Comparison of Tc-99 measurement of glomerular filtration rate vs. calculated creatinine clearance to assess renal function pretransplant in pediatric patients undergoing hematopoietic stem cell transplantation.

We compared the results of Tc-99 evaluation of glomerular filtration rate (GFR) vs. the calculation of the creatinine clearance (CCrC) as a predictor for the development of renal insufficiency in pediatric patients following hematopoietic stem cell transplantation (HSCT). We reviewed 95 consecutive patients receiving autologous (n = 37) or allogeneic (n = 58) HSCT at Children's Memorial Hospital between January, 1995 and February, 1998. Diagnoses included leukemia (n = 43), solid tumor (n = 27), bone marrow failure syndrome (n = 12), non-malignant disease (n = 8), CNS tumors (n = 5) and immunodeficiency (n = 3). Tc-99 GFR was compared with a calculated creatinine clearance derived from the Schwartz formula (CCrC) prior to HSCT. These measures of renal function were compared with the patient's subsequent clinical course to determine if patients who developed renal insufficiency of sufficient magnitude as to require continuous veno-venous hemofiltration (CVVH) or dialysis, could have been identified. Overall comparison of the two methods of evaluation of renal function showed low correlation with values obtained by CCrC, which were consistently higher in most patients (r-value 0.01 in the regression analysis and a p = 0.08 95% CI -24.15 to 1.48). When stratified for age, correlation between the two methods was excellent only in children younger than 5 yr of age p = 0.02 95%, CI 0.032-0.49). Eleven patients required therapy with CVVH or dialysis but neither CCrC nor Tc-99 GFR prior to transplant predicted this event. Patients who received TBI were statistically more prone to develop renal insufficiency than those without TBI (p < 0.0001, 95% CI 0.25-0.008). Neither the Tc-99 GFR nor the CCrC was predictive of the development of renal insufficiency in HSCT patients as the majority of patients who required dialysis had normal Tc-99 GFR prior to transplant. The characteristics found in the patients who developed renal insufficiency and required dialysis include: the use of total body irradiation as part of the transplant-conditioning regimen (p < 0.0001) and the use of continuous infusion CSA (p = 0.04).

Prolonged survival of a patient with sickle cell trait and metastatic renal medullary carcinoma.

PURPOSE: The treatment and outcome of a patient with sickle cell trait and metastatic renal medullary carcinoma is described. PATIENT AND METHODS: A 12-year-old boy with sickle cell trait had metastatic renal medullary carcinoma. After surgical resection of the primary tumor, he received chemotherapy with methotrexate, vinblastine, doxorubicin, and cisplatin. The carcinoma progressed after a 6-month period of stable disease. At that time, he received chemotherapy including ifosfamide, etoposide, carboplatin, and topotecan. RESULTS: The patient died of progressive disease 15 months from diagnosis. The patient's tumor in this report showed no progression while he was receiving methotrexate, vinblastine, doxorubicin, and cisplatin, but eventually became refractory to these and other cytotoxic agents. CONCLUSION: Renal medullary carcinoma is a highly chemotherapy-resistant tumor. Average survival after diagnosis is 15 weeks; the longest survival reported in the literature is 12 months from diagnosis. The patient in this report survived longer than the previously described patients before dying from progressive disease.

Total body irradiation, cyclophosphamide, and etoposide with stem cell transplant as treatment for infants with acute lymphocytic leukemia.

BACKGROUND: Acute lymphoblastic leukemia (ALL) in infants has a very poor outcome with modern chemotherapy. We reviewed our experience with the infants diagnosed with ALL at Children's Memorial Hospital from 1992 to 1997. PROCEDURE: During this time period, 10 infants were diagnosed with ALL. Seven of them were transplanted, four with marrow from HLA-matched siblings and three with umbilical cord blood. Four of the transplanted patients had the MLL gene rearrangement and the other three transplanted patients had one or more other high-risk features including CD10-blasts, age less than 6 months at diagnosis, or prior relapse. The patients were conditioned with a regimen of total body irradiation (TBI), etoposide, and cyclophosphamide (CY). Peritransplant toxicity was tolerable. The graft infused contained a median total nucleated cell dose/kg of 3 x 10(8) (.3 x 10(8)-6 x 10(8)). The median CD34+ cell dose/kg was 5 x 10(6) (.25 x 10(6)-31 x 10(6)). RESULTS: All of the patients engrafted with a median of 18 days (11-29) to reach an absolute neutrophil count (ANC) of 500/microliter. The median time to reach an unsupported platelet count greater than 20,000/microliter was 24 days (18-64). Four of seven of the transplanted patients are leukemia-free survivors at a median follow-up of 775 days. Of the three patients who were not transplanted, one is surviving 2+ years off therapy. CONCLUSIONS: Allogeneic stem cell transplant is an alternative to chemotherapy alone as a treatment for infant ALL when a suitable donor is available.