Changes in intensive care for allogeneic hematopoietic stem cell transplant recipients

Area of Science:

• Hematology
• Critical Care Medicine
• Transplant Immunology

Background:

• Allogeneic hematopoietic stem cell transplant (HSCT) recipients admitted to the intensive care unit (ICU) historically face high mortality.
• Recent trends in ICU utilization and outcomes for these patients remain largely uncharacterized.

Purpose of the Study:

• To evaluate changes in ICU admission patterns and associated outcomes for adult allogeneic HSCT recipients.
• To identify factors influencing 90-day mortality in this patient population over time.

Main Methods:

• Retrospective analysis of 497 adult allogeneic HSCT recipients admitted to three ICUs between 1997 and 2011.
• Comparison of two cohorts: 1997-2003 (n=209) and 2004-2011 (n=288).
• Identification of factors associated with 90-day mortality using statistical analysis.

Main Results:

• The recent cohort (2004-2011) was older, received less intense conditioning, and had greater use of peripheral blood or unrelated-donor grafts.
• ICU admissions in the recent cohort were more frequent for patients in hematological remission and without graft-versus-host disease (GVHD) or invasive fungal infection.
• Despite a stable ICU admission rate, 90-day survival significantly improved in the recent cohort (49% vs. 31%).
• Graft-versus-host disease (GVHD), mechanical ventilation (MV), and renal replacement therapy (RRT) were independent predictors of hospital mortality.
• Survival was notably lower for patients requiring MV or RRT, especially those with GVHD (18% and 6% respectively).

Conclusions:

• Changes in ICU admission practices for allogeneic HSCT recipients have led to improved survival.
• Advanced life support interventions, including mechanical ventilation and renal replacement therapy, offer limited benefit for patients with GVHD.
• Strategic ICU utilization is crucial for optimizing outcomes in critically ill HSCT patients.