Abstract



BACKGROUND: Hemorrhagic cystitis (HC) is one of common complications in patients undergoing hematopoietic stem cell transplantation (HSCT). It is of great value for improvement in the HSCT outcome to describe the clinical characteristics of HC and risk factors.
OBJECTIVE: To investigate the incidence of HC in children after HSCT, and to analyze its clinical characteristics and risk factors.
DESIGN: Case analysis
SETTING: Center of Hematopoietic Stem Cell Transplantation, Department of Pediatrics, Second Affiliated Hospital of Sun Yat-sen University.
PARTICIPANTS: Experiments were performed at the Center of Hematopoietic Stem Cell Transplantation, Department of Pediatrics of Second Affiliated Hospital of Sun Yat-sen University from October 1998 to June 2004. Eighty-eight patients receiving umbilical cord blood transplantation (UCBT) and peripheral blood stem cell transplantation (PBSCT) were enrolled; 49 were males and 39 were females. The age ranged from 2 to 18 years with an average of 8.0 years. Guardians of child patients signed informed consents. The experimental procedures were approved by Medical Ethics Committee.
METHODS: ①Conditioning regimens included combination of cyclophosphamide (CY, 120-200 mg/kg) with busulphan (BU, 14-20 mg/kg)-based chemotherapy and combination of CY with total body irradiation (TBI, 2-8 Gy) or total lymphoid irradiation (TLI, 2-8 Gy)-based radiotherapy. ②HC was defined according to the criteria proposed by references 7 and 8. The incidence, clinical characteristics, laboratory examination, treatment and outcome for HC were described. The association of various clinical factors including age, gender, human leucocyte antigen (HLA) typing, diseases for transplant, the type of stem cell, the type of transplantation, the occurrence of acute graft-versus-host disease (aGVHD) and cytomegalovirus (CMV) infection with the development of HC were examined.
MAIN OUTCOME MEASURES: ①Incidence of HC, ②HC patient characteristics and laboratory examination, ③HC treatment and outcome, and ④risk factors analysis.
RESULTS: All 88 patients were included in the final analysis. ①The incidence of HC: 16 patients (18.2%, 16/88) developed HC post-transplant with the severity graded as mild in 11 cases (68.7%) and severe in 5 cases (31.3%). ②HC patient characteristics and laboratory examination: All had hematuria and 8 cases (50.0%) had typical pollakisuria, urinary urgency, odynuria and gross hematuria; 10 cases (62.5%) had gross hematuria and 11 had proteinuria (+ to +++); Leucocytes were detected in 7 cases. ③Treatment and outcome: All patients recovered at a median of 13.5 days (range 2-53 days). ④Risk factors analysis: The incidence of HC was significantly higher in the group of ≥ 6 years old, presence of aGVHD and development of cytomegalo-virus (CMV) infection (P < 0.05-0.01).
CONCLUSION: ①HC has its own clinical characteristics following HSCT in children but with good prognosis. ②The risk factors for HC are ≥ 6 years old, presence of aGVHD and CMV infection.

INTRODUCTION

Hemorrhagic cystitis (HC) is one of common complications after hematopoietic stem cell transplantation (HSCT). Although HC is not usually life-threatening complication, it leads to severe pain and prolongs hospital stay. The most serious outcome could be renal failure and occasional bladder tamponade with urinary obstruction [1-2]. HC is caused by certain conditioning regimens such as cyclophosphamide (CY), bacterial or viral urinary tract infections [3-5]. Various protective measures, forced diuresis, bladder irrigation and the use of the anti-crosslinking agent 2-mercaptoethane-sulfonate (Mesna), have been taken to reduce the risks of HC, but some of these procedures are still controversial [1, 4, 6].
There are few reports on HC that occurs in children after HSCT. The authors therefore performed the retrospective review to analyze clinical characteristics for any risk factors predicting the development of HC in children.

