Mortality of Hemato-Oncologic Patients Admitted to a Pediatric Intensive Care Unit: A Single-Center Experience

Mortality-Related Risk Factors in Patients with Hematologic Neoplasm Admitted to the Intensive Care Unit: A Systematic Review

BACKGROUND

Hematooncology patients admitted to intensive care units (ICUs) are at high risk for mortality due to the severity of their critical illness. Such complications can develop into complex clinical management, thus signaling an urgent need to identify mortality-related factors to improve interventions and outcomes for these patients.

METHODS

A systematic review of studies published between 2012 and 2023 in databases such as PubMed, Scopus, and Web of Science was conducted, following the PRISMA guidelines. A meta-analysis was carried out to determine the significance of mortality-related factors.

RESULTS

In a review of twenty-four studies, it was found that invasive mechanical ventilation (IMV) was associated with an odds ratio (OR) between 2.70 and 8.26 in 75% of the studies. The use of vasopressor support had an OR of 6.28 in 50% of the studies, while pulmonary involvement by tumor had an OR of 6.73 in 30% of the studies. Sepsis showed an OR of 5.06 in 60% of the studies, and neutropenia upon admission increased mortality in 40% of the studies. Severe respiratory failure (PaO2/FiO2 < 150) had an OR of 7.69 in 55% of the studies. Additionally, ICU readmission and late admission were identified as risk factors for increased mortality.

CONCLUSIONS

Mortality among hematooncology ICU patients is associated with IMV, vasopressor support, pulmonary involvement, sepsis, neutropenia, severe respiratory failure, ICU readmission, and late admission. Identifying and managing these factors in a timely manner can improve survival and the quality of care.

The epidemiology of pediatric oncology and hematopoietic cell transplant admissions to U.S. intensive care units from 2001-2019

Children with cancer or hematopoietic cell transplant (HCT) frequently require ICU care. We conducted a retrospective cohort study using Healthcare Cost and Utilization Project's State Inpatient Databases from 21 U.S. states from 2001-2019. We included children <18 years with oncologic or HCT diagnosis and used ICD-9-CM and ICD-10-CM codes to identify diagnoses, comorbidities, and organ failures. We used generalized linear Poisson regression and Cuzick's test of trend to evaluate changes from 2001-2019. Among 2,157,991 total pediatric inpatient admissions, 3.9% (n=82,988) were among oncology patients and 0.3% (n=7,381) were among HCT patients. ICU admission prevalence rose from 13.6% in 2001 to 14.4% in 2019 for oncology admissions and declined from 23.9% to 19.5%, for HCT admissions. Between 2001-2019, the prevalence of chronic non-oncologic comorbidities among ICU patients rose from 44.3% to 69.1% for oncology patients (RR 1.60 [95% CI 1.46-1.66]) and from 41.4% to 81.5% (RR 1.94 [95% CI 1.61-2.34]) for HCT patients. The risk of Multiple Organ Dysfunction Syndrome more than tripled for oncology (9.5% to 33.3%; RR 3.52 [95% CI 2.97-4.18]) and HCT (12.4% to 39.7%; RR 3.20 [95% CI 2.09-4.89]) patients. Mortality decreased most for ICU patients with acute myeloid leukemia (AML) (14.6% to 8.5%) and oncology-related HCTs (15.5% to 9.2%). Critically ill pediatric oncology and HCT patients are increasingly medically complex with greater prevalence of chronic comorbidities and organ failure, but mortality did not increase. Pediatric ICUs may require increased financial and staffing support to care for these patients in the future.

Acute kidney injury following treatment with CD19-specific CAR T-cell therapy in children, adolescent, and young adult patients with B-cell acute lymphoblastic leukemia

BACKGROUND

CD19-specific chimeric antigen receptor (CAR) T-cell therapy has shown promising disease responses in patients with high-risk B-cell malignancies. However, its use may be related to complications such as immune-mediated complications, infections, and end-organ dysfunction. The incidence of post-CAR T-cell therapy acute kidney injury (AKI) in the children, adolescent, and young adult (CAYA) patient population is largely unreported.

METHODS

The objectives of this study were to determine the incidence of AKI in CAYA patients with high-risk B-cell malignancies treated with CD19-CAR T-cell therapy, evaluate potential risk factors for developing AKI, and determine patterns of kidney function recovery. We conducted a retrospective analysis of 34 CAYA patients treated with CD19-CAR T-cell at a single institution.

RESULTS

There was a cumulative incidence of any grade AKI by day 30 post-infusion of 20% (n = 7), with four cases being severe AKI (stages 2-3) and one patient requiring kidney replacement therapy. All episodes of AKI developed within the first 14 days after receiving CAR T-cell therapy and 50% of patients with AKI recovered kidney function to baseline within 30 days post-infusion. No evaluated pre-treatment risk factors were associated with the development of subsequent AKI; there was an association between AKI and cytokine release syndrome and neurotoxicity. We conclude that the risk of developing AKI following CD19-CAR T-cell therapy is highest early post-infusion, with most cases of AKI being severe.

CONCLUSIONS

Frequent monitoring to facilitate early recognition and subsequent management of kidney complications after CD19-CAR T-cell therapy may reduce the severity of AKI in the CAYA patient population.

