Vujaklija Brajkovic A, Kosuta I, Batur L, Sundalic S, Medic M, Vujevic A, Bielen L, Babel J. Patients admitted in the intensive care unit after solid organ or bone marrow transplantation: Retrospective cohort study. World J Transplant 2025; 15(1): 98975 [DOI: 10.5500/wjt.v15.i1.98975]
Corresponding Author of This Article
Ana Vujaklija Brajkovic, MD, PhD, Assistant Professor, Department of Internal Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb 10000, Croatia. avujaklija@gmail.com
Research Domain of This Article
Critical Care Medicine
Article-Type of This Article
Retrospective Cohort Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Ana Vujaklija Brajkovic, Iva Kosuta, Lucija Batur, Sara Sundalic, Marijana Medic, Andro Vujevic, Luka Bielen, Jaksa Babel, Department of Internal Medicine, University Hospital Centre Zagreb, Zagreb 10000, Croatia
Ana Vujaklija Brajkovic, Luka Bielen, School of Medicine, University of Zagreb, Zagreb 10000, Croatia
Co-first authors: Ana Vujaklija Brajkovic and Iva Kosuta.
Author contributions: Vujaklija Brajkovic A and Babel J designed the study; Kosuta I, Vujevic A, Batur L, Bielen L and Medic M collected the data; Vujaklija Brajkovic A, Kosuta I and Bielen L analyzed the data; Vujaklija Brajkovic A drafted the manuscript; Kosuta I, Sundalic S, Vujevic A, Batur L, Bielen L, Medic M and Babel J critically revised the manuscript; all authors approved the final version of the manuscript.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of the University Hospital Centre Zagreb (Approval No Class 8.1-24/103-2, number 02/013 AG, date May 6th 2024).
Informed consent statement: Due to the retrospective nature of the study, the informed consent was waived.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The dataset is available from the corresponding author (avujaklija@gmail.com). The consent was not obtained but the presented data are anonymized, and risk of identification is low.
STROBE statement: The authors have read the STROBE Statement-a checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ana Vujaklija Brajkovic, MD, PhD, Assistant Professor, Department of Internal Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, Zagreb 10000, Croatia. avujaklija@gmail.com
Received: July 11, 2024 Revised: September 27, 2024 Accepted: October 25, 2024 Published online: March 18, 2025 Processing time: 138 Days and 22.6 Hours
Abstract
BACKGROUND
Solid organ transplantation (SOT) and hematopoietic stem cell transplantation (HSCT) revolutionized the survival and quality of life of patients with malignant diseases, various immunologic, and metabolic disorders or those associated with a significant impairment in a patient's quality of life.
AIM
To investigate admission causes and treatment outcomes of patients after SOT or HSCT treated in a medical intensive care unit (ICU).
METHODS
We conducted a single-center, retrospective epidemiological study in the medical ICU at the University Hospital Centre Zagreb, Croatia covering the period from January 1, 2018 to December 31, 2023.
RESULTS
The study included 91 patients with either SOT [28 patients (30.8%)] or HSCT [63 patients (69.2%)]. The median age was 56 (43.2-64.7) years, and 60.4% of the patients were male. Patients with SOT had more comorbidities than patients after HSCT [χ² (5, n = 141) = 18.513, P < 0.001]. Sepsis and septic shock were the most frequent reasons for admission, followed by acute respiratory insufficiency in patients following HSCT. Survival rate significantly differed between SOT and HSCT [χ² (1, n = 91) = 21.767, P < 0.001]. ICU survival was 57% in the SOT and 12.7 % in the HSCT group. The need for mechanical ventilation [χ² (1, n = 91) = 17.081, P < 0.001] and vasopressor therapy [χ² (1, n = 91) = 36.803, P < 0.001] was associated with survival. The necessity for acute renal replacement therapy did not influence patients' survival [χ² (1, n = 91) = 0.376, P = 0.54]. In the subgroup of patients with infection, 90% had septic shock, and the majority had positive microbiological samples, mostly Gram-negative bacteria. The ICU survival of patients with sepsis/septic shock cumulatively was 15%. The survival of SOT patients with sepsis/shock was 45%.
