Abstract
Background Pediatric patients undergoing hematopoietic cell transplantation (HCT) may develop life-threatening complications and need for ICU admission (ICU). They may display more severe and/or unique manifestations of organ dysfunction syndromes, including acute respiratory failure, sepsis and delirium, compared to the general pediatric In this interim analysis of the POEM study, the utility of a p-MODS screening tool as a predictor of endotheliopathies and/or ICU is reported.
Methods: NCT05090345 is a prospective multi-center registry/biorepository trial of children and adolescents/young adults (AYA) undergoing HCT to assess the impact of endotheliopathies on morbidity and mortality. Patients undergoing all HCT types are prospectively monitored for 100 days post-HCT for sinusoidal obstructive syndrome (SOS), thrombotic microangiopathy (TMA), capillary leak syndrome (CLS), diffuse alveolar hemorrhage (DAH) and ICU.
The risk of p-MODS was assessed within 7 days of HCT admission and weekly for 4 weeks, to dynamically evaluate organ function across 8 systems: respiratory, cardiovascular, renal, hepatic, hematologic, neurologic, immune, and gastrointestinal. Each system was graded on a 0–5 scale based on clinical and laboratory parameters, with total pMODS calculated using the worst score per organ. Descriptive statistics were used to compare p-MODS score between groups with “events” (defined as endotheliopathy or ICU) versus “no events”. The “no event” comparison group was matched 1:1 by diagnosis, age, gender and HCT type.
Results: Among all subjects (n=151), the median age was 11.3 (range: 0.2–26.9) years and the majority (64%) male and Caucasian ( 60%) and 20% Black. Most patients (86.8%) underwent allogeneic HCT. Common indications were hematologic malignancy (45%), solid tumors (19%) and hemoglobinopathies (8.6%).Events (n=50) were observed in 35 of 151 patients, including ICU (n=26), SOS (n=19), TMA (n=3) CLS (n=1) and DAH (n=1). Events occurred at a median of 16 (range: –7 to 85) days post-HCT.
Median time to ICU was 15 (range: –7 to 82) days post-HCT. The median pMODS score at the time of ICU was 10 (range: 1–22). All three patients with TMA had preceding ICU admissions and 4 of 19 patients with SOS required ICU management. The median time to onset of endotheliopathy was 17 (range: 6–33) days post-HCT. The median pMODS score at the time of event was 11 (range: 7–18), compared to a median of 8 (range: 5–21) the week prior to onset.
Patients who developed events exhibited progressively higher scores compared to matched controls starting at week 1 (p < 0.05). This difference became more pronounced over time, reaching statistical significance at week 2 (p < 0.001). Since physiologic decline may precede overt events, we next analyzed pMODS score change between Day 0 and week 1. A significant difference was observed with median increase of 2 (range: –2 to 16) in the event group versus 1 (range: –3 to 7) in the control group (p = 0.01).
Analysis of individual organ system scores revealed notable differences between the event and control groups by Week 1, prior to median event onset. The event group had higher rates of indicators of organ dysfunction in 6 of 8 organ system. The event group had more subjects with acute kidney injury, elevated delirium scores, need for respiratory support, increased bilirubin, moderate to significant weight gain and infections. However, rates of neutropenia and lymphopenia were comparable between groups.
Conclusion In this interim analysis, a significant increase in pMODS between Day 0 and week 1 post-HCT may reflect early physiologic decline, with notable changes in respiratory status, acute kidney injury, elevated CAPD scores, and infectious burden. These findings highlight the potential utility of pMODS as an early screening tool to identify pediatric HCT recipients at risk for clinical deterioration. Prospective and dynamic monitoring of pMODS may support timely intervention and improve outcomes in this vulnerable population.
