Obesity Does Not Preclude Safe and Effective Myeloablative Hematopoietic Cell Transplantation (HCT) for Acute Myelogenous Leukemia (AML) in Adults

OBESITY DOES NOT PRECLUDE SAFE AND EFFECTIVEMYELOABLATIVE HEMATOPOIETIC CELL TRANSPLANTATION(HCT) FOR ACUTE MYELOID LEUKEMIA (AML) IN ADULTS

Willis H. Navarro, MD1, Manza-A. Agovi, MPH2, Brent R. Logan, PhD2, Karen Ballen, MD3,Brian J. Bolwell, MD4, Haydar Frangoul, MD5, Vikas Gupta, MD6, Theresa Hahn, PhD7,Vincent T. Ho, MD8, Mark Juckett, MD9, Hillard M. Lazarus, MD10, Mark R. Litzow, MD11,Jane L. Liesveld, MD12, Jan S. Moreb, MD13, David I. Marks, MD, PhD14, Philip L. McCarthy,MD7, Marcelo C. Pasquini, MD, MS2, and J. Douglas Rizzo, MD, MS21National Marrow Donor Program, Minneapolis, MN2Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin,Milwaukee, WI3Massachusetts General Hospital, Boston, MA4Cleveland Clinic Foundation, Cleveland, OH5Vanderbilt University Medical Center, Nashville, TN6Princess Margaret Hospital, Toronto, Ontario, CANADA7Roswell Park Cancer Institute, Buffalo, NY8Dana-Farber Cancer Institute, Boston, MA9University of Wisconsin Hospital and Clinics, Madison, WI10University Hospitals Case Medical Center, Cleveland, OH11Mayo Clinic Rochester, Rochester, MN12Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY13Shands Hospital, University of Florida, Gainesville, FL14Bristol Children’s Hospital, Bristol, United Kingdom.

AbstractThe incidence of excessive adiposity is increasing worldwide and is associated with numerousadverse health outcomes. We compared outcomes by body mass index (BMI) for adult patients withacute myeloid leukemia (AML) who underwent autologous (auto, n=373), related donor (RD,n=2041), or unrelated donor (URD, n=1801) allogeneic myeloablative hematopoietic celltransplantation (HCT) using marrow or peripheral blood stem cells reported to the Center for

© 2010 The American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.Corresponding Author: Willis H. Navarro, MD, National Marrow Donor Program, 3001 Broadway Street NE, Suite 100, Minneapolis,MN 55413, USA; Telephone: 612-884-8675; [email protected]'s Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customerswe are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resultingproof before it is published in its final citable form. Please note that during the production process errors may be discovered which couldaffect the content, and all legal disclaimers that apply to the journal pertain.

NIH Public AccessAuthor ManuscriptBiol Blood Marrow Transplant. Author manuscript; available in PMC 2011 October 1.

Published in final edited form as:Biol Blood Marrow Transplant. 2010 October ; 16(10): 1442–1450. doi:10.1016/j.bbmt.2010.04.009.

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International Blood and Marrow Transplant Research (CIBMTR) from 1995-2004. Four weightgroups by BMI (kg/m2) were defined: underweight < 18; normal 18 – 25; overweight >25 – 30; andobese > 30. Multivariable analysis referenced to the normal weight group showed an increased riskof death for underweight patients in the RD group (RR, 1.92; 95% CI, 1.28-2.89; P = 0.002) but notin the URD group. There were no other differences in outcomes among the other weight groupswithin the other HCT groups. Overweight and obese patients enjoyed a modest decrease in relapseincidence, though this did not translate into a survival benefit. Small numbers of patients limit theability to better characterize the adverse outcomes seen in the underweight RD but not theunderweight URD allogeneic HCT patients. Obesity alone should not be considered a barrier to HCT.

KeywordsHematopoietic cell transplantation; obesity; outcomes; acute myeloid leukemia

INTRODUCTIONObesity remains an increasingly prominent and challenging international health issue,particularly in the developed world(1-7). Excessive adiposity has been associated with anumber of medical complications including cardiovascular disease and diabetes that couldadversely impact outcomes for hematopoietic cell transplantation (HCT) for acute myeloidleukemia (AML)(6,8,9). AML is often optimally treated with HCT and in some cases, affordsthe best opportunity for long-term disease free survival. Recently, it was demonstrated thateven in the intermediate-risk setting, allogeneic HCT (alloHCT) improves overall survivalcompared to other approaches(10). However, there has been concern that obese and overweightpatients may not have equivalent outcomes when compared to those of normal weight. To date,transplant outcomes for patients with AML based on BMI have not been well-characterized.

In 2004, we published results from an observational study performed by the Center forInternational Blood and Marrow Transplantation Research (CIBMTR) for patients undergoingautologous HCT (autoHCT) for lymphoma(11). In that study, we showed that obese patientsfared at least as well as patients with normal body mass index. The purpose of this study wasto explore the impact of BMI in a different disease setting and in the context of allogeneictransplantation to understand if the previous observations regarding obesity apply.

