Identification of poor prognostic features among patients requiring mechanical ventilation after hematopoietic stem cell transplantation

Abstract

Patients who develop respiratory failure requiring mechanical ventilation after hematopoietic stem cell transplantation (HSCT) have very high mortality. Several investigators have identified prognostic features that can be used to identify a subset of these patients who are virtually certain to die, yet these have never been prospectively assessed. The objectives of this study were to determine the accuracy of published prognostic features for mortality and to determine the survival of patients who recover from respiratory failure. A systematic review of the literature was undertaken to identify reported poor prognostic features and survival rates. The study validated the reported poor prognostic features on a prospective, multicenter inception cohort of 226 patients with respiratory failure requiring mechanical ventilation after HSCT. The main outcome measures were determination of a baseline probability of death, drawn from literature review; likelihood ratio of mortality for each prognostic feature determined from the validation cohort; conditional probability of death in the presence of each feature; and 6-month survival of those who recover. Patients requiring mechanical ventilation after HSCT have a baseline probability of death of 82% to 96%. In the setting of combined hepatic and renal dysfunction, the probability of death rises to 98% to 100%.Other previously reported prognostic features are less strongly associated with mortality. For patients who recover from respiratory failure, the proportion surviving 6 months or longer ranges from 27% to 88%. It was concluded that in patients requiring mechanical ventilation after HSCT, the presence of combined hepatic and renal dysfunction is highly predictive of death.

Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis

“…67,70,71 The need for ventilatory support ranges from 28 to 76% in recent studies, 13,16,21,24,25,[27][28][29][30][31][32][33][34][35] and ICU mortality varies from 63 to 85% (Table 3). These results are far worse than the respective 70% and 62% ICU and hospital survival rates reported in a large observational study of unselected ICU patients requiring MV.…”

“…32 The presence of GvHD strongly impairs outcome, with 1-year survival of 10%. 67 Patients with active GvHD still carry a dismal outcome and MV provides no benefits in these patients. 29,36,37 However, despite these disappointing results, several points deserve to be underlined.…”

“…14 In 1998, Price et al 66 reported a 19% survival rate in patients requiring MV compared with 66% among patients not requiring MV. In a prospective multicenter trial, Bach et al 67 reported in 2001 a baseline probability of death of 82-96% in patients requiring MV, and up to 98-100% if combined with hepatic and renal dysfunction. In the publication of Jackson et al, 68 once again, patients requiring both hemodynamic support and MV had a very poor prognosis.…”

Outcome in critically ill cancer patients: past and present

“…The high mortality of more than 80% in patients requiring mechanical ventilation (Table 1) [8][9][10][11][12][13][14][15] , increasing to more than 90% to 95% in patients developing multiple organ failure or who require renal replacement therapy during ICU stay 12,[16][17][18] , particularly in the transplant setting [19][20][21] , together with the severe emotional burden endured by these patients and their relatives, and the considerable costs of advanced and prolonged life-supporting therapy 13 resulted in a general reluctance to admit such patients to the ICU 2,6,7 . However, over the past few years, several centres throughout the world have been reporting on increasingly improving survival in critically ill patients with hematological malignancies and solid tumors [22][23][24][25][26][27][28][29][30][31] , approaching survival rates reported in general ICU patients 32 .…”

“…For instance, of the 112 patients with hematological malignancies ventilated in our centre > 7 days between 1997 and 2007, 26% survived to hospital discharge and 20% were still alive at 6 months (unpublished data). However, the survival of ventilated allogeneic bone marrow or peripheral stem cell transplantation recipients remains particularly poor [19][20][21] although some improvement has been achieved [36][37][38] . Encouraging results have also been obtained in cancer patients requiring renal replacement therapy for acute renal failure, even in case of multiple organ failure or in combination with ventilatory support [33][34][35][36] .…”