SUBJECTS AND METHODS

Subjects
From October 1998 to June 2004, a total of 88 patients were treated with umbilical cord blood transplantation (UCBT) and peripheral blood stem cell transplantation (PBSCT) at the Department of Pediatrics, Second Affiliated Hospital, Sun Yat-sen University. There were 49 males and 39 females. The average age of the patients was 8.0 years (range from 2 to 18 years). Data of each patient were summarized in Table 1. Guardians of child patients signed informed consents. The experimental procedures were approved by Medical Ethics Committee.

Methods
Conditioning regimen
Considering disease and clinical status individualized conditioning regimens, which included CY(120-


200 mg/kg) combined with busulphan (BU, 14-20 mg/kg) or total body irradiation(TBI,2-8 Gy) or total lymphoid irradiation (TLI, 2-8 Gy), were applied to the patients. 50 patients also received either horse antithymocyte globulin (ATG, 90 mg/kg) or rabbit ATG (22.5 mg/kg), 35 patients undergoing additional fludarabine (150 mg/m2), 15 patients undergoing additional thiotepa (6 mg/kg) and 9 received melphalan (90 mg/m2). 5 cases received TLI. 7 cases were given a combination of CY and TBI.

Diagnosis and Prevention of HC
A diagnosis of HC was made by the presence of when the macroscopic hematuria or sustain microhematuria more than 7 days with clinical signs of cystitis. HC was classified into 4 grades according to the following criteria [7-8]: grade Ⅰ microhematuria; grade Ⅱ gross hematuria; grade Ⅲ gross hematuria with clot; grade Ⅳ hematuria with clot leading to urinary tract obstruction. Grade Ⅰ and Ⅱ were regarded as mild, while Grade Ⅲ and Ⅳ were regarded as severe. According to the onset of HC, HC appeared within 48 hours after conditioning regimen was defined, as early onset, while the onset after 48 hours was late [9]. According to the course of hematuria, HC was further classified as transient (< 7 days) or persistent (≥ 7 days) [7].
During the conditioning regimen, HC prevention was performed based on hyperhydration, 3 000-3 500 mL/m2 per day of fluid as continuous infusion. Alkalinizing [5% NaHCO3 80-100 mL/m2 per day, sustaining urine PH 7.0-8.0], forceful diuresis (i.v. furosemide 1-2 mg/kg, keeping urinary volume > 150 mL/h averagely for –5 d-0 d) and mesna were used in patients receiving CY in conditioning regimen. Urinalysis, bacterial urine culture and CMV inclusion body tests were regularly performed after HSCT. CMV isolation from urine specimens and antigenemia PP65 of CMV detection were performed.
Outcome measures
The Incidence, clinical characteristics, laboratory examination, treatment and outcome for HC were described. Age, CY dosage, time of neutrophil engraftment and platelet engraftment were compared between patients with HC and without HC. The influence of various clinical factors including age, gender, human leucocyte antigen (HLA) typing, diseases for transplant, the type of stem cell, the type of transplantation, the occurrence of aGVHD and CMV infection on the development of HC were analyzed.

Statistical analysis
Statistical analysis was performed by the second author using SPSS 11.0 software. The clinical features, laboratory test, treatment and progress of all the patients were conducted by descriptive analysis. t test was employed for measurement data, and Chi-square test for enumeration data. The risk factors for the development of HC were test by univariate analysis. A value of P < 0.05 were considered statistically significant.

RESULTS

Quantitative analysis of participants
All 88 patients were enrolled in final analysis.

Incidence of HC
HC occurred in 16 of the 88 cases (18.2%). Nine patients were boys and seven were girls. HC scored as grade Ⅰ in 4 cases (25.0%), grade Ⅱ in 7 cases (43.7%) and grade Ⅲ in 5 cases (31.3%). No grade Ⅳ was found. That is, mild HC developed in 11 cases (68.7%) and severe HC in 5 cases (31.3%). HC was classified as early onset in 6 cases (37.5%) and late onset in 10 cases (62.5%). Transient HC occurred in 7 cases (43.7%) and persistent HC occurred in 9 cases (56.3%). The median time of HC diagnosis was 15 days after transplantation, ranging from 2 to 28 days.
Of the 16 cases with HC, 10 cases developed HC before engraftment of neutrophil (absolute neutrophil count, ANC≥ 0.5×109/L) at a median of 8 days (ranged 2-13 days), and 6 cases developed HC after neutrophil engraftment at a median of 16 days (ranged 12-28 days). There were 10 cases with pollakisuria, 9 with urinary urgency and 8 with odynuria. Thus, 8 cases had simultaneous onset of pollakisuria, urgent micturition, odynuria. 6 cases of the 16 cases had microhematuria and 10 had gross hematuria. Of the latter cases, 7 developed total hematuria and 3 had terminal hematuria. Of the 5 cases with HC, 1 had membranous mucosa noticed in the urine, and 4 initially had pollakisuria, urgent micturition and odynuria, but hematuria or gross hematuria occurred 2 or 3 days later. There were 9 cases with cutaneous and mucosal bleeding associated and 7 were febrile.

