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Mortality of Oncohematological Patients Undergoing Hematopoietic Stem Cell Transplantation Admitted to the Intensive Care Unit
Mortality of Oncohematological Patients Undergoing Hematopoietic Stem Cell Transplantation Admitted to the Intensive Care Unit Y. Corcía Palomoa,*, T. Knight Asoreyb, I. Espigadob, L. Martín Villéna, and J. Garnacho Monteroa a Intensive Care Unit Service, UH Virgen del Rocío, Seville, Spain; and bHaematology and Haemotherapy Service, UH Virgen del Rocío, Seville, Spain
ABSTRACT Background. Both autologous and allogenic hematopoietic stem cell transplantation (HSCT) are potentially curative treatments for hematological malignancies. Patients with related complications may need admission to the intensive care unit (ICU) for specific therapy and organ support. A consensus on treatment between hematologists and intensive care specialists is essential. Methods. This observasional, retrospective study included all recipients of HSCT in a third-level hospital during 2013 and 2014. Certain parameters were taken into account for patients who needed to be admitted to the ICU, evolution, and ICU and hospital mortality. Results. A total of 228 HSCT were carried out: 127 autologous (55.7%) and 101 allogenic (44.3%). Twenty-four patients were admitted to the ICU; 22 had received allogenic HSCT and 2 autologous. The main underlying conditions were acute leukemias (41.6%) and myelodysplastic syndromes (20.8%). Of these patients, 45.8% were in complete remission and 33.3% were in relapse or progression. Causes of admission to the ICU were mainly respiratory failure (70.8%) followed by shock requiring vasoactive drugs. High values for severity scores were observed for APACHE II 25 (19e28) and SOFA 10 (8e14). During hospitalization, a high percentage of patients had hemodynamic (91.7%), renal (87.5%), hepatic (79.2%), and respiratory (87.5%) failure. Mortality in the ICU was 83.3% and hospitalary, 91.7%. All patients requiring invasive mechanical ventilation died in the ICU. Conclusions. Of recipient patients of allogenic HSCT, 21.8% were admitted to the ICU, presenting a mortality rate of >95%. The main reason for admission was respiratory failure with requirement of invasive mechanical ventilation. Patients with autologous HSCT presented very few complications needing organ support.
H
EMATOPOIETIC STEM CELL TRANSPLANTATION (HSCT) with cells harvested either from peripheral blood or bone marrow is a standard treatment for many patients with hematological malignancies. HSCT is associated with multiple complications that often lead to organ failures, requiring admission in the intensive care unit (ICU) [1]. Although the prognosis of patients with hematological malignancies admitted to the ICU has improved over past years [2,3], it remains poor in allogeneic HSCT recipients and is associated with a high mortality rate. Life-threatening complications occur more frequently as a result of therapy rather than the hematological disease. This is why a consensus treatment between hematologists
and the intensive care physician should be essential to improve survival rates for these patients [4]. METHODS We performed an observational, retrospective analysis of data collected from all HSCT adult recipients admitted to the ICU in a tertiary hospital during 2013 and 2014. Data of consecutive HSCT recipients for a total of patients with hematological admissions were obtained, such as patient demographics data, underlying hematologic disease and its *Address correspondence to Yael Corcía Palomo, Intensive Care Unit Service, UH Virgen del Rocío, Av. Manuel Siurot s/n. 41013, Seville, Spain. E-mail: [email protected]
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.09.033
Transplantation Proceedings, 47, 2665e2666 (2015)
2665
2666
CORCÍA PALOMO, KNIGHT ASOREY, ESPIGADO ET AL Table 1. Baseline Characteristics of Patients n ¼ 24 HSCT
Sex (female), n (%)
Reason for admission ICU Age, median (IQR) 41 (33e54) Respiratory failure Diagnoses Shock AML 5 (20.8) Others ALL 5 (20.8) APACHE II MDS 5 (20.8) SOFA MM 1 (4.2) Organ failure HL 1 (4.2) Respiratory failure NHL 3 (12.5) Renal failure Aplastic anemia 4 (16.7) Liver failure Status Supportive care Complete remission 11 (45.8) Mechanical ventilation Partial remission 1 (4.2) Vasoactive agents Progression 3 (12.5) RRT Relapse 5 (20.8) ICU mortality Not evaluated 4 (16.7) Hospital mortality
n ¼ 24 HSCT
11 (45.8)
17 2 5 25 10
(70.8) (8.3) (20.8) (19e28) (8e14)
20 (83.3) 21 (87.5) 19 (79.2) 21 (87.5) 22 7 20 22
(91.7) (29.2) (83.3) (91.7)
Abbreviations: AML, acute myeloid leukemia; ALL, acute lymphocytic leukemia; MDS, myelodysplastic syndrome; MM, multiple myeloma; HL, Hodgkin’s lymphoma; NHL, non-Hodgkin’s lymphoma; RRT, renal replacement therapy.
