Blood and Marrow Transplant Handbook (eBook)

Preface and Acknowledgments 5
Contents 7
Contributors 9
Part I The Nuts and Bolts of Stem Cell Transplant 12
1 Overview of Hematopoietic Stem Cell Transplantation 13
1.1 The Language of Transplantation 13
1.2 Research Efforts in HSCT 16
1.3 Horizons/Challenges 17
References 18
2 The Business of Cellular Therapy and Hematopoietic Stem Cell Transplantation 19
2.1 Complexity of Care 20
2.2 Phases 20
2.3 Contracts and Reimbursement Strategies 23
2.4 Integrated Structure for Contract Management 24
2.5 Private Payers 24
2.6 Governmental Payers 25
2.7 Regulatory 26
2.8 Quality 27
2.9 Data Management 28
2.10 Summary 28
2.11 Resources 28
2.11.1 Websites 28
Reference 29
3 Stem Cell Sources 30
3.1 Donor Selection 30
3.2 Bone Marrow 31
3.3 Peripheral Blood (PBSC) 31
3.4 Umbilical Cord Blood 34
References 35
4 Pre-transplant Evaluation 36
4.1 Considerations and/or Indications for Transplant 36
4.2 Sources of Hematopoietic Stem Cells (see Table 4.4) 40
4.3 Patient Evaluation 40
4.4 General Guidelines for Patient Eligibility 41
4.5 Allogeneic Donor Evaluation 45
References 45
5 Conditioning Regimens 47
5.1 Common Conventional (Ablative) Conditioning Regimens 48
5.2 Common RIT Conditioning Regimens 48
5.3 Common Autologous Conditioning Regimens 48
5.4 Conditioning Agents 49
5.5 Antiemetic Dosing 55
References 56
6 Supportive Care 58
6.1 Pain Management 58
6.2 Nausea 61
6.3 Diarrhea (see Table 6.2) 62
6.4 Mucositis (see table 6.3) 63
6.5 Acid Suppression 64
6.6 Constipation 64
6.7 Menses 64
6.8 Tremor 66
References 66
7 Nutrition 69
7.1 Low-Bacteria Diet 69
7.2 Goals of Nutrition During Transplant 71
7.3 Use of Total Parenteral Nutrition 72
7.4 Explanation of Catabolic/Anabolic States 73
7.5 Discussion of Glutamine Controversy 74
References 75
8 Infection Prophylaxis 77
8.1 Herpes Simplex Virus (HSV)/Varicella Zoster Virus (VZV) Prophylaxis 77
8.2 Cytomegalovirus (CMV) Monitoring and Preemptive Therapy 79
8.3 Antibacterial Prophylaxis 82
8.4 Encapsulated Organism Prophylaxis for Patients with Chronic GvHD 82
8.5 Antifungal Prophylaxis 84
8.6 Pneumocystis Jiroveci (PCP) Prophylaxis 84
8.7 Vancomycin-Resistant Enterococcus (VRE) Surveillance and Contact Isolation Procedures 86
References 87
9 Graft-Versus-Host Disease Prophylaxis 89
9.1 Standard Regimens 89
9.2 Agents Used for GVHD Prophylaxis 90
References 101
10 Transfusion Medicine 106
10.1 Pre-transplant Considerations 106
10.2 Peri-transplant Considerations 107
10.3 Day 0 Transplant Infusion Considerations 110
10.4 Post-transplant Considerations 112
References 113
11 Antithrombotic Guidelines 115
11.1 Patients on Antithrombotic Therapy 115
11.2 Antithrombotic Therapy 117
11.3 Patients Who Develop Thrombosis 121
References 122
12 Engraftment 123
12.1 Autologous 123
12.2 Allogeneic 124
12.3 Engraftment Syndrome 124
12.4 Foundation for the Accreditation of Cellular Therapy (FACT) Standards for Review of Engraftment 125
Reference 127
13 Follow-Up Care 128
13.1 Follow-Up 128
13.2 Immunosuppression 131
13.3 Immunizations 132
13.4 Central Venous Catheters 136
13.5 Activities of Daily Living Guidelines 137
13.6 Osteoporosis 138
13.7 Skin Care 140
13.8 Diet and Food Preparation (See Chapter 7 for Additional Recommendations) 140
13.9 Endocrine Assessment 140
13.10 Travel Safety 141
References 142
Part II Transplant Complications 144
14 Infectious Complications 145
14.1 Temporal Sequence of Infections (see Fig. 14.1) 145
14.2 Empiric Antimicrobial Therapy and Evaluation of Neutropenic Fever 147
