Abstract
There is a growing population of transplant survivors receiving both a solid organ (SOT) and a hematopoietic cell transplantation (HCT). This group remains underreported and not well described. We conducted a single center retrospective study aimed at assessing safety and long-term survival outcomes of 40 patients receiving both HCT and SOT at the University of Minnesota. Twenty-seven patients underwent HCT followed by SOT (13 kidney, 10 lung, 2 liver, 1 heart, 1 heart/kidney) with median age of 40 years (range 5–72) at time of SOT at a median of 88 months (range 24–302) following the HCT. The 1, 5 and 10-year overall survival (OS) from the SOT was 93%, 76%, and 49% respectively with only 4 organ failures reported. Thirteen other patients received a HCT following a prior kidney (n=8), liver (n=4) or pancreas/kidney (n=1) SOT with median age of 42 (range, 3–66) at time of the HCT and a median 154 months (range 1–304) from the SOT. The 1, 5 and 10-year OS from HCT were 46%, 46% and 17% respectively. In patients receiving SOT followed by HCT, survival outcomes were better in kidney transplant recipients, and patients subsequently requiring an autologous rather than an allogeneic HCT. There were no HCT engraftment failures. Our findings show that in a select patient population, undergoing a second transplant at a specialized center can lead to favorable outcomes with long-term survival and low incidence of graft rejection, organ failure and malignant disease relapse. A large-scale study is needed to determine the incidence and risk factors preferred for a successful subsequent SOT or HCT. Those studies are crucial to further guide selection and management of patients who would benefit most from a second transplant.
Keywords: Hematopoietic cell transplantation, Solid organ transplantation, organ failure, long-term complications
Introduction:
Advances in transplant and surgical techniques, increasing donor pools, and supportive care strategies are increasing the number of both solid organ transplantation (SOT) and hematopoietic cell transplantation (HCT) survivors. Longevity and transplant related toxicities including immunosuppression from a first transplant could lead to end stage organ failure or secondary malignancies requiring a second transplant. Therefore, intersection of the need for HCT and SOT is growing and often lifesaving for a selected patient population.
Organ toxicity and later organ failure are recognized and likely underreported complications after HCT. Organ failure is often multifactorial and secondary to prior exposure to cytotoxic and nephrotoxic antibiotic or immunosuppressive therapy, vascular injury and other post-transplant complications. Kidney injury and liver failure after transplantation have been well recognized in pediatric and adult HCT survivors with major impact on morbidity and mortality (1–5).
Additionally, ongoing immunosuppression, drug therapies and some genetic or acquired conditions can result in a need for allogeneic or autologous HCT following a prior SOT. Secondary malignancies, viral-associated malignancies or inborn errors of metabolism can lead to these HCT indications, even many years after the earlier SOT. Genetic and acquired diseases associated with abnormal hematopoiesis, such as hemoglobinopathies and amyloidosis, sometimes necessitate SOT due to organ dysfunction caused by the disease physiology or treatment.
We report our institutional experience with recipients having both HCT and SOT. We analyzed the indications and safety of transplantation, long-term organ function and survival in two cohorts: patients who underwent SOT followed by HCT and HCT recipients following a prior SOT.
Methods:
Study design and inclusion criteria
We conducted a retrospective analysis of the hematopoietic cell transplant (including bone marrow (BM), filgrastim-stimulated peripheral blood stem cells (PBSC) or umbilical cord blood (UCB)) and SOT research databases at the University of Minnesota. We identified 43 patients who have received both HCT and SOT. Of those, three SOT recipients who underwent HCT at an outside institution with no clinical data available were excluded from analysis. Of the remaining 40 patients, 31 received both transplants at the University of Minnesota and 9 received their HCT at an outside institution.
All ages were included. HCT patients received either autologous or allogeneic transplants from different donor sources, including HLA-compatible sibling, HLA-matched unrelated donors, or UCB. SOT recipients included recipients of heart, kidney, liver, lung, pancreas and dual organ grafts. SOT grafts had varying HLA matching, donor source (deceased, living related, living unrelated) and donor relation (related, unrelated). The institutional review board of the University of Minnesota approved this study.
