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Abdelhay A, Mahmoud A, Mostafa M, Jain T, Elseidy S, Fahmawi S, Alkasem M, Ammari O. Delay in treatment of adult hemophagocytic lymphohistiocytosis is associated with worse in-hospital outcomes. Ann Hematol 2023; 102:2989-2996. [PMID: 37392369 DOI: 10.1007/s00277-023-05271-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/09/2023] [Indexed: 07/03/2023]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening condition characterized by uncontrolled activation of the immune system leading to multiorgan failure. Timely initiation of HLH-specific treatment is believed to be essential and lifesaving. Due to the rarity of the condition in adults, there is no data available in the literature to investigate the effects of treatment delay in this age group. We used data from the National Inpatient Sample (NIS) to evaluate the inpatient practices of HLH treatment initiation over 13 years (2007-2019) and their association with clinically relevant inpatient outcomes. Patients were divided into early treatment group (<6 days) and late treatment group (≥ 6 days). We compared outcomes using multivariate logistic regression models adjusting for age, sex, race, and HLH-triggering conditions. There were 1327 and 1382 hospitalizations in the early and late treatment groups, respectively. Hospitalization in the late treatment group had higher rates of in-hospital mortality (OR 2.00 [1.65-2.43]), circulatory shock (OR 1.33 [1.09-1.63]), requiring mechanical ventilation (OR 1.41 [1.18-1.69]), venous thromboembolism (OR 1.70 [1.27-2.26]), infectious complications (OR 2.24 [1.90-2.64]), acute kidney injury (OR 2.27 [1.92-2.68]), and requiring new hemodialysis (OR 1.45 [1.17-1.81]). Additionally, we observed no significant trend in the mean time to treatment over the study period. This study shows the importance of early initiation of HLH treatment and highlights the adverse outcomes of treatment delay.
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Affiliation(s)
- Ali Abdelhay
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA.
| | - Amir Mahmoud
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Mariam Mostafa
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Tripti Jain
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Sheref Elseidy
- Department of Internal Medicine, Rochester General Hospital, 1425 Portland Avenue, Rochester, NY, 14621, USA
| | - Suhib Fahmawi
- Department of Internal Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Mouaz Alkasem
- School of Medicine, University of Jordan, Amman, Jordan
| | - Omar Ammari
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
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La Marle S, Richard-Colmant G, Fauvernier M, Ghesquières H, Hot A, Sève P, Jamilloux Y. Mortality and Associated Causes in Hemophagocytic Lymphohistiocytosis: A Multiple-Cause-of-Death Analysis in France. J Clin Med 2023; 12:jcm12041696. [PMID: 36836229 PMCID: PMC9967667 DOI: 10.3390/jcm12041696] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 01/26/2023] [Accepted: 02/07/2023] [Indexed: 02/22/2023] Open
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome with an overall mortality rate of 40%. A multiple-cause-of-death analysis allows for the characterization of mortality and associated causes over an extended period. Death certificates, collected between 2000 and 2016 by the French Epidemiological Centre for the Medical Causes of Death (CepiDC, Inserm), containing the ICD10 codes for HLH (D76.1/2), were used to calculate HLH-related mortality rates and to compare them with the general population (observed/expected ratios, O/E). HLH was mentioned in 2072 death certificates as the underlying cause of death (UCD, n = 232) or as a non-underlying cause of death (NUCD, n = 1840). The mean age at death was 62.4 years. The age-standardized mortality rate was 1.93/million person-years and increased over the study period. When HLH was an NUCD, the most frequently associated UCDs were hematological diseases (42%), infections (39.4%), and solid tumors (10.4%). As compared to the general population, HLH decedents were more likely to have associated CMV infections or hematological diseases. The increase in mean age at death over the study period indicates progress in diagnostic and therapeutic management. This study suggests that the prognosis of HLH may be at least partially related to coexisting infections and hematological malignancies (either as causes of HLH or as complications).