PATIENTS AND METHODSData Sources

The CIBMTR is a research affiliation of the International Bone Marrow Transplant Registry(IBMTR), Autologous Blood and Marrow Transplant Registry (ABMTR) and the NationalMarrow Donor Program (NMDP) established in 2004 that comprises a voluntary workinggroup of more than 450 transplantation centers worldwide that contribute detailed data onconsecutive allogeneic and autologous hematopoietic SCT to a Statistical Center at the MedicalCollege of Wisconsin in Milwaukee and the NMDP Coordinating Center in Minneapolis.Participating centers are required to report all transplants consecutively; compliance ismonitored by on-site audits. Patients are followed longitudinally, with yearly follow-up.Computerized checks for discrepancies, physicians’ review of submitted data and on-site auditsof participating centers ensure data quality. Observational studies conducted by the CIBMTRare performed in compliance with the Privacy Rule (HIPAA) as a Public Health Authority, andin compliance with all applicable federal regulations pertaining to the protection of humanresearch participants as determined by continual review of the Institutional Review Boards ofthe National Marrow Donor Program and the Medical College of Wisconsin since 1985.

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PatientsOur study inclusion criteria included all patients with AML who received a first allogeneicmarrow or peripheral stem cell graft HCT from a related donor (RD alloHCT) or an unrelateddonor (URD alloHCT) or received an autoHCT between 1995 and 2004 and reported to theCIBMTR. Patients whose transplant center reported myeloablative conditioning (asdetermined by the transplant center) and whose disease status prior to transplant was reportedas primary induction failure (PIF), first or second complete remission (CR1, CR2) or firstrelapse were included in this study. For the autologous cohort, recipients of purged grafts(n=55) were excluded. A total of 4,735 patients met these initial selection criteria. We furtherexcluded 520 patients (74 autologous; 305 RD, 141 URD) from teams with inadequate follow-up or inconsistent reporting over the study period in order to reduce selection and reportingbias of patients. To ensure that the research patients were representative of all registeredpatients in the CIBMTR database, demographics and relapse and survival rates betweenresearch and registered patients were compared and no differences were noted.

The final study population included 1,801 and 2,041 patients who received an URDalloHCTor RDalloHCT, respectively, and 373 patients who underwent autoHCT. Patients were dividedinto groups based on body mass index (BMI) calculated from weight at the time oftransplantation. Weight groups were defined according to consensus weight designations bythe World Health Organization(12) and the National Heart Lung and Blood Institute ExpertPanel(13) as follows: underweight, BMI <18 kg/m2; normal, BMI 18 to 25 kg/m2; overweight,BMI >25 to 30 kg/m2; and obese, BMI >30 kg/m2. Obese (BMI >30 to 34) and morbidly obesegroups (BMI ≥ 35) were combined for all analyses after confirmation of the lack of significantoutcomes differences when analyzed separately (see section on overall survival-multivariateanalysis for details).

Data CollectionAll missing or inconsistent data at the time of data file preparation were queried. Unavailabledata from the transplant centers was treated as missing in the analysis. Cytogenetics data at thetime of diagnosis or prior to transplantation were queried if not previously reported.Cytogenetic data were available for 79% of patients. Follow-up was updated for all patients inthe data file. The median follow-up by transplant type and the completeness of follow-up indexat 3 years(14) were 74 months and 94% for RD alloHCT, 58 months and 86% for URDalloHCT, and 85 months and 80% for autoHCT, respectively.

Study End PointsPrimary end points were overall survival (OS), transplant-related mortality (TRM), relapse,and leukemia-free survival (LFS). OS was defined as time to death from any cause; survivingpatients were censored at time of last follow-up. TRM was defined as death within the first 28days of transplantation from any cause or death in continuous complete remission at anysubsequent time point. Relapse was defined as the time to onset of clinical or hematologicrecurrence, disease progression, or persistent disease. For relapse, patients with persistentdisease were considered events at day 28. LFS was defined as survival in continuous completeremission of primary disease; disease relapse or persistence, or deaths were considered asevents.

Secondary end points studied included rates of primary neutrophil and platelet engraftment,grade II-IV acute graft-versus-host disease (GVHD), and chronic GVHD. Neutrophilengraftment was defined as the time to achieve a sustained absolute neutrophil count ≥500cells/μL for three consecutive days. Time to platelet engraftment was defined as time to achievea platelet count of 20,000/μL, evaluable at 7 days from the last platelet transfusion.



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Acute and chronic GVHD were graded by the transplant center according to standard criteria(15,16).

Statistical AnalysisPatient-, disease-, and transplant-related factors were compared among the four BMI groupsby using the Chi-squared test for categorical variables and the Kruskal-Wallis test forcontinuous variables. Univariate probabilities LFS and OS were estimated by using the Kaplan-Meier method(17). The log rank test was used for comparing survival curves. Probabilities ofTRM, relapse, neutrophil engraftment, platelet engraftment, acute and chronic GVHD wereestimated by using cumulative incidence to allow for competing risks. In the multivariateanalyses we used Cox proportional hazards regression models separately for each donor type.Models were constructed to compare the outcomes among the four BMI groups, with normalBMI used as the baseline group, while adjusting for all covariates listed in the demographicstables (Table 1). A model was built for each primary outcome of interest as a dependent variableand all the relevant exposure variables as explanatory variables. A main effect term for the fourBMI groups was forced into the model. The proportional hazards assumption for all thevariables was examined by using time-varying covariates, but violations of this assumptionwere not detected. Interactions between weight groups and other significant explanatoryvariables were explored but none were found significant. The models were adjusted for thegeographical region of the patient (US, Canada, Europe, Asia, Australia/New Zealand,Mideast/Africa, Central/South America) using a stratified Cox model to account for imbalancesin the BMI groups by region. Bonferroni corrections were applied to allow adjustment formultiple comparisons between each weight group and the normal weight group. A P value <.0167 was therefore considered statistically significant, whereas the P values for inclusion inthe final models of all other potentially confounding covariates were set at <.05. Comparisonsof all secondary outcomes were limited to univariate comparisons.