Statistical analysis
We descriptively assessed characteristics and overall survival for patients receiving either a HCT with subsequent SOT (n=27) or patients receiving an SOT with subsequent HCT (n=13). Data was retrospectively reviewed from information prospectively collected by the University of Minnesota HCT and SOT databases and supplemented by medical record review. Overall survival was estimated by Kaplan-Meier curves through ten years post last transplant.
Results:
SOT after HCT
Patient Characteristics
We identified 27 patients receiving SOT after HCT and their clinical characteristics are shown in Table 1. Thirteen patients received their HCT between the years 1983 and 2000, and 14 between 2001 and 2015. The majority of the patients (n=25) had received their SOT after 2000. Median age at the time of HCT was 29 years (range, 3–67); while median age at SOT was 40 years (range, 5–72). No sequential transplants, with pre-planned HCT followed by SOT, were performed in this group. The median time from the HCT to the SOT was 88 months with a wide range of 24 to 302 months. Ten patients had received a previous autologous and 17 patients had a previous allogeneic HCT.
Table 1.
Patient and Transplant Characteristics: SOT after HCT
| All Patients | |
|---|---|
| N | 27 |
| Gender: Male | 17(63%) |
| Age at HCT | |
| Median(Range) | 29(3–67) |
| Age at SOT | |
| Median(Range) | 40(5–72) |
| Interval (HCT-SOT)-months | |
| Median(Range) | 88(24–302) |
| HCT Donor Type | |
| Sibling | 11(41%) |
| URD | 4(15%) |
| UCB | 2(7%) |
| Autologous | 10(37%) |
| HCT Conditioning | |
| MAC | 9(33%) |
| MAC: Cy/TBI | 8(30%) |
| RIC | 2(7%) |
| Unknown | 8(30%) |
| HCT GvHD Prophylaxis | |
| CsA/MMF | 7(26%) |
| MTX alone | 1(4%) |
| MTX/ATG/Prednisone | 1(4%) |
| CNI/MTX/Prednisone | 1(4%) |
| Unknown | 7(26%) |
| Autologous Transplant (NA) | 10(36%) |
| HCT Diagnosis | |
| AA | 2(8%) |
| ALL | 2(8%) |
| AML | 1(4%) |
| CML | 3(12%) |
| MDS | 4(16%) |
| NHL | 4(16%) |
| HL | 4(16%) |
| Neuroblastoma | 1(4%) |
| Wilms Tumor | 1(4%) |
| MM | 3(12%) |
| Year of HCT | |
| 1982–2000 | 13(48%) |
| 2001–2015 | 14(52%) |
| Year of SOT | |
| 1960–2000 | 2(7%) |
| 2001–2017 | 25(93%) |
| Type of SOT | |
| Kidney | 13(48%) |
| IgA or Diabetic nephropathy | 3 |
| MPGN/ nephritis | 3 |
| Congenital kidney anomaly | 1 |
| CNI/chemical nephrotoxicity | 5 |
| Microangiopathy | 1 |
| Liver | 2(7%) |
| Cirrhosis: Type C | 1 |
| Hepatoma HCC and Cirrhosis | 1 |
| Lung | 10(37%) |
| Pulmonary fibrosis | 5 |
| Bronchiolitis obliterans | 2 |
| GVHD | 2 |
| Chemical exposure | 1 |
| Heart | 1(4%) |
| Restrictive cardiomyopathy | 1 |
| Heart/Kidney | 1(4%) |
| Restrictive cardiomyopathy | 1 |
| Solid Organ Donor | |
| Deceased donor | 19(70%) |
| Living related donor | 4(15%) |
| Living unrelated donor | 4(15%) |
| Donor Relation | |
| Child | 1 (4%) |
| Full Sibling | 4(14%) |
| Mother | 1 (4%) |
| Unrelated | 20(74%) |
| Spouse | 1 (4%) |
| SOT HLA Match | |
| 6/6 | 3 (12%) |
| 4–5/6 | 2 (8%) |
| 3/6 | 3 (12%) |
| 2/6 | 5 (19%) |
| 1/6 | 8(30%) |
| SOT Lymphocyte Depletion (ALG or thymoglobulin) | |
| Yes | 10(45%) |
| No | 12(55%) |
| Missing | 5 |
Abbreviations: SOT= solid organ transplantation; HCT= hematopoietic cell transplantation; URD= unrelated donor; UCB= umbilical cord blood; MAC= myeloablative, RIC= reduced intensity; Cy= cyclophosphamide; TBI= total body irradiation; GvHD= graft-versus-host disease; CsA= cyclosporine; MMF= mycophenolate mofetil; MTX= methotrexate; ATG= anti-thymocyte globulin; CNI= calcineurin inhibitor; NA= non applicable; AA= aplastic anemia; ALL= acute lymphoblastic leukemia; AML= acute myeloid leukemia; CML= chronic myeloid leukemia; MDS= myelodysplastic syndrome; NHL= non-Hodgkins lymphoma; HL= Hodgkin’s lymphoma; MM= multiple myeloma; MPGN= membranoproliferative glomerulonephritis; ALG= anti-lymphocyte globulin
