Outcome of critically ill allogeneic hematopoietic stem-cell transplantation recipients: a reappraisal of indications for organ failure supports.
OBJECTIVE
Because the overall outcome of critically ill hematologic patients has improved, we evaluated the short-term and long-term outcomes of the poor risk subgroup of allogeneic hematopoietic stem-cell transplantation (HSCT) recipients requiring admission to the intensive care unit (ICU).


METHODS
This was a retrospective multicenter study of allogeneic HSCT recipients admitted to the ICU between 1997 and 2003.


RESULTS
Two hundred nine critically ill allogeneic HSCT recipients were included in the study. Admission in the ICU occurred during the engraftment period (< or = 30 days after transplantation) for 70 of the patients and after the engraftment period for 139 patients. The overall in-ICU, in-hospital, 6-month, and 1-year survival rates were 48.3%, 32.5%, 27.2%, and 21%, respectively. Mechanical ventilation was required in 122 patients and led to a dramatic decrease in survival rates, resulting in in-ICU, in-hospital, 6-month, and 1-year survival rates of 18%, 15.6%, 14%, and 10.6%, respectively. Mechanical ventilation, elevated bilirubin level, and corticosteroid treatment for the indication of active graft-versus-host disease (GVHD) were independent predictors of death in the whole cohort. In the subgroup of patients requiring mechanical ventilation, associated organ failures, such as shock and liver dysfunction, were independent predictors of death. ICU admission during engraftment period was associated with acceptable outcome in mechanically ventilated patients, whereas patients with late complications of HSCT in the setting of active GVHD had a poor outcome.


CONCLUSIONS
Extensive unlimited intensive care support is justified for allogeneic HSCT recipients with complications occurring during the engraftment period. Conversely, initiation or maintenance of mechanical ventilation is questionable in the setting of active GVHD.
Pène
Frédéric
F
Medical Intensive Care Unit, Cochin Hospital, AP-HP, Paris, France. frederic.pene@cch.aphp.fr
Aubron
Cécile
C
Azoulay
Elie
E
Blot
François
F
Thiéry
Guillaume
G
Raynard
Bruno
B
Schlemmer
Benoît
B
Nitenberg
Gérard
G
Buzyn
Agnès
A
Arnaud
Philippe
P
Socié
Gérard
G
Mira
Jean-Paul
JP
D000208:Acute Disease; D000328:Adult; D001663:Bilirubin / Q000097:blood; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness; D005260:Female; D005602:France / Q000453:epidemiology; D006086:Graft vs Host Disease / Q000517:prevention & control; D018380:Hematopoietic Stem Cell Transplantation / Q000009:adverse effects / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D010343:Patient Admission; D011237:Predictive Value of Tests; D012121:Respiration, Artificial; D012189:Retrospective Studies; D012307:Risk Factors; D016019:Survival Analysis; D015996:Survival Rate; D014184:Transplantation, Homologous; D016896:Treatment Outcome
D001663:Bilirubin