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  • Letter to the Editor
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Response to Drs Marks and Bird

Bone Marrow Transplantation volume 41, page 993 (2008)Cite this article

We thank Drs Marks and Bird for their comments regarding our review of transplantation-associated thrombotic microangiopathy.1 With respect to the recently established diagnostic criteria from the Blood and Marrow Transplant Clinical Trials Network2 and the International Working Group (IWG),3 we agree that these definitions remain suboptimal. Using serum lactate dehydrogenase above the institutional normal range as a sole criterion for defining the syndrome indeed is problematic, given the frequency with which an abnormal lactate dehydrogenase is identified in the peritransplant period and the multitude of potential causes in this patient population. Such a strategy likely would result in overdiagnosis of this syndrome. We would like to point out, however, that the Blood and Marrow Transplant Clinical Trials Network definition does require the concomitant presence of all of the criteria stated, thereby defining a more readily identifiable syndrome and permitting development of rational clinical trials. On the other, specifying a higher lactate dehydrogenase threshold (such as twice the upper institutional values) may be worthy of consideration for future revisions of transplantation-associated thrombotic microangiopathy definitions. With respect to the IWG definition, we apologize for a typographical error overlooked by the authors and editorial staff and are sorry for any confusion it may have caused: the IWG criteria specify a platelet count <50 × 109/l, or 50% or greater reduction from previous counts.3 We, with Drs Marks and Bird, regret the fact that transplant physicians worldwide thus far have been unable to develop a single set of diagnostic criteria, but we applaud the Blood and Marrow Transplant Clinical Trials Network and the IWG for their efforts. This lack of consensus underscores the complexity of transplantation-associated thrombotic microangiopathy and our limited, although growing, knowledge of its pathophysiology. We also are hopeful that the formation of these diagnostic criteria soon will be followed by laboratory investigation and rational, multi-center prospective trials that will improve our understanding and management of this devastating complication of hematopoietic stem cell transplantation.

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References

  1. Batts ED, Lazarus HM . Diagnosis and treatment of transplantation-associated thrombotic microangiopathy: real progress or are we still waiting? Bone Marrow Transplant 2007; 40: 709–719.

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  2. Ho VT, Cutler C, Carter S, Martin P, Adams R, Horowitz M et al. Blood and marrow transplant clinical trials network toxicity committee consensus summary: thrombotic microangiopathy after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2005; 11: 571–575.

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  3. Ruutu T, Barosi G, Benjamin RJ, Clark RE, George JN, Gratwohl A et al. Diagnostic criteria for hematopoietic stem cell transplant-associated microangiopathy: results of a consensus process by an International Working Group. Haematologica 2007; 92: 95–100.

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Authors and Affiliations

  1. Division of Hematology/Oncology, Case Comprehensive Cancer Center, Case Western Reserve University and University Hospitals of Cleveland, Cleveland, OH, USA

    E D Batts

  2. Department of Medicine, Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA

    H M Lazarus

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  1. E D Batts
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  2. H M Lazarus
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Correspondence to H M Lazarus.

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Batts, E., Lazarus, H. Response to Drs Marks and Bird. Bone Marrow Transplant 41, 993 (2008). https://doi.org/10.1038/bmt.2008.8

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