Thirteen received kidney grafts with their renal injury as a consequence of drug toxicity, microangiopathy, membranoproliferative glomerulonephritis, IgA nephropathy. Lung transplants (n=10) were required for pulmonary fibrosis, graft versus host disease, and bronchiolitis obliterans. One patient received a dual heart/kidney transplant for restrictive cardiomyopathy that developed 12 years after cyclophosphamide/TBI based myelobablative unrelated donor HCT for CML. For the majority, the solid organ was from an unrelated donor (n=20). One patient received a matched sibling allogeneic HCT for aplastic anemia followed 6 years later by a successful kidney transplant from the same donor for diabetic nephropathy.
Outcomes
The 1-year overall survival (OS) after SOT was 93% (95% CI, 74–98%), 5-year OS was 76% (95% CI, 54–88%), and 10-year OS was 49% (95% CI, 24–70%). Survival outcome is detailed in Table 2 per SOT organ, graft source, years from HCT (<5 or ≥5 years) and year of SOT. The 1-year OS was 100% in patients receiving kidney SOT (n=13) and 90% after a lung transplant (n=10). The long-term outcomes were best in patients receiving a kidney transplant. The 5 and 10-year OS were 85% and 58% in patients receiving a kidney graft and 68% and 34% in patients receiving a lung graft. The two liver transplant patients with underlying cirrhosis were surviving with adequate organ function at 10-year follow-up. When further stratified by time between transplants, patients who had a SOT<5 years following HCT had better survival at 1, 5 and 10 years compared to patients receiving a SOT ≥5 years following HCT. Additionally, patients receiving a SOT graft since 2006 (n=19) had similar short-term survival at 1 year, but superior long term outcome with 64% OS at 10 years (95% CI, 30–85%). This long term OS advantage was also seen in patients receiving HCT since 2000 (n=15) with 79% OS at 10 years (95% CI, 49–93%). Of note, none of the patients developed grade II-IV acute graft-versus-host disease (GVHD) or chronic GVHD after SOT.
Table 2.
Outcomes following SOT: SOT after HCT
| N Evaluable | # events | 1 year OS (95% CI) | 5 year OS (95% CI) | 10 year OS (95% CI) | |
|---|---|---|---|---|---|
| Overall survival | 27 | 10 | 93% (74–98%) | 76% (54–88%) | 49% (24–70%) |
| Type of SOT | |||||
| Kidney | 11 | 4 | 100% | 85% (51–96%) | 58% (21–83%) |
| Liver | 2 | 0 | 100% | 100% | 100% |
| Lung | 10 | 5 | 90% (47–99%) | 68% (29–88%) | 34% (5–67%) |
| Kidney or Heart | 2 | 1 | 50% | 50% | 50% |
| Solid Organ Donor | |||||
| Deceased donor | 18 | 8 | 89% (64–97%) | 71% (44–87%) | 40% (13–65%) |
| Living related | 5 | 2 | 100% | 75% | 40% (1–83%) |
| Living Unrelated donor | 4 | 0 | 100% | 100% | 100% |
| Years from HCT | |||||
| <5 | 8 | 1 | 100% | 88% (39–98%) | 88% (39–98%) |
| ≥5 | 19 | 9 | 89% (64–97%) | 70% (42–87%) | 41% (17–64%) |
| Year of SOT | |||||
| 1993–2005 | 8 | 5 | 88% (39–98%) | 75% (31–93%) | 38% (9–67%) |
| 2006–2017 | 19 | 5 | 95% (68–99%) | 77% (49–91%) | 64% (30–85%) |
| Year of HCT | |||||
| 1982–1999 | 12 | 7 | 92% (54–99%) | 75% (41–91%) | 38% (12–64%) |
| 2000–2013 | 15 | 3 | 93% (61–99%) | 79% (49–93%) | 79% (49–93%) |
Abbreviations: SOT= solid organ transplantation; HCT= hematopoietic cell transplantation; OS= overall survival
We also investigated the causes of death and incidence of organ failure. Of the 10 patients receiving a lung graft, five patients had died by the 10-year follow up. Causes of death included one primary graft failure, graft failure secondary to infection, and a cerebrovascular event. Of the four kidney graft recipients, one died of secondary graft failure after polyomavirus infection, one had bacterial infections, one had relapsed malignancy, and one of diabetes mellitus related complications. The patient who received a heart/kidney transplant died of infectious complications less than a year after transplant. Of the 27 patients in this group, organ failure occurred in two patients receiving a lung graft (recurrent pulmonary fibrosis; infections) and two patients receiving a kidney graft.