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Affiliation(s)
- Solène La Marle
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
| | - Gaëlle Richard-Colmant
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
| | - Mathieu Fauvernier
- Département de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69000 Lyon, France
| | - Hervé Ghesquières
- Département d’Hématologie, Hôpital Lyon Sud—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69495 Lyon, France
| | - Arnaud Hot
- Département de Médecine Interne, Hôpital Edouard Herriot—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69003 Lyon, France
| | - Pascal Sève
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
| | - Yvan Jamilloux
- Département de Médecine Interne, Hôpital de la Croix Rousse—Hospices Civils de Lyon, Université Claude Bernard-Lyon 1, 69002 Lyon, France
- Lyon Immunopathology Federation (LIFE), Université Claude Bernard-Lyon 1, 69000 Lyon, France
- Correspondence: ; Tel.: +33-426-732-636
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Wang D, Tong X, Liu S, Zhang W, Wang L, Zhang S, Zhang T, Wang Q, Fan H. Clinical characteristics and risk factors for 90-day overall survival among 204 adult patients with secondary hemophagocytic lymphohistiocytosis: Experience from a single-center retrospective study. Front Med (Lausanne) 2022; 9:774959. [PMID: 36300188 PMCID: PMC9589347 DOI: 10.3389/fmed.2022.774959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 09/12/2022] [Indexed: 11/22/2022] Open
Abstract
Objectives To describe the clinical characteristics of secondary hemophagocytic lymphohistiocytosis (HLH) among adult patients, investigate its risk factors for 90-day overall survival (OS) from diagnosis, and establish a new prognostic model applicable to adult patients with secondary HLH. Methods We conducted a retrospective cohort study of 204 adult patients with secondary HLH, between January 2010 and December 2020. All patients met at least five HLH-2004 criteria. Clinical features, laboratory results, treatments, and clinical outcomes of the patients were reviewed. Prognostic factors associated with 90-day overall survival from diagnosis were screened using Cox proportional hazard models. Results The most common trigger was malignancy (61.3%). Multivariate analysis showed that age, coagulopathy, levels of hemoglobin, aspartate aminotransferase (AST), lactate dehydrogenase (LDH), creatinine, ferritin, and prothrombin time (PT) were independent prognostic factors for 90-day OS from the diagnosis of HLH. Based on the above risk factors, the patients were further divided into two groups: low-risk (≤4 risk factors) and high-risk (>4 risk factors), with overall 90-day survival rates of 82.7 and 28.1%, respectively (P < 0.001). Conclusion Patients with older age, coagulopathy, lower hemoglobin, and AST levels, elevated LDH, creatinine and ferritin levels, and prolonged PT tended to have a worse prognosis. Moreover, our prognostic model provides the possibility of forecasting the clinical outcome of adult secondary HLH patients, although a larger sample, multicenter, randomized controlled clinical study is needed to verify the accuracy of the prognostic model.
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Affiliation(s)
- Dongguang Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Xiang Tong
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Sitong Liu
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Wentao Zhang
- College of Computer Science, Sichuan University, Chengdu, China
| | - Lian Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Shijie Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Tianli Zhang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Qian Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China
| | - Hong Fan
- Department of Respiratory and Critical Care Medicine, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, China,*Correspondence: Hong Fan
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Lu M, Xie Y, Guan X, Wang M, Zhu L, Zhang S, Ning Q, Han M. Clinical analysis and a novel risk predictive nomogram for 155 adult patients with hemophagocytic lymphohistiocytosis. Ann Hematol 2021; 100:2181-2193. [PMID: 33977332 DOI: 10.1007/s00277-021-04551-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 05/02/2021] [Indexed: 12/16/2022]
Abstract
Recently, more and more attention has been paid on adult hemophagocytic lymphohistiocytosis (HLH), a disease with complicated symptoms and high mortality. In order to analyze the clinical characteristics and prediction risk factors of mortality, we designed a retrospective study with 1-year follow-up and included 155 patients admitted to Tongji Hospital diagnosed as HLH. One hundred seven patients formed the training cohort for nomogram development, and 48 patients formed the validation cohort to confirm the model's performance. All patients' clinical characteristics, laboratory results, medical records, and prognosis were analyzed. Among all the 107 patients in the training cohort, 46 were male and 61 were female, with the median age of 49.0 (IQR 31.0-63.0). The 1-year mortality rate was 43.9% (47/107) and 45.8% (22/48) in the training and validation cohort, respectively. And further multivariate logistic regression analysis in the training cohort showed that male (odds ratio 5.534, 95% CI 1.507-20.318, p = 0.010), altered mental status (11.876, 1.882-74.947, p = 0.008), serum ferritin ≥ 31,381 μg/L (8.273, 1.855-36.883, p = 0.006), and IL-6 ≥ 18.59 pg/mL (19.446, 1.527-247.642, p = 0.022) were independent risk factor of mortality. A nomogram included the four prediction factors mentioned above was also tabled to help clinicians evaluate the probability of poor outcome. Area under the receiver operating characteristic curve (AUROC) analysis, calibration curves, and decision curve analysis (DCA) certify the accuracy and the clinical usefulness of the nomogram. Our research reveals that male, altered mental status, serum ferritin ≥ 31,381 µg/L, and IL-6 ≥ 18.59 pg/mL are four independent predictors for poor prognosis. Doctors should pay more attention to patients with altered mental status, high serum ferritin, and IL-6 level, who have a higher risk of death.
