Zinter Matt S, Logan Brent R, Fretham Caitrin, Sapru Anil, Abraham Allistair, Aljurf Mahmoud D, Arnold Staci D, Artz Andrew, Auletta Jeffery J, Chhabra Saurabh, Copelan Edward, Duncan Christine, Gale Robert P, Guinan Eva, Hematti Peiman, Keating Amy K, Marks David I, Olsson Richard, Savani Bipin N, Ustun Celalettin, Williams Kirsten M, Pasquini Marcelo C, Dvorak Christopher C
Department of Pediatrics, Division of Critical Care Medicine, University of California, San Francisco, San Francisco, California.
Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA; Center for International Blood and Marrow Transplant Research, Milwaukee, WI, USA.
Biol Blood Marrow Transplant. 2020 Feb;26(2):333-342. doi: 10.1016/j.bbmt.2019.09.027. Epub 2019 Sep 26.
Critically ill pediatric allogeneic hematopoietic cell transplant (HCT) patients may benefit from early and aggressive interventions aimed at reversing the progression of multiorgan dysfunction. Therefore, we evaluated 25 early risk factors for pediatric intensive care unit (PICU) mortality to improve mortality prognostication. We merged the Virtual Pediatric Systems and Center for International Blood and Marrow Transplant Research databases and analyzed 936 critically ill patients ≤21 years of age who had undergone allogeneic HCT and subsequently required PICU admission between January 1, 2009, and December 31, 2014. Of 1532 PICU admissions, the overall PICU mortality rate was 17.4% (95% confidence interval [CI], 15.6% to 19.4%) but was significantly higher for patients requiring mechanical ventilation (44.0%), renal replacement therapy (56.1%), or extracorporeal life support (77.8%). Mortality estimates increased significantly the longer that patients remained in the PICU. Of 25 HCT- and PICU-specific characteristics available at or near the time of PICU admission, moderate/severe pre-HCT renal injury, pre-HCT recipient cytomegalovirus seropositivity, <100-day interval between HCT and PICU admission, HCT for underlying acute myeloid leukemia, and greater admission organ dysfunction as approximated by the Pediatric Risk of Mortality 3 score were each independently associated with PICU mortality. A multivariable model using these components identified that patients in the top quartile of risk had 3 times greater mortality than other patients (35.1% versus 11.5%, P < .001, classification accuracy 75.2%; 95% CI, 73.0% to 77.4%). These data improve our working knowledge of the factors influencing the progression of critical illness in pediatric allogeneic HCT patients. Future investigation aimed at mitigating the effect of these risk factors is warranted.
危重症小儿异基因造血细胞移植（HCT）患者可能受益于旨在逆转多器官功能障碍进展的早期积极干预措施。因此，我们评估了25个小儿重症监护病房（PICU）死亡的早期风险因素，以改善死亡预后。我们合并了虚拟儿科系统和国际血液与骨髓移植研究中心的数据库，并分析了2009年1月1日至2014年12月31日期间936例年龄≤21岁的危重症患者，这些患者接受了异基因HCT，随后需要入住PICU。在1532次PICU入院中，PICU总体死亡率为17.4%（95%置信区间[CI]，15.6%至19.4%），但对于需要机械通气（44.0%）、肾脏替代治疗（56.1%）或体外生命支持（77.8%）的患者，死亡率显著更高。患者在PICU停留的时间越长，死亡率估计值显著增加。在PICU入院时或接近入院时可获得的25个HCT和PICU特定特征中，HCT前中度/重度肾损伤、HCT前受者巨细胞病毒血清学阳性、HCT与PICU入院间隔<100天、因潜在急性髓细胞白血病进行HCT以及用儿童死亡率风险3评分近似的更大入院器官功能障碍均与PICU死亡率独立相关。使用这些因素的多变量模型确定，风险最高四分位数的患者死亡率是其他患者的3倍（35.1%对11.5%，P<.001，分类准确率75.2%；95%CI，73.0%至77.4%）。这些数据提高了我们对影响小儿异基因HCT患者危重症进展因素的认识。有必要开展未来研究以减轻这些风险因素的影响。