Laboratory examination
Large quantity of red blood cells was seen in routine urianlysis in all 16 cases with HC. 11 cases of them had proteinuria (+ to +++). Leucocytes were detected in 7 cases. Urine cultures for bacteria, fungus and cytomegalo virus (CMV) were negative. In 1 case, biopsy of urinary bladder showed that the mucous membrane hyperemia and oedema, and also diffuse punctate hemorrhage with inflammatory cell infiltration. Serum creatinine and blood urea nitrogen were normal. Peripheral blood white cell count, hemoglobin and platelet were (7.50±2.35)×109/L，(90.8±10.50) g/L and (29.09±20.15)×109/L, respectively. Eight of the sixteen patients had active infection in peripheral blood after CMV-Ag and PP65 tests.

HC treatment and outcome
Supportive treatments were adopted including hyperhydration (3 000-3 500 mL/m2/d), urine alkalinization, forceful diuresis and adding mesna. Underlying causes were sought and managed accordingly. Eight patients with reactivated CMV infection were given ganciclovir and gamma globulin. Eleven patients with aGVHD were treated by combination of cyclosporin (CsA) and methylprednisolone (MP). Eleven cases with marked thrombocytopenia ［(9-20)×109/L］ were transfused with platelet concentrate. Three of five patients with severe HC were managed with continuous bladder irrigation with saline or aldomycin to keep a clear urine outflow. The irrigation continued for 6, 8 and 30 days respectively. All of the 16 patients recovered. The mean duration of HC was 13.5 days (range from 2-53 days).

Comparison between HC patients and non-HC patients
The patients with HC were older than those without HC (P < 0.05). There were no significant difference between the two groups in the dosage of CY, the time of neutrophil engraftment (ANC≥0.5×109/L) and platelet engraftment (PLT≥ 20×109/L, P > 0.05, Table 2).

Analysis of risk factors
We analyzed the influence of age, gender, HLA typing, diseases for transplant, the type of stem cell, the type of transplantation, the occurrence of aGVHD and CMV infection on the development of HC. The age of ≥ 6 years old (26.0% vs. 7.9%, P=0.03), presence of aGVHD (28.9% vs. 10.0%, P=0.02) and CMV infection (50.0% vs. 11.1%, P=0.001) was associated with high incidence of the HC. The other factors, however, had no correlation with HC (Table 3).

DISCUSSION

HSCT can cure hematological malignancy and hereditary non-malignant hematological disease in children. Transplant-related complications are important factors affecting transplanted outcome.
The incidence of HC in adult after HSCT was 3%-35% and severe HC accounted for 2%-20% with fatality up to 30%-40% [1-4]. There were not many reports of HC in children after HSCT, in which the incidence of HC was reported from 3.6% to 11.0% [10-11]. In this study, the incidence was 18.2% which was higher than those reported in the literature. There were several explanations for the high incidence: Firstly, the conditioning regimen in our study was mainly composed of CY and Bu. The dosage of CY ranged 120-200 mg/kg (mean 160 mg/kg) which was higher than that reported in other studies [6-7]. Hassan et al[12] showed that patients given combination of CY and BU had a marked decrease in glutathion and P450 in the body. The metabolism of the two medications was thus decreased, and accumulation of their combination leaded to high incidence of HC as a result. Secondly, CMV infection plays an important role in the development of HC especially for late HC [11, 13-14]. Out of 16 cases of CMV infection, 8 developed late HC. Despite adopting prophylaxis including hyperhydration, forceful diuresis, urine alkalinization and use of mesna, the incidence of HC was still high, better preventive prophylaxis should be studied.
 

