Dapsone-Associated Anemia in Heart Transplant Recipients with Normal Glucose-6-Phosphate Dehydrogenase Activity.

Dapsone is considered an alternative for pneumocystis jirovecii pneumonia (PJP) prophylaxis in sulfa-allergic or -intolerant transplant patients with normal glucose-6-phosphate dehydrogenase (G6PD) activity. Despite normal G6PD activity, anemia can still occur while on dapsone therapy. We retrospectively reviewed heart transplant patients transplanted at our center between January 2016 and June 2018 and identified those taking dapsone prophylaxis. There were 252 heart transplant recipients at our center between January 2016 and June 2018. 36 patients received dapsone prophylaxis. All had normal G6PD activity assessed prior to dapsone initiation. 8 (22%) patients developed significant anemia attributed to dapsone: 2 were hospitalized for anemia, 1 of whom required blood transfusion. These patients had a median reduction in hemoglobin of 2.1 g/dL from baseline prior to dapsone initiation. Overt evidence of hemolysis was present in six patients. Once dapsone was discontinued, Hgb increased by at least 2 g/dL in a median of 30 days. Anemia from dapsone may occur in a significant proportion of patients despite normal G6PD activity and resulting in significant morbidity. Careful monitoring of transplant recipients on dapsone prophylaxis is warranted, as well as consideration of alternative agents.

Evaluation of Low- Versus High-dose Valganciclovir for Prevention of Cytomegalovirus Disease in High-risk Renal Transplant Recipients.

BACKGROUND: Despite proven efficacy of prolonged cytomegalovirus (CMV) prophylaxis using valganciclovir 900 mg/day, some centers use 450 mg/day due to reported success and cost savings. This multicenter, retrospective study compared the efficacy and safety of 6 months of low-dose versus high-dose valganciclovir prophylaxis in high-risk, donor-positive/recipient-negative, renal transplant recipients (RTR). METHODS: Two hundred thirty-seven high-risk RTR (low-dose group = valganciclovir 450 mg/day [n = 130]; high-dose group = valganciclovir 900 mg/day [n = s7]) were evaluated for 1-year CMV disease prevalence. Breakthrough CMV, resistant CMV, biopsy-proven acute rejection (BPAR), graft loss, opportunistic infections (OI), new-onset diabetes after transplantation (NODAT), premature valganciclovir discontinuation, renal function and myelosuppression were also assessed. RESULTS: Patient demographics and transplant characteristics were comparable. Induction and maintenance immunosuppression were similar, except for more early steroid withdrawal in the high-dose group. Similar proportions of patients developed CMV disease (14.6% vs 24.3%; P = 0.068); however, controlling CMV risk factor differences through multivariate logistic regression revealed significantly lower CMV disease in the low-dose group (P = 0.02; odds ratio, 0.432, 95% confidence interval, 0.211-0.887). Breakthrough and resistant CMV occurred at similar frequencies. There was no difference in renal function or rates of biopsy-proven acute rejection, graft loss, opportunistic infections, or new-onset diabetes after transplantation. The high-dose group had significantly lower mean white blood cell counts at months 5 and 6; however, premature valganciclovir discontinuation rates were similar. CONCLUSIONS: Low-dose and high-dose valganciclovir regimens provide similar efficacy in preventing CMV disease in high-risk RTR, with a reduced incidence of leukopenia associated with the low-dose regimen and no difference in resistant CMV. Low-dose valganciclovir may provide a significant cost avoidance benefit.

Plerixafor as first- and second-line strategies for autologous stem cell mobilization in patients with non-Hodgkin's lymphoma or multiple myeloma.

STUDY OBJECTIVE: To describe the institutional experience of plerixafor plus filgrastim as the initial peripheral blood stem cell (PBSC) mobilization (first-line strategy) and as rescue therapy after failure with filgrastim plus cyclophosphamide (second-line strategy). DESIGN: Retrospective medical record review. SETTING: Academic medical center. PATIENTS: Thirty-three patients (median age 62 yrs) who received plerixafor between January 2008 and December 2009. MEASUREMENTS AND MAIN RESULTS: We collected data on total CD34(+) cell yield and number of apheresis sessions in both first-line and second-line plerixafor recipients. Mobilization with plerixafor plus filgrastim resulted in a median yield of 8.95 × 10(6) and 2.45 × 10(6) CD34(+) cells/kg in patients with multiple myeloma or non-Hodgkin's lymphoma, respectively. As rescue mobilization, plerixafor plus filgrastim successfully mobilized CD34(+) cells in 16 (84%) of 19 patients. When comparing first-line plerixafor plus filgrastim therapy with second-line therapy, we found an increase in CD34(+) yield and 1 less apheresis day in patients with multiple myeloma, but no difference in patients with non-Hodgkin's lymphoma. CONCLUSION: A regimen of plerixafor plus filgrastim successfully mobilized CD34(+) cells in a median of 1 apheresis day for patients with multiple myeloma and 2 apheresis days for patients with non-Hodgkin's lymphoma, including patients who failed initial filgrastim plus cyclophosphamide mobilization. Plerixafor plus filgrastim could be a viable first-line option in patients with multiple myeloma, as it improved CD34(+) cell yield and decreased number of apheresis days compared with second-line plerixafor plus filgrastim therapy, whereas it was comparable to second-line therapy in patients with non-Hodgkin's lymphoma.