Lin Richard J, Elko Theresa A, Devlin Sean M, Shahrokni Armin, Jakubowski Ann A, Dahi Parastoo B, Perales Miguel-Angel, Tamari Roni, Shaffer Brian C, Sauter Craig S, Papadopoulos Esperanza B, Gyurkocza Boglarka, Korc-Grodzicki Beatriz, Barker Juliet N, Maloy Molly A, Giralt Sergio A
Adult BMT Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Bone Marrow Transplant. 2020 Jan;55(1):157-164. doi: 10.1038/s41409-019-0654-6. Epub 2019 Aug 30.
Older patients are at increased risk for complications and death following allogeneic hematopoietic cell transplantation (allo-HCT). Traditional transplant-specific prognostic indices such as hematopoietic cell transplant comorbidity index (HCT-CI) may not capture all underlying geriatric vulnerabilities, and in-depth evaluation by a geriatrician prior to transplant may not always be available. We hypothesize that routine pretransplant interdisciplinary clinical assessment may uncover prognostically important geriatric deficits. Using an institutional database of 457 adults aged 60 years and older who underwent first allo-HCT for hematological malignancies from 2010 to 2017, we examined the prognostic impact of pretransplant deficits in geriatric domains of function, mobility, mood, medication, nutrition, and relevant biochemical markers. We found that impairment in instrumental activities of daily living (IADL) was associated with reduced survival through increased nonrelapse mortality (NRM, HR = 1.82; 95% CI, 1.04-3.19). The combination of IADL impairment with either HCT-CI/age index or disease risk index readily stratified NRM and overall survival, respectively. In addition, we found that even mild renal dysfunction adversely impacted survival in older transplant patients. Our findings establish important geriatric vulnerabilities in older patients prior to allo-HCT and may provide an entry point for prospective, interventional trials to improve their outcomes.
老年患者在异基因造血细胞移植（allo-HCT）后发生并发症和死亡的风险增加。传统的移植特异性预后指标，如造血细胞移植合并症指数（HCT-CI），可能无法涵盖所有潜在的老年脆弱性，而且移植前老年病医生的深入评估也并非总能实现。我们假设，常规的移植前跨学科临床评估可能会发现对预后具有重要意义的老年缺陷。利用2010年至2017年期间457例60岁及以上因血液系统恶性肿瘤接受首次allo-HCT的成年患者的机构数据库，我们研究了移植前在功能、活动能力、情绪、用药、营养以及相关生化标志物等老年领域存在的缺陷对预后的影响。我们发现，日常生活工具性活动（IADL）受损与因非复发死亡率（NRM）增加导致的生存率降低相关（HR = 1.82；95%CI，1.04 - 3.19）。IADL受损与HCT-CI/年龄指数或疾病风险指数的组合分别很容易对NRM和总生存进行分层。此外，我们发现，即使是轻度肾功能不全也会对老年移植患者的生存产生不利影响。我们的研究结果确定了老年患者在allo-HCT前存在的重要老年脆弱性，并可能为改善其预后的前瞻性干预试验提供一个切入点。
