Acute renal failure requiring dialysis after allogeneic blood and marrow transplantation identifies very poor prognosis patients

Abstract

Summary:We examined the incidence, risk factors and associated mortality of acute renal failure requiring dialysis (Renal Bearman Grade [BG] 3) in a 3-year cohort of 97 consecutive allogeneic blood and marrow transplantation (alloBMT) patients. In all, 20 (21%) developed Renal BG3 (all died by day +132) and 77 (79%) developed renal insufficiency (Renal BG1-2). Renal BG3 was a contributing or primary cause of death in 18 (90%) patients who continued to require dialysis at time of death. The two Renal BG3 patients whose deaths were not related to renal failure died on day +103 of hemorrhage and day +132 of underlying disease. By univariate analysis, age, unrelated donor, veno-occlusive disease (VOD) and grade III-IV acute graft-versus-host disease with hepatic involvement were significantly associated with Renal BG3. The multivariate model of time to Renal BG3 determined only a prior diagnosis of severe acute GVHD (RR ¼ 4.1, 95% CI 1.6-10.3, P ¼ 0.003) and VOD (RR ¼ 9.1, 95% CI 3.5-23.7, Po0.001) as significant independent predictors. Renal BG3 is generally considered a conditioning regimen-related toxicity. This study demonstrates that Renal BG3 is most commonly a complication of hepatic co-morbidities after allogeneic blood and marrow transplantation and identifies patients with a very poor prognosis.

Acute renal failure after allogeneic myeloablative stem cell transplantation: retrospective analysis of incidence, risk factors and survival

“…Hypertension before transplantation as a risk factor for ARF was not identified in previous studies. 6,10,11,[15][16][17][18][19] Hypertension is a known risk factor for chronic kidney disease. 20 The patients with hypertension before SCT in our cohort did not have lower estimated GFRs (data not shown), so there was no apparent renal dysfunction.…”

“…In the first months after SCT, the major complications seen are sepsis (possibly leading to organ failure and admission to the intensive care unit (ICU)), 1 sinusoidal occlusion syndrome (SOS) (also known as veno-occlusive disease), 2 thrombotic thrombocytopenic purpura (TTP), 3 acute graft-versus-host disease (GVHD) 4 and cytomegalovirus (CMV) reactivation. 5 Several of these complications can be accompanied by acute renal failure (ARF), 2,3,[6][7][8][9] and are therefore risk factors for ARF. However, ARF can also occur in the absence of these complications, mainly as a result of nephrotoxic medications, such as amphotericin B 8 and cyclosporine.…”

Acute kidney injury in HCT: an update

“…Several studies have recently recognized and documented a stepwise increase in hazard of short-and long-term mortality in patients developing AKI after myeloablative and non-myeloablative HCT and, in patients requiring dialysis, mortality approached 100%. 11,13,25,26,32,33,61,79,80,83,104,105 Moreover, many of these studies have also established an increased association of numerous organ toxicities, primarily hepatic and pulmonary, as well as sepsis with AKI following either conditioning regimen. 13,54,61,80,83 CONCLUSIONS In summary, AKI occurs commonly both in myeloablative and in non-myeloablative HCT, and is associated with poor outcome.…”

“…Acute GVHD is independently linked with an increased risk of the occurrence of AKI in both myeloablative and non-myeloablative conditioning regimens. 13,25,32,61 Although in GVHD all organs should be possible targets for donor T cells, the kidney as a target organ for acute GVHD is still not considered by many physicians. Furthermore, histologically confirmed diagnosis of renal GVHD is rarely done and pathologic criteria have not yet been established for renal involvement in acute GVHD.…”

“…The HCT-specific comorbidity index, which stratifies patients according to the severity of pre-HCT hepatic, pulmonary, cardiac and renal impairment and assesses the presence of prior solid tumors, has been shown to predict non-relapse mortality and overall survival of HCT patients, as well as post-HCT AKI. 81,82 Common risk factors for AKI specifically related with myeloablative regimens were hepatic SOS, 61,80,83 lung toxicity, 25 high-risk disease 32 and acute GVHD, 26 while previous myeloablative HCT, 25,84 high-risk disease, 84 acute GVHD, 13,25,32 CMV reactivation, 25 incomplete HLA-matched transplant, 13 MTX, 32 as well as the need for more than three lines of therapy before HCT 32 significantly increased the risk for the development of AKI in patients undergoing nonmyeloablative HCT (Table 2). OUTCOME Several studies have evidenced poorer early outcomes for AKI patients compared with those without renal dysfunction, 85,86 specifically longer lengths of intensive care unit and hospital stay, higher in-hospital and post-discharge mortality, and an increased likelihood of discharge to an extended care facility.…”