We suspect that in this group, the presence of GVHD was a marker for engraftment and inhibitor Bortezomib for a later time point posttransplantation, both of which may be associated with a better prognosis for survival after an ICU admission. This hypothesis is supported by the finding that, in the HSCT Admission group, patients with GVHD were admitted to the ICU at a significantly later time-point posttransplantation than those without GVHD (14 days, intraquartile range 11�C31 days versus 9 days, intraquartile range 2�C14 days, resp.; P = .003). In the other subgroups, and for the entire cohort, GVHD had no significant effect on survival. Our study has shown that the outcome of HSCT patients who require ICU-level care is not as poor as previously described.
Our own institution has seen an improvement in the survival of HSCT patients who require mechanical ventilation. However, although ICU-level care may be appropriate, mortality does remain high in this patient population, particularly among those who had an allogeneic transplant, require vasopressors or mechanical ventilation, or are neutropenic. As seen by our tree model (Figure 4), each of these factors negatively affects the prognosis for 6-month survival in HSCT patients admitted to the ICU. Furthermore, the reported ICU survival rate of the unselected, heterogeneous ICU population is about 70% [24] and thus better than that of HSCT patients (47%). Therefore, clinicians need to be encouraged to use studies like ours to provide patients with accurate estimates of outcome and initiate early discussions regarding advance directives.
As recommended by Crawford and Rubenfeld in the original study regarding hematopoietic transplant and ICU care, ��the goal of HSCT is to cure the underlying condition and return the patient to an acceptable quality of life. When these goals are no longer attainable, intensive life support should cease�� [7]. Nonetheless, with advances in technology and medicine, both the effectiveness of ICU therapeutic modalities and hematopoietic transplantation may improve. It is important that we continue to monitor the effects of these changes on outcome over time. Figure 3 Kaplan Meier survival curves for 6 months after admission to ICU depending on requirement for ventilation, vasopressor-use, hemodialysis, and the presence of neutropenia.
Split-liver transplantation (SLT) is an attractive alternative procedure to expand the donor pool in patients waiting for liver transplantation. Paramount to the success of SLT is a careful donor and recipient selection. The standard split-liver procedure for a child and an adult (Adult/Pediatric Split Liver Ttransplantation, A/P SLT), by splitting segment II-III for pediatric recipient and segment I-IV-V-VI-VII-VIII for an adult, is an accepted surgical option with GSK-3 good results both for the adult and for pediatric recipient [1].