RESULTSPatient Characteristics

Patients included in this analysis were age 18 years or older, with AML in first or secondcomplete remission (CR), in first relapse, or with primary induction failure after initial therapywho underwent HCT between 1995-2004, inclusive. A total of 4,215 patients were evaluatedin this study. Comparisons of patient-, disease-, and transplant-related characteristics amongthe weight groups are listed in Table 1. Because of low numbers of patients in the underweightarm for those undergoing autoHCT (n=5), this group was omitted from analysis. With respectto the key risk characteristics of age, Karnofsky performance status (KPS) < 90, disease statusat transplant, cytogenetic risk group, and, for unrelated allogeneic transplants, donor matching,no differences among the normal weight, overweight, and obese groups were observed. Forthe underweight group, there were some differences compared to the normal weight group forthe RD alloHCT group (more primary induction failures [PIF] and first relapses: 38% vs 28%,respectively) and for the URD alloHCT group (median age: 26 vs 40; KPS <90: 58 vs 32%;and well-matched donor(18): 18 vs 39%, respectively). Table 2 summarizes the rates ofneutrophil and platelet engraftment according to BMI group and transplant type. Hematopoieticrecovery was similar among all BMI groups.

Overall Survival-Univariate AnalysisFigure 1 shows Kaplan-Meier estimates of OS by transplant type and weight group. For theRD alloHCT group, probabilities of OS in the univariate analysis were similar between thenormal (63% [95% CI, 60%-66%]), and overweight (60% [95% CI, 56%-64%]) groups,slightly worse in the obese group (52% [95% CI, 47%-58%]), and markedly worse in theunderweight group (38% [95% CI, 22%-55%]) at 1 year. Corresponding OS probabilities at 5



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years were 47% (95% CI, 44%-50%), 44% (95% CI, 40%-49%), 37% (95% CI, 31%-43%),and 19% (95%CI, 6%-35%), respectively. For the URD alloHCT and the autoHCT groups,there were no statistically significant differences among the weight groups.

Overall Survival-Multivariate AnalysisIn multivariate analysis (Table 3) in the RD alloHCT setting, with normal weight patients asthe reference, the underweight group had a higher risk of mortality (RR, 1.92; 95% CI,1.28-2.89; P = .002); there were no differences among the normal, overweight, and obesegroups. The morbidly obese group (BMI ≥ 35) was analyzed separately for OS versus thenormal weight group: RD group n=118, RR=1.05 (0.81-1.35), p=0.733; URD group: n=170,RR=1.11 (0.91-1.35), p=0.317. Other factors associated with higher risks of mortality wereage >50 years, KPS <90%, and disease stage worse than first remission at transplantation; CSA+/− other, T cell depletion for GVHD prophylaxis (CSA/MTX as the reference group); highrisk cytogenetics (normal cytogenetics as reference); and use of TBI. For the URD alloHCTand autoHCT groups, there were no differences in overall survival among the weight groups.

Transplant-Related MortalityPoint wise probabilities of TRM are summarized in Table 2. In multivariable analysis in theRD alloHCT setting, the underweight group experienced a relative risk (RR) of TRM of 2.23(95% CI: 1.17-4.25; P =0.014) compared to the normal weight group. There were nodifferences among the other weight groups. Other significant variables increasing the risk ofTRM were age >40, KPS <90, GVHD prophylaxis with CSA +/− other or T cell depletion,and a disease status of primary induction failure at transplant. A favorable factor was year oftransplant between 2000 and 2004 (versus 1995 to1999). In the URD alloHCT and autoHCTsettings, there were no differences among the BMI groups.

RelapseTable 2 summarized the univariate probabilities of leukemia relapse by BMI group at eachtransplant type. In multivariate analysis, in the RD alloHCT setting, the underweight grouphad a higher risk of relapse compared to the normal weight group, with a RR of 2.06 (95% CI,1.20-3.54, P = 0.009). There were no differences in the other weight groups. Interestingly,similar to the previous study of autoHCT for lymphoma, the relative risk of relapse was reducedfor the URD alloHCT overweight (RR 0.82, 95% CI 0.68-0.99, P = 0.044) and obese (RR 0.76,95% CI 0.0.60-0.96, P = 0.022) groups, though this difference did not translate into a survivalbenefit. There were no differences among the weight groups in the autoHCT group(underweight was excluded, n=5).

Leukemia-Free SurvivalIn multivariate analysis, LFS was worse in the RD alloHCT setting for the underweight group(RR 2.07, 95% CI 1.36-3.13, P = <0.001). Otherwise, no other differences were observed forany other groups in any other setting.

Acute and Chronic Graft-versus-Host Disease (GVHD)The rates of acute and chronic GVHD by transplant type are summarized in Table 2. Nostatistically significant differences were observed among the weight groups in either allo HCTsetting for either type of GVHD.

DISCUSSIONIn this contemporary, retrospective, large study in AML patients, we demonstrated that obesityas defined by BMI at time of transplantation does not correlate with worse survival outcomes



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but that underweight recipients of RD allo HCT have shorter survival compared to patientswithin the normal BMI range. Similar to our previous study in patients with lymphoma, thecurrent study demonstrates that obesity does not appear to represent a significant barrier tosuccessful HCT for AML.

The impact of obesity on transplant outcomes remains controversial. The HCT-specificcomorbidity index developed by Sorror et al included obesity (BMI >35kg/m2) as one of thecomponents to predict non-relapse mortality at 2 years(19). This study included 708 patientsin the training set who underwent allogeneic HCT for several indications; of these, 2% wereobese. The data in this analysis predate the collection of HCT-CI-specific information initiatedby CIBMTR in 2007 so no direct comparison is possible. However, transplant-related mortalityin our study was not significantly higher in obese AML patients compared to normal weightpatients, regardless of the donor type.

