Outcome of Acute Respiratory Failure Secondary to Engraftment in Children After Hematopoietic Stem Cell Transplant.

Lama Elbahlawan,Renee Madden,Sujuan Huang,Ying Li,Cheng Cheng,Ray Morrison,Yvonne Avent

doi:10.3389/fonc.2020.584269

Abstract

Introduction: Respiratory complications due to engraftment syndrome (ES) in the post-hematopoietic stem cell transplant (HSCT) setting can lead to acute respiratory failure (ARF). Outcomes of children developing ARF due to engraftment are unknown.Methods: We conducted a retrospective analysis of 1,527 pediatric HSCT recipients and identified children who developed ARF due to ES over a 17-year period. Thirty patients that developed ARF and required invasive mechanical ventilation (IMV) due to ES were included in this study.Results: The survival rate for our cohort was 80% [alive at intensive care unit (ICU) discharge]. The most common underlying primary disease was hematologic malignancy, and 67% of children underwent allogeneic HSCT. Further, 73% required vasopressor drips and 23% underwent dialysis. Survivors had a shorter median ICU length of stay than did non-survivors (15 vs. 40 days, respectively, p = 0.01). Survivors had a significantly lower median cumulative fluid overload % on days 4 and 5 after initiation of IMV than did non-survivors (2.8 vs. 14.0 ml/kg, p = 0.038 on day 4, and 1.8 vs. 14.9 ml/kg, p = 0.044 on day 5, respectively).Conclusion: Our results suggest that children who develop ARF during engraftment have better ICU survival rates than do those with other etiologies of ARF post-HSCT. Furthermore, fluid overload contributes to mortality in these children; therefore, strategies to prevent and address fluid overload should be considered.

Highlights

Respiratory complications due to engraftment syndrome (ES) in the post-hematopoietic stem cell transplant (HSCT) setting can lead to acute respiratory failure (ARF)
Pulmonary injury occurs in 25–55% of pediatric patients receiving HSCT, and transplant-related mortality is as high as 64% [1,2,3]
A total of 1,527 children underwent 2,168 HSCTs during the 17-year period: 878 patients underwent allogeneic transplants and 649 underwent autologous transplants or high-dose chemotherapy followed by stem cell rescue

Summary

Introduction

Respiratory complications due to engraftment syndrome (ES) in the post-hematopoietic stem cell transplant (HSCT) setting can lead to acute respiratory failure (ARF). Pulmonary injury occurs in 25–55% of pediatric patients receiving HSCT, and transplant-related mortality is as high as 64% [1,2,3] Such pulmonary complications after HSCT may be attributed to infectious and/or noninfectious lung injury [4]. ARF Post-HSCT Children With Engraftment syndrome (ES) is one such non-infectious complication that may result in acute respiratory failure (ARF) [5]. Symptoms usually appear before neutrophil engraftment and have been attributed to a pro-inflammatory condition as a result of the release of cytokines and other inflammatory mediators. Pulmonary complications during engraftment occur secondary to this cytokine release and capillary leak, which leads to acute lung injury and hypoxia. Respiratory distress with hypoxia can occur and progress to ARF, which requires an escalation of respiratory support to non-invasive mechanical ventilation or invasive mechanical ventilation (IMV)

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