Nonmyeloablative Allogeneic Hematopoietic Stem Cell Transplant in Patients with End Stage Renal Disease Requiring Dialysis – a Single Institution Experience

Patients with end stage renal disease (ESRD) historically have not been offered allogeneic hematopoietic cell transplantation (HCT) because of the presumed high risk of toxicity. Use of nonmyeloablative (NMA) conditioning regimens has made allogeneic HCT a viable option for patients with variety of baseline medical comorbidities. We report our experience with NMA allogeneic HCT for patients with ESRD who were on hemodialysis (HD) or peritoneal (PD) before receiving NMA allogeneic HCT. We reviewed our institutional database at Fred Hutchinson Cancer Research Center from 1997-2013. Eight patients were on dialysis (7 on HD and 1 on PD) before they received NMA allogeneic HCT (Age: 13-67; F/M: 3/5).  Six of eight patients (75%) were on dialysis when the decision for NMA allogeneic HCT was made. One patient was started on HD before the conditioning regimen and one required HD after finishing the conditioning and before the infusion of stem cells. Etiologies of ESRD included: Myeloma kidney (3), polycystic kidney disease (2), hemolytic uremic syndrome secondary to E-coli infection (1), acute tubular necrosis (ATN) (1) and acute obstructive kidney injury (AKI) (1). Four patients (50%) had previously received an autologous transplant (as part of an auto/allo tandem approach). Primary diagnosis included multiple myeloma (n=4), NHL (n=2) MDS/MPN (n=1), Wiskott–Aldrich syndrome (n=1). The conditioning regimen included Fludarabine/2GyTBI (n=3), 2GyTBI (n=1), Fludarabine/Melphalan/2GyTBI (n=1) and Fludarabine/Cyclophosphamide/2GyTBI (n=1). Fludarabine and Melphalan were administered after dialysis but with no dose reduction. Immunosuppression included Mycophenolate mofetil with cyclosporine (n=5) or Tacrolimus (n=3). Seven of eight patients died during the follow-up period (median 10.1; range 0.2-84.6 months). Two patients died within 2 weeks after transplant and neither was on dialysis at the time of referral for HCT. One had progressive Mantle cell lymphoma and was started on HD 7 days before the HCT because of obstructive AKI secondary to abdominal lymphadenopathy and the second patient had a diagnosis of multiple myeloma and required HD because of ATN after the conditioning regimen before stem cell infusion.  This patient died from multi-system organ failure secondary to conditioning regimen-related toxicities (Flu/Mel/TBI).  All other 7 patients survived for a median of 11.5 months (range 3.8 – 84.6). Causes of death included: CMV pneumonia, fungal CNS infection, uncontrolled bleeding during open heart surgery, relapse, and sepsis. One patient is still alive 3.8 months post auto/allo HCT.  In conclusion, review of these cases indicates that NMA allogeneic SCT for patients with ESRD on dialysis at the time of referral did not lead to adverse outcomes but initiation of dialysis shortly before HCT was associated with early mortality after transplant.