Abstract 147

Background:

Hematopoietic cell transplantation – specific comorbidity index (HCT-CI) based on pre-transplant comorbidities was shown to be predictive of survival and non-relapse mortality in patients undergoing allogeneic stem cell transplantation (ASCT). We assessed HCT-CI as a predictive instrument for survival in patients admitted to intensive care unit (ICU) early after ASCT.

Methods:

Patients older than 18 who were admitted to ICU between the preparative regimen initiation and post-transplant day 100 were included. Demographics, pre-transplant comorbidities, disease characteristics, transplant data, dates of transplantation, ICU admission, and last follow-up were gathered from institutional registries. Reason for ICU transfer, date and survival status at the time of hospital discharge were gathered from individual medical records. HCT-CI scores were calculated as previously described by Sorror et al. Patients who were transferred to a hospice and died within 7 days of the transfer were considered to have died in the hospital for the purpose of current analyses.

Results:

Of 3039 patients who underwent ASCT between June 2001 and December 2011 at MD Anderson Cancer Center, 377 patients (12%) were transferred to ICU within 100 days of the transplant. Disease and transplant characteristics of the patients are demonstrated in the Table. The most common reasons for ICU transfer were respiratory failure (n=230), septic shock (n=44), altered mental status (n=33), hemorrhage (excluding intracranial, n=28), and arrhythmias (n=20). Median age was 53 years with a range of 19–80. The most common pre-transplant comorbidities were pulmonary in 302 (80%) and cardiac in 73 patients (19%). Overall 240 patients (64%) died in the hospital. A comprehensive logistic regression model demonstrated HCT-CI score ≥3 to be associated with a higher risk of death in the hospital (Table). Patients with myeloproliferative diseases and those admitted to ICU during the preparative regimen had less risk of dying in the hospital while those who received ablative regimens had an increased risk. One-year overall survival (OS) rates were 22%, 16%, 16%, and 10% among patients with HCT-CI scores of 0–1, 2, 3, and ≥4, respectively. A Cox proportional hazards model demonstrated HCT-CI score of ≥4 to be a poor prognostic factor on OS (HR: 1.72, 95% CI: 1.21–2.44). The only other significant prognostic factor on OS was the age.

Conclusion:

Overall prognosis in patients who are transferred to ICU within 100 days of ASCT is poor. HCT-CI score could aid clinicians to identify the worst-to-perform patients within this population.