status at ICU admission, comorbidities, reasons for admission, type of organ failure, and major treatments. Severity scores (APACHE II and SOFA) were collected from the ICU for each patient within the first 24 hours after their admission. Patient evolution and mortality rates were also analyzed. Continuous variables were reported as medians with the use of interquartile range (IQR). Qualitative variables were reported as numbers and percentages.
RESULTS
During the study period a total of 228 medical patients underwent HSCT, of whom 127 (55.7%) were autologous and 101 (44.3%) were allogenic. Baseline characteristics of these patients are summarized in Table 1. Twenty-four patients were admitted to the ICU; 22 had recieved allogenic HSCT and 2 autologous HSCT. Women comprised 45.8%; and median age was 41 (range, 33e54) years. The most common underlying hematological diagnoses were acute myeloid leukaemia (AML) (n ¼ 5, 20.8%), acute lymphoblastic leukaemia (ALL) (n ¼ 5, 20.8%), and myelodysplastic syndrome (MDS) (n ¼ 5, 20.8%). Regarding stage of disease at ICU admission, 45.8% of patients were in complete remission and 33.3% in relapse or progression. The main reasons for ICU admission were respiratory failure (70.8%) followed by shock requiring
vasoactive drugs (8.3%). High values for severity scores were observed in mean APACHE II score 25 (range, 19e28) and mean SOFA 10 (range, 8e14). A high percentage of patients developed hemodynamic (91.7%), renal (87.5%), hepatic (79.2%), and respiratory (87.5%) failure. ICU mortality was 83.3% and hospitalary was 91.7%. All patients who required invasive mechanical ventilation died in the ICU. DISCUSSION
Our study underlines a high mortality rate in this specific subgroup of patients. Worst clinical condition at ICU admission, need of invasive mechanical ventilation, and higher rate of organ failure could be factors associated with outcome. CONCLUSIONS
Of recipient patients of allogenic HSCT, 21.8% were admitted to the ICU, presenting a mortality rate >95%. The main reason for admission was respiratory failure with requirement of invasive mechanical ventilation. Patients with autologous HSCT presented very few complications needing organ support. Knowing the reasons for these differences between patients should merit further investigation and may help to improve survival rates. Further work is needed to find valid prognostic tools that can assist with decisión-making and patient selection for ICU admission. Close interactions between hematologists and intensivists are necessary to identify patients who may potentially benefit from lifesustaining therapies with reasonable likelihood of survival. REFERENCES [1] Pène F, Aubron C, Azoulay E, et al. Outcome of critically ill allogeneic hematopoietic stem-cell transplantation recipients: a reappraisal of indications for organ failure supports. J Clin Oncol 2006;24:643e9. [2] Parakh S, Piggin A, Neeman T, et al. Outcomes of haematology/oncology patients admitted to intensive care unit at the Canberra Hospital. Intern Med J 2014;44:1087e94. [3] Soubani AO, Kseibi E, Bander JJ, et al. Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a Medical ICU. Chest 2004;126:1604e11. [4] Townsend WM, Holrovd A, Pearce R, et al. Improved intensive care unit survival for critically ill allogeneic haematopoietic stem cell transplant recipients following reduced intensity conditioning. Br J Haematol 2013;161:578e86.
