Elsevier

Mayo Clinic Proceedings

Volume 67, Issue 2, February 1992, Pages 128-130
Mayo Clinic Proceedings

Hemorrhagic Cystitis Complicating Bone Marrow Transplantation

https://doi.org/10.1016/S0025-6196(12)61312-3Get rights and content

Hemorrhagic cystitis is a potentially serious complication of high-dose cyclophosphamide therapy administered before bone marrow transplantation. As standard practice at our institution, patients who are scheduled to receive a bone marrow transplant are treated prophylactically with forced hydration and bladder irrigation. In an attempt to obviate the inconvenience of bladder irrigation, we conducted a feasibility trial of uroprophylaxis with mesna, which neutralizes the hepatic metabolite of cyclophosphamide that causes hemorrhagic cystitis. Of 97 patients who received standard prophylaxis, 4 had symptomatic hemorrhagic cystitis. In contrast, two of four consecutive patients who received mesna uroprophylaxis before allogeneic bone marrow transplantation had severe hemorrhagic cystitis for at least 2 weeks. Because of this suboptimal result, we resumed the use of bladder irrigation and forced hydration to minimize the risk of hemorrhagic cystitis.

Section snippets

MATERIAL AND METHODS

At our institution, the standard conditioning regimen for allogeneic bone marrow transplantation in patients with a neoplasm has been cyclophosphamide (60 mg/kg daily for 2 days) in conjunction with fractionated total-body irradiation (1,325 cGy twice daily for 3 days). In patients with aplastic anemia, we have administered cyclophosphamide in a dosage of 50 mg/kg daily for 4 days. All our patients have been prophylactically treated with forced hydration with use of saline (250 ml/h) beginning

RESULTS

Among the initial 97 patients who received standard prophylaxis, we noted 4 cases of symptomatic hemorrhagic cystitis (4%; 90% confidence interval, 1.1 to 8.5%). All four patients also had active graft-versus-host disease at the time of onset of hemorrhagic cystitis. In one patient, the hemorrhagic cystitis subsided without treatment; the three other patients required hydration and continuous bladder irrigation before the hematuria resolved.

Four consecutive patients who underwent allogeneic

DISCUSSION

Despite the fact that our report does not include prospectively randomized patients, the extremely low incidence of symptomatic hemorrhagic cystitis among our initial 97 patients is striking and compares favorably with other reported series. Two essential factors are careful insertion of the irrigation catheter to minimize trauma and diligent nursing supervision to record urinary output. Because our preliminary experience does not substantiate that uroprophylaxis with mesna is as effective as

ACKNOWLEDGMENT

We acknowledge the work of Barbara A. Schafer, R.N., and all the paramedical personnel who devoted time and effort to the care of the patients in this study.

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    Although mild forms usually resolve with supportive treatment, severe HC may require antiviral therapy such as vidarabine, hyperbaric oxygen treatment, amifostine, factor XIII, bladder irrigation with intravesicular instillation of E-aminocaproic acid, methyl prednisolone or formalin, cystoscopy and cauterization, and even cystectomy.4-12 In general, alkylating agents such as cyclophosphamide (CTX), radiation therapy, or adenovirus and BK polyoma virus infection have been implicated in the etiology of HC.13-24 However, previous studies evaluating risk factors for HC have been carried out on either small numbers of patients or in heterogeneous populations including different preparative regimens.1,16,20,21

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