Prevalence of acute liver dysfunction and impact on outcome in critically ill patients with hematological malignancies: a single-center retrospective cohort study

Potential effects of liver dysfunction at the time of diagnosis in patients with acute myeloid leukemia

Whilst severe liver dysfunction is rarely encountered at the time of diagnosis for patients with acute myeloid leukemia (AML), mild elevations aminotransferase (<5 times the upper limit of normal) may be more frequently seen. Liver dysfunction at the time of diagnosis of AML is a parameter that requires investigation and can assist the clinicians in predicting prognosis. The aim of the present study was to investigate liver dysfunction at the time of diagnosis using the assoicated parameters in patients with AML. The present retrospective study included 90 patients diagnosed with AML who were hospitalised in the Hematology Clinic of Dışkapı Yıldırım Beyazıt Training and Research Hospital (Ankara, Turkey). The demographic characteristics of the patients were recorded together with hemogram results, anemia parameters, measurable residual disease positivity (MRD) and risk category, the presence of hepatosplenomegaly, infection, neutrophil recovery time (NRT), platelet recovery time (PRT) and liver dysfunction. The patients were analyzed in two groups following sorting into the liver dysfunction (n=45) and normal liver function test group (n=45). In the analysis of independent quantitative data (age, white blood cell count, hemoglobin, platelet, international normalized ratio, albumin, B12 vitamin, NRT, PRT) the Mann Whitney U-test was used. Independent qualitative data (sex, hepatomegaly, splenomegaly, MRD, risk category, infection) were analyzed using the χ2 test or the Fischer test. The effect level was investigated using univariate and multivariate logistic regression. A receiver operating characteristic curve was applied to determine the effect level and cut-off values. In the group with liver dysfunction, NRT, PRT, MRD positivity, risk category and the presence of infection were found to be statistically significantly higher. These findings suggest that during the first evaluation of patients diagnosed with AML, liver function tests are simple, rapid and necessary. The results obtained in the present study showed that liver dysfunction at diagnosis can be associated with the high-risk group, in addition to more frequent infection, poorer prognosis and mortality.

Impact of critical illness on continuation of anticancer treatment and prognosis of patients with aggressive hematological malignancies

BACKGROUND

Maintaining the dose-intensity of cancer treatment is an important prognostic factor of aggressive hematological malignancies. The objective of this study was to assess the long-term outcomes of intensive care unit (ICU) survivors with acute myeloid leukemia (AML) or aggressive B-cell non-Hodgkin lymphoma (B-NHL) with emphasis on the resumption of the intended optimal regimen of cancer treatment.

PATIENTS AND METHODS

We conducted a retrospective (2013-2021) single-center observational study where we included patients with AML and B-NHL discharged alive from the ICU after an unplanned admission. The primary endpoint was the change in the intended optimal cancer treatment following ICU discharge. Secondary endpoints were 1-year progression-free survival and overall survival rates. Determinants associated with modifications in cancer treatment were assessed through multivariate logistic regression.

RESULTS

Over the study period, 366 patients with AML or B-NHL were admitted to the ICU, of whom 170 survivors with AML (n = 92) and B-NHL (n = 78) formed the cohort of interest. The hematological malignancy was recently diagnosed in 68% of patients. The admission Sequential Organ Failure Assessment (SOFA) score was 5 (interquartile range 4-8). During the ICU stay, 30 patients (17.6%) required invasive mechanical ventilation, 29 (17.0%) vasopressor support, and 16 (9.4%) renal replacement therapy. The one-year survival rate following ICU discharge was 59.5%. Further modifications in hematologic treatment regimens were required in 72 patients (42%). In multivariate analysis, age > 65 years (odds ratio (OR) 3.54 [95%-confidence interval 1.67-7.50], p < 0.001), ICU-discharge hyperbilirubinemia > 20 µmol/L (OR 3.01 [1.10-8.15], p = 0.031), and therapeutic limitations (OR 16.5 [1.83-149.7], p = 0.012) were independently associated with modifications in cancer treatment. Post-ICU modifications of cancer treatment had significant impact on in-hospital, 1-year overall survival and progression-free survival.

CONCLUSION

The intended cancer treatment could be resumed in 58% of ICU survivors with aggressive hematological malignancies. At the time of ICU discharge, advanced age, persistent liver dysfunction and decisions to limit further life-support therapies were independent determinants of cancer treatment modifications. These modifications were associated with worsened one-year outcomes.

Hepatic haemophagocytosis in haematology patients with hepatic dysfunction: prognostic impact and contribution of liver biopsy combined with the haemophagocytic syndrome diagnostic score (HScore)

Hepatic dysfunction (HD) is common in patients with haematological malignancies. Hepatic haemophagocytosis (HH) was detected in >50% of liver biopsies taken when HD remained unresolved after standard examination. We aimed to explore the contribution of liver biopsy in patients with both haematological malignancies and HD, describe the population of patients with HH, assess the prognostic impact of HH, and investigate haemophagocytic syndrome diagnostic score (HScore) utility in patients with HH. Between 2016 and 2019, 116 consecutive liver biopsies (76 transjugular, 40 percutaneous) were taken in 110 patients with haematological malignancy and HD (hyperbilirubinaemia, elevated transaminases, and/or cholestasis) and without a clear diagnosis. Liver biopsies were safe and diagnostically efficient. Predominant diagnoses included: HH (56%), graft-versus-host disease (55%), associated infections (24%), sinusoidal obstruction syndrome (15%), and tumoral infiltration (8%). Of patients, 35% were critically ill and 74% were allogeneic haematopoietic stem cell transplantation recipients, while 1-year overall survival (OS) was 35% with HH versus 58% without HH (p = 0.026). The 1-year OS was 24% with a HScore of ≥169 versus 50% with a HScore of <169 (p = 0.019). Liver biopsies are feasible in and contribute significantly to haematology patients with HD. HH occurred frequently and was associated with a poor prognosis. Combined with liver biopsy, the HScore may be helpful in refining haemophagocytic syndrome diagnosis.