Characteristics and prognosis of patients with myelodysplastic syndromes admitted to the intensive care unit

Myelodysplastic syndromes (MDS) are hematologic disorders characterized by bone marrow failure and potential transformation into acute myeloid leukemia (AML). Survival rates of approximately 45% at 3 years have been recently reported [1]. Studies have suggested that the intensity of end-of-life care might be suboptimal with high utilization of intensive care unit (ICU) resources and low rate of hospice or palliative care referrals [2,3]. As ICU admission may decrease the quality of life at the end-of-life in cancer patients [4], assessing the prognosis of MDS patients admitted to the ICU and whether they benefit from ICU admission is relevant in order to guide medical decisions and optimize end-of-life care. After approval by the Penn State Health Institutional Review Board (number 11148), we retrospectively reviewed the charts of all patients with MDS admitted to the medical ICU at Penn State Health Milton S Hershey Medical Center between 2008 and 2018, excluding patients in remission after hematopoietic stem cell transplant and patients with AML transformation. The data collected are presented in Table 1. MDS was classified according to the revised international prognostic scoring system (IPSS-R) [5]. Results are presented as median (interquartile range) and number (percentage) for continuous and categorical variables, respectively, and Wilcoxon rank-sum test or chi-square tests were, respectively, used to compare hospital survivors and non-survivors (R statistical package version 3.6.1). Twenty patients (aged 69 (59–75) years, 70% males) were included in the final analysis (Table 1). The Charlson comorbidity index was 4 [3–6] [6]. Sixteen patients had IPSS-R grouping information available and had very low (n1⁄4 1), low (n1⁄4 4), intermediate (n1⁄4 2), high (n1⁄4 8), and very high (n1⁄4 1) risk MDS. Prior treatments included azacitidine or decitabine (n1⁄4 10), transfusions alone (n1⁄4 7), and surveillance (n1⁄4 2). Patients were admitted 392 (170–697) days after MDS diagnosis, chiefly for sepsis (55%) and acute respiratory failure (35%); 95% of patients had full code status on ICU admission. Fifteen patients (75%) developed sepsis during ICU admission, predominantly ascribed to pneumonia (n1⁄4 9) followed by urinary tract infection (n1⁄4 3). Vasopressors, mechanical ventilation, and renal replacement therapy were required in 80%, 75%, and 20% of patients, respectively. Palliative care medicine was consulted for 30% (n1⁄4 6) of patients and for 5 of them the consultation was requested after ICU admission. The ICU length of stay was 5 (3–13) d, ICU and hospital mortality were 70% (n1⁄4 14) and 80% (n1⁄4 16), respectively. For 8 (50%) of the non-survivors, death was preceded by a transition to comfort care status, whereas five other patients had donot-resuscitate orders and two were still full code at the time of death. The only significant difference between survivors and non-survivors is that survivors had higher white blood cell count on ICU admission (16.5 (7.0–26.9) versus 1.5 (0.5–5.9) 10/L, p1⁄4 . 04). The time elapsed between MDS diagnosis and ICU admission tended to be longer in non-survivors, but the difference did not reach statistical significance (505 (173–765) versus 322 (161–335) d, p1⁄4.14). Interestingly, all patients had an echocardiogram performed as part of the diagnostic work-up and 11 of them (55%) had signs of pulmonary hypertension. The goal of this study was to focus on patients with isolated MDS, and we observed that its prevalence in our ICU population was much lower than de novo AML for instance (approximately 400 de novo AML patients were admitted during the same period), despite comparable prevalence reported in the general population [7]. This is consistent with a large prospective study of patients with hematological malignancies requiring ICU admission where only 4.5% of patients had MDS [8] and this likely accounts for the paucity of data regarding their ICU survival in the literature. The main reasons for ICU admission were acute respiratory failure and sepsis, in agreement with previous reports in patients with hematological malignancies in general (acute respiratory failure and shock accounted for 60% and 40% of ICU admissions, respectively, in the study by Azoulay et al. [8]). A higher proportion of our patients (75–80%) required vital organ