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H/O RC > BMT > Flashcards

BMT Flashcards

1
Q

cGVHD RF

A

aGVHD
unmatched donor
unrelated donor
F donor, M recipient
alloimmunization (DSA)
PBSC > BM > cord
TBI
malignant indication

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2
Q

HSCT related CMV tx and tox

A

reduce immunosuppression
Valganciclovir - graft rejection/myelosuppression, HTN, renal
Foscarnet - NVD, renal/lytes
Cidofovir
IVIG (if pneumonitis)
Letermovir (new, phase II data)

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3
Q

Tisagenlecleucel Maude study outcomes

A

phase 2, CAR-T R/R ALL
3mo remission rate 81%
6mo EFS 73%, OS 90%
12mo EFS 50%, OS 76%

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4
Q

Inotuzumab s/e with HSCT

A

VOD - 50%

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5
Q

VOD dx

A

tender hepatomegaly
weight gain >5%
elevated bili
ascites
thrombocytopenia (transfusion refractory)

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6
Q

VOD US findings

A

portal vein decreased/reverse flow
monophasic hepatic vein flow
increased hepatic artery resistance
confirmation of hepatomegaly/ascites

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7
Q

engraftment syndrome presentation

A

fever
erythrodermic rash (>25% TBSA)
noncardiogenic pulmonary edema (diffuse pulm infiltrates)
hypoxemia

median onset 9d

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8
Q

pulmonary cGVHD manifestations and tx

A

-vbronchiolitis obliterans (fibrotic occlusion of small airways)
- BOOP: PFT obstruction, air trapping, bronchiectasis
- Idiopathic pneumonia syndrome
- diffuse alveolar hemorrhage

FAM = fluticasone, azithromycin, montelukast
ruxolitinib

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9
Q

aGHVD RF

A

CMV donor + recipient neg
older donor
F donor, M recipient
HLA mismatch
lack of manipulation (CD34 selection, a/b depletion)

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10
Q

TA-TMA RF

A

CNI (CSA, tac, sirolimus)
TBI
HD Busulfan

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11
Q

Describe CAR-T mechanism

A

patient autologous T cells manipulated with specific target fused to TCR so that binding causes automatic T cell activation

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12
Q

MHC Class I and II antigens

A

Class I: A, B, C
- expressed on all cells

Class II: DR, DP, DQ
- expressed on professional Ag presenting cells

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13
Q

Define 6/6, 8/8, 10/10

A

6/6: A, B, DRB1
8/8: +C
10/10: +DQB1

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14
Q

Target stem cell dose for each source

A

BM/PB: >4-8 x 10^6 CD34/kg
Haplo: >10-20 x 10^6
Cord: >4 x 10^7 TNC/kg
CD34 selection: >5-20 x 10^6 CD34/kg

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15
Q

Auto HSCT indications and conditioning

A

NBl: CEM, Thio/Cy
CNS: carbo/thio
Lymphoma: BEAM

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16
Q

DMSO toxicity (auto HSCT)

A

HTN
bitter taste
NV
headache
rare: encephalopathy, renal, arrhythmias

17
Q

HSCT infections
- pre-engraftment
- post-engraftment

A

pre: HSV, candida, aspergillus, viridans group strep, GN bacteria, CONS

post: adenovirus, CMV, ZVZ, late aspergillus

18
Q

auto HSCT related MDS epi, RF

A

5-10%, usually 4-7y post
RF: etop, TBI

19
Q

VOD RF

A

Busulfan
Cy > 120 mg/kg
TBI > 14 Gy
CSA > Tac
PB > BM > cord
Allo > auto
prior gemtuzumab/inotuzumab
infection (esp pre-existing viral hepatitis)

20
Q

Conditioning
- SAA
- ALL
- AML
- JMML
- SCD
- HLH

A
  • SAA: Cy/ATG
  • ALL: TBI/cyclo +- thio, etop, flu
  • AML: Bu/Flu or Bu/Cy
  • JMML: Bu/Cy/Mel
  • SCD: RIC; campath/TBI
  • HLH: RIC; campath
21
Q

