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Additional CSO Cards > Chapter 15: Hematopoietic Cell Transplantation > Flashcards

Chapter 15: Hematopoietic Cell Transplantation Flashcards

1
Q

Describe the HCT process

A

Collect cells (source varies), then administer a conditioning regimen to kill any remaining cells(totally kills the immune system), weaken the immune system, and prevent the body from rejecting the new cells. Then new cells aka “graft” are inserted.

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2
Q

Define “graft”

A

The new stem cells that are inserted into the recipient

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3
Q

Define “engraftment”

A

The process in which the new cells (the “graft”) infuse/home

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4
Q

When is engraftment first evident?

A

When new WBC, RBC, platelets appear in the blood

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5
Q

Define Autologous HCT & which type of blood cancers they’re usually used for

A

Stem cells are collected from yourself prior to the conditioning process.

Usually used with lymphomas or MM

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6
Q

Define Syngeneic HCT

A

Cells are collected from an identical twice

think “same gene”

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7
Q

Define Allogenic HCT

A

Cells are collected from a full or closely matched donor
-matched related
-matched unrelated
-mismatched unrelated
-half-matched related
-umbilical cord blood

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8
Q

The conditioning regimen prior to HCT transplant includes _______, ________, or both

A

Chemo
Total body radiation

*goal is to kill the immuno system to prevent graft rejection

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9
Q

What are the 3 types of conditioning regimens?
*note conditioning isnt always just for transplant

A
  1. High-dose, myelo-ablative - high dose chemo, requires stem cell infusion
  2. Nonmyeloablative - Uses chemo w/ minimal cytopenias thus does not require stem cell infusion
  3. Reduced-intensity conditioning (RIC) - uses less intensive chemo, TBI, or both that causes prolonged cytopenias
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10
Q

Which 2 conditioning regimens require stem-cell infusion?

A
  1. High-intensity, myeloablative
  2. Reduced intensity conditioning
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11
Q

Which conditioning regimen has the highest organ toxicity?

A

High-intensity (myeloablative)

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12
Q

What is the graft-versus-tumor effect

A

A response in which the graft stem cells attack the remaining cancer cells that were not killed by the lower chemotherapy doses

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13
Q

Which conditioning regimen requires the lowest reliance on the graft-versus-tumor effect?

A

High-intensity (aka myeloablative)

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14
Q

Why may non-myeloablative or reduced-intensity conditionings be used

A

Used for older, sicker patients who cannot tolerate myeloablative conditioning

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15
Q

What is the least intensive conditioning regimen?

A

Low dose TBI

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16
Q

Name 4 chemos typically used as part of conditioning regimens

“Conditioning For Bone Marrow”

A
  1. Fludarabine -
  2. Melphalan
  3. Cyclophosphamide
  4. Busulfan
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17
Q

What is the regimen for the highest intensity conditioning?

A

High dose TBI + busulfan + cyclophosphamide

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18
Q

How long does the engraftment process take

A

2-3 weeks, very neutropenic during this time. Yet takes months to return to full immune function.

**Autologous shortest, umbilical cord longest (21 days)

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19
Q

What should MNT focus on during the conditioning period

A

Overcoming decreased oral intake & impaired nutrient utilization d/t GI toxicities

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20
Q

T/F: Nutrition assessments are recommended for all patients undergoing HCT

A

True, should get a baseline assessment to determine who may require intervention prior to transplantation

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21
Q

What are 2 risks associated with poor nutrition status prior to HCT

A
  1. Delayed engraftment
  2. Post-transplant complications
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22
Q

What are protein & kcal needs for HCT adult ?

A

30-35 kcal/kg or BMR 1.3-1.5

1.5 g/kg (2-2.5 IBW for BMI >/= 30)

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23
Q

No length of time has been determined for how long immunosuppressed must limit their diet, but these are some guidelines: (13)

*Typically suggest 3 months for autologous and until immunosuppresive therapy completes for allogenic

A

Avoid
1. Raw/undercooked fish & meat
2. Raw tofu (unless pasteurized/aseptically packaged)
3. Lunch meats/hot dogs (unless heated until steamed)
4. Refrigerated smoked seafood (lox, pickled fish)
5. Unpasteurized milk, cheese, yogurt
6. Blue-veined cheese (blue, gorgenzola)
7. Uncooked soft cheese (brie)
8. Mexican style soft-cheese (queso blanco/queso fresco)
9. Cheese containing chili peppers or other uncooked vegetables
10. Fresh salad dressings w/ raw eggs or inappropriate cheeses
11. Unwashed raw/frozen fruits & vegetables or those with mold. Avoid all sprouts.
12. Unpasteurized fruit/vegetable juices
13. Well water (unless boiled)

24
Q

What are kcal & protein needs for children w/ HCT

A

BMR x 1.4-1.8 depending on age
1.8-3.0 g/kg BW depending on age

25
Q

How to calculate fluid needs for HCT?