VariableNDied in hospital (%)OR*95% CI for ORMedian OS (days)HR†95% CI for HR
Age at transplant        
    <=55 221 139 (63) 1.00 — 37 1.00 — 
    >55 156 101 (65) 1.19 0.74–1.92 28 1.27 1.00–1.61 
Diagnosis        
    Acute leukemia/MDS 194 127 (65) 1.00 — 33 1.00 — 
    Lymphoma 123 80 (65) 0.94 0.56–1.57 32 1.01 0.79–1.30 
    Myeloproliferative disease 30 14 (47) 0.41 0.18–0.96 93.5 0.78 0.51–1.19 
    Multiple myeloma 13 9 (69) 1.29 0.36–4.68 14 1.51 0.83–2.75 
    Other 17 10 (59) 1.19 0.39–3.61 48 1.05 0.59–1.87 
Transplant period at ICU admission        
    During preparative regimen 13 2 (15) 0.15 0.03–0.66 126 0.59 0.31–1.14 
    Pre-engraftment 127 81 (64) 1.00 0.59–1.69 38 1.06 0.81–1.38 
    Post-engraftment 237 157 (66) 1.00 — 28 1.00 — 
Graft type        
    Peripheral blood 224 140 (63) 1.00 — 32 1.00 — 
    Umbilical cord 42 31 (74) 1.73 0.63–4.71 37.5 1.25 0.78–1.98 
    Bone marrow 111 69 (62) 1.18 0.67–2.07 38 1.06 0.80–1.39 
HLA match status        
    Mismatch 100 66 (66) 1.00 — 34.5 1.00 — 
    Match 277 174 (63) 1.11 0.59–2.07 34 0.95 0.70–1.28 
Donor relation        
    Unrelated 224 144 (64) 1.00 — 38 1.00 — 
    Related 153 96 (63) 0.96 0.58–1.60 26 1.06 0.82–1.36 
Conditioning dose intensity        
    Reduced intensity 178 107 (60) 1.00 — 37 1.00 — 
    Ablative 199 133 (67) 1.65 1.02–2.67 31 1.26 0.99–1.61 
aGVHD at the time of ICU admission        
    No 269 164 (61) 1.00 — 40 1.00 — 
    Yes 108 76 (70) 1.75 0.97–3.14 21.5 1.26 0.95–1.66 
HCT-CI Scores        
    0–1 56 26 (46) 1.00 — 83.5 1.00 — 
    2 61 40 (66) 2.00 0.92–4.32 32 1.35 0.90–2.03 
    3 114 73 (64) 2.16 1.09–4.28 30.5 1.41 0.99–2.02 
    >=4 146 101 (69) 2.70 1.38–5.26 27 1.72 1.21–2.44 
VariableNDied in hospital (%)OR*95% CI for ORMedian OS (days)HR†95% CI for HR
Age at transplant        
    <=55 221 139 (63) 1.00 — 37 1.00 — 
    >55 156 101 (65) 1.19 0.74–1.92 28 1.27 1.00–1.61 
Diagnosis        
    Acute leukemia/MDS 194 127 (65) 1.00 — 33 1.00 — 
    Lymphoma 123 80 (65) 0.94 0.56–1.57 32 1.01 0.79–1.30 
    Myeloproliferative disease 30 14 (47) 0.41 0.18–0.96 93.5 0.78 0.51–1.19 
    Multiple myeloma 13 9 (69) 1.29 0.36–4.68 14 1.51 0.83–2.75 
    Other 17 10 (59) 1.19 0.39–3.61 48 1.05 0.59–1.87 
Transplant period at ICU admission        
    During preparative regimen 13 2 (15) 0.15 0.03–0.66 126 0.59 0.31–1.14 
    Pre-engraftment 127 81 (64) 1.00 0.59–1.69 38 1.06 0.81–1.38 
    Post-engraftment 237 157 (66) 1.00 — 28 1.00 — 
Graft type        
    Peripheral blood 224 140 (63) 1.00 — 32 1.00 — 
    Umbilical cord 42 31 (74) 1.73 0.63–4.71 37.5 1.25 0.78–1.98 
    Bone marrow 111 69 (62) 1.18 0.67–2.07 38 1.06 0.80–1.39 
HLA match status        
    Mismatch 100 66 (66) 1.00 — 34.5 1.00 — 
    Match 277 174 (63) 1.11 0.59–2.07 34 0.95 0.70–1.28 
Donor relation        
    Unrelated 224 144 (64) 1.00 — 38 1.00 — 
    Related 153 96 (63) 0.96 0.58–1.60 26 1.06 0.82–1.36 
Conditioning dose intensity        
    Reduced intensity 178 107 (60) 1.00 — 37 1.00 — 
    Ablative 199 133 (67) 1.65 1.02–2.67 31 1.26 0.99–1.61 
aGVHD at the time of ICU admission        
    No 269 164 (61) 1.00 — 40 1.00 — 
    Yes 108 76 (70) 1.75 0.97–3.14 21.5 1.26 0.95–1.66 
HCT-CI Scores        
    0–1 56 26 (46) 1.00 — 83.5 1.00 — 
    2 61 40 (66) 2.00 0.92–4.32 32 1.35 0.90–2.03 
    3 114 73 (64) 2.16 1.09–4.28 30.5 1.41 0.99–2.02 
    >=4 146 101 (69) 2.70 1.38–5.26 27 1.72 1.21–2.44 
*

: Multivariate Odds ratio for death in the hospital,

†

: Multivariate hazards ratio for overall survival, CI: Confidence interval, MDS: Myelodysplastic syndrome,

a

GVHD: Acute graft-versus-host disease

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Disclosures:

No relevant conflicts of interest to declare.

Topics:
comorbidity, hematopoietic stem cell transplantation, intensive care unit, transplantation, homologous, transplantation, autologous stem cell transplant, transfer technique, graft-versus-host disease, myeloproliferative disease, prognostic factors

Author notes

*

Asterisk with author names denotes non-ASH members.

© 2011 by The American Society of Hematology
2011
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