ABSTRACT Background. Both autologous and allogenic hematopoietic stem cell transplantation (HSCT) are potentially curative treatments for hematological malignancies. Patients with related complications may need admission to the intensive care unit (ICU) for specific therapy and organ support. A consensus on treatment between hematologists and intensive care specialists is essential. Methods. This observasional, retrospective study included all recipients of HSCT in a third-level hospital during 2013 and 2014. Certain parameters were taken into account for patients who needed to be admitted to the ICU, evolution, and ICU and hospital mortality. Results. A total of 228 HSCT were carried out: 127 autologous (55.7%) and 101 allogenic (44.3%). Twenty-four patients were admitted to the ICU; 22 had received allogenic HSCT and 2 autologous. The main underlying conditions were acute leukemias (41.6%) and myelodysplastic syndromes (20.8%). Of these patients, 45.8% were in complete remission and 33.3% were in relapse or progression. Causes of admission to the ICU were mainly respiratory failure (70.8%) followed by shock requiring vasoactive drugs. High values for severity scores were observed for APACHE II 25 (19e28) and SOFA 10 (8e14). During hospitalization, a high percentage of patients had hemodynamic (91.7%), renal (87.5%), hepatic (79.2%), and respiratory (87.5%) failure. Mortality in the ICU was 83.3% and hospitalary, 91.7%. All patients requiring invasive mechanical ventilation died in the ICU. Conclusions. Of recipient patients of allogenic HSCT, 21.8% were admitted to the ICU, presenting a mortality rate of >95%. The main reason for admission was respiratory failure with requirement of invasive mechanical ventilation. Patients with autologous HSCT presented very few complications needing organ support.
H
EMATOPOIETIC STEM CELL TRANSPLANTATION (HSCT) with cells harvested either from peripheral blood or bone marrow is a standard treatment for many patients with hematological malignancies. HSCT is associated with multiple complications that often lead to organ failures, requiring admission in the intensive care unit (ICU) [1]. Although the prognosis of patients with hematological malignancies admitted to the ICU has improved over past years [2,3], it remains poor in allogeneic HSCT recipients and is associated with a high mortality rate. Life-threatening complications occur more frequently as a result of therapy rather than the hematological disease. This is why a consensus treatment between hematologists
and the intensive care physician should be essential to improve survival rates for these patients [4]. METHODS We performed an observational, retrospective analysis of data collected from all HSCT adult recipients admitted to the ICU in a tertiary hospital during 2013 and 2014. Data of consecutive HSCT recipients for a total of patients with hematological admissions were obtained, such as patient demographics data, underlying hematologic disease and its *Address correspondence to Yael Corcía Palomo, Intensive Care Unit Service, UH Virgen del Rocío, Av. Manuel Siurot s/n. 41013, Seville, Spain. E-mail: [email protected]
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.09.033
Transplantation Proceedings, 47, 2665e2666 (2015)
2665
2666
CORCÍA PALOMO, KNIGHT ASOREY, ESPIGADO ET AL Table 1. Baseline Characteristics of Patients n ¼ 24 HSCT
Sex (female), n (%)
Reason for admission ICU Age, median (IQR) 41 (33e54) Respiratory failure Diagnoses Shock AML 5 (20.8) Others ALL 5 (20.8) APACHE II MDS 5 (20.8) SOFA MM 1 (4.2) Organ failure HL 1 (4.2) Respiratory failure NHL 3 (12.5) Renal failure Aplastic anemia 4 (16.7) Liver failure Status Supportive care Complete remission 11 (45.8) Mechanical ventilation Partial remission 1 (4.2) Vasoactive agents Progression 3 (12.5) RRT Relapse 5 (20.8) ICU mortality Not evaluated 4 (16.7) Hospital mortality
n ¼ 24 HSCT
11 (45.8)
17 2 5 25 10
(70.8) (8.3) (20.8) (19e28) (8e14)
20 (83.3) 21 (87.5) 19 (79.2) 21 (87.5) 22 7 20 22
(91.7) (29.2) (83.3) (91.7)
Abbreviations: AML, acute myeloid leukemia; ALL, acute lymphocytic leukemia; MDS, myelodysplastic syndrome; MM, multiple myeloma; HL, Hodgkin’s lymphoma; NHL, non-Hodgkin’s lymphoma; RRT, renal replacement therapy.
