Models using acute GVHD (aGVHD) to predict post allo-HCT survival rely on criteria with considerable inter-observer subjectivity. We study the impact of clinical, laboratory and pharmacologic parameters, during the immediate post-transplant phase [from hematologic engraftment till day 90 (±7)] on NRS and OS. In this analysis, 326 consecutive pts underwent allo-HCT between 09/2000 until 03/2007; 26 pts who died within 90 days from stem cell infusion and 3 recipients of syngeneic allo-HCT were excluded. A total of 297 (M/F=170/127) pts, median age 46 (range: 17–69) yrs received an allo-HCT [MRD=154 (52%), MUD=109 (37%), MMRD=3 (1%), MMUD=31 (10%)] using PBSC=261 (88%) or BM=36 (12%) following myeloablative=99 (33%), RIC=174 (59%), or NMT=24 (8%) for various hematologic malignancies stratified by CIBMTR risk [low=87 (30%); int=85 (29%); high=125 (42%)] using various GVHD prophylaxis regimens [MTX-based=244(82%); MMF-based=53 (18%)]. Pre-transplant variables [significant (p<0.05) or not-significant (NS) (p≥0.05) in multivariable Cox proportional hazards regression analysis] included: age (≥55 vs. < 55 yrs) [OS: p=0.035, HR=1.6 (95% CI: 1.0–2.4); NRS: p=0.03, HR=2.0 (95% CI: 1.1–3.6)], donor-gender [OS: NS; NRS: NS], cell source (BM vs. PB) [OS: NS; NRS: NS], baseline Karnofsky score (KPS) (≤80 vs. >80) [OS: NS; NRS: NS], CIBMTR risk (low vs. int. vs. high) [OS: NS; NRS: NS], regimen (myeloablative vs. RIC/NMT) [OS: NS; NRS: NS], donor/recipient matching-status (MRD, MUD, mismatched (ref)) [OS: p=0.03, MRD vs. ref: HR=2.7 (95% CI: 1.2–6.1), MUD vs. ref: HR=2.7 (95% CI: 1.2–6.1); NRS: NS], CD34+ dose (< 3×106/kg, 3–7.9 ×106/kg, ≥8×106/kg) [OS: NS; NRS: NS], GVHD prophylaxis (MTX-based vs. MMF-based) [OS: NS; NRS: NS], recipient/donor CMV status [OS: NS; NRS: NS]. Multivariable regression analysis of post-transplant variables (table 1) at day 90 show that a KPS<80 and hypoalbuminemia <3.0 g/dl are independent predictors of worse NRS and OS. A worsening serum creatinine (≥30%) and additional antimicrobials apart from standard prophylaxis are independent predictors of worse OS; whereas pneumonia (>0 episode by day 90) and cumulative dose of prednisone exceeding >2,650 mg are independent predictors of worse NRS. A KPS <80 and hypoalbuminemia (<3.0 g/dl), at day 90, are stronger predictors of survival than aGVHD, and should be considered when prognosticating outcome after allo-HCT. Multivariable Regression Analysis for OS and NRS† Post-transplant variables at day 90 (±7) post-allo HCT§

