An update on pulmonary complications of hematopoietic stem cell transplantation

Clinical characteristics of late-onset interstitial pneumonia after allogeneic hematopoietic stem cell transplantation

Non-infectious pulmonary complications after allogeneic hematopoietic stem cell transplantation (HSCT) remain fatal. In particular, information regarding late-onset interstitial lung disease predominantly including organizing pneumonia and interstitial pneumonia (IP) is limited. A retrospective nationwide survey was conducted using data collected from the Japanese transplant outcome registry database from 2005 to 2010. This study focused on patients (n = 73) with IP diagnosed after day 90 post-HSCT. A total of 69 (94.5%) patients were treated with systemic steroids, and 34 (46.6%) experienced improvement. The presence of chronic graft-versus-host disease at the onset of IP was significantly associated with non-improvement of symptoms (odds ratio [OR] 0.35). At the time of last follow-up (median, 1471 days), 26 patients were alive. Of the 47 deaths, 32 (68%) were due to IP. The 3-year overall survival (OS) and non-relapse mortality (NRM) rates were 38.8% and 51.8%, respectively. In the multivariate analysis, the predictive factors for OS were comorbidities at IP onset (hazard ratio [HR]: 2.19) and performance status (PS) score of 2-4 (HR 2.77). Furthermore, cytomegalovirus reactivation requiring early intervention (HR 2.04), PS score of 2-4 (HR 2.63), and comorbidities at IP onset (HR 2.90) were also significantly associated with increased risk of NRM.

Impact of pre-transplant individual comorbidities on risk of ICU admission and survival outcomes following allogeneic hematopoietic stem cell transplantation

Patients undergoing allogeneic hematopoietic stem cell transplantation (allo-hsct) can require intensive care unit (ICU) admission in the post-transplant period. Whereas outcomes of ICU admission are poor, little is known about the pre-transplant risk factors leading to them. We conducted a retrospective analysis to investigate the impact of pre-transplant individual comorbidities on acute inpatient complications, focusing on ICU admission, ventilator support and multi-system organ failure, following allo-hsct. During the initial hospitalization, 33 (11%) patients required ICU admission, 29 (10%) required ventilator support and 33 (11%) developed multi-system organ failure. Risk factors for ICU admission and ventilator support included pre-transplant infection, pre-transplant diabetes, time to neutrophil engraftment, donor type and older transplant decade (2008-2010). Risk factors for multi-system organ failure included pre-transplant diabetes, time to neutrophil engraftment and older transplant decade (2008-2010). For ICU patients, the 60-day and 6-month mortality was 58% and 67%, respectively and the median overall survival was 1.4 months. Patients with diabetes and infection at the time of HSCT and longer time to neutrophil engraftment during transplant are at an increased risk for ICU admission, ventilator support and multi-system organ failure. Patients admitted to the ICU are also at a high risk for mortality leading to poor survival.

High-Dose Busulfan-Fludarabine Conditioning and Low Alveolar Volume as Predictors of Pulmonary Complications after Allogeneic Peripheral Blood Stem Cell Transplantation in Children

This study was conducted to investigate risk factors and predictors of infectious and noninfectious pulmonary complications (PCs) after allogeneic hematopoietic stem cell transplantation in children. We conducted a retrospective analysis of the post-transplantation PCs of 240 patients who underwent allogeneic peripheral blood stem cell transplantation (allo-PBSCT) between 2009 and 2018. Transplantation-related variables, pretransplantation baseline spirometry, body plethysmography, and CO diffusing capacity were analyzed for association with the development of infectious PCs (IPCs) and noninfectious PCs (NIPCs). Compared with the control group, the PC group had statistically significantly lower overall survival (50.6% versus 77.8%; P < .001), higher disease-related mortality (26.6% versus 54.4%; P < .001), and higher nonrelapse mortality (31.6% versus 5.9%; P < .001). A greater number of patients received pretransplantation conditioning with high-dose busulfan (520 mg/m²; Bu 520) and fludarabine (160 mg/m²; Flu 160) in both the IPC and NIPC groups. In the multivariate Cox hazard regression analysis, Bu 520 significantly increased the risk of NIPCs (hazard ratio [HR], 1.99; 95% confidence interval [CI], 1.13 to 3.49; P = .016), and Flu 160 was a predictor of IPCs (HR, 1.99; 95% CI, 1.13 to 3.49; P = .016). The Bu 520 + Flu 160 regimen was associated with a statistically significant increase in the risk of NIPC (HR, 1.92; 95% CI, 1.09 to 3.37; P = .023). In a multivariate analysis using pretransplantation baseline lung function, alveolar volume (VA) grades 3 and 4 and lung function score (LFS) VA categories III and IV were associated with increased risk for both IPCs and NIPCs. Our data identify receipt of the high-dose Bu-Flu conditioning regimen as an independent risk factor for NIPCs after allo-PBSCT. Impaired CO diffusing capacity before transplantation, especially VA reduction, contributes to the risk of post-transplantation pulmonary complications, and pretransplantation risk can be estimated by grading the degree of insufficiency of VA and LFS VA.

Association between early corticosteroid administration and long-term survival in non-infectious pulmonary complications after allogeneic hematopoietic stem cell transplantation

Non-infectious pulmonary complications (NIPCs) after allogeneic hematopoietic stem cell transplantation (HSCT) are associated with poor outcomes. It is important to maximize the effectiveness of primary treatment because secondary treatment has not been established. We analyzed data from 393 patients who underwent allogeneic HSCT during a 10-year period. Thirty-seven were diagnosed with NIPCs, which consisted of idiopathic pneumonia syndrome, bronchiolitis obliterans, and interstitial lung disease including cryptogenic organizing pneumonia. Among these, 18 died (Dead group) while 19 remained alive (Alive group) during the study period. The median time between NIPC diagnosis and first administration of ≥ 1 mg/kg/day corticosteroids (prednisolone dose equivalent) was significantly longer in the Dead group than the Alive group, at 9 days versus 4 days (p = 0.01). We further divided these cases into those who received prednisolone within seven days and after 8 days. We found that the ≤ 7 days group were more likely to survive after their NIPC diagnosis compared to the ≥ 8 days group (p = 0.06). Our analysis showed that early initiation of corticosteroid therapy is associated with long-term survival in NIPCs.

Mesenchymal stromal cells as treatment for acute respiratory distress syndrome. Case Reports following hematopoietic cell transplantation and a review

Acute respiratory distress syndrome (ARDS) is a life-threatening lung disease. It may occur during the pancytopenia phase following allogeneic hematopoietic cell transplantation (HCT). ARDS is rare following HCT. Mesenchymal stromal cells (MSCs) have strong anti-inflammatory effect and first home to the lung following intravenous infusion. MSCs are safe to infuse and have almost no side effects. During the Covid-19 pandemic many patients died from ARDS. Subsequently MSCs were evaluated as a therapy for Covid-19 induced ARDS. We report three patients, who were treated with MSCs for ARDS following HCT. Two were treated with MSCs derived from the bone marrow (BM). The third patient was treated with MSCs obtained from the placenta, so-called decidua stromal cells (DSCs). In the first patient, the pulmonary infiltrates cleared after infusion of BM-MSCs, but he died from multiorgan failure. The second patient treated with BM-MSCs died of aspergillus infection. The patient treated with DSCs had a dramatic response and survived. He is alive after 7 years with a Karnofsky score of 100%. We also reviewed experimental and clinical studies using MSCs or DSCs for ARDS. Several positive reports are using MSCs for sepsis and ARDS in experimental animals. In man, two prospective randomized placebo-controlled studies used adipose and BM-MSCs, respectively. No difference in outcome was seen compared to placebo. Some pilot studies used MSCs for Covid-19 ARDS. Positive results were achieved using umbilical cord and DSCs however, optimal source of MSCs remains to be elucidated using randomized trials.

