Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
Department of Internal Medicine, Yale New Haven Health, Bridgeport Hospital, Bridgeport, CT.
Chest. 2021 Jun;159(6):2325-2333. doi: 10.1016/j.chest.2021.01.008. Epub 2021 Jan 9.
Diffuse alveolar hemorrhage (DAH) is an uncommon complication of hematopoietic stem cell transplantation (HCT) that carries high morbidity and mortality. Limited contemporary data are available regarding the incidence, outcomes, and risk factors for DAH.
What are the incidence, outcomes, and risk factors for DAH developing after HCT?
This was a single-center retrospective cohort study of patients who underwent HCT between January 1, 2005, and December 31, 2016. The incidence and outcomes of DAH development were evaluated. A multivariate logistic regression model was used to analyze differences between survivors and nonsurvivors.
Of 4,350 patients undergoing first-time HCT, DAH was diagnosed in 99 (2.3%). DAH was seen in 40 of 3,536 autologous HCT recipients (1.1%) and 59 of 814 allogeneic HCT recipients (7.2%). Mean age was 53 ± 13 years, and median time of DAH diagnosis was 126 days (interquartile range, 19-349 days) after HCT. In-hospital mortality and mortality 1 year after DAH diagnosis were 55.6% and 76.8%, respectively. DAH diagnosis more than 30 days after transplantation (OR, 7.06; 95% CI, 1.65-30.14), low platelet count (OR, 0.98; 95% CI, 0.96-1.0; P = .02), elevated international normalized ratio (INR; OR, 4.08; 95% CI, 0.64-25.88; P = .046) and need for invasive mechanical ventilation (OR, 8.18; 95% CI, 1.9-35.21) were associated with higher in-hospital mortality. Steroid treatment did not alter mortality (P = .80) or length of stay (P = .65). However, among those who received steroids, survival was higher in whose who received modest-dose steroids (< 250 mg methylprednisolone equivalent/d) compared with those who received high-dose steroids (≥ 250 mg methylprednisolone equivalent/d; OR, 0.21; 95% CI, 0.07-0.72).
The mortality of DAH after HCT remains high, and DAH can occur long after transplantation. Later development of DAH (>30 days after HCT), need for invasive mechanical ventilation, thrombocytopenia, and elevated INR are all associated with worse outcomes.
弥漫性肺泡出血（DAH）是造血干细胞移植（HCT）的一种罕见并发症，具有较高的发病率和死亡率。目前关于 DAH 发生的发病率、结局和危险因素的当代数据有限。
HCT 后 DAH 发生的发病率、结局和危险因素是什么？
这是一项单中心回顾性队列研究，纳入了 2005 年 1 月 1 日至 2016 年 12 月 31 日期间接受 HCT 的患者。评估了 DAH 发展的发病率和结局。采用多变量逻辑回归模型分析了幸存者和非幸存者之间的差异。
在 4350 例首次接受 HCT 的患者中，诊断出 99 例（2.3%）发生了 DAH。在 3536 例自体 HCT 受者中有 40 例（1.1%）和 814 例异基因 HCT 受者中有 59 例（7.2%）发生了 DAH。平均年龄为 53±13 岁，中位 DAH 诊断时间为 HCT 后 126 天（四分位距，19-349 天）。住院死亡率和 DAH 诊断后 1 年的死亡率分别为 55.6%和 76.8%。移植后 30 天以上诊断 DAH（OR，7.06；95%CI，1.65-30.14）、血小板计数低（OR，0.98；95%CI，0.96-1.0；P=0.02）、国际标准化比值（INR）升高（OR，4.08；95%CI，0.64-25.88；P=0.046）和需要有创机械通气（OR，8.18；95%CI，1.9-35.21）与较高的住院死亡率相关。皮质类固醇治疗并未改变死亡率（P=0.80）或住院时间（P=0.65）。然而，在接受皮质类固醇治疗的患者中，接受低剂量皮质类固醇（<250mg 甲泼尼龙等效剂量/天）治疗的患者比接受高剂量皮质类固醇（≥250mg 甲泼尼龙等效剂量/天）的患者的生存率更高（OR，0.21；95%CI，0.07-0.72）。
HCT 后 DAH 的死亡率仍然很高，并且 DAH 可能在移植后很长时间才发生。较晚发生的 DAH（HCT 后>30 天）、需要有创机械通气、血小板减少和 INR 升高均与较差的结局相关。