HCT after SOT
Patient Characteristics
We identified twelve patients who had both transplants at the University of Minnesota and one other patient who had HCT at an outside institution with sufficient clinical data to report. Their clinical characteristics are outlined in Table 3. Most patients (n=13) had SOT between 1960 and 2000; 6 from 1983–2000, and 7 between 2011–2015. Median age at the time of SOT was 19 (range, 0–65), while median age at HCT was 42 years old (range, 3–66) with a median time of 154 months (range, 1 to 304) between the procedures. Nine patients received an allogeneic HCT (6 matched sibling and 3 matched unrelated donors). The indications for HCT after SOT included both malignant and non-malignant disorders. Four received an autologous HCT; 3 for multiple myeloma and 1 for non-Hodgkin lymphoma.
Table 3.
Patient and Transplant Characteristics: SOT before HCT
| All Patients | |
|---|---|
| N | 13 |
| Gender: Male | 8(62%) |
| Age at HCT | |
| Median(Range) | 42(3–66) |
| Age at SOT | |
| Median(Range) | 19(0–65) |
| Interval (SOT-HCT)-months | |
| Median(Range) | 154(1–304) |
| HCT Donor Type | |
| Sibling | 6(46%) |
| URD | 3(23%) |
| Autologous | 4(31%) |
| HCT Conditioning | |
| MAC: TBI based | 1(8%) |
| MAC: Cy/TBI or Cy/Flu/TBI | 5(38%) |
| MAC: Melphalan | 3(23%) |
| MAC: Non TBI based | 2(15%) |
| RIC: Cy/Flu/TBI | 1(8%) |
| Unknown | 1(8%) |
| HCT GvHD Prophylaxis | |
| CsA/MMF | 9(69%) |
| Autologous transplant (NA) | 4(31%) |
| HCT Diagnosis | |
| AA | 1(8%) |
| Immune deficiency | 1(8%) |
| Metabolic disorder | 1(8%) |
| ALL | 2(15%) |
| MDS | 1(8%) |
| NHL | 3(23%) |
| MPN | 1(8%) |
| MM | 3(23%) |
| Neutrophil engraftment | |
| Median (range)- days | 15.5(9–28) |
| Autologous HCT | 11(9–12) |
| Allogeneic HCT | 21(9–28) |
| Year of HCT | |
| 1983–2000 | 6(46%) |
| 2001–2015 | 7(54%) |
| Year of 1st SOT | |
| 1960–2000 | 12(92%) |
| 2001–2017 | 1(8%) |
| Type of SOT | |
| Kidney | 8(62%) |
| Congenital nephrotic syndrome | 1 |
| FSGS | 1 |
| Nephritis | 4 |
| Congenital kidney anomaly | 1 |
| Unknown | 1 |
| Liver | 4(31%) |
| Polycystic liver disease | 1 |
| Wolman’s/ Metabolic disorder | 2 |
| Unknown | 1 |
| Pancreas/Kidney | 1(8%) |
| Diabetes Mellitus | 1 |
| Solid Tumor Donor | |
| Deceased donor | 6(46%) |
| Living related donor | 6(46%) |
| Living unrelated donor | 1(8%) |
| SOT Donor Relation | |
| Child | 1(8%) |
| Full Sibling | 3(23%) |
| Mother | 2(15%) |
| Unrelated | 7(54%) |
| SOT HLA Match | |
| 6/6 | 1(8%) |
| 5/6 | 0 |
| 4/6 | 1(8%) |
| 3/6 | 2(15%) |
| 2/6 | 1(8%) |
| 1/6 | 4(31%) |
| 0/6 | 1(8%) |
| Unknown | 4(31%) |
| SOT Lymphocyte Depletion (ALG or thymoglobulin) | |
| Yes | 2(33%) |
| No | 4(67%) |
| Missing | 7 |
Abbreviations: SOT= solid organ transplantation; HCT= hematopoietic cell transplantation; URD= unrelated donor; MAC= myeloablative, RIC= reduced intensity; Cy= cyclophosphamide; TBI= total body irradiation; Flu= fludarabine; GvHD= graft-versus-host disease; CsA= cyclosporine; MMF= mycophenolate mofetil; NA= non applicable; AA= aplastic anemia; ALL= acute lymphoblastic leukemia; MDS= myelodysplastic syndrome; NHL= non-Hodgkins lymphoma; MPN= myeloproliferative neoplasm; MM= multiple myeloma; FSGS= focal segmental glomerulosclerosis; ALG= anti-lymphocyte globulin
