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Blood, 1 December 2001, Vol. 98, No. 12, pp. 3234-3240
CLINICAL OBSERVATIONS, INTERVENTIONS, AND THERAPEUTIC TRIALS
Identification of poor prognostic features among patients
requiring mechanical ventilation after hematopoietic stem cell
transplantation
Peter B. Bach,
Deborah Schrag,
David M. Nierman,
David Horak,
Peter White Jr,
James W. Young, and
Jeffrey S. Groeger
From the Department of Epidemiology and
Biostatistics, the Department of Anesthesiology and Critical Care, and
the Department of Medicine, Memorial Sloan-Kettering Cancer Center, the
Department of Medicine, The Mount Sinai Medical Center, New York, NY;
City of Hope National Medical Center, Duarte, CA; the Department of
Medicine, the University of Arkansas for Medical Sciences; and the John
L. McClellan Memorial Veterans Hospital, Little Rock, AK.
Patients who develop respiratory failure requiring mechanical
ventilation after hematopoietic stem cell transplantation (HSCT) have
very high mortality. Several investigators have identified prognostic
features that can be used to identify a subset of these patients who
are virtually certain to die, yet these have never been prospectively
assessed. The objectives of this study were to determine the accuracy
of published prognostic features for mortality and to determine the
survival of patients who recover from respiratory failure. A systematic
review of the literature was undertaken to identify reported poor
prognostic features and survival rates. The study validated the
reported poor prognostic features on a prospective, multicenter
inception cohort of 226 patients with respiratory failure requiring
mechanical ventilation after HSCT. The main outcome measures were
determination of a baseline probability of death, drawn from literature
review; likelihood ratio of mortality for each prognostic feature
determined from the validation cohort; conditional probability of death
in the presence of each feature; and 6-month survival of those
who recover. Patients requiring mechanical ventilation after HSCT have
a baseline probability of death of 82% to 96%. In the setting of
combined hepatic and renal dysfunction, the probability of death rises to 98% to 100%. Other previously reported prognostic features are
less strongly associated with mortality. For patients who recover from
respiratory failure, the proportion surviving 6 months or longer ranges
from 27% to 88%. It was concluded that in patients requiring
mechanical ventilation after HSCT, the presence of combined hepatic and
renal dysfunction is highly predictive of death. The presence of this
feature may justify the recommendation to withdraw life-sustaining measures.
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