Hepatic, renal dysfunction predict death after transplant-related ventilation

NEW YORK, (Reuters Health) – Combined hepatic and renal dysfunction is highly predictive of death in patients requiring mechanical ventilation after hematopoietic stem cell transplantation (HSCT), according to a report in the December 1st edition of Blood.

Families often agonize over whether to withhold or withdraw life-sustaining measures when respiratory failure occurs after stem cell transplantation, the authors explain, and physicians lack highly predictable prognostic features associated with death.

Dr. Peter Bach from Memorial Sloan-Kettering Cancer Center in New York and colleagues sought to determine the accuracy of prognostic features for mortality and good-quality survival in this setting, using published reports and their own cohort of 226 patients treated at 5 centers. ]

Simultaneous hepatic dysfunction (defined as bilirubin greater than 4 mg/dL) and renal dysfunction (defined as serum creatinine greater than 2 mg/dL) were associated with the highest likelihood of death, the authors report. The combination increased the likelihood of death 9.48-fold, to 98% to 100%.

None of 10 other reported prognostic features predicted death as reliably, the report indicates, although such features as ventilation for more than 4 days and lung injury in association with other abnormalities increased the likelihood of death by 58% and 90%, respectively.

For those subjects who survived mechanical ventilation and hospitalization, the researchers note, survival was considerable (a median 15 to 21 months), and quality of life was probably good.

"It is important to be able to give families a reasonable estimate of the probability that an individual in this circumstance will survive if given maximal therapy," Dr. Bach told Reuters Health.

"Most of the prognostic features that we reviewed and evaluated turned out to not be that helpful in this process, in the sense that individuals with these features and individuals without these features had similar probabilities of survival," Dr. Bach said.

The exception was the combination of elevated creatinine and bilirubin reported in their paper. "Given a patient with this poor prognostic feature," Dr. Bach said, "it would be reasonable to tell the family that the probability of survival was quite low."

Blood 2001;98:3234-3240.

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