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Acute graft-versus-host disease (GvHD) is a serious complication of allogeneic hematopoietic stem cell transplantation (allo-HSCT) and a major cause of morbidity and non-relapse mortality. Accurate human leukocyte antigen (HLA) matching, using reduced-intensity conditioning regimens, and anti-infectious prophylaxis improved GvHD rates. However, with an estimated 20% of patients requiring intense and aggressive immunosuppressive treatment and admission to the intensive care unit (ICU), transplant-associated GvHD remains a challenge. Severe complications may be induced by a range of causes, including the consequences of GvHD disease, opportunistic infections due to immunosuppression, or toxicity of anti-GvHD therapy. Previous reports indicate poor prognosis for patients requiring ICU admission and those with pre-existing comorbidities. However, it remains unclear whether the need for life-sustaining treatment remains the same throughout the course of the disease or may be futile at some point in the GvHD trajectory.
To address those questions, Claire Pichereau and colleagues analyzed the per-intensive care GvHD trajectories and their impact on mortality in critically ill allo-HSCT recipients. The results were recently published in the journal Bone Marrow Transplantation.1
Table 1. Outcomes by the GvHD trajectory group
aGvHD, acute graft-versus-host disease; ICU, intensive care unit *One patient lost to follow-up after discharge from ICU. |
||||
Characteristics |
Group 1: no aGvHD (n = 57) |
Group 2: controlled aGvHD (n = 82) |
Group 3: uncontrolled aGvHD (n = 31) |
Group 4: untreated aGvHD (n = 17) |
---|---|---|---|---|
Patients discharged from ICU, % |
82.5* |
76.8 |
87.1 |
94.1 |
Patients alive at Day 90, % |
70.2 |
56.1 |
25.8 |
58.8 |
Overall survival, % |
42.1 |
41.5 |
6.5 |
35.3 |
Table 2. Multivariate analysis of Day 90 mortality
CI, confidence interval; GvHD, graft-versus-host disease; ICU, intensive care unit; OR, odds ratio; SOFA, sequential organ failure assessment |
||
|
OR (95% CI) |
p value |
---|---|---|
ICU admission for respiratory failure |
2.18 (1.09–4.38) |
0.02 |
ICU admission for liver failure |
11 (1.2–100.4) |
0.03 |
Acute kidney injury at ICU admission |
1.87 (0.82–4.30) |
0.13 |
SOFA score at ICU admission |
1.21 (1.06–1.34) |
0.004 |
GvHD trajectories Group 1 Group 2 Group 3 Group 4 |
Reference 1.47 (0.67–3.22) 6.64 (2.23–19.67) 0.73 (0.19–2.70) |
0.34 0.0007 0.64 |
The results of this study highlight the poor outcomes of patients with uncontrolled aGVHD at the time of ICU admission and provide a way to stratify patients based on mortality risk. In patients with high allo-GRRR-OH score, doctors may need to decide at some point whether to continue aggressive life-supporting measures with limited benefit. Nevertheless, the authors advise that clinicians should avoid early end of life decisions in these patients before they have had a time-limited trial of at least 14 days.
In contrast, the authors suggest to promptly admit patients with intermediate-risk to the ICU and provide the best standard of care in order to improve mortality risk. However, in patients with low allo-GRRR-OH scores, the authors suggest that aggressive critical care management can be avoided. A prospective study is needed to verify the results in a bigger patient population.
References
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