P-131: Cyclosporine as a rescue therapy for Primary Graft failure in Myeloma Autologous transplant

Introduction: Melphalan autograft is part of standard treatment protocol for newly diagnosed multiple myeloma.Graft failure is an extremely rare complication in Myeloma autotransplant.It has life threatening complications like infections and bleeding diathesis.Here we describe a rare case of Multiple myeloma who developed primary graft failure after Autologous stem cell transplant and how cyclosporine helped to effectively salvage this patient.

Methods: In this retrospective study , we analysed BMT records of 170 patients who underwent autologous stem cell transplant for multiple myeloma between 2017 and 2024. Only one of our patients (0.59% incidence) had primary graft failure defined as abscence of neutrophil recovery by D28. We analysed the baseline characteristics of this patient and how cyclosporine was used as an effective salvage regimen for this patient.

Results: 63 year old female patient, IgG Kappa Multiple Myeloma, R-ISS 2 with no high risk cytogenetic abnormalities on FISH test received 4 cycles of induction with VRd regimen. She achieved CR after 4 cycles and was planned for Autologous stem cell transplant. Her pre transplant evaluation was unremarkable.She did not develop any infections prior to transplant. She underwent autologous stem cell transplant with Melphalan 200mg/m2 as conditioning. Stem cell dose of 11million/kg was infused.She was started on G CSF from Day2 .Her neutrophil count did not recover till day 28. She developed probable fungal pneumonia on D25 which was managed with appropriate antifungals. She was started on Eltromopag 150 mg once daily and Cyclosporine (3 mg/kg in 2 divided doses with target tarough levels of 200-250) from Day 25 of transplant. Therapeutic level of Cyclosporine was attained after a week. Patients blood counts started improving one week after initiation of Cyclosporine and Eltromopag. Neutrophil engraftment was achieved by D43 and platelet engraftment by Day 60. Cyclosporine was tapered off by 60 days after count recovery

Conclusions: Pathogenic mechanism of primary graft failure in Multiple myeloma is largely unknown and T cell mediated supression of hematopoeisis could be a likely cause.We report our experience with successful use of empiric Cyclosporine in this case. Cyclosporine should be considered as a therapeutic option in all cases of Myeloma with primary graft failure post autologous stem cell transplant.