14.3 Treatment of Common Specific Infections in the Stem Cell Patient Population 151
References 165
15 Acute Graft-Versus-Host Disease 168
15.1 Pathophysiology 168
15.2 Risk Factors 169
15.3 Incidence 169
15.4 Clinical Presentation 170
15.5 Evaluation and Diagnosis 171
15.6 Staging/Grading 171
15.7 Treatment (See Chapter 9 for Discussion of GvHD Prophylaxis) 174
15.8 Steroid Refractory Disease 176
15.9 Autologous GvHD 185
15.10 Conclusions 185
References 186
16 Chronic Graft-Versus-Host Disease 189
16.1 Incidence and Prognosis 189
16.2 Risk Factors 191
16.3 Stigmata/Clinical Features of cGvHD 191
16.4 Diagnosis and Grading 191
16.5 Monitoring 196
16.6 Therapy 202
16.7 Follow-Up 211
References 211
17 Oral Complications 213
17.1 Pathophysiology 213
17.2 Risk Factors 213
17.3 Prophylaxis 214
17.4 Management of Oral Complications 215
17.5 Infections 220
17.6 Pre-dental Procedures 220
17.7 Taste Alterations 221
17.8 Discharge 221
References 221
18 Gastrointestinal Complications 223
18.1 Upper Gastrointestinal 223
18.2 Lower Gastrointestinal 225
18.3 Hepatobiliary Diseases 227
References 230
19 Pulmonary Complications 232
19.1 Bronchoscopy 233
19.2 Diffuse Alveolar Hemorrhage (DAH) 233
19.3 Idiopathic Pneumonia Syndrome (IPS) 236
19.4 Bronchiolitis Obliterans Syndrome (BOS) 237
19.5 Cryptogenic Organizing Pneumonia (COP) 241
References 242
20 Cardiovascular Complications 244
20.1 Pre-transplant Cardiac Evaluation 244
20.2 Incidence and Types of Acute Toxicity 245
20.3 Basic Presentation, Workup, and Treatment of Common Acute Cardiac Toxicities 245
20.4 Treatment-Induced Hypertension 248
20.5 Incidence and Types of Toxicities Occurring Years Following HSCT 249
References 250
21 Acute Kidney Injury 252
21.1 Definitions of AKI and CKD 252
21.2 Incidence of AKI 253
21.3 General Classification of Causes and Basic Workup of AKI 253
21.4 Timing and Cause of Renal Injury 254
21.5 Evaluation and Management of Common Causes of Renal Injury 254
References 258
22 Thrombotic Microangiopathies 260
22.1 Clinical Presentation 260
22.2 Risk Factors 261
22.3 Classification 261
22.4 Etiology 261
22.5 Diagnosis 262
22.6 Treatment 262
References 263
23 Graft Failure 264
23.1 Autologous Transplant 265
23.2 Allogeneic Transplant 265
23.3 Donor Leukocyte Infusion 266
23.4 Risk Factors for Graft Failure 266
23.5 Diagnosis 266
23.6 Treatment 267
References 267
24 Post-transplant Relapse 270
24.1 Considerations for Autologous Transplant Recipients 270
24.2 Considerations for Allogeneic Transplant Recipients 271
24.3 Disease-Specific Treatment for Relapse 272
24.4 Future Research Initiatives 274
References 275
25 Palliative Care 276
25.1 Definition of Palliative Medicine 276
25.2 Core Functions of Palliative Care Related to Direct Patient Care 277
25.3 When to Refer 278
References 279
26 Survivorship 280
26.1 Infection 284
26.2 Cardiovascular 284
26.3 Pulmonary 285
26.4 Neurologic 286
26.5 Endocrine 287
26.6 Musculoskeletal Complications 288
26.7 Secondary Malignant Neoplasms (SMNs) 289
26.8 Sexuality and Reproductive Issues 290
26.9 Psychosocial Concerns 292
References 293
Appendices 295
APPENDIX 1: PROCEDURE -- BONE MARROW ASPIRATE AND BIOPSY 295
Standard Tests for Marrow Studies 297
Appendix 2: Procedure: Lumbar Puncture 300
Appendix 3: Procedure Ommaya Reservoir Tap 302
Appendix 4: Procedure: Skin Biopsy 303
Appendix 5: OHSU Low-Bacteria Diet 305
Inpatient 305
Allowed Items that Must be Washed and Peeled 305
May be Eaten Unpeeled After Stems and Greens Removed and Washed 305
Not Allowed Unless Cooked or Processed 305
Outpatient 306
Index 307