Characteristics of lower respiratory tract microbiota in the patients with post-hematopoietic stem cell transplantation pneumonia

Background

Pneumonia is a leading cause of non-relapse mortality after hematopoietic stem cell transplantation (HSCT), and the lower respiratory tract (LRT) microbiome has been proven to be associated with various respiratory diseases. However, little is known about the characteristics of the LRT microbiome in patients with post-HSCT compared to healthy controls (HC) and community-acquired pneumonia (CAP).

Methods

Bronchoalveolar lavage samples from 55 patients with post-HSCT pneumonia, 44 patients with CAP, and 30 healthy volunteers were used to detect microbiota using 16S rRNA gene sequencing.

Results

The diversity of the LRT microbiome significantly decreased in patients with post-HSCT pneumonia, and the overall community was different from the CAP and HC groups. At the phylum level, post-HSCT pneumonia samples had a high abundance of Actinobacteria and a relatively low abundance of Bacteroidetes. The same is true for non-survivors compared with survivors in patients with post-HSCT pneumonia. At the genus level, the abundances of Pseudomonas, Acinetobacter, Burkholderia, and Mycobacterium were prominent in the pneumonia group after HSCT. On the other hand, gut-associated bacteria, Enterococcus were more abundant in the non-survivors. Some pathways concerning amino acid and lipid metabolism were predicted to be altered in patients with post-HSCT pneumonia.

Conclusions

Our results reveal that the LRT microbiome in patients with post-HSCT pneumonia differs from CAP patients and healthy controls, which could be associated with the outcome. The LRT microbiota could be a target for intervention during post-HSCT pneumonia.

Mesenchymal stromal cell treatment improves outcomes in children with pneumonia post-hematopoietic stem cell transplantation: a retrospective cohort study

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) is a standard therapy strategy for most malignant disorders in children. However, transplant-related pneumonia remains a major therapy challenge and mesenchymal stromal cells (MSCs) are rarely reported in HSCT-related pneumonia. The aim of our study was to assess the efficacy of MSC for HSCT-related pneumonia in children.

METHODS

We retrospectively retrieved HSCT-related (severe and non-severe) pneumonia cases (aged < 18 years), which underwent MSC treatment (MSC group) or non-MSC treatment (non-MSC group) in Guangzhou Women and Children's Medical Center, from December 2017 to December 2019. We investigated outcomes of the two different treatments among severe cases and non-severe cases, respectively. The primary endpoints were differences in overall cure rate and time to cure between MSC and non-MSC groups. The secondary endpoints were 180-day overall survival and cumulative cure rate.

RESULTS

Finally, 31 severe pneumonia cases (16 in MSC group, 15 in non-MSC group) and 76 non-severe cases (31 in MSC group, 45 in non-MSC group) were enrolled in this study. Among severe pneumonia cases, overall cure rate in MSC group was significant higher than that in non-MSC group (12[75.0%] vs. 5[33.3%]; OR = 6.00, 95% CI [1.26-28.5]; p = 0.020); the time (days) to cure in MSC group was dramatically reduced compared with that in non-MSC group (36 [19-52] vs. 62 [42-81]; OR = 0.32, 95% CI [0.12-0.88]; p = 0.009); the 180-day overall survival in MSC group was better than that in non-MSC group (74.5% [45.4-89.6] vs. 33.3% [12.2-56.4]; p = 0.013). Among non-severe pneumonia cases, the time (days) to cure in MSC group was notably decreased compared with that in non-MSC group (28 [24-31] vs. 33 [26-39]; OR = 0.31, 95% CI [0.18-0.56]; p = 0.003). Compared with non-MSC group, MSC-treated patients achieved significant improvements of cumulative cure rate not only in severe pneumonia cases (p = 0.027), but also in non-severe cases (p < 0.001).

CONCLUSIONS

This study revealed that MSC treatment could contribute to improving outcomes in children with pneumonia post-HSCT, especially in severe cases. These findings suggest MSC treatment as a promising therapy for HSCT-related pneumonia in children.

Case report: atrial septostomy as a bridge to lung transplantation in a patient with venovenous extracorporeal membrane oxygenation

INTRODUCTION

Advances in critical care management have led to the recent increase in the use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (LT). Patients with respiratory failure requiring venovenous ECMO usually experience progressive right ventricular (RV) failure. Diagnosis and treatment of RV failure during ECMO are essential for improving the prognosis of patients.

PATIENT CONCERNS

A 28-year-old female patient underwent allogeneic hematopoietic stem cell transplantation (HSCT) from a matched unrelated donor for acute myeloid leukemia presenting with progressive dyspnea.

DIAGNOSES

Computed tomography revealed multifocal patchy peribronchial and subpleural ground-glass opacities in both lungs, and the patient was clinically diagnosed with cryptogenic organizing pneumonia.

INTERVENTIONS AND OUTCOMES

Despite intensifying systemic corticosteroid therapy, her symptoms deteriorated, and mechanical ventilation and ECMO were applied. During treatment, her respiratory failure continued to progress, and systemic hypotension developed. An echocardiogram showed evidence of RV failure, and percutaneous atrial septostomy was performed for RV decompression. After a balloon atrial septostomy was performed, RV failure of the patient improved, and LT was successfully performed.

LESSONS

We report the first case of atrial septostomy as a successful bridge to LT in a HSCT recipient with venovenous ECMO. Atrial septostomy could be an option for management of RV failure during ECMO. Further studies need to be conducted to validate the effect of atrial septostomy in patients with RV failure during ECMO.

Incidence, economic burden, and treatment of acute respiratory tract infection in hematopoietic stem cell transplantation recipients using real world data in Japan: a retrospective claims data analysis

AIMS

Acute respiratory tract infections (ARTIs) are common in hematopoietic stem cell transplantation (HSCT) recipients, however, data is limited regarding epidemiology and economic burden of ARTI in HSCT recipients in Japan. We evaluated the incidence of ARTI in HSCT recipients, associated economic burden, and ARTI-related treatments post-HSCT.

MATERIALS AND METHODS

Patients receiving HSCT between July 2017 and December 2018, and those enrolled in the JMDC Claims Database for ≥6 months before index month (month when latest medical procedure code of HSCT recorded) were included. The outcomes included demographics, ARTI incidence, healthcare resource utilization (HCRU), direct costs, and ARTI-related treatments.

