413 MICROBIOLOGICAL SCREENING 414 CHAPTER 9 Haematopoietic stem cell transplantation Stem cell transplant conditioning regimens Conditioning is the treatment the patient underg oes immediately prior to a SCT. The purpose is to reduce the burden of residual disease; in allogeneic transplant recipients, it also acts as an immunosuppressant to prevent rejectio n of the graft. Many diff erent protocols using chemo- therapy alone or in combination with TBI have been developed. None has proven to be superior. Fractionation of radiation result s in less tox- icity but the total dose has to be higher to achieve similar immunosup- pres sion. Unrelated transplants might require immunosuppression with anti-T-cell monoclonal ant ibodies or ATG. Reduced intensity regimens can reduce transplant-related mortality and off ers otherwise ineligible patients a potentially curative treatment. Examples See Tables 9.6 and 9.7. Table 9.6 Commonly used transplant conditioning regimens by diseases1,2 Disease Regimen Total dose Days AML and CML Cy/TBI Cyclophosphamide Total body irradiation 120mg/kg 12 \200\22314Gy \210\2226, \210\2225 \210\2223 to \210\2221 Bu/Cy Busulfan Cyclophosphamide 16mg/kg 120mg/kg \210\2227 to \210\2224 \210\2223, \210\2222 ALL Cy/TBI Cyclophosphamide Total body irradiation 120mg/kg 12 \200\22314Gy \210\2226, \210\2225 \210\2223 to \210\2221 TBI/VP Total body irradiation Etoposide 12 \200\22313.2Gy 60mg/kg \210\2227 to \210\2224 \210\2223 Cy/VP-16/TBI Cyclophosphamide Etoposide Total body irradiation 120mg/kg 30 \200\22360 mg/kg 12 \200\22313.2Gy \210\2226, \210\2225 \210\2224 \210\2223 to \210\2221 Severe aplastic anemia Cy/ATG Cyclophosphamide ATG 200mg/kg 90mg/kg \210\2225 to \210\2222 \210\2225 to \210\2223 Thalassaemia Bu/Cy Busulfan Cyclophosphamide 14 \200\22316 mg/kg 200mg/kg \210\2229 to \210\2226 \210\2225 to \210\2222 (continued) 415 STEM CELL TRANSPLANT CONDITIONING REGIMENS Table 9.6 (continued) Commonly used transplant conditioning regi- mens by diseases1,2 Disease Regimen Total dose Days Fanconi anemia Flu/Bu/Cy Busulfan Fludarabine Cyclophosphamide ATG a 6mg/kg 100mg/m2 40mg/kg \210\2229 to \210\2226 \210\2225 to \210\2222 \210\2225 to \210\2222 \210\2224 to \210\2221 140 \200\223200mg/m2 \210\2223, \210\2222 Myeloma High dose melphalan Lymphoma BEAM (LEAM if Lomustin used) Carmustine (BCNU) Etoposide Cytarabine Melphalan 300mg/m2 800mg/m2 800 \200\2231600mg/m2 140mg/m2 \210\2226 \210\2225 to \210\2222 \210\2225 to \210\2222 \210\2221 a ATG dose depends on specifi c brand of ATG. Table 9.7 Examples of reduced intensity conditioning regimens1,2 Regimen Treatment Total dose 90mg/m2 2Gy 150mg/m2 8 \200\22310mg/kg Flu/TBI Fludarabine Total body irradiation Flu/Bu ATG Flu/Bu thiotepa Fludarabine Busulfan ATG a Thiotepa 5mg/m2 150mg/m2 140mg/m2 140 \200\223180mg/m2 150mg/m2 140g/m2 Flu/Mel alemtuzumab Fludarabine Melphalan Alemtuzumab Flu/Cy Fludarabine Cyclophosphamide a ATG dose depends on specifi c brand of ATG. References 1. Aschan, J. (2007). Risk assessment in haematopoietic stem cell transplantatio n: conditioning. Best Practice Res Clin Haematol, 20, 295 \200\223310. 2. Apperley, J. et al. (2012). The EBMT-ESH Handbook on Haemopoietic Stem Cell Transplantation, revised ed. Paris: EBMT. 416 CHAPTER 9 Haematopoietic stem cell transplantation Infusion of cryopreserved stem cells Equipment \200 Dedicated liquid nitrogen freezer con taining stem cells in liquid N2. \200 Water bath heated to 37 \200\22340 C. \200 Tongs . \200 Protective gloves. \200 Patient \200\231s notes. \200 Trolley with: syringes, needles, ampoules of 0.9% saline, blood giving sets, sterile dressing towels and gloves, ch lorhexidine spray, bags of 500mL N/saline. Ensure the patient is consented and con \201 rm identi \201 cation Method 1. Write up the stem cell infusion on the blood product infusion chart. 