The clinical manifestation of HC following transplantation was varied. In this study, HC was more often seen in older children. The mean age of the patients with HC was 9.5 years, which was significantly older than the non-HC patients (6.80). The typical manifestatios included pollakisuria, urgent micturition and odynuria and gross hematuria simultaneously, and was present in 50.0% patients. Mild manifestation only had microhematuria, while the patients with severe HC had blood clot or membranous mucosa noticed in the urine. Some of them had fever, cutaneous or mucosal bleeding. Clinicians should be familiar with the various manifestations and closely monitor the laboratory examination. Cystoscopy may be performed if diagnosis is not certain [15]. Mucous membrane hyperemia, oedema and diffuse punctate hemorrhage were found in one patient. The urine culture for bacteria, fungus and virus may help to establish the etiological cause. Most of the patients with late HC also had low amount of platelets. They had associated cutaneous or mucosal bleeding, which needed to be differentiated from simple hematuria due to thrombocytopenia. Patients with HC often had symptoms of irritation in addition to hematuria.
HC appeared to have no adverse impact on the hematological recovery, but with good prognosis, which concurred with other reports in the literature[11]. Moreover, there was no significantly difference of the timing of neutrophil and platelet engraftment between the groups HC and non-HC. The mean duration of HC was 12.8 days (2-53 days), and all the 16 patients cured. The outcome was better than other studies[11, 16]. Three patients with severe HC were given continuous bladder irrigation by use of saline or aldomycin. These measures alleviated odynuria significantly, and also prevented urinary obstruction due to blood clot. They were given bladder irrigation for 6-30 days. None had urinary tract infection. It was reported that administration of PGE2[1] in bladder irrigation had satisfactory effect and hyperbaric oxygen therapy (HOT) can successfully cure refractory or severe HC [10, 17].
The etiology of early HC is more likely related to the conditioning regimen. Large dosage of acrolein, metabolin of CY, was the important cause leading to damage of bladder mucous membrane. Late HC is probably associated with virus infection and GVHD. However, there is still much controversy on the risk factors for HC [4, 9-11]. This study identified that some risk factors related HC in children after HSCT. ①The incidence of HC in the group of ≥6 years was significantly higher than that of younger patients. Cesaro et al[10] reported that the incidence of HC after transplantation in the group of ≥8 years was significantly higher. The study from Kondo et al [16] also demonstrated that the incidence of HC after BMT was lower in children (< 7 years old).
Firstly, frequent micturition contributed to a lower incidence of HC. Younger children had not cultivated the habit of micturition and frequent micturition might shorten the interaction of acrolein with bladder membrane, thus reduce the incidence of early onset of HC. Secondly, the younger might have lower probability of viral infection and thus a lower incidence of late HC. ②GVHD may cause damage to many organs including urinary bladder. GVHD and intensive immunosuppressive treatment invites secondary viral infection and these results lead to bladder damage and subsequently development of late onset of HC. Therefore, aGVHD was regarded as one of the important risk factors of HC [10, 18].
In this study, high incidence of HC in the group of aGVHD supported the view. ③There were studies showing that some viruses such as BK virus, JC virus, adenovirus, CMV, and herpes virus [13, 15, 19-20] were correlated with the development of HC. The intensive conditioning regimen including the large dosage of radio/chemo-therapy suppressed the immune function. Post-transplant facilities are prone to acquiring virus infection or reactivation of latent virus. The viruses damage the bladder mucous membrane either by means of viremia or urethral retrograde infection. We only tested for CMV due to limited laboratory support. Of 88 patients, 16 were confirmed to have CMV infection, and 8 of them developed HC. The incidence of HC was significantly higher than that of non-CMV infection group. The finding suggested that CMV might play an important role in the development of HC.
There were reports that allo-HSCT was another risk factors for HC [10, 16, 21]. In our study, 1 one of the 9 patients undergoing auto-HSCT developed HC. However, it is not possible to draw any conclusion due to small sample size.
In conclusion, HC is relatively common complication in children following transplantation and has its own clinical characteristics. Urine analysis should be routinely monitored especially in children ≥6 years old, with CMV infection and aGVHD. Aggressive support measures should be instituted to reduce the incidence and severity of HC.