RESULTS

In 330 analyzed patients, the ARTI incidence rate was 85.5% during total follow-up, consisting of post-HSCT hospitalization of mean 2.1 months and post-discharge periods of mean 17.6 months (post-HSCT hospitalization: 44.8%; post-discharge: 77.6%). For ARTI vs non-ARTI patients during post-HSCT hospitalization, length of hospitalization was significantly longer (mean [SD] months; 2.40 [1.73] vs 1.84 [1.09]; p = 0.0004), and median cost was significantly higher (JPY; 6,250,120.00 vs 4,774,570.00; p = 0.0096). The cost of outpatient visits during post-discharge periods, drug-related and non-drug-related costs of outpatient visits were generally higher for ARTI vs non-ARTI patients. In ARTI vs non-ARTI patients, utilization of any symptom relievers (decongestants, antitussives, and antipyretics), bronchodilators, immunoglobulin G, antibiotics, antivirals, and oxygen supply were numerically higher during post-HSCT hospitalization and post-discharge periods. The proportion of patients and mean prescription days for immunosuppressants during post-HSCT hospitalization were higher in ARTI vs non-ARTI patients.

LIMITATIONS

This administrative claims study lacks clinical data and contains only direct medical costs. Patients were retained if they had at least 1 month of enrollment post-HSCT.

CONCLUSIONS

In HSCT recipients, ARTI leads to substantial incremental HCRU and direct costs for management in real-world settings in Japan.

Age-Related Disease Risks in Younger versus Older B-Cell Non-Hodgkin's Lymphoma Survivors

BACKGROUND

Younger cancer survivors may develop age-related diseases due to the cancer treatment that they undergo. The aim of this population-based study is to estimate incidence of age-related diseases besides cardiovascular disease among younger versus older B-cell non-Hodgkin's lymphoma (B-NHL) survivors compared with their respective general population cohorts.

METHODS

Survivors of B-NHL were diagnosed between 1997 and 2015 from the Utah Cancer Registry. Using the Utah Population Database, up to 5 cancer-free individuals from the general population were matched with a B-NHL survivor on sex, birth year, and state of birth. Hazard ratios (HR) for age-related disease outcomes, which were identified from medical records and statewide health care facility data, were estimated using Cox Proportional Hazards models for B-NHL survivors diagnosed at <65 years versus ≥65 years at least 5 years since B-NHL diagnosis.

RESULTS

Comparing 2,129 B-NHL survivors with 8,969 individuals from the general population, younger B-NHL survivors had higher relative risks of acute renal failure [HR, 2.24; 99% confidence interval (CI), 1.48-3.39; P heterogeneity = 0.017), pneumonia (HR, 2.42; 99% CI, 1.68-3.49; P heterogeneity = 0.055), and nutritional deficiencies (HR, 2.08; 99% CI, 1.48-2.92; P heterogeneity = 0.051) ≥5 years after cancer diagnosis.

CONCLUSION

Younger B-NHL survivors had higher relative risks of acute renal failure, pneumonia, and nutritional deficiencies than older B-NHL survivors compared with their respective general population cohorts, ≥5 years after cancer diagnosis.

Pulmonary Complications After Pediatric Stem Cell Transplant

The number of disorders that benefit from hematopoietic stem cell transplantation (HSCT) has increased, causing the overall number of HSCT to increase accordingly. Disorders treated by HSCT include malignancy, benign hematologic disorders, bone marrow failure syndromes, and certain genetic diagnoses. Thus, understanding the complications, diagnostic workup of complications, and subsequent treatments has become increasingly important. One such category of complications includes the pulmonary system. While the overall incidence of pulmonary complications has decreased, the morbidity and mortality of these complications remain high. Therefore, having a clear differential diagnosis and diagnostic workup is imperative. Pulmonary complications can be subdivided by time of onset and whether the complication is infectious or non-infectious. While most infectious complications have clear diagnostic criteria and treatment courses, the non-infectious complications are more varied and not always well understood. This review article discusses pulmonary complications of HSCT recipients and outlines current knowledge, gaps in knowledge, and current treatment of each complication. This article includes some adult studies, as there is a significant paucity of pediatric data.

Pretransplant Risk Factors Can Predict Development of Acute Respiratory Distress Syndrome after Hematopoietic Stem Cell Transplantation

Rationale: Acute respiratory distress syndrome (ARDS) is a common complication after hematopoietic stem cell transplantation (HCT) and is a major contributor to nonrelapse mortality. Objectives: To better understand pretransplant risk factors for developing ARDS after HCT. Methods: This is a single-center observational study comparing risk factors for ARDS development in 164 patients who went on to develop post-HCT ARDS compared with 492 patients who did not. The patients were matched 1 to 3 on age, sex, type of transplant (allogeneic vs. autologous), and underlying disease. Pertinent risk factors were analyzed separately in multivariable conditional logistic regression after adjustment for a priori variables known to be associated with ARDS development. Results: Patients with ARDS were more likely to have a lower pretransplant pulmonary function as measured by forced vital capacity (FVC) (odds ratio [OR], 0.54 [0.42-0.70] per liter increase in FVC; P < 0.001), forced expiratory volume in one second (FEV₁) (OR, 0.52 [0.38-0.71] per liter increase in FEV₁; P < 0.001) and diffusing capacity (OR, 0.92 [0.88-0.96] per ml/min/mm Hg increase in diffusing capacity; P < 0.001). Several laboratory indices were predictive of subsequent ARDS development including elevated AST (aspartate aminotransferase) (OR, 1.01 [1.00-1.01]; P < 0.008), lower serum albumin (OR, 0.44 [0.30-0.66]; P < 0.001), lower pretransplant hemoglobin (OR, 0.82 [0.73-0.92]; P = 0.001), and lower leukocyte count (OR, 0.88 [0.79-0.99]; P < 0.03). Patients who went on to develop ARDS were more likely to have been hospitalized in the year before the transplant (OR, 1.11 [1.04-1.20]; P = 0.003), and required invasive or noninvasive ventilation during that hospitalization. Lastly, patients with ARDS were significantly more likely to have received carboplatin, thalidomide, methotrexate, and cisplatin than the non-ARDS control subjects. Conclusions: Several risk factors for developing ARDS after HCT are identifiable at the time of transplantation, well before the development of critical illness and ARDS. The identification of risk factors long before ARDS develops is relatively unique to the HCT population. Further work is needed to develop usable risk prediction tools in this setting.

Characteristics and Outcome of Periengraftment Respiratory Distress Syndrome after Autologous Hematopoietic Cell Transplant

Rationale: The periengraftment respiratory distress syndrome (PERDS) is an early important cause of morbidity following autologous hematopoietic cell transplantation (HCT). There are few contemporary data describing PERDS. Objectives: To determine prevalence, risk factors, and outcomes of PERDS after autologous HCT. Methods: This was a historical cohort study of adults undergoing autologous HCT at Mayo Clinic, Rochester, Minnesota, between 2005 and 2016. PERDS was defined as 1) respiratory failure requiring supplemental oxygen within 5 days on either side of the neutrophil engraftment date, 2) new pulmonary opacities on chest imaging, and 3) exclusion of an infectious or cardiac etiology to explain the clinical presentation. Results: Of 3,473 patients undergoing autologous HCT, 167 (4.8%) developed PERDS. Radiographic changes preceded engraftment in 77% of cases. In a multivariable regression model, risk factors for PERDS included female sex (odds ratio [OR], 1.73; P = 0.001), the number of preengraftment platelet transfusions (OR, 1.22; P = 0.002), and more rapid engraftment (OR, 0.72 per day longer; P < 0.001). PERDS cases were more likely to be admitted to the intensive care unit (47.3% vs. 9.5%, P < 0.001) and require intubation (20.4% vs. 1.6%, P < 0.001). In an adjusted 100-day death analysis, those diagnosed with PERDS were more likely to die (hazard ratio, 3.1; 95% confidence interval, 1.5-6.2; P = 0.002). Conclusions: PERDS is a common complication of autologous HCT and is associated with increased mortality and healthcare use. Radiographic evidence of pulmonary involvement precedes hematopoietic recovery. A larger number of platelet transfusions and more rapid engraftment appear to increase risk for PERDS.

