in patients receiving treatment with cyclosporine. The study was conducted in patients with bone marrow transplant undergoing immunosuppressive therapy, considering the effect of cyclosporine as the only drug or following a scheme of mixed immunosuppression associated to prednisone. We observed a reversible increase in the plasmatic levels of uric acid in patients treated with cyclosporine, which was positively correlated to an increase in VLDL triglycerides. Hence, the cyclosporine produced an increase of uric acid which was neither observed when associated to prednisone nor in the group of self-transplanted patients.

[Bone marrow necrosis as a manifestation of leukemic relapse in a patient with bone marrow transplant]. / Necrosis medular como manifestación de recaída leucémica en paciente trasplantado de medula ósea.

A case of bone marrow necrosis (BMN) in transplanted acute lymphoblastic leukaemia (ALL) is presented. The propositus is a 16 year-old boy with L-2 type ALL on whom allogeneic bone marrow transplantation (BMT) had been performed after the second relapse. He was admitted to hospital at 415 after BMT with fever, malaise and hip pain. One week later he had aplasia without blast cells. Scanty cellularity with necrobiosis was found in bone marrow aspirates; bone marrow biopsy confirmed the suspicion of BMN. Osseus scintigraphy with 99-Tc-diphosphonate showed poor, irregular distribution. Steroid therapy was followed by a favourable response. Peripheral blast cells appeared two weeks later, and the relapse was confirmed by bone marrow aspiration. Chemotherapy was started, but the patient died on day 467 after BMT. BMN has been reported in ALL at onset, in relapses, after chemotherapy and as necropsy finding; however, it had not been found in patients subjected to BMT. The experience of these Service was revised, this being the only case of 140 patients subjected to BMT who presented such severe complication.

Renal involvement in chronic graft-versus-host disease: a report of two cases.

We report details of renal involvement during the course of chronic graft-versus-host disease (cGVHD) in two patients undergoing bone marrow transplantation as treatment for acute leukemia. In both cases, the clinical picture was primarily characterized by proteinuria without hypertension or renal failure. Electron microscopy of renal biopsy specimens revealed a similar pattern in the two cases with extensive coalescence of foot processes and intramembraneous deposition of electron-dense material. Our data suggest that the kidney may be a target organ in chronic GVHD.

A controlled trial of prophylactic granulocyte transfusions during induction chemotherapy for acute nonlymphoblastic leukemia.

Thirty-five noninfected patients undergoing induction chemotherapy for acute nonlymphoblastic leukemia (ANLL) were randomized to either receive (19 patients) or not receive (16 control patients) prophylactic granulocyte transfusions (PGT) when their granulocyte count fell below 0.5 X 10(9)/1. Both groups received identical anti-infectious and supportive care except for granulocyte transfusions. The authors found a nonstatistically significant decrease of the infection rate in the prophylactic group. However, the bacteriologically documented infections and septicemia incidence was significantly higher in the control than in the prophylactic group (P less than 0.05). In the control group they observed in 8 of 16 cases life-threatening infections in contrast with only 1 case in the prophylactic group (P less than 0.01). A significant reduction of deaths due to infectious causes in the prophylactic versus control group were also found (P less than 0.05). The authors did not find an increase of pneumonia or pulmonary infiltrates in the patients belonging to prophylactic in comparison to control group.