A three month old born with Wolman’s disease, a congenital metabolic disorder, underwent a successful liver transplant and subsequently a URD allogeneic HCT at three years of age complicated by GVHD and survived 68 months after HCT. A 16 year old with a congenital metabolic disorder underwent sequential liver and URD bone marrow allogeneic HCT within 1 month though died of infection. A 34 year old with type I diabetes mellitus underwent a dual pancreas/kidney transplant and 7 years later developed a post-transplant lymphoproliferative disorder necessitating a sibling donor allogeneic HCT complicated by severe infections and death.
Outcomes
For the 13 HCT after SOT recipients, the 1-year and 5-year OS after HCT were similar at 46% (95% CI, 19–70%) and 10-year OS was 17% (95% CI, 1–50%). Survival outcome is detailed in Table 4. Seven died within one year of their HCT and 6 patients survived beyond 5 years after HCT. Patients undergoing HCT after a kidney transplant (n=9) had better 5-year OS (56%; 95% CI, 20–80%) compared to the other SOT recipients (25%; 95% CI, 1–67%). Time from SOT to the HCT did not significantly impact the post-HCT survival as the 1 and 5- year OS was 40% in patients receiving HCT <5 years from SOT and 50% when HCT was ≥5 years later. The 1-year OS was better in patients who received HCT (57% vs 33%) or SOT (63% vs 20%) since 2000. As expected, survival after an allogeneic HCT was poorer than after autologous HCT at both 1 and 5 years (33% vs 75%).
Table 4.
Outcomes following HCT: SOT before HCT
| N Evaluable | # events | 1 year OS (95% CI) | 5 year OS (95% CI) | |
|---|---|---|---|---|
| Overall survival | 13 | 7 | 46% (19–70%) | 46% (19–70%) |
| Type of SOT | ||||
| Kidney | 9 | 4 | 56% (20–80%) | 56% (20–80%) |
| Other | 4 | 3 | 25% (1–67%) | 25% (1–67%) |
| Solid Tumor Donor | ||||
| Deceased donor | 6 | 5 | 17% (1–52%) | 17% (1–52%) |
| Living related/unrelated | 7 | 2 | 71% (26–92%) | 71% (26–92%) |
| Organ Failure | ||||
| No | 9 | 4 | 56% (20–80%) | 56% (20–80%) |
| Yes | 4 | 3 | 25% (1–67%) | 25% (1–67%) |
| Years from SOT to HCT | ||||
| <5 | 5 | 3 | 40% (5–75%) | 40% (5–75%) |
| ≥5 | 8 | 4 | 50% (15–77%) | 50% (15–77%) |
| Year of SOT | ||||
| 1960–2000 | 5 | 4 | 20% (1–58%) | 20% (1–58%) |
| 2001–2017 | 8 | 3 | 63% (23–86%) | 63% (23–86%) |
| Year of HCT | ||||
| 1983–2000 | 6 | 4 | 33% (5–68%) | 33% (5–68%) |
| 2001–2015 | 7 | 3 | 57% (17–84%) | 57% (17–84%) |
| HCT Type | ||||
| Autologous | 4 | 1 | 75% (13–96%) | 75% (13–96%) |
| Allogeneic | 9 | 6 | 33% (8–62%) | 33% (8–62%) |
Abbreviations: SOT= solid organ transplantation; HCT= hematopoietic cell transplantation; OS= overall survival
Three patients had prior history of solid organ failure (one liver and two kidney transplants) and 2–8 years later received HCT for hematological malignancies. Of the evaluable patients, none had primary graft failure after HCT and one kidney graft failure was reported 4 years after HCT. Acute GVHD was the primary cause of early death after HCT in three patients. Of the nine patients with hematologic malignancies, three relapsed within one year of HCT. Three patients died of recurrent malignancy, two of infectious complications and one of multiorgan failure.