Major pulmonary complications following Hematopoietic stem cell transplantation: What the pulmonologist needs to know

Hematopoietic stem cell transplantation (HSCT) is used for treatment of a myriad of both malignant and non-malignant disorders. However, despite many advances over the years which have resulted in improved patient mortality, this subset of patients remains at risk for a variety of post-transplant complications. Pulmonary complications of HSCT are categorized into infectious and non-infectious and occur in up to one-third of patients undergoing HSCT. Infectious etiologies include bacterial, viral and fungal infections, each of which can have significant mortality if not identified and treated early in the course of infection. Advances in the diagnosis and management of infectious complications highlight the importance of non-infectious pulmonary complications related to chemoradiation toxicities, immunosuppressive drugs toxicities, and graft-versus-host disease. This report aims to serve as a guide and clinical update of pulmonary complications following HSCT for the general pulmonologist who may be involved in the care of these patients.

A Pilot Study of RNA Sequencing to Improve the Diagnostic Yield of Bronchoalveolar Lavage Specimens in Pediatric Allogeneic Hematopoietic Stem Cell Transplant Recipients

BACKGROUND

Pulmonary complications often cause morbidity and mortality in pediatric allogeneic hematopoietic stem cell transplant (HSCT) recipients. While detection of infection and initiation of appropriate antimicrobial therapy improves survival, present techniques oftentimes do not detect infections in bronchoalveolar lavage (BAL) samples because of pretreatment with antimicrobial therapies and the need for a priori knowledge of likely viral pathogens, decreasing the yield of BAL.

OBJECTIVE

We evaluated whether RNA-based massively parallel sequencing (MPS) would improve detection of infections in BAL fluid in pediatric allogeneic HSCT recipients.

RESULTS

Nine patients underwent 10 BAL (1 patient underwent 2 BAL) and had sufficient BAL fluid for inclusion in this study. Clinical microbiological testing identified infections in 7 patients, and MPS identified infections in 5 patients, although some of these detected organisms were not detected by clinical testing. Results were fully concordant in 5 patients, fully discordant in 3 patients, and partially discordant in 2 patients. Bacterial, viral, and fungal infections were detected via both techniques.

CONCLUSION

This suggests that MPS in conjunction with routine clinical testing increases the yield of detection of infectious organisms in the BAL fluid.

Predictors of a short hospitalization in bone marrow transplantation patients presenting to the emergency department

BACKGROUND

Despite the advantages of bone marrow transplantation (BMT), patients receiving this intervention visit the emergency department (ED) frequently and for various reasons. Many of those ED visits result in hospitalization, and the length of stay varies.

OBJECTIVES

The objective of our study was to identify the patients who were only briefly hospitalized and were thus eligible for safe discharge from the ED.

METHODS

This was a retrospective cohort study conducted on all adult patients who have completed a successful BMT and had an ED visit that resulted in hospitalization.

RESULTS

Our study included 115 unique BMT with a total number of 357 ED visits. Around half of those visits resulted in a short hospitalization. We found higher odds of a short hospitalization among those who have undergone autologous BMT (95%CI [1.14-2.65]). Analysis of the discharge diagnoses showed that patients with gastroenteritis were more likely to have a shorter hospitalization in comparison to those diagnosed with others (95%CI [1.10-3.81]). Furthermore, we showed that patients who presented after a month from their procedure were more likely to have a short hospitalization (95%CI [1.04-4.87]). Another significant predictor of a short of hospitalization was the absence of Graft versus Host Disease (GvHD) (95%CI [2.53-12.28]). Additionally, patients with normal and high systolic blood pressure (95%CI [2.22-6.73] and 95%CI [2.81-13.05]; respectively), normal respiratory rate (95%CI [2.79-10.17]) and temperature (95%CI [2.91-7.44]) were more likely to have a shorter hospitalization, compared to those presenting with abnormal vitals. Likewise, we proved higher odds of a short hospitalization in patients with a quick Sepsis Related Organ Failure Assessment score of 1-2 (95%CI [1.29-5.20]). Moreover, we demonstrated higher odds of a short hospitalization in patients with a normal platelet count (95%CI [1.39-3.36]) and creatinine level (95%CI [1.30-6.18]).

CONCLUSION

In our study, we have shown that BMT patients visit the ED frequently and many of those visits result in a short hospitalization. Our study showed that patients presenting with fever/chills are less likely to have a short hospitalization. We also showed a significant association between a short hospitalization and BMT patients without GvHD, with normal RR, normal T °C and a normal platelet count.

Utility of Bronchoscopy with Bronchoalveolar Lavage among Hematologic Transplant Recipients in the Era of Noninvasive Testing

BACKGROUND

Pulmonary complications are common among hematologic stem cell transplant (HSCT) recipients. Their evaluation can be pursued through bronchoscopy with bronchoalveolar lavage (BAL) and a variety of available noninvasive studies, which include newer molecular markers for detecting a variety of infectious agents.

OBJECTIVE

The objective of this study is to evaluate the diagnostic yield of BAL among HSCT patients relative to the yield of noninvasive testing.

METHOD

This is a retrospective analysis of HSCT recipients who underwent both BAL and noninvasive testing at a cancer center in 2013 and 2014.

RESULTS

There were 210 diagnostic results among 98 HSCT recipients. There were 84 unique findings on noninvasive testing that were not evident on BAL, and 36 unique findings on BAL that were not evident on noninvasive testing. Noninvasive testing tended to yield bacterial and viral infections more commonly, while BAL yielded mycobacterial isolates more commonly.

CONCLUSION

While both noninvasive testing and BAL are helpful in this population, each appeared more precise than the other with individual lung diseases. Bronchoscopy with BAL and noninvasive testing should be considered complementary strategies in the workup of pulmonary complications among HSCT patients.

Lung Function Predicts Outcome in Children With Obstructive Lung Disease After Hematopoietic Stem Cell Transplantation

Obstructive lung disease (OLD) that develops after hematopoietic stem cell transplantation (HSCT) has a significant impact on morbidity and mortality. We investigated the role of pulmonary function tests (PFTs) in the prediction of prognosis of OLD in children who have undergone HSCT. We retrospectively reviewed 538 patients who underwent allogenic HSCT in the Department of Pediatrics, Seoul St. Mary's Hospital, South Korea, from April 2009 to July 2017. OLD was identified on PFTs or chest computed tomography scans obtained from 3 months after HSCT onwards. OLD developed after HSCT in 46 patients (28 male individuals, median age: 11.2 y). The group that developed OLD with an unfavorable prognosis (n=23) had a lower forced vital capacity (FVC) (% of predicted, 78.53±24.00 vs. 97.71±16.96, P=0.01), forced expiratory volume in 1 second (FEV1) (% of predicted, 52.54±31.77 vs. 84.44±18.59, P=0.00), FEV1/FVC (%, 59.28±18.68 vs. 79.94±9.77, P=0.00), and forced expiratory flow at 25% to 75% of forced vital capacity (FEF25-75) (% of predicted, 30.95±39.92 vs. 57.82±25.71, P=0.00) at diagnosis than the group that developed OLD with a favorable prognosis (n=23). The group that developed OLD with an unfavorable prognosis had significant reductions in FVC, FEV1, FEV1/FVC, and FEF25-75 at 2 years after diagnosis. Children who develop OLD with an unfavorable prognosis after HSCT already have poor lung function at the time of diagnosis. Additional treatment should be considered in patients who develop OLD after HSCT according to their PFTs at diagnosis.

