Bone Marrow Transplantation (2014) 49, 1123 © 2014 Macmillan Publishers Limited All rights reserved 0268-3369/14 www.nature.com/bmt
LETTER TO THE EDITOR
Reply to Canet et al: Acute kidney injury in critically ill allo-HSCT recipients Bone Marrow Transplantation (2014) 49, 1123; doi:10.1038/ bmt.2014.101; published online 12 May 2014 We would like to thank Canet et al.1 for their interest in our article and their reported observations. We fully agree with the fact, that allo-HSCT recipients are at high risk for renal impairment due to several risk factors as outlined by the authors. Yu et al.2 published their data about the occurrence and risk factors for acute kidney injury (AKI) in the early post-allo-HSCT setting. Their report emphasizes the fact that, AKI is rarely the cause of mortality itself but AKI leads to significantly decreased survival rate even outside of ICU. The strong relation to acute GVHD in this report is in line
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with the letter by Canet et al.,1 who would not even take these patients to intensive care unit (ICU) because of the compromised outcome. Regarding the impact of diminished renal clearance leading to decreased drug dosing or even omittance of several important medications as well as increased toxicity if not adequately adapted dosing is performed, patient care is difficult in this highly fragile group of patients. Our publication has mainly focused on the risk factors leading to ICU admittance and mostly, renal insufficiency was not the leading cause for ICU admission. However, 16 out of 33 patients admitted to ICU had AKI grade II and higher according to the Kidney Disease Improving Global Outcomes guidelines (49%) and 9 of those needed renal replacement therapy. Renal replacement therapy (P = 0.021), but not renal insufficiency (P = 0.911) was associated with poorer OS in the univariate analysis (Figure 1). The lack of a significant difference in the OS of AKI patients in our study is most likely explained by the clearly inferior survival of patients without renal insufficiency as compared with the data presented by Canet et al.1 In conclusion, AKI is a significant risk factor for morbidity and mortality in allo-HSCT patients. Regular monitoring of renal function, especially if patients are treated with nephrotoxic drugs is mandatory. CONFLICT OF INTEREST The authors declare no conflict of interest.
R Benz1 and G Stussi2 Department of Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland and 2 Division of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland E-mail: [email protected]
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Figure 1. Cumulative survival of patients admitted to ICU with (green line) and without (blue line) renal replacement.
1 Canet E, Lengline E, Zafrani L, Peraldi M-N, Socié G, Azoulay E. Acute kidney injury in critically ill allo-HSCT recipients. Bone Marrow Transplant 2014; 49: 1121–1122. 2 Yu ZP, Ding JH, Chen BA, Liu BC, Liu H, Li YF et al. Risk factors for acute kidney injury in patients undergoing allogeneic hematopoietic stem cell transplantation. Chin J Cancer 2010; 29: 946–951.
LETTER TO THE EDITOR
Reply to Canet et al: Acute kidney injury in critically ill allo-HSCT recipients Bone Marrow Transplantation (2014) 49, 1123; doi:10.1038/ bmt.2014.101; published online 12 May 2014 We would like to thank Canet et al.1 for their interest in our article and their reported observations. We fully agree with the fact, that allo-HSCT recipients are at high risk for renal impairment due to several risk factors as outlined by the authors. Yu et al.2 published their data about the occurrence and risk factors for acute kidney injury (AKI) in the early post-allo-HSCT setting. Their report emphasizes the fact that, AKI is rarely the cause of mortality itself but AKI leads to significantly decreased survival rate even outside of ICU. The strong relation to acute GVHD in this report is in line
1.0
0.8
0.6
with the letter by Canet et al.,1 who would not even take these patients to intensive care unit (ICU) because of the compromised outcome. Regarding the impact of diminished renal clearance leading to decreased drug dosing or even omittance of several important medications as well as increased toxicity if not adequately adapted dosing is performed, patient care is difficult in this highly fragile group of patients. Our publication has mainly focused on the risk factors leading to ICU admittance and mostly, renal insufficiency was not the leading cause for ICU admission. However, 16 out of 33 patients admitted to ICU had AKI grade II and higher according to the Kidney Disease Improving Global Outcomes guidelines (49%) and 9 of those needed renal replacement therapy. Renal replacement therapy (P = 0.021), but not renal insufficiency (P = 0.911) was associated with poorer OS in the univariate analysis (Figure 1). The lack of a significant difference in the OS of AKI patients in our study is most likely explained by the clearly inferior survival of patients without renal insufficiency as compared with the data presented by Canet et al.1 In conclusion, AKI is a significant risk factor for morbidity and mortality in allo-HSCT patients. Regular monitoring of renal function, especially if patients are treated with nephrotoxic drugs is mandatory. CONFLICT OF INTEREST The authors declare no conflict of interest.
R Benz1 and G Stussi2 Department of Internal Medicine, Kantonsspital Münsterlingen, Münsterlingen, Switzerland and 2 Division of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland E-mail: [email protected]
0.4
1
0.2
REFERENCES
0.0 0
1000
2000 Survival (days)
3000
4000
Figure 1. Cumulative survival of patients admitted to ICU with (green line) and without (blue line) renal replacement.
1 Canet E, Lengline E, Zafrani L, Peraldi M-N, Socié G, Azoulay E. Acute kidney injury in critically ill allo-HSCT recipients. Bone Marrow Transplant 2014; 49: 1121–1122. 2 Yu ZP, Ding JH, Chen BA, Liu BC, Liu H, Li YF et al. Risk factors for acute kidney injury in patients undergoing allogeneic hematopoietic stem cell transplantation. Chin J Cancer 2010; 29: 946–951.