2. 30min before re-infusion, ensur e water bath is fi lled and heated to 37 \200\22340 C and give (chlorphenamine) 10mg IV an d paracetamol 1g PO. 3. When ready to return the stem cells take the equipment trolley to the patient \200\231s bedside. 4. Check the patient \200\231s vital signs. 5. Set up a standard blood giving set with micr o-aggregate fi lter. Never use additional fi lters. Prime with 500mL 0.9% saline, connect t o the patient and ensure good fl ow before starting to thaw any cells. 6. Check the water b ath is 37 \200\22340 C and using the protective gloves and large tongs remove a bag of cel ls from liquid nitrogen container. Carefully remove from the outer sleeve and place in wate r bath and allow 1min. DMSO (dimethyl sulfoxide) cryopreservative is very toxic to cells on ce thawed so it is important to go straight from rapid thaw to infusion. 7. Remove bag of cells from water bath using the tongs, spray with chlorhexidine and allow it to dry. Check patient identifi cation number and date of birth with the patient and conn ect to the giving set. 8. Cells should be returned as quickly as possible. Each bag con- tains approximately 100 \200\223150mL. Providing the fl ow is good, start thawing the next bag. Only thaw the next bag if you are able to fi nish the previous bag within the next minute. Check the patient \200\231s details on every bag. 9. Check the patient \200\231s observations at 15min intervals. 10. If the patient complain s of abdominal pain, nausea, or feeling faint, slow down the IVI for a short time. If sympt oms persist or patient develops chest tightness or wheezing \200\224stop the infusion. O2 nebulized salbutamol may be required. Anaphylaxis rare. Reinfusion must continue. 417 INFUSION OF CRYOPRESERVED STEM CELLS Special considerations 3 If the bag splits/leaks do not re-infuse \200\224contents will not be sterile. Very rarely, a bag could start to expand rapidly upon thawing if all the air i s not removed from the bag before freezing. A sterile needle may be used to pierce the bag if release of pressure appears essential. 3 Acute anaphylaxis is very rare but epinephrine (adrenaline) (1mL of 1:1000) should be ava ilable in the patient \200\231s room for SC or IM adminis- tration. 3 Central access required for reinfusion. 418 CHAPTER 9 Haematopoietic stem cell transplantation Infusion of fresh non-cryopreserved stem cells Ensure patient is consented and understands procedure. In general, BM will be in a larger volume than an apheresis product. Procedure 1. A medical staff member must be available to start the infusion and stay with the patient for the fi rst 30min. 2. Give paracetamol 1g PO and chlorphenamine 10mg IV 30min prior to start of infusion. 3. Prime blood giving set without an in-line fi lter with 500mL 0.9% saline and connect to the patient \200\224check there is a good fl ow. 4. Check details of patient and donation. 5. Check BP, pulse, and chest auscultation before the infusion Check observations regularly (every 15 \200\22330min). Patient on saturation monitor. 6. Cells are given fresh (not frozen). Give stem cells as slowly as pos- sible for the fi r st 15min, then increase the rate to 100mL in 60min. If after 2h the patient is tolerating i nfusion without problems, increase to 200mL/h until completion. 7. Watch for fl uid overload \200\224give diuretic if necessary. Complications of stem cell infusion \200 Microemboli occasionally cause dyspnoea and cyan osis. O2 should be available. Slow down or stop the stem cell infusion if dyspnoea. Pyrexia, rash, and rigors can occur \200\224treat with further hydrocortisone 100mg IV and chlorphenamine 10mg IV. More frequently seen in blood group mis matched transplant. More severe reactions can be seen in blood group mismatched transplants due to the red cells present in the donation. Hypertension may occur (especially if patient fl uid overloaded). Usually responds to diuretic. 