Hematopoetic stem cell transplantation supportive care Flashcards
How to prevent mucositis
- Sodium chloride + sodium bicarb mouth rinse
- oral cryotherapy
oral cryotherapy + in which cancer it is used for
Iceing during administration during chemotherapy (standard in high dose melphalan)
Common indication for TPN in BMT
undergoing HCT + severe mucositis
Testing prior to transplant for all patients
Hep panel
SOS/VOD pathophys
Injury to the sinusoidal epithelium
SOS/VOD diagnosis
Clinical
*liver bx not needed
Criteria included in VOD diagnosis
*variable depending on criteria
- timing
- total t bili
- hepatomegaly
- RUQ pain
- Ascites
- Weight gain
Medication approved for treatment of pts with SOS/VOD with renal or pulmonary dysfunction
defibrotide (protects the sinusoidal endothelium)
Management of SOS/VOD
primarily supportive
- fluid restriction and diuretics to treat ascites
- paracentesis
- pain control
- minimize exposure to hepatotoxins
Pulmonary complication of HCT
Idiopathic pneumonia syndrome (IPS)
IPS presentation
- acute onset cough, dyspnea, hypoxemia, +/- fever, that often progresses rapidly to respiratory failure
- People are very sick (60% mortality rate)
Imaging of IPS
Diffuse infiltrates
IPS management
- Bronch to rule out infection
- High dose steroids (but usually doesn’t work)
medication used for CMV ppx in seropositive patients
letermovir
how long does engraftment take?
usually 2-3 weeks
platelet indication for transfusion
10K
Blood product tranfusion requirements post-transplant + why
- Irradiated (inactive lymphocytes and reduce risk of GVHD
- leukocyte reduced (prevent HLA alloimmunization and reduce risk of CMV transmission)
common cause of prolonged anemia post transplant + why
ABO mismatch (they are inherited independently of HLA complex and they are not considered primary criteria for donor selection)
ABO mismatch may lead to what syndrome?
early or delayed hemolytic transfusion reactions
how hemolysis is prevented in major and minor ABO mismatch
Major: Deplete RBCs from graft
Minor: Plasma depletion from graft
Role of prophylactic platelet transfusion in transplant patients
controversial (they have a short half life and also accelerate alloimmunization against platelets)
- has shown to reduce bleeding but not mortalitity
When CSFs are used
- auto transplants (have been shown to accelerate neutrophil engraftment and reduce duration of neutropenia)
- less well defined in PBC autos or allos
Role for TPO-Ras
- May be considered in patients with severe, prolonged thrombocytopenia after HCT
(retrospective studies have shown benefit but larger prospective studies are needed)
Differential for pancytopenia after HCT
- poor engraftment
- drugs
- relapse
Management of pancytopenia after HCT
- BM biopsy to rule out relapse
- check donor chimerism
- avoid marrow suppressive drugs
- G-CSF
- Consider TPO-receptor agonists
Other location for chronic GVHD presentation
Oral
- skin, nails, hair
- muscle, fascia, joints
- lungs
- genitalia
- serous membranes
Treatment of oral chronic GVHD
Oral dexamethasone rinses
Pulmonary sequelae of chronic GVHD
- Bronchiolitis obliterans syndrome
- Cryptogenic organizing pneumonia
Only FDA approved treatment for chronic GVHD
Ibrutinib
What is extracorporeal photophoresis?
- investigational approach to GVHD treatment in which ECP induces apoptosis of leukocytes, which are reinfused to generate cytokines and induce tolerance
Post HCT vaccinations
- *inactivated flu vaccine 3 months post transpland and then annually
- 1 year post transplant: meningococcal, pneumococcal, polio, hep A and B, TDap, HIB
- **NO live vaccines until 2 years post transplant
Late effects post transplant
- metabolic syndrome
- hypothyroidism, AI, hypogonadism
- bone complications (osteopenia, AVN)
- iron overload (very common)
- neuropsychological
- subsequent malignancies (2-3x that of general population)
Management of iron overload syndrome post transplant
- phlebotomy
- if anemic, iron chelators
Iron overload correlated to mortality?
A meta-analysis says none
Major vs. Minor ABO mismatch
Major = RECIPIENT anti-donor ABO antibodies
Minor = DONOR anti-recipient ABO antibodies