transplant

Question 1

post-chronic GVHD pulm illness

Answer 1

bronchiolitis obliterans- narrowing of airways, wheeze, CXR normal, CT shows thickening, bronchiectasis. PFT- obstructive, can be stabilized with increased immunosuppression.

Question 2

parainfluenza

Answer 2

must delay, as pneumonia is fatal in 30%; wait until PCR negative

Question 3

re-vaccination

Answer 3

12 months post-transplant, not altered by other factors such as immunosuppression

Question 4

AVN of hip

Answer 4

common post-Allo comp: associated with steroids and TBI

Question 5

chronic GVHD

Answer 5

usually requires re-institution of immunosuppressants, very long slow taper, but usually possible; sicca-like symptoms, rash, higher rates in peripheral blood aloo, calcineurin inhib/prednisone can treat 50-70%,

Question 6

acute GVHD

Answer 6

rash, n/v/diarrhea, ileus, jaundice

Question 7

immunosuppressants

Answer 7

if no GVHD can taper at 3 months, discontinue at 6 months

Question 8

Palifermin

Answer 8

reduces duration of GVHD

Question 9

SCT for thalassemia

Answer 9

best results if done before hepatomegaly or fibrosis. 70-90% cure

Question 10

alloSCT results for AML/ALL

Answer 10

50-70% 5-yr DFS.

Question 11

CML transplant

Answer 11

restrict to progression following TKIs

Question 12

HLA class 1 determinents

Answer 12

HLA-A, HLA-B, HLA-C. class 2: HLA-DP, DQ, DR (ch 6). low recombination frequency

Question 13

liklihood of finding a HLA matched sibling

Answer 13

1- .75^n (n is number of siblings). if n=2, then ~45%. ABO not expressed on stem cells, so doesn’t matter

Question 14

mismatching and outcome

Answer 14

mismatch slightly worsens leukemia relapse outcomes.

Question 15

tolerability of HLA mismatches

Answer 15

HLAB and HLA-C are better tolerated. HLA A and DRB1 less tolerated. if peripheral CD34+ used, then HLAC mismatch less tolerated

Question 16

marrow transplantation

Answer 16

serial aspirations- 10mL. need 1-1.5L marrow

Question 17

Peripheral marrow collection

Answer 17

faster engraftment, CD34 selection and mobilization with G-CSF or GM-CSF. can use plerixafor (CXCR4 antagonist) to mobilize cells if G-CSF insufficient. (10-20% fail to mobilize with G alone)

Question 18

umbilical transplant

Answer 18

double reduces graft failure and enhances graft v tumor

Question 19

preparative regimen before transplant for nonmalignant conditions

Answer 19

aplastic anemia- needs ATG or CTX. SCID doesn’t need because immunocompromised

Question 20

DLI dosing

Answer 20

1 x 10^7–> remission of 70% with CML

Question 21

engraftment after allo

Answer 21

marrow: 1-2 weeks after, peripheral ALC increases. day 26- ANC 1000. plts recover with neutrophils. PMBC- one week sooner, umbilical- one week later.

Question 22

graft rejection

Answer 22

more common with weaker conditioning regimens, or if a lot of transfusions were given before trx, or more mismatched, or T-cell depleted. can try to tx with GMCSF, or repeat transplant with conditioning.

Question 23

acute GVHD

Answer 23

within 3 months- rash, GI, jaundice cholestasis. classic is 100d. Tx is combination MTX/MMF and calcineurin inhibitior (cyclosporine or tacro). Tx for 3 months from Trx then taper and d/c at 6 months.

Question 24

risk factors of acute GVHD

Answer 24

mismatching, old age pt or donor, multiparous donor, more intensive conditioning regimens

Question 25

chronic GVHD

Answer 25

like a collagen vascular disease. frequent in mismatched, in peripheral trx, and if prior acute GVHD. tx is steroids/calcineurin inhibitor. most pts can taper, but sometimes over months/years.

Question 26

prophylaxis for chronic GVHD tx

Answer 26

bactrim + penicillin- PCP and encapsulated organism.

Question 27

autoimmune conditions after alloSCT

Answer 27

5%. hemolytic anemia, ITP. tx with cyclosporine, pred, or ritux

Question 28

Trx infection prophy

Answer 28

anti-fungal: flucon or voricon

Question 29

HSV prophy after transplant, CMV prophy

Answer 29

IV acyclovier 250mg q8hr starteing 1 week before Trx and 1 month after Trx. can use gancyclovire st time of engraftment to reduce risk if latent CMV before. reduced risk of CMV with lymphodepleted blood products.

Question 30

gancyclovir toxicities

Answer 30

granulocytopenia. responds to G-CSF. foscarnet good salvage, but causes electrolyte wasting

Question 31

late post-trx infection

Answer 31

VZV (>3 months0. if chronic GVHD–>bacterial/fungal –> use propgy bactrim, penn, acyclovir.

Question 32

post-transplant vaccination

Answer 32

1 year after: tetanus, diphtheria, heme inf, polio, pneumococcal. MMR/VZV/Pertussus at 24 months.

Question 33

oral mucositis associated with preparative regimens

Answer 33

5-7 days post. need PCA pump. palifermin can shorten duration of mucositis

Question 34

SOS

Answer 34

1-4 weeks post prepchemo. 5%. possible treat with difibrotide. prophylax with ursodeoxycholic acid.

Question 35

idiopathic pneumonia syndrome

Answer 35

3-6 month post-trx related to chemo. 5% of pts. frequent following high-dose radiation. 50% mortality, no treatments.s

Question 36

PTLD following transplant

Answer 36

high-dose chemoradiotherapy at increased risk, T-cell depletd at risk,.

Question 37

DLI success by malignancy type

Answer 37

CR rate: CML 70%, advanced CML 12%, AML/MDS 29%, ALL 0%. half develop GVHD, 20% mortality. keep less than 10x10^7 cells.

Question 38

CML relapse after transplant, options

Answer 38

DLI, interferon (35% CR)