status at ICU admission, comorbidities, reasons for admission, type of organ failure, and major treatments. Severity scores (APACHE II and SOFA) were collected from the ICU for each patient within the first 24 hours after their admission. Patient evolution and mortality rates were also analyzed. Continuous variables were reported as medians with the use of interquartile range (IQR). Qualitative variables were reported as numbers and percentages.
RESULTS
During the study period a total of 228 medical patients underwent HSCT, of whom 127 (55.7%) were autologous and 101 (44.3%) were allogenic. Baseline characteristics of these patients are summarized in Table 1. Twenty-four patients were admitted to the ICU; 22 had recieved allogenic HSCT and 2 autologous HSCT. Women comprised 45.8%; and median age was 41 (range, 33e54) years. The most common underlying hematological diagnoses were acute myeloid leukaemia (AML) (n ¼ 5, 20.8%), acute lymphoblastic leukaemia (ALL) (n ¼ 5, 20.8%), and myelodysplastic syndrome (MDS) (n ¼ 5, 20.8%). Regarding stage of disease at ICU admission, 45.8% of patients were in complete remission and 33.3% in relapse or progression. The main reasons for ICU admission were respiratory failure (70.8%) followed by shock requiring
vasoactive drugs (8.3%). High values for severity scores were observed in mean APACHE II score 25 (range, 19e28) and mean SOFA 10 (range, 8e14). A high percentage of patients developed hemodynamic (91.7%), renal (87.5%), hepatic (79.2%), and respiratory (87.5%) failure. ICU mortality was 83.3% and hospitalary was 91.7%. All patients who required invasive mechanical ventilation died in the ICU. DISCUSSION
Our study underlines a high mortality rate in this specific subgroup of patients. Worst clinical condition at ICU admission, need of invasive mechanical ventilation, and higher rate of organ failure could be factors associated with outcome. CONCLUSIONS
Of recipient patients of allogenic HSCT, 21.8% were admitted to the ICU, presenting a mortality rate >95%. The main reason for admission was respiratory failure with requirement of invasive mechanical ventilation. Patients with autologous HSCT presented very few complications needing organ support. Knowing the reasons for these differences between patients should merit further investigation and may help to improve survival rates. Further work is needed to find valid prognostic tools that can assist with decisión-making and patient selection for ICU admission. Close interactions between hematologists and intensivists are necessary to identify patients who may potentially benefit from lifesustaining therapies with reasonable likelihood of survival. REFERENCES [1] Pène F, Aubron C, Azoulay E, et al. Outcome of critically ill allogeneic hematopoietic stem-cell transplantation recipients: a reappraisal of indications for organ failure supports. J Clin Oncol 2006;24:643e9. [2] Parakh S, Piggin A, Neeman T, et al. Outcomes of haematology/oncology patients admitted to intensive care unit at the Canberra Hospital. Intern Med J 2014;44:1087e94. [3] Soubani AO, Kseibi E, Bander JJ, et al. Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a Medical ICU. Chest 2004;126:1604e11. [4] Townsend WM, Holrovd A, Pearce R, et al. Improved intensive care unit survival for critically ill allogeneic haematopoietic stem cell transplant recipients following reduced intensity conditioning. Br J Haematol 2013;161:578e86.