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AKI treated with kidney replacement therapy in critically Ill allogeneic hematopoietic stem cell transplant recipients

Bone Marrow Transplantation volume 59, pages 178–188 (2024)Cite this article

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Abstract

Acute kidney injury (AKI) is a frequent complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT), but few studies have focused on AKI treated with kidney replacement therapy (AKI-KRT), particularly among critically ill patients. We investigated the incidence, risk factors, and 90-day mortality associated with AKI-KRT in 529 critically ill adult allo-HSCT recipients admitted to the ICU within 1-year post-transplant at two academic medical centers between 2011 and 2021. AKI-KRT occurred in 111 of the 529 patients (21.0%). Lower baseline eGFR, veno-occlusive disease, thrombotic microangiopathy, admission to an ICU within 90 days post-transplant, and receipt of invasive mechanical ventilation (IMV), total bilirubin ≥5.0 mg/dl, and arterial pH <7.40 on ICU admission were each associated with a higher risk of AKI-KRT. Of the 111 patients with AKI-KRT, 97 (87.4%) died within 90 days. Ninety-day mortality was 100% in each of the following subgroups: serum albumin ≤2.0 g/dl, total bilirubin ≥7.0 mg/dl, arterial pH ≤7.20, IMV with moderate-to-severe hypoxemia, and ≥3 vasopressors/inotropes at KRT initiation. AKI-KRT was associated with a 6.59-fold higher adjusted 90-day mortality in critically ill allo-HSCT vs. non-transplanted patients. Short-term mortality remains exceptionally high among critically ill allo-HSCT patients with AKI-KRT, highlighting the importance of multidisciplinary discussions prior to KRT initiation.

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Fig. 1: Flowchart and timeline.
Fig. 2: Longitudinal trends in ICU admission, AKI-KRT, and death.
Fig. 3: Timing of ICU admission, AKI-KRT, and death.
Fig. 4: Independent Risk Factors for AKI-KRT.
Fig. 5: Univariable Risk Factors for Death among AKI-KRT Patients.
Fig. 6: Allo-HSCT vs. non-allo-HSCT Critically Ill Patients with AKI-KRT and Death.
Fig. 7: Frequency and 90-Day Mortality Associated with Varying Stages of AKI.

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Data availability

The datasets generated during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

No funding was provided for this study. The authors are supported by the following grants from the National Institutes of Health: K23DK125672 (SG); R01HL142093-01 (RMB); R01DK130839 (MES); and R01HL144566, R01DK125786, and R01DK126685 (DEL).

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Author notes

  1. These authors contributed equally: Helena Kim, Rafia Ali.

Authors and Affiliations

  1. Division of Renal Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    Helena Kim, Rafia Ali, Sarah Kaunfer, Shobana Krishnamurthy, Lavanya Durai, Osman Yilmam, Tushar Shenoy, Audrey E. Monson, Charlotte Thomas, Isabel Park, Shruti Gupta & David E. Leaf

  2. Larner College of Medicine, University of Vermont, Burlington, VT, USA

    Samuel Short

  3. Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Dylan Martini

  4. Division of Hematology & Oncology, Dana-Farber Cancer Institute, Boston, MA, USA

    Richard Newcomb

  5. Hematopoietic Cell Transplant and Cellular Therapy Program, Massachusetts General Hospital, Boston, MA, USA

    Richard Newcomb & Zachariah DeFilipp

  6. Division of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA

    Roman M. Shapiro & Robert J. Soiffer

  7. Division of Pulmonary and Critical Care Medicine, Brigham and Women’s Hospital, Boston, MA, USA

    Rebecca M. Baron

  8. Adult Survivorship Program, Dana-Farber Cancer Institute, Boston, MA, USA

    Shruti Gupta

  9. Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

    Meghan E. Sise

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  1. Helena Kim
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Contributions

Research idea and study design: HK, RA, RS, RMB, SG, MS, DEL; Data acquisition: HK, RA, SS, LD, SAK, SK, OY, CT, DM, RN, RS, ZD, IP, TS, AEM; Data analysis/interpretation: HK RA, DEL; Statistical analysis HK, RA, DEL; Supervision or mentorship: HK, RA, DEL. Each author contributed important intellectual content during paper drafting.

Corresponding author

Correspondence to David E. Leaf.

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Competing interests

The authors report no competing financial interests in relation to this work. DEL received research support from BioPorto, BTG International, and Metro International Biotech LLC, and has received consulting fees from Sidereal Therapeutics, Casma Therapeutics, and MexBrain. RJS has received consulting fees from Vor Biopharma, Smart Immune, Daiichi Sankyo Inc., Neovii, CSL Behring, Bluesphere Bio, Cugene, Jasper, Takeda, Jazz Pharmaceuticals, Precision Biosciences, Alexion, and Rheos Therapeutics. RMB served on advisory boards for Genentech and Merck. SG received research support from BTG International, GE Healthcare, and AstraZeneca, is a member of GlaxoSmithKline’s Global Anemia Council, a consultant for Secretome and Proletariat Therapeutics, and founder of the American Society of Onconephrology.

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Kim, H., Ali, R., Short, S. et al. AKI treated with kidney replacement therapy in critically Ill allogeneic hematopoietic stem cell transplant recipients. Bone Marrow Transplant 59, 178–188 (2024). https://doi.org/10.1038/s41409-023-02136-8

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