Acute bleeding after allogeneic bone marrow transplantation: association with graft versus host disease and effect on survival

Background. Hemorrhagic complications are frequently implicated clinically for the high morbidity and mortality of acute graft versus host disease (GV HD), however, only few reports characterize the incidence and timing of ble eding in relation to GVHD, and essentially no study has quantified the effe ct of bleeding on survival of allogeneic patients with GVHD. This study exa mines the association of bleeding with acute GVHD and the effect of both co mplications on survival. Methods. A total of 463 allogeneic patients transplanted at the Johns Hopki ns Hospital, were included in the study. Bleeding evaluation was based on d aily scores of intensity and blood transfusions. All bleeding sites were re corded. GVHD staging was defined by the extent of rash, serum bilirubin, di arrhea, and confirmatory histology. Results. The incidence of GVHD was 27.4%, bleeding occurred in 40.2%. The i ncidence of bleeding was higher in patients with GVHD as compared with non- GVHD, and correlated with GVHD severity. The higher bleeding incidence in G VHD was due to gastrointestinal hemorrhage, hemorrhagic cystitis, and pulmo nary hemorrhage. While the majority of bleeding (51/75) in non-GVHD patient s initiated within 30 days after bone marrow transplantation (BMT), only 32 .3% (21/65) of the bleeding in the GVHD group initiated within 30 days, and the risk for bleeding continued until day 100. Bleeding was a late event c ompared to GVHD, however, most bleeding episodes were associated with activ e GVHD. Both GVHD and bleeding were individually associated with reduced su rvival, with profound additive adverse effect: median survival in 221 nonbl eeding non-GVHD was >83.2 months, GVHD nonbleeding (39 patients) had median of 10.6 months, bleeding non-GVHD (99 patients) had median of 4.3 months, and median survival of the GVHD bleeding group (85 patients) was 3.2 months . Conclusions. Our results support an association of bleeding with acute GVHD , suggesting that GVHD is a risk factor for bleeding after BMT. The occurre nce of bleeding clearly identified poor outcome subgroup within GVHD, sugge sting further evaluation for clinical application of bleeding in the assess ment of GVHD severity.