Predictive mortality scale in AML-associated neutropenic enterocolitis: A systematic review of the literature

Neutropenic enterocolitis (NE) is a severe complication in immunocompromised patients, especially those with acute myeloid leukemia (AML) receiving intensive chemotherapy treatment. Despite medical advances, NE continues to be associated with a high mortality rate, particularly when its diagnosis and treatment are delayed. The present study aimed to identify the risk factors linked to mortality in patients with NE and develop a predictive scale for optimizing clinical decisions.

A systematic review was conducted in accordance with the PRISMA 2020 guidelines and included 24 clinical studies (n = 1,172). Factors associated with in-hospital mortality were identified through odds ratio (OR) and relative risk (RR), with a 95% confidence interval (CI), and bivariate statistical tests, such as the chi-square and Fisher's exact tests (p < 0.05). A predictive scale was constructed based on said factors. A meta-analysis was carried out, using the DerSimonian and Laird random effects model for evaluating granulocyte colony-stimulating factor (G-CSF) as a protective factor, with heterogeneity (I²) and leave-one-out sensitivity tests. Quality of evidence was evaluated using the GRADE system.

The overall mortality rate was 23.6%. The identified predictors of greater mortality were profound neutropenia, comorbidities, concomitant infection, admission to the intensive care unit, late diagnosis, age ≥60 years, and absence of G-CSF use. The meta-analysis yielded a combined OR of 0.68 (95% CI 0.62-0.72; I² = 0 %) in favor of G-CSF use. Factors with no statistical significance or affected by indication bias, such as surgery or cytarabine, were excluded. The resulting scale stratifies patients into four risk categories, with estimated mortality rates of ≤10%, 11-30%, 31-50%, and >50%.

An exploratory mortality risk scale for patients with NE and AML, constructed from aggregate data and systematic evidence, is presented herein. Even though it yielded statistical robustness and clinical plausibility, the scale should not be employed for making clinical decisions until it has been prospectively validated in independent cohorts with multivariate adjustment.