3 Acute anaphylaxis is very rare but adrenaline (1mL of 1:1000) should be available in the patient \200\231s room for SC or IM administration. 3 Central access required for reinfusion. 419 INFUSION OF FRESH NON-CRYOPRESERVED STEM CELLS 420 CHAPTER 9 Haematopoietic stem cell transplantation Blood product support for SCT Irradiation \200 All cellular blood products given to allogeneic and autologous SCT patients must be irradiated to prevent transfusion-associated GvHD due to transfused T lymp hocytes. Transfusion-associated GvHD is often fatal particularly in allografts. \200 Irradiation p rotocol is standard 2500cGy. \200 Commence blood product irradiation 2 weeks prior to all ogeneic SCT until 1 year post-SCT or off all immunosuppression, whichever is later. Commence blood product irradiation 2 weeks prior to autologous SCT until 6 months post-SCT. Cell-free blood products, e.g. FFP, cryoprecipitate, or albumin do not need to be irradiated. Marrow or blood stem cell transplant itself is never irradiated. CMV status of blood products \200 CMV is not destroyed by irradiation. \200 Due to leuc odepletion of all donations some countries have now switched to no longer requiring CMV \210\222ve products and hence use CMV unscreened products. Further recommendations on CMV a re therefore partly historical but remain widely used. These recommendations should therefo re be read in conjunction with local guidelines/protocols. Transplant recipients should ideally receive CMV \210\222ve red cells and platelet transfusions regardless of their own CMV status if suffi cient CMV \210\222ve blo od products available. Transfused CMV carried in donor white cells may cause disease post-t ransplant regardless of the CMV status of the patient. CMV \210\222ve recipients must alwa ys have \210\222ve products. Should CMV \210\222ve platelets not be available at any time, it is acceptable to use unsc reened leucodepleted red cells or platelets (all donations are now leucodepleted as a stand ard). This is because CMV is carried predominantly in leucocytes. For allograft recipients, additional preventive measures are taken against CMV reactivation (E see CMV prophylaxis and treatment, p.446). Indications for RBC and platelet transfusions Identical to those for patients undergoing in tensive chemotherapy. Management of ABO incompatibility ABO incompatibility between donor and recipient does not aff ect the long-term success of the transplant or the incidence of graft failure or GvHD. However, major ABO incompatibility transfusion reactions will occur unless specifi c steps are taken to manipulate the graft where donor and recipient are ABO mismatched. Furthermore , additional care must be given post-transplant in providing appropriate ABO matched produc ts. 421 BLOOD PRODUCT SUPPORT FOR SCT ABO mismatched de \201 nitions \200 Major ABO mismatch. This is where the recipient has anti-A or anti-B antibody to donor ABO antigens, e.g. group O recipients with group A donor . Minor ABO mismatch. This is where the donor has antibodies to recipient ABO antigens, e.g. group A recipient with group O donor. \200 Bidirectional ABO mismatch. Presence of reactive allo-agglutinins in both recipient and donor plasma, e.g. recipient group B, donor group A. Management of major ABO mismatch Manipulation of donor marrow/stem cells: red cells are rem oved in the transplant laboratory by starch sedimentation or Ficoll centrifugation, prior t o infusion of the graft. Choice of red cell and platelet transfusions after HSCT \200 Red cells of group O or reci pient \200\231s own ABO group should be given. Switched to donor ABO group once ABO antibod ies to donor RBC no longer detected and DCT/DAT negative. Plasma and platelets should be of donor-type blood group. \200 The choice of platelet gro up is less critical and may be aff ected by availability. 