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Affiliation(s)
- Mengxin Lu
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Yanghao Xie
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xiaoxu Guan
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Ming Wang
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Lin Zhu
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shen Zhang
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Qin Ning
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
| | - Meifang Han
- Department and Institute of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Abstract
Hemophagocytic lymphohistiocytosis is a life-threatening condition associated with hyperinflammation and multiple organ dysfunction. It has many causes, symptoms, and outcomes. Early recognition is critical for treatment. Fever, cytopenias, coagulopathy, and hepatosplenomegaly are hallmark findings. Identifying the trigger event is crucial but challenging because of the varied presentations and infrequent provider experience. Diagnostic features include anemia, thrombocytopenia, neutropenia, elevated ferritin, hypertriglyceridemia, hypofibrinogenemia, hemophagocytosis (in bone marrow, spleen, or lymph nodes), low or absent natural killer cells, and elevated soluble interleukin 2 receptor assay. Primary treatment goals are eliminating the underlying trigger and suppressing hyperinflammation with steroids, immunoglobulins, or immunomodulators. Specific treatment includes corticosteroids, etoposide, and antithymocyte globulin followed by hematopoietic stem cell transplantation in patients with refractory or relapsing disease. Prompt immunochemical therapy is essential but often complicated by a high risk of treatment-related morbidity and disease recurrence. Despite these challenges, improvements in diagnostic technology and treatment have enhanced survival.
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Affiliation(s)
- Janice Skinner
- Janice Skinner is Adult Nurse Practitioner, School of Medicine, Department of Medicine Division of Hematology, Johns Hopkins Bayview Medical Center, Sydney Kimmel Cancer Center, 300 Mason Lord Dr, Baltimore MD 21224 . Benedicta Yankey is Nurse Clinician, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland. Brenda K. Shelton is Clinical Nurse Specialist, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Benedicta Yankey
- Janice Skinner is Adult Nurse Practitioner, School of Medicine, Department of Medicine Division of Hematology, Johns Hopkins Bayview Medical Center, Sydney Kimmel Cancer Center, 300 Mason Lord Dr, Baltimore MD 21224 . Benedicta Yankey is Nurse Clinician, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland. Brenda K. Shelton is Clinical Nurse Specialist, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | - Brenda K Shelton
- Janice Skinner is Adult Nurse Practitioner, School of Medicine, Department of Medicine Division of Hematology, Johns Hopkins Bayview Medical Center, Sydney Kimmel Cancer Center, 300 Mason Lord Dr, Baltimore MD 21224 . Benedicta Yankey is Nurse Clinician, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland. Brenda K. Shelton is Clinical Nurse Specialist, Sydney Kimmel Cancer Center, Johns Hopkins University, Baltimore, Maryland
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Dong J, Xie F, Jia L, Li J, Hu Z, Zhu Y, Yu H, Zhao Y, Yao Q, Meng Q. Clinical characteristics of liver failure with hemophagocytic lymphohistiocytosis. Sci Rep 2019; 9:8125. [PMID: 31148551 PMCID: PMC6544643 DOI: 10.1038/s41598-019-43909-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/02/2019] [Indexed: 12/13/2022] Open
Abstract
Liver failure with hemophagocytic lymphohistiocytosis (HLH) is a life-threatening syndrome with high mortality. The aim of this study was to decipher clinical and laboratory characteristics of hemophagocytic lymphohistiocytosis after definite diagnosis of liver failure and to provide clues for early diagnosis and treatment of HLH in patients with liver failure. Eleven patients diagnosed with liver failure and HLH were retrospectively investigated in this study. All patients presented with jaundice, persistent high-grade fever, pancytopenia, splenomegaly, evidence of hemophagocytes in the bone marrow and laboratory abnormalities indicating HLH. The average interval from the earliest diagnosis of liver failure to a definitive diagnosis of HLH was 17.27 days. Six (54.55%) patients died during follow-up. For patients with liver failure after admission and subsequently definitively diagnosed with HLH, bilirubin and INR were significantly decreased. HLH is definitely diagnosed at an intermediate or late stage when patients have already suffered from liver failure. The initial dose of glucocorticoid (methylprednisolone) was decreased to 1-1.5 mg/kg/d and gradually reduced thereafter. In conclusion, for patients with liver failure, HLH should be screened as early as possible upon persistent fever, splenomegaly and unexplained pancytopenia. For patients with liver failure and HLH, the dosage of glucocorticoid should be reduced to avoid serious side effects.
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Affiliation(s)
- Jinling Dong
- Department of Severe Liver Disease Medical Center, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Fang Xie
- Department of Severe Liver Disease Medical Center, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Lin Jia
- Department of Severe Liver Disease Medical Center, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Juan Li
- Department of Severe Liver Disease Medical Center, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Zhongjie Hu
- Department of Severe Liver Disease Medical Center, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Yueke Zhu
- Department of Severe Liver Disease Medical Center, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Hongwei Yu
- Department of Severe Liver Disease Medical Center, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Yujuan Zhao
- Department of Cardiology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qinwei Yao
- Department of Severe Liver Disease Medical Center, Beijing You An Hospital, Capital Medical University, Beijing, China
| | - Qinghua Meng
- Department of Severe Liver Disease Medical Center, Beijing You An Hospital, Capital Medical University, Beijing, China.
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