In the previous lymphoma study, we observed poorer outcomes in one of the underweightgroups. Interestingly, poorer survival outcomes were observed in underweight patients in theRD allo HCT group but not the URD alloHCT group. Because of the small numbers of patientsin the RD alloHCT group, there is some imbalance compared to the other weight groups withrespect to disease status at time of transplantation with disproportionately more PIF/relapseand CR2 patients, though it is not clear how much this finding accounts for the difference inleukemia-free and overall survival. Such an imbalance of disease status was not seen in theunderweight URD alloHCT group. It is noteworthy that the underweight RD alloHCT grouphad a similar KPS (P = 0.353) and cytogenetic risk (P = 0.327) compared to the other weightgroups; these important factors do not appear to account for the difference in survival. It mayalso be that the higher risk of the URD alloHCT procedure masks important but less obviousrisks associated with being underweight whereas in the related donor HCT setting, such risksbecome manifest. Small numbers of patients and lack of available data pertinent to nutritionalstatus such as serum albumin or TPN use limit the ability to better characterize this observationin underweight patients. Moreover, the analysis does not account for unknown biologicalfactors not included in the model that may be influencing outcomes in the underweight RDallo HCT group.

An important limitation of this study is that any conditioning regimen dose adjustments foroverweight and obesity used by the various transplant centers could not be assessed from theCIBMTR data. Since chemotherapy dosing in the conditioning regimen may be based on actualweight or adjusted ideal body weight, clinical outcomes may have been confounded by whetherdose adjustments were made for patients with high BMI. There is currently no acceptedstandard conditioning regimen dose adjustment schema based on weight and variousmethodologies are used, as was ascertained by Grigg and colleagues(20). A small study ofAML patients undergoing autoHCT without dose adjustment has previously suggested thatsome adjustment may be beneficial, as the lack of conditioning regimen dose adjustment inthat study resulted in unacceptable treatment-related mortality(21).

Similar to our previous study in lymphoma, the current study demonstrates that obesity doesnot appear to represent a significant barrier to successful HCT in AML. This conclusion mustbe tempered, however, with the acknowledgment that the patients who received myeloablativeHCT were likely selected by their transplant centers, and were deemed to be “fit” to withstandthe rigors of HCT. The limitations of pre-transplant co-morbidity data within the CIBMTRdatabase preclude an assessment of this issue. Thus, the caveat is that it appears that overweightand obese patients have similar outcomes to normal weight patients when they otherwise appearto be eligible HCT candidates. Obesity alone, however, should not preclude HCT whenappropriate for the treatment of AML.



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AcknowledgmentsSUPPORT

The CIBMTR is supported by Public Health Service Grant/Cooperative Agreement U24-CA76518 from the NationalCancer Institute (NCI), the National Heart, Lung and Blood Institute (NHLBI) and the National Institute of Allergyand Infectious Diseases (NIAID); a Grant/Cooperative Agreement 5U01HL069294 from NHLBI and NCI; a contractHHSH234200637015C with Health Resources and Services Administration (HRSA/DHHS); two GrantsN00014-06-1-0704 and N00014-08-1-0058 from the Office of Naval Research; and grants from AABB; Aetna;American Society for Blood and Marrow Transplantation; Amgen, Inc.; Anonymous donation to the Medical Collegeof Wisconsin; Astellas Pharma US, Inc.; Baxter International, Inc.; Bayer HealthCare Pharmaceuticals; Be the MatchFoundation; Biogen IDEC; BioMarin Pharmaceutical, Inc.; Biovitrum AB; BloodCenter of Wisconsin; Blue Crossand Blue Shield Association; Bone Marrow Foundation; Canadian Blood and Marrow Transplant Group;CaridianBCT; Celgene Corporation; CellGenix, GmbH; Centers for Disease Control and Prevention; Children’sLeukemia Research Association; ClinImmune Labs; CTI Clinical Trial and Consulting Services; CubistPharmaceuticals; Cylex Inc.; CytoTherm; DOR BioPharma, Inc.; Dynal Biotech, an Invitrogen Company; Eisai, Inc.;Enzon Pharmaceuticals, Inc.; European Group for Blood and Marrow Transplantation; Gamida Cell, Ltd.; GEHealthcare; Genentech, Inc.; Genzyme Corporation; Histogenetics, Inc.; HKS Medical Information Systems; Hospira,Inc.; Infectious Diseases Society of America; Kiadis Pharma; Kirin Brewery Co., Ltd.; The Leukemia & LymphomaSociety; Merck & Company; The Medical College of Wisconsin; MGI Pharma, Inc.; Michigan Community BloodCenters; Millennium Pharmaceuticals, Inc.; Miller Pharmacal Group; Milliman USA, Inc.; Miltenyi Biotec, Inc.;National Marrow Donor Program; Nature Publishing Group; New York Blood Center; Novartis Oncology; OncologyNursing Society; Osiris Therapeutics, Inc.; Otsuka America Pharmaceutical, Inc.; Pall Life Sciences; Pfizer Inc;Saladax Biomedical, Inc.; Schering Corporation; Society for Healthcare Epidemiology of America; Soligenix, Inc.;StemCyte, Inc.; StemSoft Software, Inc.; Sysmex America, Inc.; THERAKOS, Inc.; Thermogenesis Corporation;Vidacare Corporation; Vion Pharmaceuticals, Inc.; ViraCor Laboratories; ViroPharma, Inc.; and Wellpoint, Inc. Theviews expressed in this article do not reflect the official policy or position of the National Institute of Health, theDepartment of the Navy, the Department of Defense, or any other agency of the U.S. Government.

