Reduced Incidence of Neurologic Complications after Allogeneic Hematopoietic Stem Cell Transplantation with Calcineurin-Free Graft-versus-Host Disease Prophylaxis

Aitana Balaguer-Roselló; Sara Gil-Perotín; Juan Montoro; Luis Bataller; Brais Lamas; Marta Villalba; Ana Facal; Manuel Guerreiro; Pedro Chorão; Ana Bataller; Pablo Granados; Inés Gómez; Pilar Solves; Alberto Louro; Javier de la Rubia; Miguel Ángel Sanz; Jaime Sanz

doi:10.1016/j.jtct.2023.07.008

Reduced Incidence of Neurologic Complications after Allogeneic Hematopoietic Stem Cell Transplantation with Calcineurin-Free Graft-versus-Host Disease Prophylaxis

Transplant Cell Ther. 2023 Oct;29(10):610.e1-610.e12. doi: 10.1016/j.jtct.2023.07.008. Epub 2023 Jul 12.

Authors

Aitana Balaguer-Roselló¹, Sara Gil-Perotín², Juan Montoro³, Luis Bataller², Brais Lamas³, Marta Villalba³, Ana Facal³, Manuel Guerreiro³, Pedro Chorão³, Ana Bataller³, Pablo Granados³, Inés Gómez⁴, Pilar Solves⁴, Alberto Louro³, Javier de la Rubia⁴, Miguel Ángel Sanz³, Jaime Sanz⁴

Affiliations

¹ Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain. Electronic address: aitabalag@gmail.com.
² Neurology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
³ Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
⁴ Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain; CIBERONC, Instituto Carlos III, Madrid, Spain.

PMID: 37451486
DOI: 10.1016/j.jtct.2023.07.008

Abstract

Calcineurin inhibitors (CNIs), including cyclosporine and tacrolimus, are frequently associated with neurologic complications after allogeneic hematopoietic stem cell transplantation (HSCT). However, there is a lack of studies comparing the incidence and characteristics of neurologic complications in patients undergoing HSCT based on CNI-free or CNI-based GVHD prophylaxis. This retrospective single-center study analyzed the neurologic complications in 2 cohorts of patients undergoing HSCT with either CNI-based GVHD prophylaxis (n = 523) or CNI-free prophylaxis with post-transplantation cyclophosphamide, sirolimus, and mycophenolate mofetil (n = 371). The latter cohort included older patients and received more reduced-intensity conditioning and transplants from matched unrelated and haploidentical donors. The 2-year cumulative incidence of neurologic complications was significantly lower in the CNI-free cohort (6.9% versus 11.9%; P = .016), and GVHD prophylaxis was the sole statistically significant variable in multivariate analysis (hazard ratio, 2.2; 95% confidence interval [CI], .25 to 3.13; P = .0017). The distribution of neurologic types was similar in the 2 cohorts, with encephalopathy the most prevalent complication, except for headaches and myopathy, which decreased equally from 15% in the CNI-based cohort to 4% in the CNI-free cohort. Neurologic complications had negative impacts on mortality and survival rates, with a significantly higher 2-year cumulative incidence of nonrelapse mortality (NRM) (44% [95% CI, 34% to 54%] versus 16% [95% CI, 13% to 18%]; P < .0001) and inferior overall survival (66% [95% CI, 62% to 69%] versus 46% [95% CI, 37% to 58%]; P < .0001) in patients with neurologic complications. This study suggests that CNI-free GVHD prophylaxis with post-transplantation cyclophosphamide, sirolimus, and mycophenolate mofetil may reduce not only the incidence of GVHD incidence, but also the rates of neurologic complications and NRM, leading to improved survival outcomes in patients undergoing HSCT.

Keywords: Allogeneic stem cell transplantation; Calcineurin inhibitors; Graft-versus-host disease; Neurologic complications; Sirolimus.