REFERENCES

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儿童造血干细胞移植后出血性膀胱炎：临床特征与危险因素☆

徐宏贵，方建培，黄绍良，周敦华，陈 纯，黄 科，黎 阳
中山大学附属第二医院儿科， 广东省广州市 510120
徐宏贵☆，男，1972年生，安徽省东至县人，汉族，中山大学在读博士，主治医师，主要从事小儿血液病及造血干细胞移植的实验与临床研究。
通讯作者：方建培，博士，教授，博士生导师，中山大学附属第二医院儿科，广东省广州市 510120
摘要
背景：出血性膀胱炎是造血干细胞移植后常见并发症之一，探讨其临床特征及发病的危险因素对改善造血干细胞移植效果有重要应用意义。
目的：观察小儿造血干细胞移植后出血性膀胱炎发病情况，并分析其临床特点以及发病危险因素。
设计：病例分析。
单位：中山大学附属第二医院儿科造血干细胞移植中心。
对象：选择1998-10/2004-06在中山大学附属第二医院儿科HSCT中心88例接受脐血移植与外周血造血干细胞移植患儿，男49例，女39例，年龄2~18岁，平均8.0岁。 所有患儿家属对治疗知情同意。实验经过医院伦理委员会批准许可。
方法：①患儿预处理方案主要有环磷酰胺（120~200 mg/kg）和马利兰（Bu，14~20 mg/kg）组成为主的化疗方案，以及环磷酰胺联合全淋巴照射（2-8Gy）或全身照射（2-8Gy）组成的放疗方案。②按文献[7]及[8]标准诊断及对出血性膀胱炎分类；观察患者出血性膀胱炎发生率、临床特征、实验室检查及治疗与转归；分析年龄、性别、供受者人类白细胞抗原配型、移植病种、移植类型、移植方式、急性移植物抗宿主病的发生、巨细胞病毒感染对出血性膀胱炎发生的影响。
主要观察指标：①患儿出血性膀胱炎发生率。②临床特征与实验室检查。③治疗与转归。④出血性膀胱炎发生的危险因素。
结果：纳入患儿88例均进入结果分析。①出血性膀胱炎发生率：16例（18.2%，16/88）患儿发生出血性膀胱炎，其中轻度11例（68.7%），重度5例。②临床特征与实验室检查：患儿均有血尿，其中典型尿频、尿急、尿痛及肉眼血尿8例（50.0%）；肉眼血尿10例（62.5%）；11例蛋白尿（＋~＋＋＋），7例白细胞增高。③治疗与转归：所有出血性膀胱炎患儿均痊愈，病程2~53 d。④出血性膀胱炎发生危险因素：受者移植年龄≥6岁、急性移植物抗宿主病阳性及巨细胞病毒感染出血性膀胱炎发生率分别高于年龄＜6岁、GVHD阴性及巨细胞病毒未感染患儿，差异有统计学意义（P < 0.05~0.01）。
结论：①儿童造血干细胞移植后出血性膀胱炎有其自身的临床特征，预后多良好。②受者移植年龄≥6岁、急性移植物抗宿主病阳性、巨细胞病毒感染可能为其发生的危险因素。
关键词：出血性膀胱炎；造血干细胞移植；危险因素；临床特征；儿童
中图分类号: R394.2 文献标识码: A 文章编号: 1673-8225(2008)08-01596-05
徐宏贵，方建培，黄绍良，周敦华，陈纯，黄科，黎阳.儿童造血干细胞移植后出血性膀胱炎：临床特征与危险因素[J].中国组织工程研究与临床康复，2008，12(8):1596-1600
[www.zglckf.com/zglckf/ejournal/upfiles/08-8/8k-1596(ps).pdf]
（Edited by Jong-Beom Park/Qiu Y/Wang L）