Originally published as JCO Early Release 10.1200/JCO.2005.03.9073 on December 27 2005

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Outcome of Critically Ill Allogeneic Hematopoietic Stem-Cell Transplantation Recipients: A Reappraisal of Indications for Organ Failure Supports

From the Medical Intensive Care Unit, Cochin Hospital, AP-HP; Medical Intensive Care Unit and Bone Marrow Transplantation Unit, Saint-Louis Hospital, AP-HP; Hematology Department, Necker Hospital, AP-HP; Faculty of Medicine, Paris V-René Descartes University; Faculty of Medicine, Paris VII-Denis Diderot University, Paris; and Intensive Care Unit and Bone Marrow Transplantation Unit, Institut Gustave Roussy, Villejuif, France

Address reprint requests to Frédéric Pène, MD, Service de Réanimation Médicale, Hôpital Cochin, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; e-mail: frederic.pene{at}cch.aphp.fr

PURPOSE: Because the overall outcome of critically ill hematologic patients has improved, we evaluated the short-term and long-term outcomes of the poor risk subgroup of allogeneic hematopoietic stem-cell transplantation (HSCT) recipients requiring admission to the intensive care unit (ICU).

PATIENTS AND METHODS: This was a retrospective multicenter study of allogeneic HSCT recipients admitted to the ICU between 1997 and 2003.

RESULTS: Two hundred nine critically ill allogeneic HSCT recipients were included in the study. Admission in the ICU occurred during the engraftment period ( 30 days after transplantation) for 70 of the patients and after the engraftment period for 139 patients. The overall in-ICU, in-hospital, 6-month, and 1-year survival rates were 48.3%, 32.5%, 27.2%, and 21%, respectively. Mechanical ventilation was required in 122 patients and led to a dramatic decrease in survival rates, resulting in in-ICU, in-hospital, 6-month, and 1-year survival rates of 18%, 15.6%, 14%, and 10.6%, respectively. Mechanical ventilation, elevated bilirubin level, and corticosteroid treatment for the indication of active graft-versus-host disease (GVHD) were independent predictors of death in the whole cohort. In the subgroup of patients requiring mechanical ventilation, associated organ failures, such as shock and liver dysfunction, were independent predictors of death. ICU admission during engraftment period was associated with acceptable outcome in mechanically ventilated patients, whereas patients with late complications of HSCT in the setting of active GVHD had a poor outcome.

CONCLUSION: Extensive unlimited intensive care support is justified for allogeneic HSCT recipients with complications occurring during the engraftment period. Conversely, initiation or maintenance of mechanical ventilation is questionable in the setting of active GVHD.

F.P. and C.A. contributed equally to this work and should both be considered as first authors.

Presented in part at the 46th Annual Meeting of the American Society of Hematology, San Diego, CA, December 4-7, 2004.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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