Outcome of Diffuse Alveolar Hemorrhage in Hematopoietic Stem Cell Transplant Recipients.

Background: Hematopoietic Stem Cell Transplantation (HSCT) is being widely used as an adjunct to conventional chemoradiotherapy for many hematologic and solid malignancies and some non-malignant hematologic conditions. Diffuse Alveolar Hemorrhage (DAH) is seen in 1 to 19% of HSCT recipients who undergo bronchoscopy. Though, the reported mortality of DAH is 70–100%, the outcomes are changing with advances in preconditioning, stem cell transplantation and intensive care.

Objectives: To study the outcomes of DAH and factors associated with adverse outcomes in HSCT recipients at M.D. Anderson Cancer Center.

Methods: A retrospective review of all adult patients who underwent bronchoscopy after HSCT between January 1, 2002 and December 31, 2004 for a presumptive diagnosis of DAH. Outcome measures were recorded and analyzed over the six months following bronchoscopy. Univariate and multivariate Cox proportional hazards regression models were used to investigate prognostic value of various clinical factors.

Results: Bronchoscopy with BAL was performed in 223 patients for a clinical suspicion of DAH. Blood was seen on bronchoscopy in 87 (39%) patients. All patients received high dose steroids and other supportive care. Fifty-three (61%) met the standard criteria for diagnosis of DAH while 34 had an organism isolated on BAL. Of these 53 patients, 66% were alive at 30 days, and 45% at 6 months. Overall, 42% were alive at the end of follow-up period. Respiratory failure was recorded as the cause of death in 52%. Outcomes were significantly worse in the 34 patients with an organism in BAL. Significant associations existed between poorer overall survival and isolation of an organism in BAL (HR = 1.99, 95% CI: 1.38, 2.87), renal dysfunction (HR = 2.35, 95% CI: 1.60, 3.46), and neutropenia (HR = 2.77, 95% CI: 1.91, 4.01).

Conclusion: The survival of patients with DAH at our center is better then that reported in literature. Isolation of an organism in BAL, renal dysfunction, and neutropenia are associated with increased risk of death among patients undergoing bronchoscopy after HSCT.