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20. Grigg A, Harun MH, Szer J. Variability in determination of body weight used for dosing busulphanand cyclophosphamide in adult patients: results of an international survey. Leuk Lymphoma1997;25:487–491. [PubMed: 9250819]

21. Meloni G, Proia A, Capria S, et al. Obesity and autologous stem cell transplantation in acute myeloidleukemia. Bone Marrow Transplant 2001;28:365–367. [PubMed: 11571508]



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Figure 1.a. Adjusted probability of overall survival among BMI groups for patients (≥ 18 years) afteran RD alloHCT for AML between 1995 and 2004.1b. Adjusted probability of disease free survival among BMI groups for patients (≥ 18 years)after an RD alloHCT for AML between 1995 and 2004



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Figure 2.a. Adjusted probability of overall survival among BMI groups for patients (≥ 18 years) afteran URD alloHCT for AML between 1995 and 2004.2b. Adjusted probability of disease free survival among BMI groups for patients (≥ 18 years)after an URD alloHCT for AML between 1995 and 2004.



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Figure 3.a. Adjusted probability of overall survival among BMI groups for patients (≥ 18 years) afteran autologous HCT for AML between 1995 and 2004.3b. Adjusted probability of disease free survival among BMI groups for patients (≥ 18 years)after an autologous HCT for AML between 1995 and 2004.



NIH


NIH


NIH


NIH


NIH


NIH



Tabl

e 1

Cha

ract

eris

tics o

f pat

ient

s with

age

≥18

yea

rs, w

ho u

nder

wen

t a m

yelo

abla

tive

bone

mar

row

or

peri

pher

al b

lood

tran

spla

ntat

ion

for

AM

L,

repo

rted

to th

e C

IBM

TR

bet

wee

n 19

95 a

nd 2

004

Cha

ract

eris

tics o

f pat

ient

sT

otal

N (%

)U

nder

wei

ght

N (%

)N

orm

alN

(%)

Ove

rwei

ght

N (%

)O

bese

/Mor

bidl

yO

bese

(N %

)P-

valu

ec

Aut

olog

ous

Num

ber o

f pat

ient

s37

3-

169

119

85

Age

, med

ian

(ran

ge),

year

s46

(18-

71)

-42

(18-

71)

50 (1

9-71

)49

(18-

70)

0.00

1

Mal

e se

x18

3 (4

9)-

74 (4

3)73

(61)

36 (4

2)0.

005

Kar

nofs

ky sc

ore≥

90

285

(76)

-12

8 (7

6)92

(77)

65 (7

7)0.

989

Dis

ease

stat

us a

t tra

nspl

ant

-0.

069

PI

F/1s

t Rel

apse

27 (

7)-

14 (8

)9

(8)

4 (5

)

C

R1

247

(68)

-12

2 (7

4)68

(59)

57 (6

7)

C

R2

92 (2

5)-

30 (1

8)38

(33)

24 (2

8)

Cyt

ogen

etic

s-

0.04

9

Fa

vora

ble

risk

66 (1

8)-

33 (2

0)16

(13)

17 (2

0)

In

term

edia

te ri

sk20

4 (5

4)-

83 (4

9)75

(63)

46 (5

5)

H

igh

risk

30 (

8)-

15 (9

)6

(5)

9 (1

1)

U

nkno

wna

73 (2

0)-

38 (2

2)22

(18)

13 (1

5)

Perip

hera

l blo

od G

raft

308

(83)

-14

1 (8

3)95

(80)

72 (8

5)

Tota

l bod

y irr

adia

tion

98 (9

7)-

47 (9

4)31

(100

)20

(100

)0.

206

Lung

shie

ldin

g fo

r TB

I24

( 6)

-9

(5)

8 (7

)7

(8)

0.66

3

Yea

r of T

rans

plan

t-

0.04

5

19

95-1

999

271

(73)

-13

0 (7

7)88

(74)

53 (6

2)

20

00-2

004

102

(27)

-39

(23)

31 (2

6)32

(38)

Med

ian

follo

w-u

p, (r

ange

), m

onth

s85

(3-1

48)

-87

(3-1

48)

80 (8

-139

)72

(12-

137)

HL

A-m

atch

Sib

ling

Don

or A

lloge

neic

Num

ber o

f pat

ient

s20

4132

1178

552

279

Age

, med

ian

(ran

ge),

year

s39

(19-

67)

36 (1

9-54

)37

(18-

67)

43 (1

8-67

)43

(18-

64)

<0.0

01

Mal

e se

x10

65 (5

2)13

(41)

603

(51)

323

(59)

126

(45)

0.00

1

Kar

nofs

ky sc

ore≥

90

1398

(69)

19 (5

9)81

1 (6

9)38

9 (7

0)17

9 (6

4)0.