Clinical characteristics and outcomes of bone marrow transplantation patients presenting to the ED of a tertiary care center

BACKGROUND

Bone marrow transplantation is a breakthrough in the world of hematology and oncology. In our region, there is scarce literature studying emergency department visits among BMT patients, as well as their predictors of mortality.

OBJECTIVES

This study aimed to assess the frequency, reasons, clinical characteristics and outcomes of patients presenting to the ED after a BMT, and to study the predictors of mortality in those patients. This study also compares those variables among the different types of BMT.

METHODS

This was a retrospective cohort study conducted on all adult patients who have completed a successful BMT and visited the ED.

RESULTS

Our study included 115 BMT patients, of whom 17.4% died. Those who died had a higher median number of ED visits than those who did not die. Around 36.5% presented with fever/chills with 29.6% diagnosed with pneumonia on discharge. We found that the odds of mortality were significantly higher among those who presented with dyspnea (p < .0005) and AMS (p = .023), among septic patients (p = .001), those who have undergone allogeneic BMT (p = .037), and those who were admitted to the ICU (p = .002). Moreover, the odds of mortality were significantly higher among hypotensive (p ≤0005) and tachycardic patients (p = .015).

CONCLUSION

In our study, we have shown that BMT patients visit the ED very frequently and have high risk of in-hospital mortality. Moreover, our study showed a significant association between mortality and patients with dyspnea, AMS, sepsis, allogeneic BMT type, ICU admission, hypotension and tachycardia.

Noninfectious pulmonary complications of haematopoietic stem cell transplantation

Haematopoietic stem cell transplantation (HSCT) is an established treatment for a variety of malignant and nonmalignant conditions. Pulmonary complications, both infectious and noninfectious, are a major cause of morbidity and mortality in patients who undergo HSCT. Recent advances in prophylaxis and treatment of infectious complications has increased the significance of noninfectious pulmonary conditions. Acute lung injury associated with idiopathic pneumonia syndrome remains a major acute complication with high morbidity and mortality. On the other hand, bronchiolitis obliterans syndrome is the most challenging chronic pulmonary complication facing clinicians who are taking care of allogeneic HSCT recipients. Other noninfectious pulmonary complications following HSCT are less frequent. This review provides a clinical update of the incidence, risk factors, pathogenesis, clinical characteristics and management of the main noninfectious pulmonary complications following HSCT.

Noninfectious pulmonary complications following haematopoietic stem cell transplantation is a major cause of morbidity and mortality in this patient population. There are recent advances in the diagnosis and management of these conditions.http://bit.ly/2FgsIYG

Acute and Chronic Respiratory Failure in Cancer Patients

In 2016, there was an estimated 1.8 million new cases of cancer diagnosed in the United States. Remarkable advances have been made in cancer therapy and the 5-year survival has increased for most patients affected by malignancy. There are growing numbers of patients admitted to intensive care units (ICU) and up to 20% of all patients admitted to an ICU carry a diagnosis of malignancy. Respiratory failure remains the most common reason for ICU admission and remains the leading causes of death in oncology patients. There are many causes of respiratory failure in this population. Pneumonia is the most common cause of respiratory failure, yet there are many causes of respiratory insufficiency unique to the cancer patient. These causes are often a result of immunosuppression, chemotherapy, radiation treatment, or hematopoietic stem cell transplant (HCT). Treatment is focused on supportive care and specific therapy for the underlying cause of respiratory failure. Noninvasive modalities of respiratory support are available; however, careful patient selection is paramount as indiscriminate use of noninvasive positive pressure ventilation is associated with a higher mortality if mechanical ventilation is later required. Historically, respiratory failure in the cancer patient had a grim prognosis. Outcomes have improved over the past 20 years. Survivors are often left with significant disability.

Identifying risk factors associated with worse outcomes in adolescents and young adults undergoing hematopoietic stem cell transplantation

BACKGROUND

Adolescents and young adults (AYAs) undergoing allogeneic hematopoietic stem cell transplantation (HSCT) have unique risk factors and poor outcomes when compared to children, but this population has not been well studied. A hematopoietic stem cell transplantation-comorbidity index (HCT-CI) has been developed in adults to help predict outcomes, yet this index does not seem suitable for a younger population. Therefore, we sought to examine the prevalence of various risk factors in AYAs undergoing allogeneic HSCT and determine which factors had the greatest impact on overall survival (OS) and treatment-related mortality (TRM).

PROCEDURES

This was accomplished by retrospectively collecting data on 241 patients who received their first allogeneic HSCT at UCLA between 2005 and 2015. We investigated the effect of multiple predictors using the Cox proportional hazards model and Fine and Gray competing risk model for OS and TRM, respectively.

RESULTS

Our results showed that AYAs undergoing allogeneic HSCT had poor outcomes, with 5-year OS and NRM of 48% and 30%, respectively. We demonstrated that compared to a baseline model, the addition of the HCT-CI did not improve its ability to predict OS, while substituting individual comorbidities, that is, an unweighted comorbidity score, resulted in significant improvement in model performance. The factors associated with inferior outcomes were used to develop an AYA-specific risk score.

CONCLUSIONS

The comorbidities included in the HCT-CI as well as additional risk factors seen in younger populations need to be studied in prospective studies with the goal of validating and refining a risk score specific to AYA patients undergoing allogeneic HSCT.

Pulmonary Infection Within 100 Days After Transplantation Impaired Platelet Recovery in Patients with Hematologic Malignancies: A Propensity-Score-Matched Analysis

Background

Pulmonary infection is one of the life-threatening complications occurring during allogeneic hematopoietic stem cell transplantation (alloHSCT), even when prophylactic measures have been employed. Few studies have investigated whether pulmonary infection affects platelet recovery during alloHSCT.

Material/Methods

We retrospectively reviewed 253 consecutive patients with hematologic diseases who received alloHSCT in our institute. Among them, 62 patients (25%) had pulmonary infection within 100 days after alloHSCT. Using the one-to-two propensity-score matching logistic model, 50 patients with pulmonary infection and 100 patients without were included based on age, disease and stage, time from diagnosis to transplantation, infused CD34⁺ cells, and mononuclear cells.

Results

The incidences of prolonged thrombocytopenia in patients with pulmonary infection were 44% (22/50) and 9% (9/100) in the corresponding matched group (P<0.001). The mean time for platelet engraftment in patients with and without pulmonary infection were 19.29±13.96 days and 13.94±4.12 days (P=0.012), respectively. Multivariable logistic regression showed that pulmonary infection was an independent risk factor for impaired platelet recovery (OR: 5.335, 95% CI: 2.735–10.407, P<0.001). Impaired platelet recovery was associated with shorter survival and higher treatment-related mortality.