Discussion:
Management of transplant recipients is challenging, and requires a multidisciplinary high level of care. This is further complicated when the two transplants intersect, however long term success and immune tolerance is possible with careful patient and graft selection. Our institutional experience, concurrent with limited previously published experience, shows that in appropriately selected patients, survival following a subsequent SOT or HCT is frequent with low risks of complications and promising long-term organ function.
Several challenges and common obstacles are specific to patients with organ failure needing a second transplant. Those include: 1) Histocompatibility with possible effects on immunologic tolerance of the first or the second transplant, 2) sensitivity of solid organ graft to high-dose therapies and conditioning regimens required for HCT, 3) effect of long-term immune suppression after SOT on engraftment, infectious complications and relapse rates after HCT.
Few case reports and small series report on the outcomes of patients undergoing HCT followed by SOT(6–8) and SOT recipients subsequently receiving a HCT(9–12). A retrospective multicenter survey of EBMT centers reported the outcomes of 40 allogeneic HCT recipients subsequently undergoing a kidney, liver or lung transplant(8). The 5-year OS was 78% and incidence of organ failure was 20% at 2 years after SOT(8). In line with previous reports, patient receiving kidney transplants had better survival. Beitinjaneh et al, reported the outcomes of 12 HCT recipients undergoing a SOT at the University of Minnesota before 2004 (7). Doney et al published a combined literature review and single center analysis of 40 SOT recipients followed by autologous or allogeneic HCT, showing favorable survival probability; with 5 of 8 autologous and 4 of 8 allogeneic HCT recipients alive at a median of 4.6 and 8.7 years after HCT respectively (9). A retrospective Japanese survey of 19 patients undergoing HCT after SOT reported a 5-year OS rate of 23.1% (12).
In our institution, among the 25 patients receiving a SOT following a HCT, half were alive at 10 years following their solid organ graft and survival was better in more recent SOT experience. Since infections were the most common cause of death, improved survival could be partly attributed to improved antimicrobial prophylaxis, therapy, and supportive care. Additionally, patients receiving SOT within 5 years from HCT had better survival, but this cannot fully distinguish interval from era in this long term experience. Even with a small number of patients, this observation is intriguing, and warrants further investigation to determine whether the duration of post-HCT immunosuppression influences the success of these post-HCT organ grafts.
Late toxicity from solid organ graft supportive care, lifelong immunosuppression and long-term survival yields more patients who might need a HCT for a variety of non-malignant and malignant disorders. Patients receiving their HCT more recently, after the year 2000, had better survival outcomes. Future studies should focus on better defining the immune reconstitution prior to the HCT and adapting immune suppressive therapies to limit risks for GVHD and post-HCT infections which might be increased by the long term immunosuppression of the prior SOT.
The inferences from this institutional experience must be cautioned by our diverse population in age, underlying diagnosis, solid organ and hematopoietic cell donor source, HLA-matching, indication for transplant and time between transplants. We report our inclusive experience, which documents the feasibility and long-term outcomes in dual transplant survivors.
With the increasing number and improved survival of transplant recipients, the need for a second HCT or SOT will remain a reality for a number of patients. Larger studies may inform the incidence and risk factors for organ failure among HCT recipients. Additionally, knowing the incidence of clonal and bone marrow failure disorders following solid organ grafts may guide future monitoring of SOT survivors. In depth understanding of the immunological consequences of the first transplant is crucial to improve graft selection and tolerance. Broader multicenter experience might further inform selection guidelines for any second transplant.
Figure 1:
Overall survival for SOT recipients following HCT
Figure 2:
Overall survival for HCT recipients following SOT
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