Prevention of acute pulmonary edema after bone marrow transplantation

Risk factors and outcome of pulmonary complications after autologous hematopoietic stem cell transplant

BACKGROUND

Most reports addressing pulmonary complications (PCs) in hematopoietic stem cell transplant (HSCT) recipients have focused on allogeneics. This study describes the PCs, their risk factors, and the impact on mortality in autologous recipients.

METHODS

We reviewed the medical records of 1,243 adult autologous HSCT recipients. We collected pretransplant and posttransplant data and data on PC after transplant and long-term mortality.

RESULTS

Four hundred eighty-seven PC developed in 343 patients (27.6%): 173 infectious (13.9%), 127 noninfectious (10.2%), and 43 both infectious and noninfectious (3.5%). Bacterial, fungal, and viral pneumonias were the most common infectious complications. The main noninfectious complications were acute pulmonary edema (APE) (59 [4.7%]), diffuse alveolar hemorrhage (DAH) (26 [2.1%]), peri-engraftment respiratory distress syndrome (PERDS) (31 [2.5%]), and idiopathic pneumonia syndrome (IPS) (12 [1.0%]). Independent factors associated with PC included diffusing capacity of lung for carbon monoxide and indications for transplant. Factors associated with mortality included sex, history of pulmonary disease, disease status at the time of transplant, FVC, Karnofsky score, and underlying diagnosis. A Cox proportional hazards regression model with separate time-dependent predictors for the first 1 month, 1 to 2 months, 2 to 6 months, and 6 or more months showed an association with mortality at hazard ratios (HRs) of 32.39, 10.13, 4.29, and 0.98, respectively, compared with persons without PC.

CONCLUSIONS

More than 25% of autologous HSCT recipients develop PCs within 1 year of transplant. Most of the complications are infections. The most common noninfectious complications are APE, DAH, PERDS, and IPS. PCs increase the risk of death, with HR as high as 32.

Predictors and outcome of acute kidney injury in patients with acute myelogenous leukemia or high-risk myelodysplastic syndrome

BACKGROUND

: Acute kidney injury (AKIis a common complication in the treatment of patients with acute myelogenous leukemia (AML) or high-risk myelodysplastic syndrome (HR-MDS), but, to the authors' knowledge, its clinical relevance has not been detailed to date. The objective of the current study was to identify the incidence, predictors, and outcome for AKI in patients with AML and HR-MDS.

METHODS

: Data were analyzed from 537 patients with AML or HR-MDS undergoing induction chemotherapy from 1999 to 2007. Predictors for AKI were identified by logistic regression. Eight-week mortality of patients was estimated by the Kaplan-Meier method stratified by the RIFLE criteria, a novel multilevel classification system for AKI based on the percent rise in serum creatinine from baseline (Risk, >50%; Injury, >100%; and Failure, >200% or requiring dialysis).

RESULTS

: A total of 187 patients (36%) developed AKI. Significant independent risk factors for AKI included the following: age >/=55 years (odds ratio [OR], 1.8), mechanical ventilation (OR, 16), use of vancomycin (OR, 2.3), diuretics (OR, 3.0), amphotericin B lipid formulation (OR, 2.7), vasopressors (OR, 4.9), leukopenia (OR, 1.9), hypoalbuminemia (OR, 1.4), and use of non-fludarabine-based chemotherapy (OR, 2.7). The 8-week mortality rates were 3.8%, 13.6%, 19.6%, and 61.7% for the non-RIFLE, Risk, Injury, and Failure categories, respectively. Patients requiring dialysis (8%) had a median survival of 33 days. Survival of patients who achieved complete remission was favorable, regardless of degree of AKI.

CONCLUSIONS

: The RIFLE classification for AKI appears to have prognostic utility in predicting mortality in patients with AML or HR-MDS. Relatively mild elevations in creatinine are associated with higher mortality. Strategies to avoid nephrotoxic drugs or fluid overload may be of benefit. Cancer 2010. (c) 2010 American Cancer Society.

