Epidemiology: peripheral eosinophilia occurs in 38.9% of cases
Latency: peripheral eosinophilia occurs 67.5 days (on average) after transplantation
Age: peripheral eosinophilia occurs more commonly in younger patients
No relationship to development of graft vs host disease
No relationship to conditioning regimen used
Prognosis
Overall patient survival rates improved in those with eosinophilia compared to those without eosinophilia (88.7 vs 43.0%, P=0.0034). In particular, in patients with malignant diseases, those with eosinophilia showed a higher event-free survival (81.1 vs 44.6%, P=0.0025) and a lower relapse rate (16.0 vs 43.0%, P=0.0287) than those without eosinophilia [Significance of eosinophilia after stem cell transplantation as a possible prognostic marker for favorable outcome. Bone Marrow Transplantation (2005) 36, 985–991]
Some data suggest that eosinophilia may portend the development of graft vs host disease [Hypereosinophilia as a presenting sign of acute graft-versus-host disease after allogeneic bone marrow transplantation. Transplantation 2002; 74: 1797–1800]
DAH Occurs in 5-10% of SCT: rates are similar regardless of whether the SCT is done for hematologic malignancy vs solid organ tumors)
Allogeneic vs Autologous: incidence rates for DAH are the same for allogeneic-SCT vs. autologous-SCT
Timing: DAH usually occurs within 30 days after SCT engraftment
Risk Factors for Post-SCT Diffuse Alveolar Hemorrhage
Pre-Transplant Intensive Chemo
Total Body Irradiation
Thoracic Radiation
Advanced Age
Renal Failure
Not Risk Factors for Post-BMT/SCT Diffuse Alveolar Hemorrhage
Thrombocytopenia: not a defined risk factor, although may be higher risk at platelet counts <20k (however, most patients are thrombocytopenic at the onset of DAH)
Notably, platelet transfusions do not correct the DAH
Elevated INR/PTT: not risk factors
Physiology: lung injury (of unclear type) with some degree of microvascular damage and micro thrombi, neutrophilic infiltration with cytokine release
Diagnosis
Arterial Blood Gas (ABG) (see Arterial Blood Gas, [[Arterial Blood Gas]]): hypoxemia
Hemoptysis (see Hemoptysis, [[Hemoptysis]]): usually in <15% of cases -> this is in contrast to non-SCT population, where hemoptysis is more common
Treatment
Correct Thrombocytopenia: although platelet transfusion has not been shown to improve DAH
Steroids (500 mg-1 g methylprednisolone/day, the taper over 2-4 wks): usually used (although there are no randomized trials to address their efficacy)
High-dose steroids (as above) are probably better than low-dose steroids or no steroids
Prognosis
Mortality Rates of Post-BMT/SCT-Associated DAH: 80%
Prognosis of Post-BMT Resp Failure: (From Any Etiology): only 3% 6-month survival [Crawford SW, Petersen FB. Long-term survival from respiratory failure after marrow transplantation for malignancy. Am Rev Respir Dis 1992; 145:510-514]
Epidemiology: most reported cases had severe acute or chronic graft vs host disease (see Graft vs Host Disease, [[Graft vs Host Disease]])
Other Adverse Effects/Complications
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Prognosis
Clinical Data Related to Prognosis in Hematopoietic Stem Cell Patients Requiring ICU Care
Retrospective Canadian Study of Autologous SCT Patients Admitted to the ICU (Bone Marrow Transplant, 2009) [MEDLINE]: data from 2001-2006
ICU Admission Rate: 3.3%
Mortality Rate in the ICU: 38%
Worse Prognosis was in AL Amyloid Patients: 55% ICU mortality rate in this group
Predictors of Mortality
SOFA Score in the First 24 hrs
APACHE II Score in the First 24 hrs
Gram-Negative Sepsis
Inotropic Support >4 hrs
Mechanical Ventilation
Multiorgan Failure
French Study of Allogeneic SCT Patients Admitted to the ICU (Leuk Lymphoma, 2014) [MEDLINE]: data from 1998-2005
ICU Admission Rate: 10%
Predominant Cause for ICU Admission was Respiratory Failure
Mortality Rate in the ICU: 57%
Authors Did Not Observe Any Decrease in Mortality Rates Comparing the Periods of 1998-2004 and 2005-2008
Patients Admitted Between Day 30-100 Post-SCT Had the Worst Prognosis: mainly due to the presence of active GVHD
References
Long-term survival from respiratory failure after marrow transplantation for malignancy. Am Rev Respir Dis 1992; 145:510-514 [MEDLINE]
Pulmonary complications after bone marrow transplantation: high-resolution CT and pathologic findings. Radiographics. 1997 Nov-Dec;17(6):1359-71 [MEDLINE]
Unexplained effusions: association with allogeneic bone marrow transplantation and acute or chronic graft-versus-host disease. Bone Marrow Transplant. 1996 Feb;17(2):207-11 [MEDLINE]
Prognostic indicators for blood and marrow transplant patients admitted to an intensive care unit. Am J Respir Crit Care Med 1998; 158:876-884 [MEDLINE]
Mechanical ventilation in hematopoietic stem cell transplantation. Can we effectively predict outcomes? Chest 1999; 116:1012-1018 [MEDLINE]
Hypereosinophilia as a presenting sign of acute graft-versus-host disease after allogeneic bone marrow transplantation. Transplantation 2002; 74: 1797–1800 [MEDLINE]
Intensive care unit support and Acute Physiology and Chronic Health Evaluation III performance in hematopoietic stem cell transplant recipients. Crit Care Med 2003;31:1715–1721 [MEDLINE]
Outcome and early prognostic indicators in patients with a hematologic malignancy admitted to the intensive care unit for a life-threatening complication. Crit Care Med 2003;31:104–112 [MEDLINE]
Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a medical ICU. Chest 2004;126:1604–1611 [MEDLINE]
Significance of eosinophilia after stem cell transplantation as a possible prognostic marker for favorable outcome. Bone Marrow Transplant. 2005 Dec;36(11):985-91 [MEDLINE]
Outcome of critically ill allogeneic hematopoietic stem-cell transplantation recipients: a reappraisal of indications for organ failure supports. J Clin Oncol 2006;24:643–649 [MEDLINE]
Predictors of mortality in patients undergoing autologous hematopoietic cell transplantation admitted to the intensive care unit. Bone Marrow Transplant. 2009 Mar;43(5):411-5. doi: 10.1038/bmt.2008.336. Epub 2008 Oct 20 [MEDLINE]
Outcome in critically ill patients with allogeneic BM or peripheral haematopoietic SCT: a single-centre experience. Bone Marrow Transplant 2011;46:1186–1191 [MEDLINE]
Survival and prognostic factors of allogeneic hematopoietic stem cell transplant recipients admitted to intensive care unit. Leuk Lymphoma 2014 Jun;55(6):1417–1420. doi: 10.3109/10428194.2013.836602. Epub 2013 Sep 23 [MEDLINE]
