Hematopoietic Stem Cell Transplant (HSCT) (Bone Marrow Transplant, BMT)

Indications

Acute Myeloid Leukemia (AML) (see Acute Myeloid Leukemia, [[Acute Myeloid Leukemia]])

  • Clinical Efficacy
    • xxx

Beta Thalassemia Major (see Thalassemias, [[Thalassemias]])

  • Clinical Efficacy
    • xxx

Technique

  • xxxx

Adverse Effects/Complications

Dermatologic Complications

  • xxxx

Gastrointestinal/Hepatic Adverse Effects/Complications

  • xxxx

Hematologic Adverse Effects/Complications

Acute Graft vs Host Disease (see Graft vs Host Disease, [[Graft vs Host Disease]])

  • Epidemiology

Chronic Graft vs Host Disease (see Graft vs Host Disease, [[Graft vs Host Disease]])

  • Epidemiology

Peripheral Eosinophilia (see Peripheral Eosinophilia, [[Peripheral Eosinophilia]])

  • Epidemiology: peripheral eosinophilia occurs in 38.9% of cases
    • Latency: peripheral eosinophilia occurs 67.5 days (on average) after transplantation
    • Age: peripheral eosinophilia occurs more commonly in younger patients
    • No relationship to development of graft vs host disease
    • No relationship to conditioning regimen used
  • Prognosis
    • Overall patient survival rates improved in those with eosinophilia compared to those without eosinophilia (88.7 vs 43.0%, P=0.0034). In particular, in patients with malignant diseases, those with eosinophilia showed a higher event-free survival (81.1 vs 44.6%, P=0.0025) and a lower relapse rate (16.0 vs 43.0%, P=0.0287) than those without eosinophilia
      [Significance of eosinophilia after stem cell transplantation as a possible prognostic marker for favorable outcome. Bone Marrow Transplantation (2005) 36, 985–991]
    • Some data suggest that eosinophilia may portend the development of graft vs host disease
      [Hypereosinophilia as a presenting sign of acute graft-versus-host disease after allogeneic bone marrow transplantation. Transplantation 2002; 74: 1797–1800]

Infectious Adverse Effects/Complications

Respiratory Syncytial Virus (RSV) Infection (see Respiratory Syncytial Virus, [[Respiratory Syncytial Virus]])

  • Epidemiology: increased risk

Pulmonary Adverse Effects/Complications

Bronchiolitis Obliterans (BO) (see Bronchiolitis Obliterans, [[Bronchiolitis Obliterans]])

  • Epidemiology

Diffuse Alveolar Hemorrhage (DAH) (see Diffuse Alveolar Hemorrhage, [[Diffuse Alveolar Hemorrhage]])

  • Epidemiology
    • DAH Occurs in 5-10% of SCT: rates are similar regardless of whether the SCT is done for hematologic malignancy vs solid organ tumors)
    • Allogeneic vs Autologous: incidence rates for DAH are the same for allogeneic-SCT vs. autologous-SCT
    • Timing: DAH usually occurs within 30 days after SCT engraftment
    • Risk Factors for Post-SCT Diffuse Alveolar Hemorrhage
      • Pre-Transplant Intensive Chemo
      • Total Body Irradiation
      • Thoracic Radiation
      • Advanced Age
      • Renal Failure
    • Not Risk Factors for Post-BMT/SCT Diffuse Alveolar Hemorrhage
      • Thrombocytopenia: not a defined risk factor, although may be higher risk at platelet counts <20k (however, most patients are thrombocytopenic at the onset of DAH)
        • Notably, platelet transfusions do not correct the DAH
      • Elevated INR/PTT: not risk factors
  • Physiology: lung injury (of unclear type) with some degree of microvascular damage and micro thrombi, neutrophilic infiltration with cytokine release
  • Diagnosis
    • Arterial Blood Gas (ABG) (see Arterial Blood Gas, [[Arterial Blood Gas]]): hypoxemia
    • Bronchoscopy (see Bronchoscopy, [[Bronchoscopy]])
      • DAH (typically manifested by increasing bloodiness in subsequent BAL samples)
      • Hemosiderin-laden macrophages >20%
      • FOB is important to rule out infectious etiologies
      • TBB is contraindicated: may precipitate further bleeding
    • Chest X-Ray (see Chest X-Ray, [[Chest X-Ray]])
      • Diffuse (or Localized) Alveolar and/or Interstitial Infiltrates: more common in mid-lower lung fields
      • Radiographic changes may precede symptoms by days
    • Chest CT (see Chest Computed Tomography, [[Chest Computed Tomography]]): bil ground glass infiltrates or consolidation
  • Clinical
    • Cough (see Cough, [[Cough]])
    • Dyspnea (see Dyspnea, [[Dyspnea]])
    • Fever (see Fever, [[Fever]])
    • Hemoptysis (see Hemoptysis, [[Hemoptysis]]): usually in <15% of cases -> this is in contrast to non-SCT population, where hemoptysis is more common
  • Treatment
    • Correct Thrombocytopenia: although platelet transfusion has not been shown to improve DAH
    • Steroids (500 mg-1 g methylprednisolone/day, the taper over 2-4 wks): usually used (although there are no randomized trials to address their efficacy)
      • High-dose steroids (as above) are probably better than low-dose steroids or no steroids
  • Prognosis
    • Mortality Rates of Post-BMT/SCT-Associated DAH: 80%
    • Prognosis of Post-BMT Resp Failure: (From Any Etiology): only 3% 6-month survival
      [Crawford SW, Petersen FB. Long-term survival from respiratory failure after marrow transplantation for malignancy. Am Rev Respir Dis 1992; 145:510-514]

