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Bone Marrow Transplant

Chelsie Sievers

Background

  • Donor selection
    • Autologous: self, no matching required (no GVHD risk, but also no graft-vs-tumor effect)
    • Allogeneic: non-self, matching based on HLA (more matched = less GVHD risk)
      • Matched-related donor (MRD): fully matched sibling
      • Matched-unrelated donor (MUD): From NMDP database
      • Haploidentical: Half matched sibling or parent
  • Source of stem cells:
    • Peripheral blood stem cells (PBSCs) vs bone marrow-derived cells vs umbilical cord
  • Conditioning regimens:
    • Myeloablative vs Reduced-intensity conditioning (RIC)
  • GVHD prophylaxis (for allo-SCT):
  • Regimen varies, can include tacrolimus, MMF, MTX, or thymo and alemtuzumab during conditioning

Complications/Adverse Effects

Infectious

  • Neutropenic fever, neutropenic enterocolitis (typhlitis)
  • Bacterial infections
  • Viral infections
    • CMV: check weekly PCR levels post-allo-SCT
      • All CMV+ recipients are treated with letermovir prophylactically regardless of donor status
    • EBV: check weekly PCR levels post allo-SCT. If EBV VL >1000 on two occasions, can treat with pre-emptive rituximab to reduce the risk of PTLD
  • Invasive fungal infections (e.g. aspergillus, candida)

Non-infectious

  • Nausea, vomiting, diarrhea, mucositis, cytopenias
  • Hepatic veno-occlusive disease (VOD)/sinusoidal obstructive syndrome (SOS)
    • Pathophysiology: sinusoidal endothelial cell damage from conditioning chemo post-sinusoidal portal HTN cytokine release multiorgan failure and death
    • Diagnosis: T Bili >2, hepatomegaly/RUQ pain, weight gain >2-5%
    • Evaluation: RUQ US with doppler
    • Treatment: Per heme attending; generally supportive, consider defibrotide
  • Graft failure:
    • Primary (persistent neutropenia without engraftment)
    • Secondary (delayed pancytopenia 2/2 immune phenomena or infection after engraftment)
  • Engraftment syndrome:
    • Pathophysiology: PMN recovery cytokine storm vascular leak
    • Symptoms: fever, tachycardia, hypotension, SOB, pulmonary edema, rash, weight gain, bone pain, confusion
    • Diagnosis: Clinical
    • Treatment: high-dose IV steroids
  • Acute GVHD:
    • Only in allogenic; Increased risk with more HLA mismatch
    • Pathophysiology: donor T cells attack recipient (Th1-mediated)
    • Symptoms: skin rash, cholestatic liver injury, diarrhea
    • Treatment: IV steroids (methylprednisolone 1-2mg/kg x 5d)
      • If refractory: mycophenolate, etanercept, ruxolitinib, antithymocyte globulin
  • Chronic GVHD (typically after T+100)
    • Can involve all organs but typically see a scleroderma-like picture (xerophthalmia, xerostomia dysphagia, arthritis, skin changes, malar rash, obliterative bronchiolitis, cholestatic liver injury, cytopenias)
    • Treatment: steroids (also photophoresis for skin), consider trials of ruxolitinib, ibrutinib, rituximab if refractory
  • PTLD (post-transplant lymphoproliferative disorders)
    • Pathophysiology: B-cell proliferative disease typically 2/2 latent EBV
    • Symptoms: fever, weight loss, fatigue, lymphadenopathy, extra-nodal masses, ↑ EBV PCR
Last update: 2022-06-25 02:05:01