Conclusions

Our results indicate that patients with pulmonary infection within 100 days after alloHSCT are more likely to suffer from impaired platelet recovery and have inferior long-term survival.

Bronchoalveolar lavage with pediatric flexible fibreoptic bronchoscope in pediatric haematopoietic stem cell transplant patients: Nursing considerations for operative complications

PURPOSE

Bronchoalveolar lavage (BAL) with pediatric flexible fibreoptic bronchoscopy (FB) is used for diagnostic and therapeutic purposes in pediatric haematopoietic stem cell transplant (HSCT) patients with pulmonary complications. The aim of our study was to evaluate complications in pediatric HSCT patients undergoing BAL/FB and to explore the nursing emphases on complications.

DESIGN AND METHODS

We performed a retrospective, case-controlled study to evaluate perioperative complications of HSCT children. BAL/FB was conducted for 42 children with HSCT who experienced pulmonary complications between January 2017 and January 2018 within a tertiary hospital. Forty patients diagnosed with general pneumonia were randomly selected during the same period and served as the control group. We analyzed the signs and symptoms of all patients and compared the operative complications between the two groups. Furthermore, we presented the methods used to manage complications.

RESULTS

The presence of cough, lung rales, and imaging findings in the HSCT patients was significantly different from that of the control group (p < 0.0001). The complication rate was 66.67% (28/42) in the HSCT group and 22.5% (9/40) in the control group, and the difference was significant (p < 0.0001). Twelve out of 42 HSCT patients experienced airway mucosal bleeding (28.57%), and six had transient fever (14.29%). The topical use of epinephrine diluted saline (1:10,000) was highly effective for controlling airway mucosal bleeding without causing fluctuations in blood pressure.

PRACTICE IMPLICATIONS

There were more perioperative complications in the HSCT patients than in the general pneumonia patients who underwent BAL/FB. Airway mucosal bleeding was a key focus of perioperative nursing in HSCT patients undergoing bronchoscopy as main complication. BAL with the use of epinephrine diluted saline (1:10,000) effectively decreased airway mucosal bleeding.

Whole blood RNA sequencing reveals a unique transcriptomic profile in patients with ARDS following hematopoietic stem cell transplantation

BACKGROUND

The acute respiratory distress syndrome (ARDS) is characterized by the acute onset of hypoxemia and bilateral lung infiltrates in response to an inciting event, and is associated with high morbidity and mortality. Patients undergoing allogeneic hematopoietic stem cell transplantation (HSCT) are at increased risk for ARDS. We hypothesized that HSCT patients with ARDS would have a unique transcriptomic profile identifiable in peripheral blood compared to those that did not undergo HSCT.

METHODS

We isolated RNA from banked peripheral blood samples from a biorepository of critically ill ICU patients. RNA-Seq was performed on 11 patients with ARDS (5 that had undergone HSCT and 6 that had not) and 12 patients with sepsis without ARDS (5 that that had undergone HCST and 7 that had not).

RESULTS

We identified 687 differentially expressed genes between ARDS and ARDS-HSCT (adjusted p-value < 0.01), including IFI44L, OAS3, LY6E, and SPATS2L that had increased expression in ARDS vs. ARDS-HSCT; these genes were not differentially expressed in sepsis vs sepsis-HSCT. Gene ontology enrichment analysis revealed that many differentially expressed genes were related to response to type I interferon.

CONCLUSIONS

Our findings reveal significant differences in whole blood transcriptomic profiles of patients with non-HSCT ARDS compared to ARDS-HSCT patients and point toward different immune responses underlying ARDS and ARDS-HSCT that contribute to lung injury.

Current Approach to Non-Infectious Pulmonary Complications of Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation is an established treatment for patients with a wide range of malignant and nonmalignant conditions. Noninfectious pulmonary complications still remain a leading cause of morbidity and mortality in these patients. Treating hematopoietic stem cell transplantation recipients with noninfectious pulmonary complications is still challenging, and the current treatment armamentarium and strategies are not adequate for patients receiving hematopoietic stem cell transplantation. Further trials are needed for a better description of the pathogenesis and the complete diagnostic criteria as well as for the development of effective therapeutic approaches for the management of noninfectious pulmonary complications of the hematopoietic stem cell transplantation. This review outlines the incidence, risk factors, pathogenesis, and clinical spectrum and discusses the current approaches to the management of noninfectious pulmonary complications of Hematopoietic stem cell transplantation.

Respiratory failure in the hematopoietic stem cell transplant recipient

The number of patients receiving hematopoietic stem cell transplantation (HSCT) is rapidly rising worldwide. Despite substantial improvements in peri-transplant care, pulmonary complications resulting in respiratory failure remain a major contributor to morbidity and mortality in the post-transplant period, and represent a major barrier to the overall success of HSCT. Infectious complications include pneumonia due to bacteria, viruses, and fungi, and most commonly occur during neutropenia in the early post-transplant period. Non-infectious complications include idiopathic pneumonia syndrome, peri-engraftment respiratory distress syndrome, diffuse alveolar hemorrhage, pulmonary veno-occlusive disease, delayed pulmonary toxicity syndrome, cryptogenic organizing pneumonia, bronchiolitis obliterans syndrome, and post-transplant lymphoproliferative disorder. These complications have distinct clinical features and risk factors, occur at differing times following transplant, and contribute to morbidity and mortality.

Characteristics and Clinical Outcomes of Critically Ill Cancer Patients Admitted to Korean Intensive Care Units

Background

The objective of this study was to investigate the characteristics and clinical outcomes of critically ill cancer patients admitted to intensive care units (ICUs) in Korea.

Methods

This was a retrospective cohort study that analyzed prospective collected data from the Validation of Simplified Acute Physiology Score 3 (SAPS3) in Korean ICU (VSKI) study, which is a nationwide, multicenter, and prospective study that considered 5,063 patients from 22 ICUs in Korea over a period of 7 months. Among them, patients older than 18 years of age who were diagnosed with solid or hematologic malignancies prior to admission to the ICU were included in the present study.

Results

During the study period, a total of 1,762 cancer patients were admitted to the ICUs and 833 of them were deemed eligible for analysis. Six hundred fifty-eight (79%) had solid tumors and 175 (21%) had hematologic malignancies, respectively. Respiratory problems (30.1%) was the most common reason leading to ICU admission. Patients with hematologic malignancies had higher Sequential Organ Failure Assessment (12 vs. 8, P<0.001) and SAPS3 (71 vs. 69, P<0.001) values and were more likely to be associated with chemotherapy, steroid therapy, and immunocompromised status versus patients with solid tumors. The use of inotropes/vasopressors, mechanical ventilation, and/or continuous renal replacement therapy was more frequently required in hematologic malignancy patients. Mortality rates in the ICU (41.7% vs. 24.6%, P<0.001) and hospital (53.1% vs. 38.6%, P=0.002) were higher in hematologic malignancy patients than in solid tumor patients.

Conclusions

Cancer patients accounted for one-third of all patients admitted to the studied ICUs in Korea. Clinical characteristics were different according to the type of malignancy. Patients with hematologic malignancies had a worse prognosis than did patients with solid tumor.

