Page 1283 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

890 PART 7: Hematologic and Oncologic Disorders

RELAPSE decision-making process involved in triaging HSCT recipients for ICU
admission should include a clear understanding of the status of the
Although HSCT provides the greatest chance of a cure, it is not a patients’ underlying disease, short- and long-term prognostic factors,
guarantee of a cure and relapse remains one of the most common causes and the patients’ wishes.
of transplant failure and death for both autologous and allogeneic
HSCT. Relapse is the leading cause of death for patients undergoing
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autologous HSCT and is often attributed to the presence of residual dis-
ease, or contamination of the infused stem cell product. Contamination KEY REFERENCES
occurs when cells are collected from the patient with persistent disease, • Afessa B, Azoulay E. Critical care of the hematopoietic stem cell
who was believed to be in remission and the lack of agents effective transplant recipient. Crit Care Clin. 2010;26:133-150.
at purging such stem cells ex vivo prior to reinfusion. Allogeneic • Afessa B, Peters SG. Noninfectious pneumonitis after blood and
HSCT provides “clean” stem cells, and thus the risk of relapse lies with marrow transplant. Curr Opin Oncol. 2008;20:227-233.
residual disease in the patient at time of transplant. Unlike autologous
HSCT, the immune effect—graft-versus-malignancy effect—derived • Afessa B, Tefferi A, Litzow MR, et al. Diffuse alveolar hemorrhage
from the donor’s immune system, which will grow in the patient after in hematopoietic stem cell transplant recipients. Am J Respir Crit
the transplant, probably provides, at least in some patients, protection Care Med. 2002;166:641-645.
against relapse. Thus, failure of autologous transplant is generally due • Clark JG, Hansen JA, Hertz MI, et al. NHLBI workshop summary.
to relapse, while, the proportion of patients, transplanted in remission, Idiopathic pneumonia syndrome after bone marrow transplanta-
who relapse after allogeneic SCT is often significantly less. Patients who tion. Am Rev Respir Dis. 1993;147:1601-1606.
relapse after an autologous HSCT may be considered for a RIC alloge- • Copelan EA. Hematopoietic stem-cell transplantation. N Engl J
neic HSCT if their disease can be controlled and for those who relapse Med. 2006;354:1813-1826.
after allogeneic HSCT, a second transplant is considered on a case-by-
case basis, generally with a RIC regimen to avoid excessive toxicity from • Couriel D, Carpenter PA, Cutler C, et al. Ancillary therapy and
the conditioning. supportive care of chronic graft-versus-host disease: National
Institutes of Health consensus development project on criteria
for clinical trials in chronic graft-versus-host disease: V. Ancillary
GENERAL AND CRITICAL CARE OUTCOMES Therapy and Supportive Care Working Group Report. Biol Blood
IN HSCT RECIPIENTS Marrow Transplant. 2006;12:375-396.
• Ferrara JL, Yanik G. Acute graft versus host disease: pathophysi-
Over the past two decades, the 1-year survival rates after HSCT have ology, risk factors, and prevention strategies. Clin Adv Hematol
generally improved. In 2008, the National Marrow Donor Program Oncol. 2005;3:415-419, 428.
reported the overall survival rate at 1 year for patients <50 years
old undergoing myeloablative allogeneic HSCT for AML, CML, • Filipovich AH, Weisdorf D, Pavletic S, et al. National Institutes of
and MDS as 74% for related donor and 65% for unrelated donor Health consensus development project on criteria for clinical trials
HSCT. The improved survival has been attributed to enhancements in chronic graft-versus-host disease: I. Diagnosis and staging work-
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in HLA-matching techniques resulting in better donor selection, ing group report. Biol Blood Marrow Transplant. 2005;11:945-956.
improved overall patient selection for transplantation, and advances • Giralt S, Bishop MR. Principles and overview of allogeneic hemato-
in supportive care. A major prognostic factor for survival in trans- poietic stem cell transplantation. Cancer Treat Res. 2009;144:1-21.
plants for malignant diseases is the disease status at the time of • Gooley TA, Chien JW, Pergam SA, et al. Reduced mortality after
transplant. The causes of death in the first 100 days post- transplant allogeneic hematopoietic-cell transplantation. N Engl J Med.
mainly relate to the primary disease, GVHD, infection, and end- 2010;363:2091-2101.
organ damage. • Martin PJ, Pavletic SZ. Biology and management of chronic graft-
An analysis of 17 studies (n = 1193 patients) showed an average versus-host disease. Cancer Treat Res. 2009;144:277-298.
short-term mortality rate of 65% in the hospital or within 30 days of
ICU discharge for critically ill adult HSCT recipients. The major- • Pasquini MC, Wang Z. Current use and outcome of hematopoietic
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ity of published reports on ICU outcomes of HSCT patients before stem cell transplantation. CIBMTR Summary Slides. 2010. http://
1995 documented extremely high mortality rates (>90%) for HSCT www.cibmtr.org/ReferenceCenter/SlidesReports/SummarySlides/
recipients requiring mechanical ventilation for respiratory failure. 11,79,80 Documents/SummarySlides_2010-S.pdf.
More recent studies have reported a slight improvement in the out- • Pene F, Aubron C, Azoulay E, et al. Outcome of critically ill
come of mechanically ventilated autologous and allogeneic HSCT allogeneic hematopoietic stem-cell transplantation recipients: a
recipients with survival rates ranging from 18% to 47%. 81-85 In addition reappraisal of indications for organ failure supports. J Clin Oncol.
to enhancements in the transplantation procedure, advances in sup- 2006;24:643-649.
portive therapies for severe sepsis and ARDS are thought to contrib- • Richardson PG, Soiffer RJ, Antin JH, et al. Defibrotide for
ute to the recent improvement in ICU outcomes. In general, HSCT the treatment of severe hepatic veno-occlusive disease and
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recipients who develop severe respiratory failure requiring invasive multiorgan failure after stem cell transplantation: a multicenter,
mechanical ventilation and also develop nonpulmonary organ failure randomized, dose-finding trial. Biol Blood Marrow Transplant.
continue to have a grim prognosis. 7,9,10,12,82,83 2010;16:1005-1017.
Unfortunately, critically ill HSCT patients have not been adequately
represented in studies of various prognostic models to predict the prob- • Rubenfeld GD, Crawford SW. Withdrawing life support from
ability of hospital death, including the latest versions of the Simplified mechanically ventilated recipients of bone marrow trans-
Acute Physiology Score (SAPS), Acute Physiology and Chronic plants: a case for evidence-based guidelines. Ann Intern Med.
86
Health Evaluation (APACHE) IV, and Mortality Prediction Model 1996;125(8):625-633.
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(MPM)-III. More recently, the use of Early Warning Scores (EWS)
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and critical care outreach teams has been shown to improve out-
comes of patients with hematological malignancies including HSCT REFERENCES
recipients. Given the limited ICU resources, it is important that reliable
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prognostication models are developed for this patient population. The Complete references available online at www.mhprofessional.com/hall
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