Pre-Transplant Phase
Patient Evaluation and Preparation
- Comprehensive pre-transplant evaluation includes assessment of cardiac, pulmonary, hepatic, and renal function to determine if the patient can tolerate the intensive conditioning regimen.
- Psychosocial assessment evaluates the patient's support system, coping mechanisms, and ability to adhere to complex post-transplant care.
Key Points
- Central venous access (typically a double or triple-lumen catheter) is essential for medication administration, blood sampling, and stem cell infusion.
- Patient education must cover the entire transplant process, potential complications, and long-term follow-up care.
Conditioning Regimens
- Conditioning regimens use high-dose chemotherapy with or without total body irradiation (TBI) to eradicate malignant cells and suppress the immune system to prevent graft rejection.
- Myeloablative conditioning completely destroys bone marrow function, while reduced-intensity conditioning (RIC) causes less severe myelosuppression and relies more on graft-versus-tumor effect.
High-dose chemotherapy conditioning can cause severe mucositis, organ toxicity, and increased risk of infection. Monitor for signs of sepsis, organ dysfunction, and electrolyte imbalances.
Key Points
- Common conditioning agents include cyclophosphamide, busulfan, melphalan, and fludarabine.
- RIC regimens are often used for older patients or those with comorbidities who cannot tolerate myeloablative conditioning.
Post-Transplant Phase
Engraftment and Recovery
- Engraftment refers to the process by which transplanted stem cells migrate to bone marrow and begin producing new blood cells, typically occurring within 10-28 days post-transplant.
- Neutrophil engraftment (ANC >500 cells/μL) typically occurs first, followed by platelet engraftment (platelet count >20,000/μL without transfusion).
Key Points
- Signs of engraftment include rising blood counts, possible fever, and skin rash.
- PBSC transplants generally result in faster engraftment than bone marrow transplants.
Acute Complications
- Mucositis is inflammation and ulceration of the mucosal lining of the GI tract, resulting in pain, difficulty swallowing, and increased risk of infection.
- Infections are a major cause of morbidity and mortality, with risk highest during the neutropenic period (bacterial infections predominate) and later periods (fungal and viral infections increase).
- Veno-occlusive disease (VOD), also called sinusoidal obstruction syndrome, involves damage to hepatic sinusoids leading to portal hypertension, ascites, and potentially liver failure.
Monitor for signs of sepsis (fever, tachycardia, hypotension) in neutropenic patients. Even minor temperature elevations (>38°C or 100.4°F) require immediate evaluation and broad-spectrum antibiotics.
Key Points
- Hemorrhagic cystitis may occur due to conditioning agents like cyclophosphamide or viral infections.
- Early signs of VOD include unexplained weight gain, right upper quadrant pain, and elevated bilirubin.
Graft-versus-Host Disease (GVHD)
- GVHD occurs when donor T-cells recognize recipient tissues as foreign and mount an immune response against host tissues, affecting primarily the skin, liver, and gastrointestinal tract.
- Acute GVHD typically occurs within 100 days post-transplant, while chronic GVHD occurs later and resembles autoimmune disorders.
| Characteristic |
Acute GVHD |
Chronic GVHD |
| Timing |
Within 100 days post-transplant |
After 100 days post-transplant |
| Skin Manifestations |
Maculopapular rash, blistering |
Scleroderma-like changes, hyperpigmentation |
| GI Manifestations |
Severe diarrhea, abdominal pain |
Esophageal strictures, malabsorption |
| Liver Manifestations |
Elevated bilirubin, transaminases |
Cholestasis, cirrhosis |
| Other Features |
Rapid onset, more inflammatory |
Sicca syndrome, joint contractures, lung involvement |
Key Points
- GVHD prophylaxis typically includes calcineurin inhibitors (cyclosporine or tacrolimus) plus methotrexate or mycophenolate mofetil.
- First-line treatment for acute GVHD is high-dose corticosteroids; second-line treatments include anti-thymocyte globulin, monoclonal antibodies, and extracorporeal photopheresis.
Long-Term Complications
- Endocrine complications include thyroid dysfunction, gonadal failure leading to infertility, and growth hormone deficiency in pediatric patients.
- Secondary malignancies may develop years after transplant due to conditioning regimens, chronic immunosuppression, and chronic GVHD.
- Pulmonary complications include bronchiolitis obliterans, interstitial pneumonitis, and restrictive lung disease.
Key Points
- Cardiovascular complications include cardiomyopathy, coronary artery disease, and metabolic syndrome.
- Bone complications include osteopenia, osteoporosis, and avascular necrosis.