Objective To determine factors associated with acute respiratory failure after bone marrow transplantation which can be identified before the onset of lung disease. Design Population-based, retrospective study. Setting A referral-based pediatric intensive care unit and bone marrow transplant center. Patients Thirty-nine patients with lung disease (abnormal chest radiograph or a need for supplemental oxygen) were identified from a group of 318 pediatric bone marrow transplant patients from 1978 to 1988. Thirty-four of 39 patients with complete data were further classified into patients with mild lung disease (recovery without needing endotracheal intubation, n = 16) and patients with acute respiratory failure (requirement for endotracheal intubation, n = 18). Interventions Regression analyses were performed to define risk factors for development of respiratory failure (multivariate logistic regression) and for a shortened interval between the identification of lung disease and respiratory failure (Cox proportional hazards analysis). Measurements and Main Results Ninety-three percent (15/16) of patients with mild lung disease survived. Conversely, only 9% (2/23) of patients with respiratory failure survived. Predictors of respiratory failure included graft vs. host disease (odds ratio 28.3, 95% confidence interval 1.9–421, p = .015), a prelung disease (baseline) circulating creatinine concentration of >1.5 mg/dL (>132.6 μmol/L) (odds ratio 28.4, 95% confidence interval 1.4–577, p = .029), and male gender (odds ratio 14.6, 95% confidence interval 1–210, p = .049). Predictors of a shortened time to onset of respiratory failure included baseline serum creatinine value of >1.5 mg/dL (>132.6 μmol/L) (hazard ratio 6.2, 95% confidence interval 1.5–26.5, p = .013) and baseline total bilirubin concentration >1.4 mg/dL (>23.9 μmol/L) (hazard ratio 4.5, 95% confidence interval 0.98–20.7, p = .053). The median time to onset of respiratory failure was 4 days in patients with baseline creatinine values ≥1.5 mg/dL (>132.6 μmol/L) and 5 days in patients with baseline bilirubin concentrations ≥;1.4 mg/dL (>23.9 μmol/L) vs. >26 days in patients with creatinine <1.5 mg/dL (<132.6 μmol/L) and >29 days in patients with bilirubin <1.4 mg/dL (<23.9 μmol/L) (Kaplan-Meier analysis). Conclusions Renal and liver dysfunction preceded clinical evidence of lung disease in bone marrow transplant patients who developed respiratory failure. Lung disease leading to respiratory failure and adult respiratory distress syndrome appears to develop as one component of the multiple organ failure syndrome in pediatric bone marrow transplant patients.
Seventy-four consecutive patients with high-risk acute lymphoblastic leukemia (ALL) were given cyclophosphamide (CY; 50 mg/kg on each of 4 days) plus total body irradiation (TBI; 300 rad on each of 4 days) followed by a human leukocyte antigen (HLA)-identical allogeneic bone marrow transplant (BMT). Eighteen patients in first complete remission (CR1), 36 in CR2, 16 in CR3, and four in CR4 were transplanted. Patients in CR1 were transplanted 1 to 8 months (median, 3 months) after attaining CR. All 18 patients in CR1 had one or more poor risk factors: age more than 18 (N = 17), initial leukocyte count greater than or equal to 20,000 (N = 11), Ph 1 chromosome (N = 2), delay in attaining CR more than 6 weeks (N = 8), or extramedullary disease (N = 1). Of those transplanted in CR2, 72% had relapsed on therapy. The 5-year event-free survival (EFS) rates for patients transplanted in CR1, CR2, and CR3 are 42%, 43%, and 25%, respectively, at median follow-up times of 57, 54, and 72 months, respectively. Children aged less than 18 years transplanted in CR2 have a 5-year EFS rate of 54%. All CR4 patients died early after transplant. The actuarial probability of relapse is 20%, 26%, and 48% for those transplanted in CR1, CR2, and CR3, respectively. Although there was substantial transplant-associated mortality, it decreased over the decade of the study (P = .01). This study indicates that BMT offers an attractive alternative to postremission chemotherapy in patients in CR1 with poor prognostic factors and in patients in second remission.
Quality of life (QOL) studies in bone marrow transplantation (BMT) recipients are increasingly regarded as one of the ways to evaluate the outcome of BMT. Recent reports continue to detail acute and late psychosocial problems in BMT recipients. More and more longitudinal studies of QOL and comparisons of QOL outcomes after BMT or alternative nontransplant treatments are appearing in the literature. Several interventions that may promote positive effects on psychosocial adjustment are suggested: attention to patients' coping styles by the healthcare team, encouragement of aerobic exercise, attempts to lessen patients' levels of anxiety, and the presence of at least one staff member identified by the patient as an important source of support over time-all may have positive influences on QOL.
Peripheral blood stem cells (PBSCs) have been increasingly used for allogeneic hematopoietic cell transplantation instead of bone marrow stem cells. Current National Marrow Donor Program policy recommends 5 days of daily filgrastim, followed by either 1 or 2 days of apheresis for unrelated donors, depending on collection center choice. To date, there are no published studies comparing the differences in donor experience between 1 day and 2 days of apheresis. We examined 22,348 adult unrelated donor collections in 184 centers between 2006 and 2016. Of these 22,348 donors, 20,004 (89.5%) had collection on 1 day, and the other 2344 (9.5%) had collection over 2 days. Information on why donors underwent apheresis in 1 day or 2 days was not available. Donors who underwent apheresis in 1 day were more likely to be male (67% versus 46%; P < .001), younger (age <30 years, 48% versus 36%; P < .001), and have a higher body weight (83.0 kg versus 75.9 kg; P< .001) and body mass index (BMI; >30, 30% versus 22%; P < .001). Successful collection of the requested CD34