353

Dis

ease

stat

us a

t tra

nspl

ant

<0.0

01


NIH


NIH


NIH



Cha

ract

eris

tics o

f pat

ient

sT

otal

N (%

)U

nder

wei

ght

N (%

)N

orm

alN

(%)

Ove

rwei

ght

N (%

)O

bese

/Mor

bidl

yO

bese

(N %

)P-

valu

ec

PI

F/1s

t Rel

apse

572

(28)

12 (3

8)32

2 (2

7)74

4 (2

6)94

(34)

C

R1

1172

(57)

11 (3

4)69

3 (5

9)33

1 (6

0)13

7 (4

9)

C

R2

297

(15)

9 (2

8)16

3 (1

4)77

(14)

48 (1

7)

AM

L C

ytog

enet

ics

0.32

7

Fa

vora

ble

risk

223

(11)

3 (9

)13

2 (1

1)56

(10)

32 (1

1)

In

term

edia

te ri

sk10

78 (5

3)15

(47)

614

(52)

290

(53)

159

(57)

H

igh

risk

275

(13)

8 (2

5)15

8 (1

3)79

(14)

30 (1

1)

U

nkno

wna

465

(23)

6 (1

9)27

4 (2

3)12

7 (2

3)58

(21)

Yea

r of T

rans

plan

t0.

124

19

95-1

999

1300

(64)

17 (5

3)76

9 (6

5)35

0 (6

3)16

4 (5

9)

20

00-2

004

741

(36)

15 (4

7)40

9 (3

5)20

2 (3

7)11

5 (4

1)

B

one

mar

row

gra

ft10

04 (4

9)12

(38)

605

(51)

262

(47)

125

(45)

Tota

l bod

y irr

adia

tion

873

(98)

12 (1

00)

522

(98)

231

(98)

108

(97)

0.85

1

Lung

shie

ldin

g fo

r TB

I50

6 (2

5)9

(28)

328

(28)

115

(21)

54 (1

9)0.

001

GV

HD

Pro

phyl

axis

0.08

4

T-

cell

depl

etio

n10

5 (5

)--

56 (

5)31

( 6)

18 (

6)

C

NI +

MTX

± o

ther

1555

(76)

24 (7

5)90

4 (7

7)42

7 (7

7)20

0 (7

2)

O

ther

381

(19)

8 (2

5)21

8 (1

8)94

(17)

61 (2

2)

Med

ian

follo

w-u

p (r

ange

), m

onth

s74

(2-1

52)

83 (2

4-14

2)74

(2-1

52)

81 (3

-149

)73

(3-1

52)

Unr

elat

ed D

onor

Allo

gene

ic

Num

ber o

f pat

ient

s18

0133

864

529

375

Age

, med

ian

(ran

ge),

year

s40

(18-

70)

26 (1

8-52

)37

(18-

65)

42 (1

8-70

)42

(19-

68)

<0.0

01

Mal

e se

x95

4 (5

3)14

(42)

430

(50)

320

(60)

190

(51)

<0.0

01

Kar

nofs

ky sc

ore ≥

9011

02 (6

1)14

(42)

520

(60)

339

(64)

229

(61)

0.00

8

Dis

ease

stat

us a

t tra

nspl

ant

<0.0

01

PI

F/1s

t Rel

apse

729

(41)

14 (4

2)36

8 (4

3)42

1 (4

0)13

3 (3

6)

C

R1

549

(30)

14 (4

2)26

8 (3

1)17

2 (3

3)95

(25)

C

R2

523

(29)

5 (1

5)22

8 (2

6)14

3 (2

7)14

7 (3

9)

Cyt

ogen

etic

s at d

iagn

osis

0.02

0

Fa

vora

ble

risk

191

(11)

3 (9

)88

(10)

40 (8

)60

(16)

In

term

edia

te ri

sk89

7 (5

0)17

(51)

438

(51)

275

(52)

167

(47)


NIH


NIH


NIH



Cha

ract

eris

tics o

f pat

ient

sT

otal

N (%

)U

nder

wei

ght

N (%

)N

orm

alN

(%)

Ove

rwei

ght

N (%

)O

bese

/Mor

bidl

yO

bese

(N %

)P-

valu

ec

U

nfav

orab

le ri

sk37

8 (2

1)9

(27)

188

(22)

111

(21)

70 (1

9)

U

nkno

wna

335

(19)

4 (1

2)15

0 (1

7)10

3 (1

9)78

(21)

Yea

r of T

rans

plan

t0.

074

19

95-1

999

747

(41)

16 (4

8)38

3 (4

4)20

5 (3

9)14

3 (3

8)

20

00-2

004

1054

(59)

17 (5

2)48

1 (5

6)32

4 (6

1)23

2 (6

2)

Bon

e m

arro

w G

raft

1295

(72)

25(7

6)62

9 (7

3)38

3 (7

2)25

8 (6

9)

TBI C

ondi

tioni

ng15

0 ( 8

)7

(21)

83 (1

0)45

( 9)

15 (

4)0.

040

Lung

shie

ldin

g fo

r TB

I15

0 ( 8

)7

(21)

83 (1

0)45

( 9)

15 (

4)<0

.001

GV

HD

Pro

phyl

axis

0.24

7

T-

cell

depl

etio

n22

7 (1

3)3

( 9)

101

(12)

62 (1

2)61

(16)

C

NI +

MTX

± o

ther

1359

(75)

30 (9

1)66

4 (7

7)40

0 (7

6)26

5 (7

1)

O

ther

215

(12)

-99

(11)

67 (1

2)49

(13)

HLA

Mat

ch st

atus

b<0

.001

W

ell m

atch

ed69

9 (3

9)6

(18)

314

(36)

202

(38)

177

(47)

Pa

rtial

ly m

atch

ed64

3 (3

6)14

(42)

315

(36)

193

(36)

121

(32)

M

ism

atch

ed29

7 (1

6)5

(15)

143

(17)

86 (1

6)63

(17)

M

issi

ng H

LA d

ata

162

( 9)

8 (2

4)92

(11)

