All patients were subjected to full history taking, clinical examination, laboratory or radiological (pre-, during, or post-) transplant workup.
Bone marrow aspiration, flow cytometry, and cytogenetic study to detect minimal residual disease before transplant.
Disease-specific labs, e.g., multiple myeloma patient had serum protein electrophoresis and immunoglobulin quantitation.
ABO blood type and (HLA typing needed for allogeneic patients only).
Infectious disease screening for hepatitis (A, B, C) testing, HIV (human immunodeficiency virus), HSV (herpes simplex virus), CMV (cytomegalovirus), and EBV (Epstein-Barr virus) by both serology and PCR (polymerase chain reaction), toxoplasmosis.
Laboratory tests to check organ function:- CBC, kidney, and liver function (AST, ALT, alkaline phosphatase, γGT, albumin, total, and direct bilirubin), coagulation profile (PT, PTT, INR), serum ferritin level, and pregnancy test for females in child-bearing period.
Liver biopsy in selected cases who had pre-transplant liver cirrhosis or fibrosis to assess its grade.
Chest X-ray and pulmonary function tests, echocardiography and electrocardiogram, pelvi-abdominal ultrasound, computed tomography scan (CT Scan) to detect any residual disease before transplantation, MRI (magnetic resonance imaging) on selected part of body according to patient disease, e.g., MRI brain if there was any suspect of CNS infiltration, positron emission tomography (PET) scan to detect any residual disease before transplant mainly done in lymphoma.
During and post-transplant workup
CBC, kidney function, and liver function, (PT, PTT, INR) is done weekly, CMV PCR is done weekly, cyclosporine level is done weekly, hepatitis B, C PCR, and EBV PCR in selected cases, serum ferritin level, bone marrow aspiration and (chimerism needed for allogeneic patients only) in D28, D90, D180, D270, D360, and liver biopsy for histologic confirmation of hepatic GVHD in selected cases who had allogeneic HSCT.
In selected cases, for example, pelvi-abdominal ultrasound, hepatic veins, and portal vein duplex in case of suspecting veno-occlusive disease.
Conditioning regimen, GVHD prophylaxis, and supportive care: the conditioning regimens used for allogeneic HSCT were the following:
Busulfan 1 mg/kg/6 h PO (day 7 till day 4) in combination with fludarabine 30 mg/m2 (day 6 to 3).
Busulfan 1 mg/kg/6 h PO (day 7 till day 4) in combination with cyclophosphamide 60 mg/kg day 3 and day − 2 with mesna prophylaxis.
TBI one fraction daily (2.5 Gy) for 4 consecutive days in combination with cyclophosphamide 60 mg/kg (day − 3 and day − 2) with mesna prophylaxis.
The conditioning regimens used for autologous HSCT were the following:
Melphalan 200 mg/m2 IVI over 30 min on day − 2 was the standard conditioning regimen used in myeloma patients in our center. Patients with impaired renal functions (Cr.clearance < 30 ml/min) received 140 mg/m2 of melphalan.
Cyclophosphamide 60 mg/kg (day − 3 and day − 2 with mesna as prophylaxis) in combination with etoposide (15 mg/m2) day − 2 and day − 1 and carboplatin 400 mg/m2 (day − 3, − 2).
Melphalan 200 mg/m2 (day − 2) and Etoposide 1600mg/m2 (day − 2).
In allogeneic patients, GVHD prophylaxis included cyclosporine (CSA) plus methotrexate (MTX). CSA was started on day − 1 at a dose adjusted to trough blood levels (between 200 and 300 ng/mL). MTX was administered on days + 1, + 3, + 6, and + 11 (10 mg/m2) followed by folinic acid rescue. In vivo T cell depletion with antithymocyte globulin (ATG) was used in patients with aplastic anemia mainly.
Acyclovir, fluconazole/voriconazole, and quinolones (ciprofloxacin or levofloxacin) were administered from day − 1 until neutrophil recovery as infectious prophylaxis. CMV screening using PCR for guiding pre-emptive therapy. Galactomannan in blood samples was performed in suspected cases of neutropenic patients who are not responsive to neutropenic fever protocol ursodeoxycholic acid used as prophylactic agent to prevent liver injury.
The medical records of all patients were reviewed and details of serial liver function tests during the pre-transplant and post-transplant period were evaluated. These data were collected and analyzed for specific time periods after transplantation: − 1 to 30 days, 31 to 100 days, and 101 to regular follow-up as long as the patient is alive.
For most patients, liver function tests were carried out twice weekly during the first 30 days, were done daily in critically ill patients. Twice weekly during the next 30 to 60 days, once a week after 60 days to 180 days, and every month after 180 days to 1 year. Note was made of relevant clinical findings and subsequent investigations. In case of liver test abnormalities, patients underwent imaging studies (ultrasonography or computed tomography scan) and microbiological studies (CMV antigenemia/PCR, blood cultures, and other viral PCR studies.
The etiology of abnormal liver function and any therapeutic action taken were recorded and interoperated and classified by using diagnostic criteria of Forbes et al. .
Hepatic GVHD: the presence of clinical and histological evidence of GVHD in conjunction with the development of abnormal serum liver biochemistry. Acute and chronic GVHD were divided by a temporal cut-off of 100 days after BMT.
Drug hepatotoxicity from conditioning therapy: transient development of abnormal liver function during the first 2 weeks after BMT in the absence of other identifiable causes.
Cyclosporin hepatotoxicity: clinical features of cyclosporin toxicity (for example, fluid retention, hypertension, renal impairment, and tremor) and elevated serum cyclosporin level (whole blood cyclosporin level ˃ 400 mg/l) in conjunction with the transient development of abnormal liver function.
Hepatotoxicity from other drugs: transient abnormal liver function temporally related to the introduction of a drug known to cause hepatotoxicity.
Viral hepatitis: development of abnormal serum liver enzymes in conjunction with serological evidence of active viral infection.
Sepsis: development of/or deterioration of liver function during an episode of bacterial or fungal sepsis.
Veno-occlusive disease: clinical criteria of veno-occlusive disease developed by the Baltimore group were used. The Baltimore criteria include jaundice (bilirubin > 2.0 mg/dl) and two of the following: hepatomegaly (usually painful), ascites, or more than 5% weight gain.
Disease recurrence: development of abnormal liver function at a time of clinical evidence of disease recurrence.
The primary endpoint of the study was to determine the impact of liver function abnormalities on the outcome of autologous and allogeneic HSCT. Secondary endpoints were to classify and describe hepatic dysfunction after transplant, and to determine its frequency and risk factors. The incidences of hyperbilirubinemia, acute GVHD, and chronic GVHD were calculated using cumulative incidence estimates. All statistical analyses were performed using SPSS, version 17.0 (SPSS, Chicago, IL, USA).