Acute kidney injury following treatment with CD19-specific CAR T-cell therapy in children, adolescent and young adult patients with B-cell acute lymphoblastic leukemia

CD19-specific chimeric antigen receptor (CAR) T-cell therapy has shown promising disease responses in patients with high-risk B-cell malignancies. Treatment with CD19-CAR T-cell therapy is also associated with the risk of morbidity and mortality, primarily related to immune-mediated complications (cytokine release syndrome [CRS] and neurotoxicity [NTX]), infections, and end-organ dysfunction. Despite these well-described systemic toxicities, the incidence of post-CAR T-cell therapy acute kidney injury (AKI) in the children, adolescent and young adult (CAYA) patient population is largely unreported. The objectives of this study were to determine the incidence of AKI in CAYA patients with high-risk B-cell malignancies treated with CD19-CAR T-cell therapy, evaluate potential risk factors for developing AKI, and determine patterns of kidney function recovery. In this retrospective analysis of 34 CAYA patients treated with CD19-CAR T-cell at a single institution, we found a cumulative incidence of any grade AKI by day 30 post-infusion of 20% (n=7), with 4 cases being severe AKI (Stage 2-3) and one patient requiring kidney replacement therapy. All episodes of AKI developed within the first 14 days after receiving CAR T-cell therapy and 50% of patients with AKI recovered kidney function to baseline within 30 days post-infusion. No evaluated pre-treatment risk factors were associated with the development of subsequent AKI; there was an association between AKI and CRS and NTX. We conclude that the risk of developing AKI following CD19-CAR T-cell therapy is highest early post-infusion, with most cases of AKI being severe. Although most patients with AKI in our cohort had recovery of kidney function, frequent monitoring to facilitate early recognition and subsequent management of kidney complications after CD19-CAR T-cell therapy may reduce the severity of AKI in the CAYA patient population.

Trends in Childhood Oncology Admissions to ICUs in Australia and New Zealand

OBJECTIVES

There are few robust, national-level reports of contemporary trends in pediatric oncology admissions, resource use, and mortality. We aimed to describe national-level data on trends in intensive care admissions, interventions, and survival for children with cancer.

DESIGN

Cohort study using a binational pediatric intensive care registry.

SETTING

Australia and New Zealand.

PATIENTS

Patients younger than 16 years, admitted to an ICU in Australia or New Zealand with an oncology diagnosis between January 1, 2003, and December 31, 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We examined trends in oncology admissions, ICU interventions, and both crude and risk-adjusted patient-level mortality. Eight thousand four hundred ninety admissions were identified for 5,747 patients, accounting for 5.8% of PICU admissions. Absolute and population-indexed oncology admissions increased from 2003 to 2018, and median length of stay increased from 23.2 hours (interquartile range [IQR], 16.8-62 hr) to 38.8 hours (IQR, 20.9-81.1 hr) ( p < 0.001). Three hundred fifty-seven of 5,747 patients died (6.2%). There was a 45% reduction in risk-adjusted ICU mortality, which reduced from 3.3% (95% CI, 2.1-4.4) in 2003-2004 to 1.8% (95% CI, 1.1-2.5%) in 2017-2018 ( p trend = 0.02). The greatest reduction in mortality seen in hematological cancers and in nonelective admissions. Mechanical ventilation rates were unchanged from 2003 to 2018, while the use of high-flow nasal prong oxygen increased (incidence rate ratio, 2.43; 95% CI, 1.61-3.67 per 2 yr).

CONCLUSIONS

In Australian and New Zealand PICUs, pediatric oncology admissions are increasing steadily and such admissions are staying longer, representing a considerable proportion of ICU activity. The mortality of children with cancer who are admitted to ICU is low and falling.

Prognostic factors for multi-organ dysfunction in pediatric oncology patients admitted to the pediatric intensive care unit

Background

Pediatric oncology patients who require admission to the pediatric intensive care unit (PICU) have worse outcomes compared to their non-cancer peers. Although multi-organ dysfunction (MOD) plays a pivotal role in PICU mortality and morbidity, risk factors for MOD have not yet been identified. We aimed to identify risk factors at PICU admission for new or progressive MOD (NPMOD) during the first week of PICU stay.

Methods

This retrospective cohort study included all pediatric oncology patients aged 0 to 18 years admitted to the PICU between June 2018 and June 2021. We used the recently published PODIUM criteria for defining multi-organ dysfunction and estimated the association between covariates at PICU baseline and the outcome NPMOD using a multivariable logistic regression model, with PICU admission as unit of study. To study the predictive performance, the model was internally validated by using bootstrap.

Results

A total of 761 PICU admissions of 571 patients were included. NPMOD was present in 154 PICU admissions (20%). Patients with NPMOD had a high mortality compared to patients without NPMOD, 14% and 1.0% respectively. Hemato-oncological diagnosis, number of failing organs and unplanned admission were independent risk factors for NPMOD. The prognostic model had an overall good discrimination and calibration.

Conclusion

The risk factors at PICU admission for NPMOD may help to identify patients who may benefit from closer monitoring and early interventions. When applying the PODIUM criteria, we found some opportunities for fine-tuning these criteria for pediatric oncology patients, that need to be validated in future studies.