Bone Marrow Transplant¶
Chelsie Sievers
Background¶
- Donor selection
- Autologous: self, no matching required (no GVHD risk, but also no graft-vs-tumor effect)
- Allogeneic: non-self, matching based on HLA (more matched = less
GVHD risk)
- Matched-related donor (MRD): fully matched sibling
- Matched-unrelated donor (MUD): From NMDP database
- Haploidentical: Half matched sibling or parent
- Source of stem cells:
- Peripheral blood stem cells (PBSCs) vs bone marrow-derived cells vs umbilical cord
- Conditioning regimens:
- Myeloablative vs Reduced-intensity conditioning (RIC)
- GVHD prophylaxis (for allo-SCT):
- Regimen varies, can include tacrolimus, MMF, MTX, or thymo and alemtuzumab during conditioning
Complications/Adverse Effects¶
Infectious
- Neutropenic fever, neutropenic enterocolitis (typhlitis)
- Bacterial infections
- Viral infections
- CMV: check weekly PCR levels post-allo-SCT
- All CMV+ recipients are treated with letermovir prophylactically regardless of donor status
- EBV: check weekly PCR levels post allo-SCT. If EBV VL >1000 on two occasions, can treat with pre-emptive rituximab to reduce the risk of PTLD
- CMV: check weekly PCR levels post-allo-SCT
- Invasive fungal infections (e.g. aspergillus, candida)
Non-infectious
- Nausea, vomiting, diarrhea, mucositis, cytopenias
- Hepatic veno-occlusive disease (VOD)/sinusoidal obstructive syndrome
(SOS)
- Pathophysiology: sinusoidal endothelial cell damage from conditioning chemo post-sinusoidal portal HTN cytokine release multiorgan failure and death
- Diagnosis: T Bili >2, hepatomegaly/RUQ pain, weight gain >2-5%
- Evaluation: RUQ US with doppler
- Treatment: Per heme attending; generally supportive, consider defibrotide
- Graft failure:
- Primary (persistent neutropenia without engraftment)
- Secondary (delayed pancytopenia 2/2 immune phenomena or infection after engraftment)
- Engraftment syndrome:
- Pathophysiology: PMN recovery cytokine storm vascular leak
- Symptoms: fever, tachycardia, hypotension, SOB, pulmonary edema, rash, weight gain, bone pain, confusion
- Diagnosis: Clinical
- Treatment: high-dose IV steroids
- Acute GVHD:
- Only in allogenic; Increased risk with more HLA mismatch
- Pathophysiology: donor T cells attack recipient (Th1-mediated)
- Symptoms: skin rash, cholestatic liver injury, diarrhea
- Treatment: IV steroids (methylprednisolone 1-2mg/kg x 5d)
- If refractory: mycophenolate, etanercept, ruxolitinib, antithymocyte globulin
- Chronic GVHD (typically after T+100)
- Can involve all organs but typically see a scleroderma-like picture (xerophthalmia, xerostomia dysphagia, arthritis, skin changes, malar rash, obliterative bronchiolitis, cholestatic liver injury, cytopenias)
- Treatment: steroids (also photophoresis for skin), consider trials of ruxolitinib, ibrutinib, rituximab if refractory
- PTLD (post-transplant lymphoproliferative disorders)
- Pathophysiology: B-cell proliferative disease typically 2/2 latent EBV
- Symptoms: fever, weight loss, fatigue, lymphadenopathy, extra-nodal masses, ↑ EBV PCR
Last update:
2022-06-25 02:05:01