48 (

9)14

( 4)

Med

ian

follo

w-u

p, (r

ange

), m

onth

s58

(3-1

49)

57 (3

1-11

9)60

(4-1

49)

54 (4

-146

)51

(3-1

36)

Abb

revi

atio

ns: H

LA=

hum

an le

ukoc

yte

antig

en; G

VH

D=g

raft

vers

us h

ost d

isea

se; C

NI =

cal

cine

urin

inhi

bito

rs, M

TX =

met

hotre

xate

, PIF

=prim

ary

indu

ctio

n fa

ilure

; CR

1=fir

st c

ompl

ete

rem

issi

on; C

R2=

seco

ndco

mpl

ete

rem

issi

on.

a Unk

now

n cy

toge

netic

s inc

lude

s pat

ient

s not

test

ed fo

r cyt

ogen

etic

s or,

have

insu

ffic

ient

cyt

ogen

etic

info

rmat

ion

to c

ateg

oriz

e or

hav

e no

n ev

alua

ble

met

apha

ses.

b HLA

Mat

ch st

atus

: Wel

l mat

ched

was

def

ined

as n

o kn

own

disp

arity

at H

LA A

,B,C

,DR

B1,

par

tially

mat

ched

as o

ne lo

cus k

now

n or

like

ly d

ispa

rity

with

thei

r don

ors a

nd m

ism

atch

ed a

s ≥2

locu

s dis

parit

y.

c Chi

-squ

are

p-va

lue

was

cal

cula

ted

for c

ateg

oric

al v

alue

s


NIH


NIH


NIH



Tabl

e 2

Uni

vari

ate p

roba

bilit

ies o

f pat

ient

s ≥ 1

8 ye

ars o

f age

who

rece

ived

a m

yelo

abla

tive b

one m

arro

w o

r per

iphe

ral b

lood

tran

spla

ntat

ion

for A

ML

,fr

om a

rel

ated

don

or, r

epor

ted

to th

e C

IBM

TR

bet

wee

n 19

95 a

nd 2

004

Out

com

e ev

ent

Tot

al N

(eva

l)U

nder

wei

ght

Nor

mal

Ove

rwei

ght

Obe

se/m

orbi

dly

obes

eP-

valu

ea

Aut

olog

ous

Tran

spla

nt-r

elat

ed m

orta

lityb

364

@

1 y

ear

-5

(2-9

)%4

(1-9

) %5

(1-1

1) %

0.97

3

@

3 y

ears

-6

(3-1

0) %

6 (3

-11)

%6

(2-1

3) %

0.99

8

Rel

apse

c36

4

@

1 y

ear

-36

(29-

44) %

45 (3

6-54

) %38

(28-

49)%

0.34

1

@

3 y

ears

-46

(38-

54) %

53 (4

4-62

) %47

(36-

58)%

0.50

6

Neu

troph

il R

ecov

eryc

365

@

60

days

-96

(92-

99) %

98 (9

5-10

0)%

95 (9

0-99

) %0.

417

Plat

elet

eng

raftm

entc

357

@

100

day

s-

78 (7

2-84

) %83

(75-

89) %

86 (7

7-92

) %0.

345

Rel

ated

Don

or A

lloge

neic

Tran

spla

nt-r

elat

ed m

orta

lityb

2008

@

1 y

ear

29 (1

5-46

) %17

(15

-19)

%21

(18-

25) %

25 (1

6-31

)%0.

007

@

3 y

ears

29 (1

5-46

) %21

(18-

23) %

25 (2

2-29

) %30

(24-

35) %

0.01

0

Rel

apse

c20

08

@

1 y

ear

39 (2

3-56

) %24

(21-

26) %

22 (1

8-25

) %26

(21-

31) %

0.21

4

@

3 y

ears

42 (2

5-59

) %30

(27-

32) %

27 (2

3-31

) %31

(26-

37) %

0.28

8

Neu

troph

il en

graf

tmen

tc20

26

@

60

days

94 (8

3-99

) %96

(95-

97) %

95 (9

4-97

) %96

(93-

98) %

0.91

6

Plat

elet

eng

raftm

entc

1962

@

100

day

s72

(55-

86) %

86 (8

4-88

) %82

(79-

86) %

79 (7

4-84

) %0.

011

Chr

onic

GV

HD

b

@

1 y

ear

19 (7

-34)

%36

(34-

39) %

36 (3

2-40

) %32

(27-

38) %

0.05

3

Acu

te G

VH

Db

G

rade

s 2-4

@10

0 da

ys19

5316

(6-3

1) %

29 (2

7-32

) %34

(30-

38) %

36 (3

0-42

) %0.

007

Unr

elat

ed D

onor

Allo

gene

ic


NIH


NIH


NIH



Out

com

e ev

ent

Tot

al N

(eva

l)U

nder

wei

ght

Nor

mal

Ove

rwei

ght

Obe

se/m

orbi

dly

obes

eP-

valu

ea

Tran

spla

nt-r

elat

ed m

orta

lityb

1779

@

1 y

ear

22 (1

0-38

) %32

(28-

35) %

35 (3

1-39

) %43

(38-

48) %

0.00

1

@

3 y

ears

28 (1

4-45

) %36

(32-

39) %

40 (3

5-44

) %46

(41-

51) %

0.00

3

Rel

apse

b17

79

@

1 y

ear

31 (1

7-48

) %31

(28-

34) %

26 (2

3-30

) %22

(18-

27) %

0.01

0

@

3 y

ears

44 (2

7-61

) %36

(33-

39) %

31 (2

7-35

) %25

(21-

29) %

<0.0

01

Neu

troph

il en

graf

tmen

tb17

97

@

60

days

97 (8

5-10

0)%

91 (8

9-93

) %91

(88-

93) %

91 (8

8-94

) %0.