CONCLUSION
Patients with SOT or HSCT are frequently admitted to the ICU due to sepsis and septic shock. Despite advancements in critical care, the mortality rate of patients with refractory septic shock and multiorgan failure in this patient population is extremely high. Early recognition and timely ICU admittance might improve the outcome of patients, especially after HSCT.
Core Tip: Solid organ transplantation (SOT) and hematopoietic stem cell transplantation (HSCT) have significantly improved the survival and quality of life of numerous patients. We conducted a comprehensive study of 91 post-transplantation patients in a tertiary intensive care unit (ICU) and identified sepsis and septic shock as the main admission diagnoses. The necessity for mechanical ventilation and vasopressor therapy significantly impacted survival. The ICU survival rate was 57% in the SOT group and 12.7% in the HSCT group. Early recognition and prompt ICU admittance of post-transplant patients are crucial for improving outcomes, particularly following HSCT.
Citation: Vujaklija Brajkovic A, Kosuta I, Batur L, Sundalic S, Medic M, Vujevic A, Bielen L, Babel J. Patients admitted in the intensive care unit after solid organ or bone marrow transplantation: Retrospective cohort study. World J Transplant 2025; 15(1): 98975
Solid organ transplantation (SOT) has revolutionized the survival and quality of life of patients with end-organ dysfunction. It provides either effective treatment for terminal diseases or those associated with a significant impairment in a patient's quality of life.
Hematopoietic stem cell transplantation (HSCT) today enables the effective treatment of several diseases. For instance, autologous HSCT is used to treat lymphoma, multiple myeloma and various solid tumors, while allogeneic HSCT is used for hematologic, immunologic, and metabolic disorders[1]. The development and progress of immunosuppression protocols enabled longer graft and patient survival after SOT, and have also improved the success of HSCT[2]. In addition to the immense usefulness of immunosuppression, there also exist disadvantages, such as side effects, drug-drug interactions, and increased host susceptibility to infections. Even though there have been positive experiences of solid organ and hematopoietic stem cell co-transplantation (for example in the treatment of multiple myeloma and end-stage chronic kidney disease) which would enable a shorter duration of immunosuppressive therapy[3], such an approach is currently not a part of routine clinical practice.
The risk of developing an infection depends on various factors, including the level of immunosuppression, the time since transplantation, the type of transplanted organ, acute or chronic rejection of the graft, previous host or donor infections, etc[3]. Patients after SOT or HSCT can develop bacterial, viral, or fungal infections. The initial manifestation of the infection may differ from those seen in the general population. For example, fever is often absent due to chronic corticosteroid therapy, which is often an integral component of immunosuppression protocols. If the infection is not recognized in time and adequate treatment is not initiated, it can progress to sepsis and septic shock[4].
Sepsis is highly prevalent. According to Rudd et al[5] in 2017 there were 48.9 million sepsis cases and 11 million sepsis-related deaths worldwide, accounting for 20% of all global deaths[5]. Moreover, sepsis and septic shock are considered to be the leading causes of critical care-related mortality worldwide[6]. Sepsis mortality varies globally, ranging from 20% to 60%[6-9] with lower mortality rates in developed countries. Infection with Gram-negative bacteria and the use of mechanical ventilation or renal replacement therapy during hospitalization in the intensive care unit (ICU) are considered risk factors for in-hospital death in patients with sepsis[10]. Patients with septic shock have higher mortality rates than patients with sepsis, ranging from 26 to 45% in Europe and North America[9,11], and up to 70% reported in Turkey[8]. Paradoxically, studies suggest that SOT patients with sepsis may experience better outcomes compared with those without SOT[12]. The study conducted by Ackerman et al. is considered the first sepsis-SOT study to examine high-risk ICU patients, analyzing 439 patients with SOT and sepsis. The reported mortality of sepsis-SOT patients was quite low, at 16.1%.
The patient population with SOT and HSCT is growing and comprises an increasing number of patients hospitalized in ICUs worldwide[13-16]. Studies on critically ill patients with either diagnosis are scarce.
The primary endpoint of our research was to investigate the causes of admission and outcome (survival) of hospitalization in the medical ICU of patients after SOT or HSCT. Secondary endpoints were to investigate the necessity for organ support, including mechanical ventilation, acute renal replacement therapy and vasopressor administration.
