Kidney dysfunction after allogeneic stem cell transplantation

Abstract

Allogeneic stem cell transplantation (SCT) is a widely accepted approach for malignant and nonmalignant hematopoietic diseases. Unfortunately complications can occur because of the treatment, leading to treatment-related mortality. We studied kidney dysfunction after allogeneic SCT in 2 cohorts of patients: 1 cohort that received a myeloablative SCT (n=363) and 1 cohort that received a nonmyeloablative SCT (n=150). Acute renal failure, defined as doubling of serum creatinine from baseline within 100 days, developed in 50% of patients receiving a myeloablative SCT and in 33% of patients receiving a nonmyeloablative SCT. Only in the myeloablative cohort was dialysis required in 1% of patients. Overall survival after 6 months was 75% in patients receiving a myeloablative SCT and 84% in patients receiving a nonmyeloablative SCT. Mortality was higher in patients with acute renal failure. This was not caused by acute renal failure per se, but by complications or relapse with high mortality associated with more severe acute renal failure. Acute renal failure in the absence of a complication or relapse was probably caused by cyclosporine and these patients had similar survival as patients without acute renal failure. The incidence of chronic kidney disease, defined as persistence of a glomerular filtration rate (GFR) of <60 ml/min/1.73 m2, was 20% after 5 years in the myeloablative cohort and in 22% after 4 years in the nonmyeloablative cohort. Risk factors for chronic kidney disease were lower GFR at baseline, female gender and higher age. Overall survival was 60% after 5 years in patients receiving a myeloablative SCT and 66% after 4 years in patients receiving a nonmyeloablative SCT. Survival was not influenced by chronic kidney disease, but the reason for this might be that follow-up was still too short. SCT nephropathy, also known as bone marrow transplantation nephropathy, conditioning-associated HUS or radiation nephritis is a microangiopathic condition that can lead to chronic kidney disease and kidney failure. It is characterized by an increase in creatinine, microangiopathic hemolytic anemia, and hypertension, occurring typically 6-12 months after SCT. SCT nephropathy is a rare syndrome that occurred in 2% of patients who received high dose total body irradiation in the myeloablative conditioning regimen. However, it is a very important syndrome, because it was the only cause of end-stage kidney disease in this cohort. Patients with renal dysfunction at baseline, defined as a GFR of <60 ml/min/1.73 m2 can safely receive a standard nonmyeloablative SCT. Although the occurrence of chronic kidney disease in this group is higher compared to patients with normal renal function, cyclosporine dose, complications and mortality rate are similar. In conclusion, acute renal failure and chronic kidney disease are common complications after SCT. Acute renal failure without other complications is reversible and does not lead to impaired survival. The outcome of patients with chronic kidney disease with longer follow-up is not clear yet. Management of chronic kidney disease according to the National Kidney foundation Kidney Disease Outcomes Quality Initiative guidelines hopefully slows progression of chronic kidney disease to kidney failure.