Chapter 15: MCT for HCT Flashcards
Conditions that are treated with HCT?
Acute leukemia, chronic leukemia, lymphoma, Hodgkin’s disease, Myelodysplastic syndrome, multiple myeloma and solid tumors (advanced stage neuroblastoma, refractory Ewing’s sarcoma)
What is the object of HCT?
To replace the malignant of defective marrow in order to restore normal hematopoiesis and immunologic function. Treatment includes chemotherapy and may include total body irradiation (TBI)
How does HCT work?
Includes the collection of cells, with the source varying depending on type of transplant. This followed by a conditioning regimen intended to kill remaining cancer cells, weaken the immune system, and prevent the body from rejecting the new stem cells. When the conditioning regimen is complete, the stem cells (the graft) are infused into the ptient.
Finally, the transplanted stem cells begin homing to the patients marrow and produce blood cells of all types (this phase is called engraftment).E
When is engraftment first evidence?
New WBC, RBC, and platelets appear in pt’s blood
How many transplants are completed each year?
65,000
List the 3 types of HCT
Autologous HCT
Syngeneic HCT
Allogeneic HCT
Autologous HCT
- Uses patient’s own hematopoietic stem cells
- Primarily used to treat MM, NHL, HL
Allogeneic HCT
-Uses stem cells from a donor who is fully or closely matched
- Used to treat acute and chronic leukemias, NHL, marrow diseases (MDS, myeloproliferative diseases, severe aplastic anemia)
What are the 5 donor types used in allogeneic HCT?
Matched unrelated
Matched related
Mismatched unrelated
Half-matched related (haploidentical)
Umbilical cord blood
Syngeneic HCT
Uses stem cells from identical twin sibling donor
What is part of a conditioning regimen?
Cytotoxic chemo, total body irradiation, or both
What are the 3 categories of conditioning regimens?
High dose (myeloablative) - combo of chemo agents that ablate bone marrow hematopoiesis; pt requires stem cell infusion to rebuild bone marrow
Nonmyeloablative - uses a chemo that causes minimal cytopenias; pt does not require stem cell infusion
Reduced intensity conditioning - uses a less intensive chem or TBI (or both) that causes prolonged cytopenias; pt requires stem cell infusion
Are there standard conditioning regimens?
NO
Examples of Conditioning Regimens. The higher the number, the more intense and toxic the regimen is!
- Total body irradiation
- TBI + fludarabine (various dosing schedules)
- Fludarabine (Various dosing schedules) + busulfan (low dose)
- Fludarabine (various dosing schedules) +Treosulfan
- Fludarabine (various dosing schedules) + Melphalan
- 13II + Fludarabine (various dosing schedules) + TBI
- Cyclophosphamide + busulfan
- Busulfan + Melphalan
- Busulfan + cyclophosphamide (+/- antithymocyte globulin or thymoglobulin)
- Fludarabine (various dosing schedules) + cytosine arabinoside
- Cyclophosphamide + TBI
- Busulfan + TBI
- Busulfan + cyclophosphamide + TBI
How long is a patient neutropenic after stem cell infusion (referred to as day 0)?
2-3 weeks
What is the gold standard for assessing nutrient needs?
Indirect Calorimetry
Protein needs are increased
- Immediately post-transplant
- If pt on CRRT
- During corticosteroid treatment
Why would fluid needs be increased?
Fever
Excessive GI losses
High output renal failure
Nephrotoxic medications
Hypermetabolic
Is iron recommended for patients undergoing HCT?
NO
Serum ferritin is elevated (>1000 mcg/L). What vitamin would you need to discontinue (if using)?
Vitamin C
Common nutrition problems of HCT include
Mucositis
Sinusoidal obstructive syndrome
Hyperglycemia
Renal impairment
Infection
Acute GVHD
What are signs/symptoms of gut GVHD?
Nausea
Vomiting
Anorexia
Food intolerance
Abdominal pain
High volume diarrhea
Cramping if lower GI tract is involved
Why would a pt have high blood sugar after HCT?
Steroids
Use of PN
Metabolic alterations that happen briefly after transplant
What % of patients undergoing myeloablative conditioning regimens will develop mucositis?
80%
Why would a pt have renal impairment?
Chemo
Total body irradiation
Nephrotoxic medications (e.g., CNIs, antibiotics)
Sinusoidal obstructive syndrome
Intravascular volume depletion
Sepsis
What is GVHD?
T cell mediated immunologic reaction of engrafted lymphoid cells against the host tissues
True or False - When the donor is less matched, the risk for GVHD decreases
FALSE
Risk will increase in unrelated and mismatched donors.
Which organs are most affected by GVHD?
Skin (75%)
GI tract (50%)
Liver (20%)
A patient with GVHD has rope-like stools. Why?
The diarrhea has an elevated protein content due to loss of gut protein.
What % of patients will develop bone disease (osteoporosis) after transplant?
Up to 50% as early as 1 year post-transplant
Recommendations for osteoporosis after HCT include:
Adequate calcium intake
Adequate vitamin D intake
Weight bearing exercise
Muscle strengthening exercise
Biphosphanate therapy
A patient often requires multiple RBC transfusions s/p HCT. They are at risk of _____ overload.
Iron
- do not take iron or MVI with iron after HCT
Calorie needs for adult patients undergoing HCT are
Basal needs x 1.3-1.5
Appropriate diet progression for GVHD with GI symptoms
- Bowel rest
- Introduction of oral feedings
- Introduction of solids
- Expansion of diet
- Resumption of regular diet
Your patient develops gut GVHD 35 days after HCT. They are having large volume diarrhea and unable to get off of TPN. Zinc needs to be added to the TPN. What is an appropriate dose of Zinc?
1 mg Zinc per 100 mL stool output
Sirolimus is an immunosuppressive medication used as a prophylaxis treatment for GVHD. The drug is known to cause:
High TGs
True or False - pediatric HCT pts are less likely to develop DM and HTN than the general population
FALSE
They are more like to develop DM and HTN.
In sinusoidal obstructive syndrome, if serum bilirubin increases to above _____ mg/dL, monitor TG levels.
10
Calcium requirements for a 9 y/o pt on steroids for osteoporosis is
1500 mg/day
You are seeing a 24 y/o male s/p HCT. He is c/o 400 mL watery diarrhea per day with minimal GI cramping. He is receiving steroids and methotrexate. What do you recommend?
Allow liquids, low-residue, low-lactulose
Consider PERT
Consider alternative immunosuppressive agents that do not have diarrhea as a potential side effect
Good news, your patient is being discharged after their HCT. Their mom tells you that they use well water. What do you need to educate the family on?
Well water should be boiled for 15-20 minutes and consumed within 2 days of boiling.
How long should a low microbial diet be followed?
Until immunosuppressive therapy is stopped.
True or False - current evidence supports the role of glutamine supplementation in HCT recipients
False
Acute SOS typically presents with abdominal pain and swelling, weight gain and signs of portal hypertension (ascites, edema, varices). MNT during SOS includes
Concentration of all administered fluids
Reduction of sodium intake
Reduction or elimination of IVFE