OSNRS
†Table entry: 1st line=p-value (p) for the covariate effect, 2nd line=Hazard ratio (HR) (95% CI). §The effects of post-transplant variables were adjusted for baseline variables such as age, KPS and patient/donor CMV statuses in this regression, whenever appropriate/necessary. Statistical significance defined as <0.05; NS: not significant (p≥0.05). TPN: total parenteral nutrition; 
*from hematopoietic engraftment until day 90 (±7). 
**from initiation of conditioning chemotherapy (baseline) until day 90 (±7). 
^ additional anti-GVHD therapy(ies) apart from standard GVHD prophylaxis and glucocorticoids until day 90 (±7). 
^^ additional antimicrobials apart from acyclovir, fluconazole or voriconazole (whenever used for primary prohylaxis) and trimethoprin-sulfamethoxazole (or equivalents). 
¥ development of infiltrates requiring additional/alternative antimicrobials. 
Hospital stay ( 5 vs. >5 days)* NS NS 
Days of TPN (>0 vs. 0)* NS NS 
PRBC transfusion (>0 vs. 0)* NS NS 
Platelets transfusion (>0 vs. 0)* NS NS 
Pneumonia episodes (>0 vs. 0)*¥ NS p=0.0008 2.8 (1.5, 5.1) 
Episodes of CMV reactivation (>0 vs. 0)* NS NS 
Cumulative dose of steroids (<2,650mg vs. 2,650mg)* NS p=0.001 0.4 (0.2, 0.7) 
Total days of steroids (<60 vs.≥60)* NS NS 
Dose of steroid at day 90 (±7) (<20 vs. ≥20mg/day) NS NS 
% weight loss (≤10% vs. >10%)** NS NS 
Acute GVHD (max grade) 0–I vs. II vs. III–IV NS NS 
KPS at day 90 (±7) (<80 vs.≥ 80) p<0.0001 4.7 (3.0, 7.4) p<0.0001 3.9 (2.0, 7.5) 
Total bilirubin at day 90 (±7) (<1.1 vs. ≥1.1mg/dl) NS NS 
% Creatinine change (≥30 vs. <30)* p=0.0002 2.2 (1.5, 3.3) NS 
Albumin at day 90 (±7) < 3.0 g/dl vs. > 3.5 g/dl 3.0–3.5 g/dl vs. > 3.5 g/dl p=0.006 2.5 (1.4, 4.5) 1.5 (0.9, 2.3) p=0.01 3.2 (1.4, 7.1) 1.2 (0.6, 2.3) 
Additional immunosuppressive therapy (ies) (>0 vs. 0)^ NS NS 
Additional anti-microbial(s) (>0 vs. 0)^^ p=0.002 2.8 (1.5, 5.3) NS 
OSNRS
†Table entry: 1st line=p-value (p) for the covariate effect, 2nd line=Hazard ratio (HR) (95% CI). §The effects of post-transplant variables were adjusted for baseline variables such as age, KPS and patient/donor CMV statuses in this regression, whenever appropriate/necessary. Statistical significance defined as <0.05; NS: not significant (p≥0.05). TPN: total parenteral nutrition; 
*from hematopoietic engraftment until day 90 (±7). 
**from initiation of conditioning chemotherapy (baseline) until day 90 (±7). 
^ additional anti-GVHD therapy(ies) apart from standard GVHD prophylaxis and glucocorticoids until day 90 (±7). 
^^ additional antimicrobials apart from acyclovir, fluconazole or voriconazole (whenever used for primary prohylaxis) and trimethoprin-sulfamethoxazole (or equivalents). 
¥ development of infiltrates requiring additional/alternative antimicrobials. 
Hospital stay ( 5 vs. >5 days)* NS NS 
Days of TPN (>0 vs. 0)* NS NS 
PRBC transfusion (>0 vs. 0)* NS NS 
Platelets transfusion (>0 vs. 0)* NS NS 
Pneumonia episodes (>0 vs. 0)*¥ NS p=0.0008 2.8 (1.5, 5.1) 
Episodes of CMV reactivation (>0 vs. 0)* NS NS 
Cumulative dose of steroids (<2,650mg vs. 2,650mg)* NS p=0.001 0.4 (0.2, 0.7) 
Total days of steroids (<60 vs.≥60)* NS NS 
Dose of steroid at day 90 (±7) (<20 vs. ≥20mg/day) NS NS 
% weight loss (≤10% vs. >10%)** NS NS 
Acute GVHD (max grade) 0–I vs. II vs. III–IV NS NS 
KPS at day 90 (±7) (<80 vs.≥ 80) p<0.0001 4.7 (3.0, 7.4) p<0.0001 3.9 (2.0, 7.5) 
Total bilirubin at day 90 (±7) (<1.1 vs. ≥1.1mg/dl) NS NS 
% Creatinine change (≥30 vs. <30)* p=0.0002 2.2 (1.5, 3.3) NS 
Albumin at day 90 (±7) < 3.0 g/dl vs. > 3.5 g/dl 3.0–3.5 g/dl vs. > 3.5 g/dl p=0.006 2.5 (1.4, 4.5) 1.5 (0.9, 2.3) p=0.01 3.2 (1.4, 7.1) 1.2 (0.6, 2.3) 
Additional immunosuppressive therapy (ies) (>0 vs. 0)^ NS NS 
Additional anti-microbial(s) (>0 vs. 0)^^ p=0.002 2.8 (1.5, 5.3) NS 
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Topics:
allogeneic hematopoietic stem cell transplant, allopurinol, hypoalbuminemia, karnofsky performance status, pharmacology, weight reduction, transplantation, graft-versus-host disease, antimicrobials, brachial plexus neuritis

Disclosures: No relevant conflicts of interest to declare.

Author notes

Corresponding author

2008, The American Society of Hematology
2008
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