Clinicopathologic characteristics of secondary squamous cell carcinoma of head and neck in survivors of allogeneic hematopoietic stem cell transplantation for hematologic malignancies

The risk of late complications including secondary malignancies is increased in long-term survivors of allogeneic hematopoietic stem cell transplants (HSCT). There is limited literature on the biological behavior and clinical features of squamous cell carcinoma (SCC) of head and neck post-HSCT. We present the clinical and pathologic characteristics on six patients who were diagnosed with SCC while in remission following an allogeneic HSCT. Median follow-up was 8 years. Five patients (83%) developed SCC of tongue and one developed esophageal SCC. Five patients had oral chronic graft-versus-host disease (cGvHD). The conventional risk factors of alcohol, tobacco, and human papillomavirus were absent. The most common presenting finding was the new-onset focal oral pain and ulcerated plaques clinically indistinguishable from a flare of their oral cGvHD lesions. We demonstrated that the SCC in three patients was of donor origin.

Characteristics and outcome of patients presenting to the emergency department after autologous/allogeneic stem cell transplantation

INTRODUCTION

Hematopoietic stem cell transplantations are still associated with a high risk of complications. Here, we characterize patients after autologous or allogeneic transplantation presenting to the emergency department and investigate factors associated with patients' outcome after hospitalization.

METHODS

Patients who had previously undergone autologous or allogeneic stem cell transplantation were included in this study and data were collected retrospectively. We analyzed patients' characteristics and outcome, and identified factors associated with outcome.

RESULTS

A total of 35% of presenting autologous and 52% of allogeneic patients were hospitalized for more than 7 days. In-hospital mortality was 4% (autologous) and 11% (allogeneic patients). In patients with a history of autologous transplantation, multivariate analysis indicated radiologic signs of pneumonia as an independent factor associated with the endpoint 'hospitalization of more than 7 days' (P<0.001). Furthermore, in multivariate analysis, C-reactive protein levels greater than 5 mg/l (P=0.006), low hemoglobin (P=0.002), and radiologic signs of pneumonia (P=0.004) were associated independently with an increase in the endpoint 'total duration of hospitalization'. In patients with a history of allogeneic transplantation, multivariate analysis indicated radiologic signs of pneumonia (P<0.001) and graft-versus-host-disease (P=0.006) to be associated independently with the endpoint 'hospitalization of more than 7 days'. Furthermore, radiologic signs of pneumonia were associated independently with the endpoints 'ICU treatment' (P<0.001), the 'total duration of hospitalization' (P<0.001), and 'in-hospital mortality' (P=0.002). A low platelet count was associated independently with an increase in the endpoint 'duration of hospitalization' (P=0.001).

CONCLUSION

Radiologic signs of pneumonia were associated independently with worse clinical outcomes including hospitalization, the need for ICU treatment, and death.

Etanercept for the Treatment of Transplantation-Related Lung Injury After Hematopoietic Stem Cell Transplantation

Although some data suggest favorable outcomes with use of etanercept for treatment of transplantation-related lung injury, concerns, such as development of new infections, still exist. The objective of this study was to describe the usage of etanercept at our institution and to evaluate the efficacy and safety of etanercept for this indication. Adult patients receiving at least one dose of etanercept for the treatment of pulmonary complications in patients after hematopoietic stem cell transplant from January 2005 to December 2010 were retrospectively evaluated. Outcomes included hospital mortality, incidence of new infection after etanercept administration, and time from administration of first dose of etanercept to infection. Seventeen patients who received etanercept at our institution from January 2005 to December 2010 were included. Four patients (24%) survived their hospital stay, and 3 patients (18%) were alive at both 100 days and 1 year from the initiation of etanercept therapy. Four patients (24%) developed at least one confirmed new infection after the initiation of etanercept therapy. Both moderate and long-term survival in our cohort was low. Caution and careful assessment of the risks and benefits of therapy should be taken before initiation of etanercept for transplantation-related lung injury.

Acute Respiratory Failure After Hematopoietic Stem Cell Transplantation

Infectious and noninfectious pulmonary complications are common among HSCT recipients and are the leading cause for respiratory failure requiring mechanical ventilation and ICU admission. Unique pulmonary syndromes include peri-engraftment respiratory distress syndrome, diffuse alveolar hemorrhage, and idiopathic pneumonia syndrome. Respiratory failure requiring mechanical ventilation after HSCT continues to be associated with a poor prognosis.

Protein dysregulation in graft versus host disease

Allogeneic hematopoietic stem cell transplantation is a well-established treatment for many malignant and non-malignant hematological disorders. As a frequent complication in up to 50% of all patients, graft-versus-host disease is still the main cause for morbidity and non-relapse mortality. Diagnosis is usually done clinically, even though confirmation by pathology is often used to support the clinical findings. Effective treatment requires intensified immunosuppression as early as possible. Although several promising biomarkers have been proposed for an early diagnosis, no internationally-recognized consensus has yet been established. Protein-based biomarkers represent an interesting tool since they have been recently reported to be an important regulator of various cells, including immune cells such as T cells. Therefore, we assume that protein dysregulation is important in the pathogenesis of acute graft versus host disease and their detection might be an possibility in the early diagnosis and monitoring. In this review, we aim to summarize the previous reports of protein biomarkers, focusing on the pathogenesis of the disease and possible implications in diagnostic approaches.

Role of thymoglobulin in matched sibling allogeneic hematopoietic stem cell transplantation with busulfan and fludarabine conditioning in myeloid malignanicies

In vivo T-cell depletion using anti-thymocyte globulin (ATG) is widely used in allogeneic hematopoietic stem cell transplantation (HSCT) for prophylaxis of GvHD. We investigated the influence of thymoglobulin dose (an ATG) on GvHD following matched sibling donor (MSD) HSCT with a busulfan and fludarabine preparative regimen. Medical records of 180 patients who received MSD HSCT with a conditioning regimen of busulfan, fludarabine, and ATG (BuFluATG) were reviewed retrospectively. The median age was 53 years (range 18-68). Initial diagnoses were acute myeloid leukemia (73.3%) and myelodysplastic syndrome (26.7%). Forty-four and 68 patients (24.4 and 37.7%) experienced acute and chronic GvHD of any grade, respectively. High-dose (⩾4.5 mg/kg) ATG was independently associated with decreased risk of acute GvHD (hazard ratio=0.36, 95% confidence interval (CI): 0.15-0.84, P=0.019) compared to low-dose ATG (<4.5 mg/kg). Although ATG dose was associated with the risk of acute GvHD, it was not associated with the risk of chronic GvHD in our study. A higher dose (⩾4.5 mg/kg) of ATG decreases the risk of acute GvHD but had no significant impact on disease-free survival in MSD HSCT patients conditioned with BuFluATG. The optimal dose of ATG should be further investigated in a large prospective study context.

Epidemiology of Acute Respiratory Distress Syndrome Following Hematopoietic Stem Cell Transplantation

OBJECTIVES

Pulmonary complications are common following hematopoietic stem cell transplantation. Numerous idiopathic post-transplantation pulmonary syndromes have been described. Patients at the severe end of this spectrum may present with hypoxemic respiratory failure and pulmonary infiltrates, meeting criteria for acute respiratory distress syndrome. The incidence and outcomes of acute respiratory distress syndrome in this setting are poorly characterized.

DESIGN

Retrospective cohort study.

SETTING

Mayo Clinic, Rochester, MN.