MATERIALS AND METHODS
Data sources and recruitment
We conducted a single-center epidemiological retrospective cohort study in the medical ICU at the University Hospital Centre Zagreb, Croatia. Critically ill adult patients (≥ 18 years old) hospitalized in the period from January 1, 2018 to December 31, 2023 were considered for inclusion in the study. Patients who underwent either solid organ (liver, kidney) or hematopoietic stem cell (autologous, allogeneic) transplantation and were hospitalized in the ICU for more than 24 hours were included in the study.
Data collection
Data on patient demographics (age, sex), comorbidities (cardiovascular (hypertension, coronary artery disease, peripheral artery disease, history of stroke or transient ischemic attack), respiratory (chronic obstructive pulmonary disease, asthma, pulmonary hypertension, interstitial lung disease), chronic kidney disease, chronic hemodialysis, diabetes and malignant disease), laboratory, clinical and microbiology data were collected from electronic medical records.
Outcome measures
Primary outcome measures were indications for admission to the ICU and ICU survival. Secondary outcomes were the necessity for organ support (mechanical ventilation, acute renal replacement therapy, vasopressor administration), ICU length of stay, and hospital length of stay.
Definitions of medical terms
Malignant disease is defined according to Brown et al[17] as a disease of uncontrolled proliferation by transformed cells subject to evolution by natural selection[17]. Sepsis and septic shock were defined according to the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)[18]. Acute kidney injury was defined according to the KDIGO 2012 criteria[19].
The Acute Physiology And Chronic Health Evaluation II (APACHE II)[20] and Sequential Organ Failure Assessment (SOFA)[21] scores were used to assess organ dysfunction and/or predict mortality.
Statistical analyses
IBM SPSS Statistics 29.0.1.0. software was used for statistical analysis. Normality analysis was performed using the Shapiro-Wilk test. Numerical variables with normal distribution were expressed as means and SD, and numerical variables that were not normally distributed as median with interquartile range. Categorical variables were presented through frequency distributions. Numerical variables were compared using the student t-test or Mann-Whiney U-test. Categorical data comparison was carried out using the χ2 test or Fisher's exact test. A P value < 0.05 was considered statistically significant. The statistical methods of this study were reviewed by Luka Bielen for University of Zagreb, School of medicine.
RESULTS
In the reporting period, 3249 patients were hospitalized in the medical ICU, out of which 116 had either solid organ or HSCT. Twenty-five patients were hospitalized in the ICU for less than 24 hours and were therefore excluded from the study. In total, 91 (2.1%) with either SOT (28 patients (30.8%); 23 kidney, 4 liver, 1 patient kidney and liver transplant) or HSCT (63 patients (69.2%); 15 autologous, 45 allogeneic, 3 both autologous and allogeneic) were included in the study.
Descriptive data
The median age was 56 (43.2-64.7) years with 60.4% male patients (Table 1). Patients with SOT had more comorbidities than patients after HSCT, χ² (5, n = 141) = 18.513, P < 0.001. Cardiovascular comorbidities, chronic kidney disease, and chronic hemodialysis were more frequent in the group of solid organ recipients. There was no difference in respiratory nor vasopressor support at the ICU admission between the two groups of patients. The APACHE II score was higher in patients with HSCT compared to patients with SOT (Table 1).
Table 1 Patients’ characteristics at intensive care unit admission, n (%)/median (25th-75th percentiles).
