Prognostic factors for early severe pulmonary complications after hematopoietic stem cell transplantation

Pulmonary complications are a significant cause of early mortality (before day 100) after bone marrow transplantation (BMT). To identify factors associated with development of early post-BMT severe pulmonary complications (SPCs), we conducted a retrospective review of the medical records of 339 consecutive patients who underwent hematopoietic stem cell transplantation for hematologic disorders and identified pulmonary complications that occurred before day 60 posttransplantation. SPCs, defined as (1) diagnosis of diffuse alveolar hemorrhage, (2) need for mechanical ventilation, or (3) death from respiratory failure, occurred in 48 (24%) of 199 patients receiving allogeneic transplants and 4 (2.9%) of 140 patients receiving autologous transplants (P <.001). Multiple clinical variables were analyzed to determine their influence on the development of SPCs in allogeneic marrow recipients. The method of graft-versus-host disease (GVHD) prophylaxis was the single most important factor affecting SPC incidence. Of patients who received cyclosporine/methotrexate (CYA/MTX) as GVHD prophylaxis, 33% experienced SPCs compared with 8% of those receiving T-cell depletion (TCD) alone (P <.0001). Multivariate analysis confirmed that TCD was associated with a lower risk of SPCs (relative risk [RR], 0.18; P =.0006). In addition to GVHD prophylaxis, a reduced pretransplantation FEV1 (forced expiratory volume in 1 second) (less than or equal to 80% of predicted) was associated with an increased risk for SPCs (odds ratio, 4.4; P =.0025). Grades 2 to 4 acute GVHD, tobacco use, age greater than or equal to 50 years, sex, unrelated donor, cytomegalovirus serologic status, disease status at transplantation, pretransplantation carbon monoxide diffusing capacity, and total body irradiation were not associated with development of SPCs. We conclude that autologous BMT is associated with a significantly lower incidence of SPCs compared with allogeneic BMT and that for allogeneic BMT, GVHD prophylaxis using TCD is associated with a significantly lower risk for SPCs compared with prophylaxis using CYA/MTX. Patients with pretransplantation FEV1 of less than or equal to 80% appear to have a higher risk for SPCs.