Risk Factors for Mortality in Children with Hemorrhagic Cystitis after Hemopoietic Transplant
Gwen M. Grimsby, MD.
Phoenix Children's Hospital, Phoenix, AZ, USA.
Risk Factors for Mortality in Children with Hemorrhagic Cystitis after Hemopoietic Transplant
Background: Hemorrhagic cystitis (HC) can be a devastating complication of bone marrow (BMT) or stem cell transplantation (SCT) in children. Presently, there is lack of evidence and no consensus regarding optimal treatment for HC. This study aimed to examine risk factors associated with all-cause mortality in children with HC after BMT/SCT.
Methods: The Pediatric Health Information System billing database was searched for patients with ICD-9/10 codes for BMT/SCT, and additionally one of: gross hematuria, hematuria unspecified, or cystitis with hematuria. Microscopic hematuria was excluded as only patients with high grade HC are most likely to require urologic (GU) intervention. Demographic factors, and medical and surgical interventions frequently employed for HC, were compared between patients who expired or were discharged home using univariate and multivariate logistic regression.
Results: A total of 811 study subjects had mean age of 12.4 years (95% CI 0.2-29.7) and were 62% male. Underlying diagnosis included 388 (49%) leukemia/lymphoma, 182 (22%) blood dyscrasia, 99 (12%) solid organ tumor, 27 (3%) metabolic disease, and 115 (14%) unknown. Treatment included 377 (46%) BMT, 329 (41%) SCT, and 105 (13%) with unknown transplant. Of the 811 study patients, 89 (11%) expired. The distribution of factors among expired and discharged patients is presented in Table 1. GU morbidity was defined as having received instillation of any bladder medication or having undergone cystoscopy, bladder fulguration, clot evacuation, suprapubic or nephrostomy tube placement. Most notably, dialysis (OR=10.7, 95% CI=5.7-20.2), GU morbidity (OR=4, 95% CI=2.2-6.8) and IV cidofovir (OR=2.0, 95% CI=1.2-3.3) were significantly associated with mortality in a multivariate logistic model.
Conclusions: All-cause mortality was significantly higher in patients who received dialysis, GU intervention, or IV cidofovir. As high grade HC is a harbinger of mortality, and GU interventions are a symptom of a poor outcome in this patient population, collaboration between urologists and oncologists is needed to prevent futile treatments and patient discomfort from interventions not associated with increased survival.
Table 1
| Discharged (N=722) | Expired (N=89) | P Value | |
| Age (years) Mean (SD) | 12.3 (5.8) | 13.4 (6.2) | 0.098 |
| Gender, N (%) Female Male | 269 (37) 453 (63) | 40 (45) 49 (55) | 0.17 |
| Ethnicity, N (%) Hispanic Non-Hispanic Missing=36 | 179 (26) 5112 (74) | 15 (18) 69 (82) | 0.14 |
| Race, N (%) White Black American Indian Asian Pacific Islander Other | 458 (64) 82 (11) 4 (1) 49 (7) 4 (1) 104 (14) | 52 (58) 13 (15) 5 (6) 3 (3) 0 (0) 11 (12) | 0.35 0.38 0.0013 0.26 1.00 0.74 |
| Diagnosis, N (%) Blood Dyscrasia Leukemia/Lymphoma Solid Organ Tumor Metabolic Syndrome Unknown | 171 (24) 333 (46) 87 (12) 26 (4) 103 (14) | 11 (12) 55 (62) 12 (13) 1 (1) 10 (11) | 0.015 0.0067 0.73 0.35 0.52 |
| Transplant Type, N (%) Bone Marrow Stem Cell Unknown | 341 (47) 285 (39) 96 (13) | 36 (40) 44 (49) 9 (10) | 0.26 0.09 0.50 |
| Dialysis, N (%) | 25 (3) | 29 (33) | <0.0001 |
| IV Cidofovir, N (%) | 155 (21) | 37 (42) | <0.0001 |
| GU Instillation, N (%)* Alum Amicar Cidofovir Formaldehyde Silver nitrate | 36 (5) 9 (1) 22 (3) 4 (0.5) 0 (0) 2 (0.3) | 24 (27) 4 (4) 13 (14) 2 (2) 2 (2) 2 (2) | <0.0001 0.044 <0.0001 0.13 0.012 0.062 |
| GU Procedure, N (%)^ Bladder fulguration Cystoscopy Nephrostomy tube Suprapubic tube Clot evacuation | 40 (6) 11 (2) 19 (3) 3 (0.4) 5 (0.7) 18 (2) | 18 (20) 4 (4) 9 (10) 6 (7) 6 (7) 9 (10) | <0.0001 0.072 0.0018 <0.0001 0.0004 0.0014 |
| GU Morbidity, N (%) | 69 (10) | 31 (35) | <0.0001 |
*4 patients had instillation of more than one medication
^ 34 patients underwent more than one GU procedure
Back to 2018 Program
