Chapter 15: Hematopoietic Cell Transplantation Flashcards by Lisa Conticello

Describe the HCT process

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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Define “graft”

The new stem cells that are inserted into the recipient

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Define “engraftment”

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

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When is engraftment first evident?

When new WBC, RBC, platelets appear in the blood

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

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

Usually used with lymphomas or MM

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Define Syngeneic HCT

Cells are collected from an identical twice

think “same gene”

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Define Allogenic HCT

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

Chemo
Total body radiation

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

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

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

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Which 2 conditioning regimens require stem-cell infusion?

High-intensity, myeloablative
Reduced intensity conditioning

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Which conditioning regimen has the highest organ toxicity?

High-intensity (myeloablative)

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What is the graft-versus-tumor effect

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

High-intensity (aka myeloablative)

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

Used for older, sicker patients who cannot tolerate myeloablative conditioning

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What is the least intensive conditioning regimen?

Low dose TBI

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Name 4 chemos typically used as part of conditioning regimens

“Conditioning For Bone Marrow”

Fludarabine -
Melphalan
Cyclophosphamide
Busulfan

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What is the regimen for the highest intensity conditioning?

High dose TBI + busulfan + cyclophosphamide

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How long does the engraftment process take

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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What should MNT focus on during the conditioning period

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

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

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

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

Delayed engraftment
Post-transplant complications

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What are protein & kcal needs for HCT adult ?

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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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

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)

What are kcal & protein needs for children w/ HCT

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

How to calculate fluid needs for HCT?

Holliday-Seger

Mineral ________ should be increased w/ large-volume diarrhea

Zinc (1 mg/100 mL stool)

______ should be increased w/ corticosteroids & osteoporosis

Calcium

Oral intake typically starts to improve with ____________

Engraftment

Mucositis presents in 80% with myeloablative conditioning regimens. It's typically related to high-dose TBI or one of the following 3 chemo agents:

Melphalan, Etoposide, Methotrexate

How does Cryotherapy reduce risk for mucositis?

Reduces blood flow & exposure to chemo int he mouth

Is glutamine supplementation recommended with HCT?

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

What is Sinusoidal Obstructive Syndrome?

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

Complications with hyperglycemia post-HCT

May prolong engraftment time, delay neutrophil recovery, and increase risk for infection and graft verse host disease *Use of PN increased the risk fourfold

Why is hyperglycemia commonly seen post-HCT?

Steroids, PN, metabolic changes

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

Renal

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

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

Define Typhlitis

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

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

No. Focus on MNT for diarrhea

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

Cytomegalovirus (CMV)

What is CMV and what are the NIS?

Cytomegalovirus A type of herpes that often creates ulcerations throughout the GI tract Diarrhea, epigastric pain, odynophagia, dysphagia, colitis Requires antivirals

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

Graft-Versus-Host-Disease Usually with allogenous transplant but can occasionally occur w/ autologus (yet less severe)

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

Graft versus host disease

3 major organs affected with Graft Versus Host Disease are:

1. Skin 2. Liver 3. GI tract

What are the 6 clinical manifestations of gut GVHD

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

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

Protein Gut protein loss usually precedes symptoms

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

0.5 g/dL

Prevention for GVHD

Using leucocyte antigen matching to select donor post-HCT immunosuppresives Potentially Ursodiol

Is EN or PN preferred w/ HCT for nutrition support

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

PN should be used instead of EN in 6 situations

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

When to d/c PN

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

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

500

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

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

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

Vitamin D

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

True

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

True (cardiometabolic change)

Why is iron overload sometimes an issue post-HCT?

Frequent blood transfusions