Total population (n = 91)
SOT (n = 28)
HSCT (n = 63)
χ²
P value
Age at admission (years)
56 (43.2-64.7)
61 (51.5-68)
54 (40.5-61)
NA
< 0.01
Age at transplantation (years)
50 (36.2-59)
50 (36.7-58.2)
51 (35-60)
NA
0.86
Male gender
55 (60.4)
17 (60.7)
38 (60.3)
0.001
0.97
Comorbidities
Cardiovascular
56 (61.5)
26 (92.9)
30 (47.6)
16.76
< 0.01
Respiratory
13 (14.3)
3 (10.7)
10 (15.9)
NA
0.51
Chronic kidney disease
34 (37.4)
26 (92.9)
8 (12.7)
53.22
< 0.01
Chronic hemodialysis
11 (12.1)
9 (32.1)
2 (3.2)
NA
< 0.01
Diabetes
16 (17.6)
7 (25)
9 (14.3)
1.53
0.21
Malignant disease
11 (12.1)
4 (14.3)
7 (11.1)
NA
0.70
Disease severity
SOFA
9 (6-11)
7.5 (5-11)
9 (7-10)
NA
0.37
APACHE II
22 (17.5-27)
19 (14-22)
23 (19-27)
NA
0.01
Respiratory support
48 (52.7)
12 (42.9)
36 (57.1)
1.58
0.20
Vasoactive medication support
32 (35.2)
9 (32.1)
23 (36.5)
0.16
0.68
Outcome data
Sepsis and septic shock were the most frequent reasons for admission for the entire population, followed by acute respiratory insufficiency in patients following HSCT (Figure 1). The need for organ support increased in both patient groups during the ICU stay. Patients treated due to hematological disease more frequently required mechanical ventilation and vasoactive medications in comparison with patients after SOT who more frequently needed acute renal replacement therapy (Table 2).
Figure 1 Causes of admission to the intensive care unit.
A: Entire population; B: Solid organ transplant recipients; C: Hematopoietic stem cell transplant recipients.
Table 2 Organ support during intensive care unit stay and outcome, n (%)/median (25th-75th percentiles).
Survival rate significantly differed between recipients of solid organ transplants and HSCT, χ² (1, n = 91) = 21.767, P < 0.001. ICU survival was 57% in solid organ recipients and 12.7 % in the second group. Patients who underwent allogeneic HSCT had different survival rates in comparison to patients who underwent autologous HSCT, χ² (1, n = 63) = 3.927, P = 0.048.
The need for mechanical ventilation [χ² (1, n = 91) = 17.081, P < 0.001] and vasopressor therapy [χ² (1, n = 91) = 36.803, P < 0.001] was associated with survival. On the other hand, the necessity for acute renal replacement therapy did not influence patients’ survival, χ² (1, n = 91) = 0.376, P = 0.54.
Patients with and without sepsis
As sepsis/septic shock was the most frequent cause for admission to the ICU we compared data among the two groups; patients with sepsis/septic shock (53 patients; 16 patients with SOT and 37 HSCT) and patients admitted with no signs of infection (38 patients) (Table 3).
Table 3 Comparison of patients with and without sepsis, n (%)/median (25th-75th percentiles).
Patients’ demographic data and comorbidities were similar between groups, with chronic kidney disease being the only significant difference. Patients with sepsis/septic shock had higher APACHE II and SOFA scores at admission compared to patients without infection. Moreover, the necessity for organ support including mechanical ventilation, vasopressor application, and acute renal replacement therapy, were all more prevalent in the group of patients with sepsis/septic shock.
In the group of patients with sepsis vasopressor administration was needed in 10/16 (62.5%) SOT patients and 37/37 (100%) HSCT patients, mechanical ventilation in 11/16 (69%) SOT and 36/37 (97%) HSCT, acute renal replacement therapy in 13/16 (81%) SOT and 21/37 (57%) HSCT patients. Cumulatively, 90% of patients had septic shock. All patients with HSCT were neutropenic, 26 (70%) were receiving immunosuppressive therapy, 8 had acute graft-versus-host disease (GVHD) and 5 had chronic GVHD. The median time from hospital to ICU admission in SOT patients was 2 days and in HSCT patients 16 days.
Thirteen patients (81%) with SOT had positive microbiological samples, in which Gram-negative bacteria predominated (11 patients, 84%). All patients in the HSCT group had positive microbiological samples, two patients had a fungal infection, 12 Gram-negative, and others had a polymicrobial infection. Gram-negative bacteria included P. aeruginosa, A. baumannii, K. pneumoniae and E. coli.
The overall ICU survival differed between patients with sepsis/septic shock and other diagnoses [χ² (1, n = 91) = 6.93, P = 0.008] reaching 15% in patients with sepsis/septic shock and 42% in patients without infection. In patients with sepsis in the SOT group 7 (44%) patients survived.
DISCUSSION
We presented data on 91 patients who had undergone solid organ (kidney or liver) or HSCT (autologous and/or allogeneic) admitted to the medical ICU of a tertiary clinical center. These patients represented a minority of patients admitted to the ICU accounting for approximately 2%. The most common reason for admission was sepsis (53 patients, 58%). The need for organ support was significant. The overall ICU survival was rather low (26.4%) and differed between the SOT (57.1%) and HSCT (12.7%) groups of patients.