Delayed HSCT complications + monitoring

A

Eye: eye, retinopathy - annual optho
Dental: root anom, microdontia - dental q6mo
Pulm: IPS, DAH, BO, BOOP - PFT 1y post BMT
Endo: thyroid, growth delay, gonadal failure - yearly TSH, growth, sex hormones at 13F/14M
Cardiac: CHD, arrhythmias - echo q1-5y
Renal: CKD, TA-TMA - UA/lytes day 100, annual BP
CNS: neurocognitive
SMN

22
Q

Graft rejection RF

A

RIC
cell dose
HLA mismatch
mixed chimerism
cord source
nonmalignant disorders
hyperinflammatory state
infection, viral reactivation

23
Q

graft rejection management

A

reduce immunosuppression
DLI
CD34 boost

24
Q

3 methods of T cell depletion

A

CD 34 selection
a/b depletion
in vivo T cell depletion (ATG, campath, PT Cy)

25
Q

classic (acute) GVHD staging

A

skin: macpap rash
- grade 1: <25% BSA
- grade 2: 25-50% BSA
- grade 3: >50% BSA
- grade 4: generalized erythroderma

GI: secretory diarrhea
- grade 1: 0.5-1 L/d
- grade 2: 1-1.5 L/d
- grade 3: 1.5-2 L/d
- grade 4: >2 L/d

liver: elevated conjugated bili
- grade 1: bili 2-3 mg/dL (35-50 uM)
- grade 2: bili 3-6 mg/dL (51-100)
- grade 3: bili 6-15 mg/dL (101-255)
- grade 4: bili >15 mg/dL (>255)

26
Q

classic (acute) GVHD grading

A

Grade 1: skin I-II only
Grade 2: skin III, liver or gut I
Grade 3: liver or gut II-III
Grade 4: any IV

27
Q

cGVHD features

A

skin: sclerotic (lichen planus, scleroderma), poikiloderma
mouth: dry
GI: ulcerations, sclerosis
Liver: elevated bili
Resp: BOOP

28
Q

aGVHD tx by grade

A

grade 1: topical steroid, optimize immunosuppression
grade 2+
- methylpred 1-2 mg/kg/d BID x7-14d
- steroid refractory: ruxolitinib and others

29
Q

cGVHD tx

A

pred 1 mg/kg/d x6w then eod, usual duration 2y

steroid refractory: ruxolitinib, ibrutinib, MMF, MTX, ritux, etc

30
Q

VOD EBMT criteria, Seattle Criteria, Baltimore Criteria

A

EBMT: 2 of
- unexplained consumptive thrombocytopenia
- unexplained w loss >5% over 3 days
- hepatomegaly
- ascites
- bili rising 2+ mg/dL over 3 days

Seattle: 2 of
- bili >2 mg/dL (34.2)
- hepatomeg or RUQ pain
- W gain >2%

Balitmore: bili > 2mg/dL plus 2 of
- tender hepatomeg
- ascites
- W gain >5%
- plt refractoriness

31
Q

VOD proph, tx

A

proph: RIC, Tac > CSA, urdodiol

Defibrotide
supportive: maintain euvolemia, remove hepatotoxic meds, transfusions (>30 on defibrotide)
refractory: FFP, antithrombin, etc

32
Q

TA-TMA screening criteria:

A

3+ of
- anemia
- thrombocytopenia
- elevated LDH
- schistocytes
- refractory HTN
- proteinuria 1+ mg

33
Q

TA-TAM dx criteria

A

biopsy proven
4+ of following present 2x over 2w:
- anemia
- thrombocytopenia
- elevated LDH
- urine Pr:Cr 1+
- HTN
- schistocytes
- elevated sC5b-9

34
Q

Describe TA-TMA

A

endothelial damage leading to fibrin deposition and microvascular thromboses, MAHA, plt consumption. Impacts kidney primarily, also resp, GI, neuro

35
Q

CRS features, ix, tx

A

fever, hypotension, hypoxia, capillary leak, rash, tachycardia, coagulopathy

elevated ferritin, CRP, IL-6, IL-10, IFNg

tocilizumab +- steroid (limit in CAR-T)

H/O RC (31 decks)

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