PURPOSE: The mortality of diffuse alveolar hemorrhage (DAH) in cancer patients is 70 to 100%. Minimal data exists regarding other effective treatments; however, retrospective studies mostly in hematopoeitic stem cell transplant (HSCT) patients cite steroids as the primary therapy. A recent study suggested that high dose methylprednisolone (MP) combined with the antifibrinolytic agent aminocaproic acid (ACA) reduces mortality, but it was limited to 8 HSCT patients. Consequently, we investigated the use of ACA and MP versus MP alone to compare the impact on survival in a larger sample.
METHODS: We retrospectively analyzed all ICU patients diagnosed with DAH over 13 consecutive months who received either high dose MP and ACA infusion, or high dose MP alone. Diagnosis was based on available bronchoscopic and autopsy findings, or a clinical presentation consistent with DAH.
RESULTS: A total of 68 patients were included in the study. 75% had leukemia, 20.6% had lymphoma, and 4.4% had solid tumors. 41% were HSCT recipients. There were no differences in baseline platelet counts, respiratory infections, APACHE III, SOFA or SAPS scores between the two groups. 60.3% of the patients (n=41) received high dose MP and ACA infusion, and 39.7% (n=27) received high dose MP alone. The mean steroid dose was 500 milligrams/day. Of the patients treated with MP and ACA, 100 day mortality was 87.8% vs. 77.8% in the group treated with MP alone (p=0.75). There were also no differences in ventilator days (p=0.46), ICU length of stay (p=0.64) or hospital length of stay (p=0.9) between the two groups. Incidence of deep vein thrombosis, myocardial infarction and ischemic stroke, were not significantly different. A subgroup analysis of patients with bronchoscopic and/or autopsy findings diagnostic of DAH (n=21) also found no differences in outcomes.
CONCLUSIONS: In cancer patients with DAH, combined treatment with ACA and MP did not improve mortality as compared to MP alone.
CLINICAL IMPLICATIONS: Despite previously published data, this study indicates that ACA may not be an effective adjunct for the treatment of cancer-related DAH.
DISCLOSURE: The following authors have nothing to disclose: Nisha Rathi, Andrew Dinh, Sajid Haque, Lei Feng, Suyu Liu, Wenli Dong, Michael Hovden, Kristen Price, Joseph Nates
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