Risk Factors and Outcome of Hemorrhagic Cystitis in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplant

Amima Sabir; Jahanzeb Ur Rehman; Mehreen Ali Khan; Momina Javed; Hashim Khan; Zahid Khanzada

Authors

Amima Sabir Department of Clinical Hematology and Bone Marrow Transplant. National University of Medical Sciences, Rawalpindi,
Jahanzeb Ur Rehman Department of Clinical Hematology and Bone Marrow Transplant. National University of Medical Sciences, Rawalpindi
Mehreen Ali Khan Department of Clinical Hematology and Bone Marrow Transplant. National University of Medical Sciences, Rawalpindi
Momina Javed Department of Clinical Hematology and Bone Marrow Transplant. National University of Medical Sciences, Rawalpindi
Hashim Khan Department of Clinical Hematology and Bone Marrow Transplant. National University of Medical Sciences, Rawalpindi,
Zahid Khanzada Department of Clinical Hematology and Bone Marrow Transplant. National University of Medical Sciences, Rawalpindi,

Keywords:

Hemorrhagic Cystitis

Abstract

Background: Hemorrhagic cystitis (HC), a significant complication of hematopoietic stem cell transplantation (HSCT) linked to chemotherapy-induced injury and viral reactivation. Given its impact on morbidity, mortality, and quality of life, we conducted a retrospective analysis to identify key risk factors associated with HC. The objective is to evaluate the relationship between transplant-related variables and outcomes, aiming to improve risk stratification and guide early, targeted interventions in post-HSCT care.

Methodology: This study was carried out retrospectively at tertiary care hospital in Rawalpindi between 2013 and 2024 including 138 patients who underwent allogeneic HSCT. Data collected included demographic characteristics, transplant variables, post-transplant complications such as graft-versus-host disease (GVHD), cytomegalovirus (CMV) reactivation, BK viruria, and hemorrhagic cystitis (HC). HC was graded from microscopic hematuria to severe cases requiring surgical intervention. Engraftment times, infection rates, and overall survival (OS) were analyzed. OS was defined from the start of conditioning to death or last follow-up and was assessed using Kaplan-Meier curves.

Results: 138 patients (mean age 21.3 years) who underwent allogeneic HSCT from 2013 to 2024 were included. The majority were male (73.9%), and the most common underlying disorder was Beta Thalassemia Major (43.5%), followed by Aplastic Anemia and Acute Lymphoblastic Leukemia. Fully HLA-matched sibling donors were donors in majority cases, with bone marrow harvest as the predominant stem cell source. Myeloablative conditioning was administered to 66.7% of patients. HC occurred in 55.8% of patients, mostly as grade 1–2. Significant associations were observed between HC and GVHD prophylaxis involving cyclosporine (particularly CSA+MTX), BK virus reactivation (59.7% of HC cases), chronic GVHD, and secondary graft failure (p<0.05). No significant correlation was found with donor gender, conditioning regimen, or CMV reactivation. Most HC cases (85%) responded to supportive management including hydration, bladder irrigation, and antivirals. Responders showed a higher overall survival (OS) rate of 97%, while non-responders had poor outcomes. OS in HC patients was 87% at 100 days post-transplant, dropping to 66.7% at a cumulative follow up of 10 years.

Conclusion: Our study identifies BK virus reactivation, cyclosporine-based GVHD prophylaxis, and chronic GVHD as significant contributors to HC following allogeneic HSCT. Despite limited therapeutic options, supportive care proved effective in most cases. The high incidence and associated morbidity of HC highlights the need for early risk stratification, viral monitoring, and improved access to targeted therapies.