Pre-engraftment syndrome in hematopoietic stem cell transplantation

The clinical findings of fever and skin rash with or without evidence of fluid retention, which mimic engraftment syndrome, have been observed during the pre-engraftment period in patients undergoing hematopoietic stem cell transplantation. In order to characterize this newly observed clinical syndrome called pre-engraftment syndrome (pES), we retrospectively analyzed the clinical records of 50 patients. Three out of 14 patients (23.1%) who underwent cord blood stem cell transplantation developed non-infectious fever, skin rash, and tachypnea 4-15 days prior to neutrophil engraftment. Two patients spontaneously recovered with fluid restriction and oxygen inhalation. One patient died of a complicated pulmonary hemorrhage in spite of aggressive supportive therapy and steroid treatment. Four out of 23 patients (17.4%) who underwent allogeneic bone marrow transplantation developed non-infectious fever and skin rash 4 to 5 days prior to neutrophil engraftment. All four of these patients recovered with only steroid treatment. These characteristic findings were not observed in patients who had undergone autologous peripheral blood stem cell transplantation. Interestingly, the speed of neutrophil engraftment was significantly faster for the patients suffering from pre-engraftment syndrome. The close observation and further pathophysiological research are required to better understand this syndrome.

Non-infectious pulmonary complications after bone marrow transplantation

Bone marrow transplantation (BMT) is a successful and recognised treatment option for patients with a number of haematological and non-haematological malignant and non-malignant conditions. Pulmonary complications both infectious and non-infectious are common after BMT. Multiple factors are thought to contribute to pulmonary complications, including the type and duration of immunological defects produced by the underlying disease and treatment, the development of graft-versus-host disease (GVHD), and the conditioning regimens employed. These complications are classified as early or late, depending on whether they occur before or after 100 days from transplantation. Early non-infectious pulmonary complications typically include pulmonary oedema, upper airway complications, diffuse alveolar haemorrhage, cytolytic thrombi, and pleural effusion. Bronchiolitis obliterans, veno-occlusive disease, and secondary malignancies occur late after BMT. Idiopathic pneumonia syndrome, GVHD, and radiation induced lung injury can occur in early or late period after BMT.

Bone marrow transplantation: issues for critical care nurses

Bone marrow transplantation (BMT) is becoming a wide used therapeutic modality in the field of cancer care. Offering long-term disease-free survival in more than half of some patients with previously fatal diseases, this therapy has challenged clinicians to reevaluate critical care management strategies for such patients. Critical illness occurs in approximately one third of allogeneic transplants, necessitating that critical care nurses be familiar with this therapy and its reported complications. Critical care nurses are an integral part of producing the reported cure and remission rates, despite significant complications. In this article, the authors outline the common critical care problems of this patient population. The chronologic format enables the practitioner to correlate and differentiate key characteristics of potential complications. A case study, with clinical symptoms representing several potential etiologies, demonstrates the application of these concepts. Through the use of nursing knowledge of the unique needs of these patients, there is the potential to continue to improve patient outcomes.

Opportunistic pneumonia

Patients with abnormalities in their immune defense mechanisms are frequently encountered in the practice of medicine. These patients have increased susceptibility to infections that often involve the lung. Many of these infections are caused by opportunistic organisms that typically do not produce disease in individuals with a normally functioning immune system. To complicate the evaluation of these patients, they frequently develop noninfectious lung disease, which can have a radiographic appearance that is similar to infection. The purpose of this article is to present an approach to the evaluation of chest radiographic abnormalities in the immunocompromised patient with suspected pneumonia. Clinical information that is pertinent in the evaluation of immunocompromised patients is discussed. The various chest radiographic patterns seen in both infectious and noninfectious diseases that occur in the immunocompromised patient are reviewed. Integration of clinical information and radiographic findings in the development of a list of differential diagnoses is stressed.