A

Holliday-Seger

26
Q

Mineral ________ should be increased w/ large-volume diarrhea

A

Zinc

(1 mg/100 mL stool)

27
Q

______ should be increased w/ corticosteroids & osteoporosis

A

Calcium

28
Q

Oral intake typically starts to improve with ____________

A

Engraftment

29
Q

Mucositis presents in 80% with myeloablative conditioning regimens.

It’s typically related to high-dose TBI or one of the following 3 chemo agents:

A

Melphalan, Etoposide, Methotrexate

30
Q

How does Cryotherapy reduce risk for mucositis?

A

Reduces blood flow & exposure to chemo int he mouth

31
Q

Is glutamine supplementation recommended with HCT?

A

No - although it may help reduce mucositis it also may increase risk for relapse of malignancy. More studies needed.

32
Q

What is Sinusoidal Obstructive Syndrome?

A

A cascade of events that leads to the narrowing & occlusion of hepatic vessels. It leads to decreased hepatic outflow, ascites, hepatomegaly and potentially multi organ failure

This occurs when the side effects of chemotherapy cause sinusoidal endothelial and hepatocyte damage

*usually occurs within the first few weeks of HCT

May require diuresis, sodium restriction, dialysis

33
Q

Complications with hyperglycemia post-HCT

A

May prolong engraftment time, delay neutrophil recovery, and increase risk for infection and graft verse host disease

*Use of PN increased the risk fourfold

34
Q

Why is hyperglycemia commonly seen post-HCT?

A

Steroids, PN, metabolic changes

35
Q

_______ insufficiency post-transplant may be related to nephrotoxic chemo, SOS, TBI

A

Renal

36
Q

__________ is a major source of morbidity & mortality for HCT patients

A

Infection (bloodstream, PNA, C. diff, PN, typhilitis

37
Q

Define Typhlitis

A

AKA “neutropenic enterocolitis” following cytoxic chemotherapy. Requires antibiotics and either bland diet OR PN.

38
Q

Should anti-diarrheals be used w/ C.diff?

A

No. Focus on MNT for diarrhea

39
Q

About half of all patients undergoing HCT develop clinically significant ________________ within the first 100 days

A

Cytomegalovirus (CMV)

40
Q

What is CMV and what are the NIS?

A

Cytomegalovirus

A type of herpes that often creates ulcerations throughout the GI tract

Diarrhea, epigastric pain, odynophagia, dysphagia, colitis

Requires antivirals

41
Q

The risk for ____________ increases as the donor source becomes less matched

A

Graft-Versus-Host-Disease

Usually with allogenous transplant but can occasionally occur w/ autologus (yet less severe)

42
Q

This is a t-cell mediated immunologic reaction of engrafted lymphoid cells against the host . Typically occurs within the first 100 days but can appear after

A

Graft versus host disease

43
Q

3 major organs affected with Graft Versus Host Disease are:

A
  1. Skin
  2. Liver
  3. GI tract
44
Q

What are the 6 clinical manifestations of gut GVHD

A
  1. Nausea
  2. Vomiting
  3. Anorexia
  4. Food intolerance
  5. Abdominal pain
  6. Voluminous diarrhea & cramping if lower GI is involved
45
Q

Diarrhea associated with GVHD has an elevated ________ content, which can give the stool a rope-like appearence

A

Protein

Gut protein loss usually precedes symptoms

46
Q

Albumin losses of >/= __________ may be a useful marker in impending lower-gut GVHD

A

0.5 g/dL

47
Q

Prevention for GVHD

A

Using leucocyte antigen matching to select donor

post-HCT immunosuppresives

Potentially Ursodiol

48
Q

Is EN or PN preferred w/ HCT for nutrition support

A

EN. The gut microbiota may play a beneficial role in reducing GVHD development

PN used to be considered the standard of care but no-longer necessary w/ reduced-intensity conditioning

49
Q

PN should be used instead of EN in 6 situations

A
  1. Diarrhea > 1 L stool/day
  2. Severe mucositis (>/= grade 3)
  3. Ileus
  4. Intractable vomiting
  5. Inability to place NG tube
  6. Intolerance to EN
50
Q

When to d/c PN

A

When engraftment has occurred, when the pt can eat orally/enterally, and when the excess stool from GVHS has controlled

51
Q

Transition from PN to isotonic, low lactose fluids when diarrhea is < _______/day and when nausea/vomiting is infrequent

A

500

52
Q

What are some associated eating challenges with chronic GVHD that can lead to malnutrition?

A

Oral issues (sensitivity, xerostomia, dyphagia), GI issues (malabsorption - possibly pancreatic insufficiency, diarrhea), pulmonary insufficiency (increases metabolic demands)

53
Q

D/t risk for osteoporosis & potential benefit to reduce GVHD, _______ supplementation may be recommended

A

Vitamin D

54
Q

T/F: Children w/ HCT may have decreased growth velocity, growth hormone deficiency, and delayed onset of puberty

A

True

55
Q

T/F: Pediatric HCT survivors are more likely to develop DM & HTN post-HCT

A

True (cardiometabolic change)

56
Q

Why is iron overload sometimes an issue post-HCT?

A

Frequent blood transfusions

Additional CSO Cards (26 decks)

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