1st, 2nd, and 3rd choice groups for platelet transfusions are shown in Table 9.8. Management of minor ABO mismatch Manipulation of donor stem cells: prior to infusion, the g raft will have been plasma reduced in the transplant laboratory by centrifugation to remove antibody that could be passively transferred. Delayed immune haemol- ysis, which may be se vere and intravascular, can occur after minor ABO mismatch due to active production of anti body by engrafting donor lym- phocytes. Maximum haemolysis occurs 9 \200\22316d post-transp lant. Choice of red cell and platelet transfusions after HSCT \200 Red cells of donor ABO group should be given. \200 Plasma and platelets should be of recipient-type blood group. Switched to donor group once ABO antibodies to donor RBC no longer detected and DCT/DAT neg ative. Platelet transfusions 1st, 2nd, and 3rd choice group is shown in Table 9.8. Management of bidirectional ABO incompatibility Choice of red cell and platelet transfusion s after HSCT \200 Give group O red cells. Switch to donor ABO group once ABO antibodies to donor RBC no longer detected and DCT/DAT \210\222ve. \200 Plasma and plate lets group AB until RBC of recipient group no longer detected, than switch to donor group. 422 CHAPTER 9 Haematopoietic stem cell transplantation Table 9.8 Initial choice of ABO group of blood/platelets in ABO mismatch BMT (see text for products given once ABO antibodies to donor RBC no longer detected and DCT/DAT negative) Platelets Donor Recipient Red cells 1st 2nd choice 3rd choice choice Major ABO mismatch A O O A B O B O O B A O AB O O A B Ba Aa Ba Aa O Oa Oa Oa Oa A B B/O A B A A/O B AB A A/O A AB B B/O B Minor ABO mismatch Ba Aa Ba Ba Aa Oa Oa Oa Oa Oa O A O A O B O B Aa Aa Ba O AB O A AB A B AB B a Risk of haemolysis but do not withhold. RhD mismatch Anti-D is not a naturally occurring antibody but may be induced by sensi- tiza tion with RhD +ve cells through pregnancy or previous incompatible transfusion. It is essen tial both recipient and donor serum are screened for the presence of anti-D. \200 When ei ther donor or recipient serum contains anti-D, RhD \210\222ve blood products should always be given post-transplant. Note: in the situation where an RhD +ve recipient receives a graft from a donor whose serum contains anti-D, immune haemolysis may occur despite plasma reduct ion of the donor marrow due to active production of donor lymphocyte derived anti-D. This c annot be prevented but is rarely severe. Provided neither donor nor recipient have anti-D in the serum, specifi c pre-transplant manipulation of the product is only required in the situation of R hD +ve donor going into RhD \210\222ve recipient where red cell depletion is required pre- transplant. It will occasionally be necessary to give RhD +ve platelet support when RhD \210\222ve is preferable simply due to lack of availability of RhD \210\222ve pl atelet products. If RhD +ve platelets have to be given, anti-D 250IU SC can be given post-transfusion. 