transplant Flashcards
post-chronic GVHD pulm illness
bronchiolitis obliterans- narrowing of airways, wheeze, CXR normal, CT shows thickening, bronchiectasis. PFT- obstructive, can be stabilized with increased immunosuppression.
parainfluenza
must delay, as pneumonia is fatal in 30%; wait until PCR negative
re-vaccination
12 months post-transplant, not altered by other factors such as immunosuppression
AVN of hip
common post-Allo comp: associated with steroids and TBI
chronic GVHD
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%,
acute GVHD
rash, n/v/diarrhea, ileus, jaundice
immunosuppressants
if no GVHD can taper at 3 months, discontinue at 6 months
Palifermin
reduces duration of GVHD
SCT for thalassemia
best results if done before hepatomegaly or fibrosis. 70-90% cure
alloSCT results for AML/ALL
50-70% 5-yr DFS.
CML transplant
restrict to progression following TKIs
HLA class 1 determinents
HLA-A, HLA-B, HLA-C. class 2: HLA-DP, DQ, DR (ch 6). low recombination frequency
liklihood of finding a HLA matched sibling
1- .75^n (n is number of siblings). if n=2, then ~45%. ABO not expressed on stem cells, so doesn’t matter
mismatching and outcome
mismatch slightly worsens leukemia relapse outcomes.
tolerability of HLA mismatches
HLAB and HLA-C are better tolerated. HLA A and DRB1 less tolerated. if peripheral CD34+ used, then HLAC mismatch less tolerated
marrow transplantation
serial aspirations- 10mL. need 1-1.5L marrow
Peripheral marrow collection
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)
umbilical transplant
double reduces graft failure and enhances graft v tumor
preparative regimen before transplant for nonmalignant conditions
aplastic anemia- needs ATG or CTX. SCID doesn’t need because immunocompromised
DLI dosing
1 x 10^7–> remission of 70% with CML
engraftment after allo
marrow: 1-2 weeks after, peripheral ALC increases. day 26- ANC 1000. plts recover with neutrophils. PMBC- one week sooner, umbilical- one week later.
graft rejection
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.
acute GVHD
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.
risk factors of acute GVHD
mismatching, old age pt or donor, multiparous donor, more intensive conditioning regimens
chronic GVHD
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.
prophylaxis for chronic GVHD tx
bactrim + penicillin- PCP and encapsulated organism.
autoimmune conditions after alloSCT
5%. hemolytic anemia, ITP. tx with cyclosporine, pred, or ritux
Trx infection prophy
anti-fungal: flucon or voricon
HSV prophy after transplant, CMV prophy
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.
gancyclovir toxicities
granulocytopenia. responds to G-CSF. foscarnet good salvage, but causes electrolyte wasting
late post-trx infection
VZV (>3 months0. if chronic GVHD–>bacterial/fungal –> use propgy bactrim, penn, acyclovir.
post-transplant vaccination
1 year after: tetanus, diphtheria, heme inf, polio, pneumococcal. MMR/VZV/Pertussus at 24 months.
oral mucositis associated with preparative regimens
5-7 days post. need PCA pump. palifermin can shorten duration of mucositis
SOS
1-4 weeks post prepchemo. 5%. possible treat with difibrotide. prophylax with ursodeoxycholic acid.
idiopathic pneumonia syndrome
3-6 month post-trx related to chemo. 5% of pts. frequent following high-dose radiation. 50% mortality, no treatments.s
PTLD following transplant
high-dose chemoradiotherapy at increased risk, T-cell depletd at risk,.
DLI success by malignancy type
CR rate: CML 70%, advanced CML 12%, AML/MDS 29%, ALL 0%. half develop GVHD, 20% mortality. keep less than 10x10^7 cells.
CML relapse after transplant, options
DLI, interferon (35% CR)