PATIENTS

Patients undergoing autologous and allogeneic hematopoietic stem cell transplantation between January 1, 2005, and December 31, 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were screened for acute respiratory distress syndrome development within 1 year of hematopoietic stem cell transplantation. Acute respiratory distress syndrome adjudication was performed in accordance with the 2012 Berlin criteria. In total, 133 cases of acute respiratory distress syndrome developed in 2,635 patients undergoing hematopoietic stem cell transplantation (5.0%). Acute respiratory distress syndrome developed in 75 patients (15.6%) undergoing allogeneic hematopoietic stem cell transplantation and 58 patients (2.7%) undergoing autologous hematopoietic stem cell transplantation. Median time to acute respiratory distress syndrome development was 55.4 days (interquartile range, 15.1-139 d) in allogeneic hematopoietic stem cell transplantation and 14.2 days (interquartile range, 10.5-124 d) in autologous hematopoietic stem cell transplantation. Twenty-eight-day mortality was 46.6%. At 12 months following hematopoietic stem cell transplantation, 89 patients (66.9%) who developed acute respiratory distress syndrome had died. Only 7 of 133 acute respiratory distress syndrome cases met criteria for engraftment syndrome and 15 for diffuse alveolar hemorrhage.

CONCLUSIONS

Acute respiratory distress syndrome is a frequent complication following hematopoietic stem cell transplantation, dramatically influencing patient-important outcomes. Most cases of acute respiratory distress syndrome following hematopoietic stem cell transplantation do not meet criteria for a more specific post-transplantation pulmonary syndrome. These findings highlight the need to better understand the risk factors underlying acute respiratory distress syndrome in this population, thereby facilitating the development of effective prevention strategies.

Characteristics and Outcome of Patients After Allogeneic Hematopoietic Stem Cell Transplantation Treated With Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome

OBJECTIVES

The acute respiratory distress syndrome is a frequent condition following allogeneic hematopoietic stem cell transplantation. Extracorporeal membrane oxygenation may serve as rescue therapy in refractory acute respiratory distress syndrome but has not been assessed in allogeneic hematopoietic stem cell transplantation recipients.

DESIGN

Multicenter, retrospective, observational study.

SETTING

ICUs in 12 European tertiary care centers (Austria, Germany, France, and Belgium).

PATIENTS

All allogeneic hematopoietic stem cell transplantation recipients treated with venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome between 2010 and 2015.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Thirty-seven patients, nine of whom underwent noninvasive ventilation at the time of extracorporeal membrane oxygenation initiation, were analyzed. ICU admission occurred at a median of 146 (interquartile range, 27-321) days after allogeneic hematopoietic stem cell transplantation. The main reason for acute respiratory distress syndrome was pneumonia in 81% of patients. All but one patient undergoing noninvasive ventilation at extracorporeal membrane oxygenation initiation had to be intubated thereafter. Overall, seven patients (19%) survived to hospital discharge and were alive and in remission of their hematologic disease after a follow-up of 18 (range, 5-30) months. Only one of 24 patients (4%) initiated on extracorporeal membrane oxygenation within 240 days after allogeneic hematopoietic stem cell transplantation survived compared to six of 13 (46%) of those treated thereafter (p < 0.01). Fourteen patients (38%) experienced bleeding events, of which six (16%) were associated with fatal outcomes.

CONCLUSIONS

Discouraging survival rates in patients treated early after allogeneic hematopoietic stem cell transplantation do not support the use of extracorporeal membrane oxygenation for acute respiratory distress syndrome in this group. On the contrary, long-term allogeneic hematopoietic stem cell transplantation recipients otherwise eligible for full-code ICU management may be potential candidates for extracorporeal membrane oxygenation therapy in case of severe acute respiratory distress syndrome failing conventional measures.

Critical Care Prognosis and Outcomes in Patients with Cancer

Advances in cancer treatment and patient survival are associated with increasing number of these patients requiring intensive care. Over the last 2 decades, there has been a steady improvement in the outcomes of critically ill patients with cancer. This review provides data on the use of the intensive care unit (ICU) and short and long-term outcomes of critically ill patients with cancer, the ICU system practices that influence patients outcomes, and the role of the different clinical variables in predicting the prognosis of these patients.

Critical care of patients with cancer

Answer questions and earn CME/CNE The increasing prevalence of patients living with cancer in conjunction with the rapid progress in cancer therapy will lead to a growing number of patients with cancer who will require intensive care treatment. Fortunately, the development of more effective oncologic therapies, advances in critical care, and improvements in patient selection have led to an increased survival of critically ill patients with cancer. As a consequence, critical care has become an important cornerstone in the continuum of modern cancer care. Although, in many aspects, critical care for patients with cancer does not differ from intensive care for other seriously ill patients, there are several challenging issues that are unique to this patient population and require special knowledge and skills. The optimal management of critically ill patients with cancer necessitates expertise in oncology, critical care, and palliative medicine. Cancer specialists therefore have to be familiar with key principles of intensive care for critically ill patients with cancer. This review provides an overview of the state-of-the-art in the individualized management of critically ill patients with cancer. CA Cancer J Clin 2016;66:496-517. © 2016 American Cancer Society.

Lower Respiratory Tract Infections

This review will focus on the infectious etiologies and more common noninfectious causes of lower respiratory tract syndromes among major immunosuppressed populations. The changing epidemiology of infections in the era of highly active antiretroviral therapy (HAART) in the case of HIV-positive patients and the impacts of both newer immune-suppressant therapies and anti-infective prophylaxis for other immunocompromised hosts will be discussed, with emphasis on diagnostic approaches and practice algorithms.

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

The outcome of allogeneic hematopoietic stem cell transplantation (allo-HSCT) patients has significantly improved over the past decade. Still, a significant number of patients require intensive care unit (ICU) management because of life-threatening complications. Literature from the 1990s reported extremely poor prognosis for critically ill allo-HSCT patients requiring ICU management. Recent data justify the use of ICU resources in hematologic patients. Yet, allo-HSCT remains an independent variable associated with mortality. However, outcomes in allo-HSCT patients have improved over time and many classic determinants of mortality have become irrelevant. The main actual prognostic factors are the need for mechanical ventilation, the presence of GvHD and the number of organ failures at ICU admission. Recently, the development of reduced-intensity conditioning regimens, early ICU admission and the increased use of noninvasive ventilation, combined with time effect and general advances in hematology, in allo-HSCT procedures and in ICU management have contributed to improve general outcome. A rational policy of ICU admission triage in these patients is very hard to define, as each decision for ICU admission is a case-by-case decision at patient bedside. The collaboration between hematologists and intensivists is crucial in this context.

Major Pulmonary Complications After Hematopoietic Stem Cell Transplant

Both autologous and allogeneic hematopoietic stem cell transplants are important therapeutic options for several benign and malignant disorders. Pulmonary complications, although they have become less frequent, remain a significant cause of morbidity and mortality after hematopoietic stem cell transplant. These complications range from bacterial, fungal, and viral pulmonary infections to noninfectious conditions such as diffuse alveolar hemorrhage and idiopathic pneumonia syndrome. Bronchiolitis obliterans syndrome is the primary chronic pulmonary complication, and treatment of this condition remains challenging. This report highlights the advances in the diagnosis and management of the major pulmonary complications after hematopoietic stem cell transplant. It also underscores the need for prospective and multicenter research to have a better understanding of the mechanisms behind these complications and to obtain more effective diagnostic tool and therapeutic options.