423 BLOOD PRODUCT SUPPORT FOR SCT 424 CHAPTER 9 Haematopoietic stem cell transplantation Graft-versus-host disease (GvHD) prophylaxis In vitro T-cell depletion of graft or in vivo T-cell depletion with alemtu- zumab or antithymocyte globulin (ATG) are successful in reduc ing both the incidence and severity of GvHD in graft recipients. However there is an associ ation with an i risk of relapse. Both are used in VUD and haploi- dentical grafts where the risk of severe GvHD is i. The \200\230Seattle protocol \200\231 is most commonly used pos t graft infusion and consists of a combination of ciclosporin and stat pulses of IV MTX. Ci closporin is initially given IV (od) from before stem cell infusion and later switched to o ral dosing (bd). Some RIC regimens use oral ciclosporin from the outset. MTX dosage \200 MTX: IV bolus 15mg/m2 on day +1, then 10mg/m2 days +3, +6 and +11. \200 Folinic acid rescue 15mg/m2 IV tds may be given 24h after each MTX injection for 24h (resc ue protocol designed to reduce mucositis), but not always needed. MTX dose reduced depending on renal/hepatic function. \200 See Table 9.9. Table 9.9 Methotrexate dosage reductions MTX dose (%) Creatinine (micromol/L) 100 50 25 omit dose <145 146 \200\223165 166 \200\223180 >180 Bilirubin (micromol/L) MTX dose (%) <35 36 \200\22350 51 \200\22385 >85 100 50 25 Omit dose Side eff ects Although reduced by folinic acid rescue, mucositis may remain severe and requ ire IV diamorphine and occasionally omission of dose. Ciclosporin administration Powerful immunosuppressant with profound eff ects on T-cell sup- pressor function. Available for IV and oral use. IV regimen Commence on day \210\2221. Dosing schedules vary. Range from 5mg/kg OD IV on da y \210\2221 followed by 3mg/kg from day 0, to 1.5 mg/kg IV BD from day \210\2221. Given i n 100mL 0.9% saline/2h. If fl ushing, nausea, or pro- nounced tremor, slow infusion rate 4 \200\2236h/dose. Following loading, adjust ciclosporin dosage based on plasma ciclosporin l evel together with renal and hepatic function. 425 GRAFT-VERSUS-HOST DISEASE PROPHYLAXIS Oral regimen Switch IV l oral when patient can tolerate oral medication and is eating and w hen there are no clinical concerns regarding absorption. Dosage conversion is 2 \227 the I V dose. If od IV schedule is used, this is changed to bd dosing once oral. Some RIC conditi oning regimens use oral ciclo- sporin from the start, commencing on day \210\2222. Monitoring ciclosporin levels \200 Ciclosporin is toxic and renal impairment is the most frequent dose- limiting toxicity. Ciclosporin levels should be monitored at least twice weekly. Levels taken just before the next dose is due (trough level). Never take blood for ciclosporin levels from the central catheter through which ciclosporin has been given as ciclosporin adheres to plastic and falsely high levels will be obtained. One lumen should be marked for ciclosporin administration and ano ther lumen marked for blood levels testing. Instruct patient to delay the morning dose of ciclosporin until after the blood level has b een taken. The optimum blood ciclosporin level is not known and varies between regimens and centers. Target range generally 100 \200\223300ng/mL. Aim towards the top of the therapeut ic range in the early post-transplant period and lower part of the range at later times. In practice, the dose is often limited by a rise in serum creatinine. If serum creatinine >13 0micromol/L \200\224adjust dose. Dosage adjustment Ciclosporin has a very long t1 \201\2042. \200 To d ciclosporin level o mit 1 \200\2232 doses and make a 25 \200\22350% reduction in ongoing maintenance dose, recheck levels at 48h. To i levels, give 1 additional dose, increase maintenance dose by 25 \200\22350%, recheck level in 48h. Monitor renal function and LFTs daily. Check serum calcium and magnesium twice weekly. Ciclosporin toxicity \200 Nephrotoxicity. Worse with concurrent use of nephrotoxic drugs (e.g. aminoglycosides, vancomycin, and amphotericin). Hypertension \200\224often associated with fl uid retention and potentiated by steroids. Treat initially with