Serum Albumin Level < 32 g/l on Day 30 Can Predicts Higher Risk of Non-Relapse Mortality in Acute Lymphoblastic Leukemia Following Allogeneic Stem Cell Transplantation
Authors: Alfraih Feras , Gupta Vikas , Kuruvilla John , Lipton Jeffrey H. , Messner Hans A. , Seftel Matthew D. , Uhm Jieun , Kim Dennis Dong Hwan 
Published: October 2019

Introduction:
It is extremely significant issue to predict hematopoietic stem cell transplant (HSCT) outcomes using a biomarker. In this study, we attempted to evaluate the impact of post-transplant serum albumin on outcomes in patients with acute lymphoblastic leukemia (ALL).
Methods:
123 patients with ALL receiving HSCTs between 1999 and 2012 at our center were evaluated for post-transplant serum albumin levels and their correlation with transplant's outcome. The level of serum albumin was retrospectively retrieved in certain time point ± 3 days for following periods: 1 month pre HSCT and then weekly after transplantation for first 3 months. 100 patients had available serum albumin levels. The ROC analyses were used to determine the most statistically significant cutoff level of serum albumin level correlating with NRM at 1 year. The ROC analysis suggested the level of 32 g/l at 4 weeks post HSCT as the best cutoff level for further analysis. Thus patients were stratified into low versus high albumin level group according to that cutoff level.
Results:
Median age for all patients is 37 (range 17-61), 35% were female and related donors were 57%. Matched donors were 83%. 71% were in 1st complete remission. 37% were Philadelphia chromosome positive. GVHD prophylaxis was CSA/MTX 60%, CSA/MMF 22%. Conditioning regimen was myeloablative in 95%. 61% received peripheral blood stem cells.
With a median follow-up among survivors of 60 months (range 21-100), 61% patients showed albumin level ³ 32g/l at day 30 while 39% showed dropped albumin level <32 g/l at day 30.
The OS rate at 2 years was 61% in high albumin group versus 23% in low albumin group (p < 0.001). The NRM rate was 62% in high albumin group versus 17% in low albumin group (p < 0.001). However, no difference of relapse incidence was noted between the two groups.
The cumulative incidence of overall acute GVHD, grades 2/4, grades 3/4 at day 120 and overall chronic GVHD at 2 years was 67%, 59%, 16% and 45% in high albumin group versus 72%, 70%, 49% and 39% in low albumin group, suggesting higher incidence of grade 3/4 acute GVHD in low albumin group vs high.
In multivariate analysis, serum albumin level < 32 g/l at 4 weeks was confirmed as an independent adverse risk factor for NRM (p=0.04, HR 2.81) together with acute GVHD grades 3/4 (p 0.01, HR 3.79) and chronic GVHD (p²0.001, HR 0.21). For OS, albumin level was not confirmed as an independent risk factor, but acute GVHD grade 3/4 (p< 0.001, HR 3.36) and chronic GVHD (p <0.001, HR 0.008) were found to be independent factors. For relapse chronic GVHD grade 3-4 was the only independent prognostic factor (p <0.001, HR 0.27).
Conclusion:
The present study suggested that 1) serum albumin level less than 32 g/l at day 30 can predicts higher risk of non-relapse mortality and 2) dropped serum albumin might be affected by in part the occurrence of severe acute GVHD, and by independent mechanism of gut GVHD. Further study is strongly warranted to confirm the prognostic role of serum albumin level on transplant outcomes in a prospectively designed study.
Figure 1 Figure 1.

Disclosures
No relevant conflicts of interest to declare.