Hematopoetic stem cell transplantation supportive care

Question 1

How to prevent mucositis

Answer 1

• Sodium chloride + sodium bicarb mouth rinse
• oral cryotherapy

Question 2

oral cryotherapy + in which cancer it is used for

Answer 2

Iceing during administration during chemotherapy (standard in high dose melphalan)

Question 3

Common indication for TPN in BMT

Answer 3

undergoing HCT + severe mucositis

Question 4

Testing prior to transplant for all patients

Answer 4

Hep panel

Question 5

SOS/VOD pathophys

Answer 5

Injury to the sinusoidal epithelium

Question 6

SOS/VOD diagnosis

Answer 6

Clinical
*liver bx not needed

Question 7

Criteria included in VOD diagnosis

Answer 7

*variable depending on criteria
- timing
- total t bili
- hepatomegaly
- RUQ pain
- Ascites
- Weight gain

Question 8

Medication approved for treatment of pts with SOS/VOD with renal or pulmonary dysfunction

Answer 8

defibrotide (protects the sinusoidal endothelium)

Question 9

Management of SOS/VOD

Answer 9

primarily supportive
- fluid restriction and diuretics to treat ascites
- paracentesis
- pain control
- minimize exposure to hepatotoxins

Question 10

Pulmonary complication of HCT

Answer 10

Idiopathic pneumonia syndrome (IPS)

Question 11

IPS presentation

Answer 11

• acute onset cough, dyspnea, hypoxemia, +/- fever, that often progresses rapidly to respiratory failure
• People are very sick (60% mortality rate)

Question 12

Imaging of IPS

Answer 12

Diffuse infiltrates

Question 13

IPS management

Answer 13

• Bronch to rule out infection
• High dose steroids (but usually doesn’t work)

Question 14

medication used for CMV ppx in seropositive patients

Answer 14

letermovir

Question 15

how long does engraftment take?

Answer 15

usually 2-3 weeks

Question 16

platelet indication for transfusion

Answer 16

10K

Question 17

Blood product tranfusion requirements post-transplant + why

Answer 17

• Irradiated (inactive lymphocytes and reduce risk of GVHD
• leukocyte reduced (prevent HLA alloimmunization and reduce risk of CMV transmission)

Question 18

common cause of prolonged anemia post transplant + why

Answer 18

ABO mismatch (they are inherited independently of HLA complex and they are not considered primary criteria for donor selection)

Question 19

ABO mismatch may lead to what syndrome?

Answer 19

early or delayed hemolytic transfusion reactions

Question 20

how hemolysis is prevented in major and minor ABO mismatch

Answer 20

Major: Deplete RBCs from graft
Minor: Plasma depletion from graft

Question 21

Role of prophylactic platelet transfusion in transplant patients

Answer 21

controversial (they have a short half life and also accelerate alloimmunization against platelets)
- has shown to reduce bleeding but not mortalitity

Question 22

When CSFs are used

Answer 22

• auto transplants (have been shown to accelerate neutrophil engraftment and reduce duration of neutropenia)
• less well defined in PBC autos or allos

Question 23

Role for TPO-Ras

Answer 23

• May be considered in patients with severe, prolonged thrombocytopenia after HCT
  (retrospective studies have shown benefit but larger prospective studies are needed)

Question 24

Differential for pancytopenia after HCT

Answer 24

• poor engraftment
• drugs
• relapse

Question 25

Management of pancytopenia after HCT

Answer 25

- BM biopsy to rule out relapse - check donor chimerism - avoid marrow suppressive drugs - G-CSF - Consider TPO-receptor agonists

Question 26

Other location for chronic GVHD presentation

Answer 26

Oral - skin, nails, hair - muscle, fascia, joints - lungs - genitalia - serous membranes

Question 27

Treatment of oral chronic GVHD

Answer 27

Oral dexamethasone rinses

Question 28

Pulmonary sequelae of chronic GVHD

Answer 28

- Bronchiolitis obliterans syndrome - Cryptogenic organizing pneumonia

Question 29

Only FDA approved treatment for chronic GVHD

Answer 29

Ibrutinib

Question 30

What is extracorporeal photophoresis?

Answer 30

- investigational approach to GVHD treatment in which ECP induces apoptosis of leukocytes, which are reinfused to generate cytokines and induce tolerance

Question 31

Post HCT vaccinations

Answer 31

- *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

Question 32

Late effects post transplant

Answer 32

- metabolic syndrome - hypothyroidism, AI, hypogonadism - bone complications (osteopenia, AVN) - iron overload (very common) - neuropsychological - subsequent malignancies (2-3x that of general population)

Question 33

Management of iron overload syndrome post transplant

Answer 33

- phlebotomy - if anemic, iron chelators

Question 34

Iron overload correlated to mortality?

Answer 34

A meta-analysis says none

Question 35

Major vs. Minor ABO mismatch

Answer 35

Major = RECIPIENT anti-donor ABO antibodies Minor = DONOR anti-recipient ABO antibodies