Approximately one-third of patients were admitted after SOT, with a predominance of kidney recipients. The variation in admissions might be explained by the fact that UHC Zagreb carries out most kidney transplantations in Croatia, while liver transplantation has only recently become more frequent at our institution. Notably, patients who had undergone heart or lung transplants were mostly treated in other specialized units and were not part of this study. UHC Zagreb is renowned for its expertise in treating patients with hematopoietic stem cells and is currently the only center performing allogeneic HSCT in Croatia, which partially accounts for the majority of hematological patients in our study.
We observed certain discrepancies in demographic data and comorbidities between SOT and HSCT patients. SOT patients tended to be older and had more comorbidities, particularly cardiovascular diseases, chronic kidney disease, and chronic hemodialysis, compared to HSCT patients. This could be attributed to the high number of kidney transplant recipients, in whom cardiovascular diseases and chronic kidney disease with ongoing hemodialysis are common indications for transplantation[22].
Sepsis and septic shock (58%) were the most common causes of ICU admission regardless of the type of transplant. Interestingly, at the ICU admission half of the patients required respiratory support and one-third vasopressor application. The need for organ support increased during the ICU stay, specifically in the HSCT group, indicating failure of conventional sepsis/septic shock treatment. 97% of HSCT patients required mechanical ventilation, 100% vasopressor and 57% acute renal replacement therapy pointing toward the development of multiorgan failure. Given the percentage of vasopressor necessity, we can claim that 90% of patients with infection had septic shock. However, due to the study's retrospective design, the exact dosage of vasopressors used was unknown, making it challenging to accurately estimate the prevalence of refractory septic shock[23]. In refractory septic shock, patients do not respond to conventional therapy and develop progressive multiorgan failure. This subset of patients has very high mortality, reaching 80-90% regardless of age, comorbidities, and country’s economic standards[24-26]. The dose and timing of vasopressors significantly affect patient survival in the ICU. Patients whose vasopressor dosage can be rapidly reduced have lower mortality, while those requiring increasing doses have higher mortality[26,27]. Besides the substantial need for organ support in the described population, the presence of positive microbiological samples is also interesting. 80 % of SOT patients and all HSCT patients had positive microbiology samples with the predominance of Gram-negative bacteria. Previous research found that Gram-negative sepsis is associated with higher mortality[28]. Given the large percentage of multiorgan failure and Gram-negative infection in the described population high mortality is expected. However, the ICU survival of patients with sepsis/septic shock of only 15% is extremely low. Patients with SOT had better survival than HSCT, approximately 45 %, which is in accordance with the mortality of patients with septic shock. Ackerman et al[12] reported rather low mortality of SOT patients with sepsis[12]. However, in that population, 90% of patients with sepsis had a median SOFA of 7, 10% of patients had septic shock, 40 % had positive microbiology results of any source, and 15% had positive blood cultures with fewer Gram-negative microorganisms. In contrast, septic shock was present in 62% of our SOT population, 69% received mechanical ventilation, 80% had positive microbiology samples and the SOFA score was higher. Considering the above, even though the number of included patients in our research is rather low, patients were severely ill, and the survival rate might be considered acceptable.