Cryptogenic Organizing Pneumonia (COP) (see Cryptogenic Organizing Pneumonia, [[Cryptogenic Organizing Pneumonia]])

  • Epidemiology

Transudative Pleural Effusion (see Pleural Effusion-Transudate, [[Pleural Effusion-Transudate]])

  • Epidemiology: most reported cases had severe acute or chronic graft vs host disease (see Graft vs Host Disease, [[Graft vs Host Disease]])

Other Adverse Effects/Complications

  • xxxx
  • xxxx
  • xxxx
  • xxxx

Prognosis

Clinical Data Related to Prognosis in Hematopoietic Stem Cell Patients Requiring ICU Care

  • Retrospective Canadian Study of Autologous SCT Patients Admitted to the ICU (Bone Marrow Transplant, 2009) [MEDLINE]: data from 2001-2006
    • ICU Admission Rate: 3.3%
    • Mortality Rate in the ICU: 38%
      • Worse Prognosis was in AL Amyloid Patients: 55% ICU mortality rate in this group
    • Predictors of Mortality
      • SOFA Score in the First 24 hrs
      • APACHE II Score in the First 24 hrs
      • Gram-Negative Sepsis
      • Inotropic Support >4 hrs
      • Mechanical Ventilation
      • Multiorgan Failure
  • French Study of Allogeneic SCT Patients Admitted to the ICU (Leuk Lymphoma, 2014) [MEDLINE]: data from 1998-2005
    • ICU Admission Rate: 10%
      • Predominant Cause for ICU Admission was Respiratory Failure
    • Mortality Rate in the ICU: 57%
      • Authors Did Not Observe Any Decrease in Mortality Rates Comparing the Periods of 1998-2004 and 2005-2008
    • Patients Admitted Between Day 30-100 Post-SCT Had the Worst Prognosis: mainly due to the presence of active GVHD

References

  • Long-term survival from respiratory failure after marrow transplantation for malignancy. Am Rev Respir Dis 1992; 145:510-514 [MEDLINE]
  • Pulmonary complications after bone marrow transplantation: high-resolution CT and pathologic findings. Radiographics. 1997 Nov-Dec;17(6):1359-71 [MEDLINE]
  • Unexplained effusions: association with allogeneic bone marrow transplantation and acute or chronic graft-versus-host disease. Bone Marrow Transplant. 1996 Feb;17(2):207-11 [MEDLINE]
  • Prognostic indicators for blood and marrow transplant patients admitted to an intensive care unit. Am J Respir Crit Care Med 1998; 158:876-884 [MEDLINE]
  • Mechanical ventilation in hematopoietic stem cell transplantation. Can we effectively predict outcomes? Chest 1999; 116:1012-1018 [MEDLINE]
  • Hypereosinophilia as a presenting sign of acute graft-versus-host disease after allogeneic bone marrow transplantation. Transplantation 2002; 74: 1797–1800 [MEDLINE]
  • Intensive care unit support and Acute Physiology and Chronic Health Evaluation III performance in hematopoietic stem cell transplant recipients. Crit Care Med 2003;31:1715–1721 [MEDLINE]
  • Outcome and early prognostic indicators in patients with a hematologic malignancy admitted to the intensive care unit for a life-threatening complication. Crit Care Med 2003;31:104–112 [MEDLINE]
  • Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a medical ICU. Chest 2004;126:1604–1611 [MEDLINE]
  • Significance of eosinophilia after stem cell transplantation as a possible prognostic marker for favorable outcome. Bone Marrow Transplant. 2005 Dec;36(11):985-91 [MEDLINE]
  • Outcome of critically ill allogeneic hematopoietic stem-cell transplantation recipients: a reappraisal of indications for organ failure supports. J Clin Oncol 2006;24:643–649 [MEDLINE]
  • Predictors of mortality in patients undergoing autologous hematopoietic cell transplantation admitted to the intensive care unit. Bone Marrow Transplant. 2009 Mar;43(5):411-5. doi: 10.1038/bmt.2008.336. Epub 2008 Oct 20 [MEDLINE]
  • Outcome in critically ill patients with allogeneic BM or peripheral haematopoietic SCT: a single-centre experience. Bone Marrow Transplant 2011;46:1186–1191 [MEDLINE]
  • Survival and prognostic factors of allogeneic hematopoietic stem cell transplant recipients admitted to intensive care unit. Leuk Lymphoma  2014 Jun;55(6):1417–1420. doi: 10.3109/10428194.2013.836602. Epub 2013 Sep 23 [MEDLINE]