520

Plat

elet

eng

raftm

entb

1768

@

100

day

s67

(50-

82) %

69 (6

6-72

) %69

(65-

73) %

65 (6

1-70

) %0.

668

Chr

onic

GV

HD

b17

87

@

1 y

ear

38 (2

2-55

) %32

(29-

36) %

36 (3

2-41

) %34

(29-

38) %

0.50

2

Acu

te G

VH

Db

1773

G

rade

s 2-4

@10

0 da

ys48

(31-

66) %

44 (4

1-47

) %46

(42-

50) %

50 (4

5-55

) %0.

228

Abb

revi

atio

ns: G

VH

D=

graf

t vs.

host

dis

ease

a Poin

t-wis

e p-

valu

e un

less

oth

erw

ise

note

d.

b Prob

abili

ties o

f rel

apse

, tre

atm

ent-r

elat

ed m

orta

lity,

eng

raftm

ent a

nd G

VH

D w

ere

calc

ulat

ed u

sing

the

cum

ulat

ive

inci

denc

e.


NIH


NIH


NIH



Tabl

e 3

Mul

tivar

iabl

e an

alys

is o

f AM

L p

atie

nts ≥

18 y

ears

of a

ge w

ho r

ecei

ved

a bo

ne m

arro

w o

r pe

riph

eral

blo

od tr

ansp

lant

bet

wee

n 19

95 a

nd 2

004,

repo

rted

to th

e C

IBM

TR

HC

T T

ype

Nor

mal

Und

erw

eigh

tO

verw

eigh

tO

bese

Ove

rall

P-va

lue

Aut

olog

ous

n=16

4n=

5n=

112

n=81

Dea

th--

0.98

(0.7

0-1.

38)

0.89

(0.6

1-1.

29)

(p=0

.925

)(p

=0.5

32)

Pover

al=0

. 809

Trea

tmen

t fai

lure

--0.

98 (0

.70-

1.38

)0.

12 (0

.78-

1.59

)

(p=0

.919

)(p

=0.5

42)

Pover

all =

0.76

8

Rel

apse

--1.

11 (0

.76-

1.62

)1.

19 (0

.81-

1.75

)

(p=0

.574

)(p

=0.3

63)

Pover

all =

0.64

9

TRM

--0.

79 (0

.33-

1.91

)0.

97 (0

.37-

2.52

)

(p=0

.606

)(p

=0.9

53)

Pover

all =

0.86

1

Rel

ated

Allo

gene

icn=

1176

n=32

n=55

3n=

275

Dea

th1.

92 (1

.28-

2.89

)1.

05 (0

.91-

1.21

)1.

16 (0

.97-

1.38

)

(p=0

.002

)(p

=0.5

32)

(p=0

.109

)Pov

eral

l =0.

008

Trea

tmen

t fai

lure

2.07

(1.3

6-3.

13)

0.97

(0.8

4-1.

12)

1.09

(0.9

1-1.

31)

(p=

<0.0

01)

(p=

0.72

0)(p

=0.3

30)

Pover

all =

0.00

5

Rel

apse

2.06

(1.2

0-3.

54)

0.87

(0.7

1-1.

05)

0.96

(0.7

5-1.

23)

(p=0

.009

)(p

=0.1

46)

(p=0

.757

)Pov

eral

l =0.

020

TRM

2.23

(1.1

7-4.

25)

1.12

(0.9

0-1.

38)

1.27

(0.9

7-1.

66)

(p=0

.014

)(p

=0.3

04)

(p=0

.081

)Pov

eral

l =0.

040

Unr

elat

ed A

lloge

neic

n=84

6n=

31n=

523

n=36

8

Dea

th0.

86 (0

.56-

1.33

)0.

96 (0

.84-

1.09

)1.

04 (0

.89-

1.21

)

(p=0

.496

)(p

=0.5

02)

(p=0

.621

)Pov

eral

l =0.

683

Trea

tmen

t fai

lure

0.91

(0.6

0-1.

38)

0.93

(0.8

2-1.

06)

0.99

(0.8

6-1.

15)

(p=0

.652

)(p

=0.2

84)

(p=0

.931

)Pov

eral

l = 0

.716

Rel

apse

1.04

(0.6

0-1.

78)

0.82

(0.6

8-0.

99)

0.76

(0.6

0-0.

96)

(p=0

.893

)(p

=0.0

44)

(p=0

.022

)Pov

eral

l = 0

.059

TRM

0.85

(0.4

4-1.

66)

1.03

(0.8

6-1.

24)

1.16

(0.9

6-1.

41)


NIH


NIH


NIH



HC

T T

ype

Nor

mal

Und

erw

eigh

tO

verw

eigh

tO

bese

Ove

rall

P-va

lue

(p=0

.635

)(p

=0.7

12)

(p=0

.129

)Pov

eral

l =0.

439

Abb

revi

atio

ns: -

- = n

ot d

one

due

to in

suff

icie

nt n

umbe

r of p

ts; t

reat

men

t fai

lure

= d

eath

or r

ecur

renc

e of

dis

ease

; TR

M =

trea

tmen

t rel

ated

mor

talit

y


Obesity Does Not Preclude Safe and Effective Myeloablative Hematopoietic Cell Transplantation (HCT) for Acute Myelogenous Leukemia (AML) in Adults

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