On the contrary, all patients after HSCT died during the ICU stay. Infection and GVHD remain common causes of nonrelapse transplant-related mortality[29,30]. In critical illness, neutropenia is recognized as an independent risk factor for increased mortality[31,32]. Previous research found an extremely low probability of ICU survival (< 10%) in patients with leukemia[33], as well as after allogeneic HSCT[34]. Factors associated with decreased survival of hematological patients are previous allogeneic stem cell transplantation, the time between hospital and ICU admission, time spent in the ICU, need for mechanical ventilation, acute renal replacement therapy or vasopressor therapy, etc[34,35]. Another possible explanation for the extremely high mortality rate of HSCT patients might be that most patients with HSCT, particularly allogeneic bone marrow transplantation in our institution are treated in a hematological high-dependency unit during the HSCT procedure, or if admitted due to complications such as acute GVHD. These patients are transferred to the ICU only in cases of severe hemodynamic instability or acute respiratory failure requiring mechanical ventilation. Hemodynamic instability unresponsive to volume resuscitation or even low doses of noradrenaline, or failure to achieve optimal oxygenation despite maximal oxygen flow through an oronasal mask, are the most common indications for the presentation of these patients to the intensivist. Therefore, the high incidence of mechanical ventilation and vasopressors in this group is expected. The long period between hospital and ICU admission (16 days) supports this observation, although due to the retrospective study design, we could not reconstruct precisely the time between the onset of organ injury and ICU admission. Nevertheless, our results could imply the need to revise the hospital policy of delayed ICU admission. The more intensive hemodynamic monitoring and earlier or more precise circulatory stabilization could impact the survival rate. It has been shown previously that allogeneic HSCT recipients admitted to the ICU as soon as they show signs of organ injury had a better outcome. Patients who were admitted later on following the first organ injury (> 1 day) or with more organ injuries (> 2 organ injuries) had the worst outcome[36]. A significant proportion of our HSCT patients had severe acute GVHD or chronic GVHD, which preceded the episode of sepsis/septic shock and the patient's deterioration. Acute GVHD has been described as an unfavorable prognostic factor in the ICU[37-40]. In several earlier cohort studies, nearly all severe GVHD patients who required mechanical ventilation died[41-43]. The question of whether these patients should be admitted to the ICU, particularly if requiring mechanical ventilation, remains to some extent controversial[44]. In critically ill patients with chronic GVHD, liver GVHD was associated with poor outcomes, as well as the need for mechanical ventilation or hemodialysis[45].
The most significant limitation of our study is its retrospective design due to which some patients might have been excluded from the study and some clinical data were missing, specifically regarding the vasopressor dose (noradrenaline equivalent dose). Moreover, the sample size is rather low and uneven between the SOT and HSCT groups.
Another limitation of the current research might be the different duration and level of immunosuppression among groups. Patients who undergo SOT receive induction immunosuppression during surgery and continue lifelong maintenance therapy to prevent allograft rejection. The level of immunosuppression varies between liver and kidney recipients, usually being lower in the liver recipients[22]. HSCT is performed by first conditioning the recipient with chemotherapy and/or total body irradiation followed by the infusion of donor HSCs. Patients after allogeneic HSCT receive immunosuppression to prevent and treat acute GVHD[1]. Based on the above we could conclude that patients who are treated with allogeneic HSCT are the most immunocompromised subgroup of patients presented in this study and probably had the highest risk of developing sepsis.
CONCLUSION
This paper provides an overview of the SOT and HSCT patients treated in the medical ICU of a high-volume transplant center. The gathered data sheds light on the frequency and causes of admission, disease severity, and treatment outcomes, and provides an opportunity to analyze the strengths and areas for improvement in critical care for this patient population. We can conclude that patients undergoing SOT and HSCT are often admitted due to infection, requiring extensive organ support, and despite advancements in critical care, the mortality rate remains high. Our results emphasize the importance of early recognition of this patient population in our emergency rooms and general wards and raise awareness of their increased risk of a lethal outcome. This paper also raises several important questions. Should patients with SOT and HSCT be admitted to the ICU at an earlier stage? Should protocols for admitting post-HSCT patients be enhanced or modified? Should the establishment of specialized ICU for post-transplant patients be considered? Lastly, should the education of intensivists in the field of transplantation medicine be expanded in high-volume transplant centers to improve patient outcomes post-transplantation?
ACKNOWLEDGEMENTS
We thank all physicians of the Department of Intensive Care Medicine for all their help and support in writing this article.
Footnotes
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Corresponding Author's Membership in Professional Societies: University Hospital Centre Zagreb, University Hospital Centre Zagreb; European Society of Intensive Care.
Specialty type: Transplantation
Country of origin: Croatia
Peer-review report’s classification
Scientific Quality: Grade A, Grade C, Grade D
Novelty: Grade A, Grade B, Grade C
Creativity or Innovation: Grade B, Grade B, Grade C
Scientific Significance: Grade A, Grade C, Grade C
P-Reviewer: Majeed HM; Yan X S-Editor: Liu H L-Editor: A P-Editor: Zhao YQ
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