diuretic to baseline weight. Neurological syndromes, esp. grand mal seizures (usually if untreated hypertension/fl uid retention). Anorexia. \200 Nausea and vomiting. \200 Tremor (almost always occurs \200\224if severe suggests overdosage). \200 Hirsutism and gum hypertrophy with prolonged usage. \200 He patotoxicity \200\224less common than nephrotoxicity. Usually intrahepatic cholestatic picture on LFTs. Potentiated by concurrent drug administration, e.g. macrolide antibiotics, norethisterone, and the azole antifungals. Hypomagnesaemia commonly occurs. Potentiated by combination with amphotericin. Give 20mmol IVI if levels <0.5micromol/L or if symptoms develop. Oral supplem ents often needed and given throughout. 426 CHAPTER 9 Haematopoietic stem cell transplantation If concerns regarding malabsorption (patient with diarrhea), consider switching back to IV ciclosporin temporarily to maintain adequate therapeutic leve ls. The same concern arises in patient with severe mucositis who are unable to take their ciclosporin orally. Post-transplant TTP 2 to ciclosporin. Emergency and potentially life- threatening. Requir es instant intervention. Neurological symptoms, renal impairment, and raised LDH raise the suspicion; MAHA on blood fi lm confi rms the diagnosis. Ciclosporin should be stopped immed iately and an alternative agent started. Ciclosporin drug interactions See Table 9.10. Levels might need to be checked more frequent ly. Table 9.10 Ciclosporin drug interactions Drugs that i ciclosporin levels Drugs that d ciclosporin levels Azole antifungals Rifampicin l major eff ect Digoxin Phenytoin l major eff ect Macrolide antibiotics, especially Sulfonamides erythromycin Carbamazepine Imipenem/meropenem Ca2+ channel blockers Oral contraceptives Drugs worsening ciclosporin nephrotoxicity \200 Aminoglycosides. \200 Amphotericin. \200 Ciprofl oxacin. \200 Co-trimoxazole. \200 ACE inhibitors. \200 Other nephrotoxi c drugs. Mycophenolate mofetil (MMF) \200 Immunosuppressant. \200 Reversible inhibitor of inosin e monophosphate dehydrogenase (IMPDH) in purine (guanine) biosynthesis which is necessary for the growth of T cells and B cells. Guideline starting dose 1g bd IV. Comes in oral preparation as well. \200 MMF/CsA appears to have equivalent activity to CsA/MTX in control of acute GvHD with reduced mucositis and duration of neutropenia but a possible i risk of viral infection, myelosuppression, and gu t ulceration. 2nd choice of agent if ciclosporin has to discontinued. 427 GRAFT-VERSUS-HOST DISEASE PROPHYLAXIS Tacrolimus \200 Calcineurin inhibitor that prevents early T-cell activation; mechanism of action, pharmacology, drug interactions, and toxicity similar to ciclosporin. Renal impairment, neurotoxicity, and cardiomyopathy. \200 0.03mg/kg/d by continuous IV in fusion from day \210\2222; once weaning starts taper 20% every 2 weeks. Monitor blood leve l and toxicities and modify dose accordingly. Methylprednisolone, sirolimus, alemtuzumab, cyclophosphamide occasionally used. 428 CHAPTER 9 Haematopoietic stem cell transplantation Acute GvHD The major cause of early transplant-related mortality. Median incidence of clini cally signifi cant (grade II \200\223IV) acute GvHD is 740%. Risk factors for acute GvHD in clude: older recipients, older donors, \231\202 recipient of \231\200 SCT (i risk with pr evious donor pregnancies), matched unrelated donors, haploidentical sibling donor, PBSC gra ft (> BM > cord blood). Defi ned as GvHD occurring within 1st 100d post-transplant (most fre- quently between d7 an d d28 post-transplant). Ranges from mild self-lim- iting condition to extensive disease and may be fatal. Characterized by fever, rash, abnormal LFTs, diarrhea, suppression of engraf tment and/ or viral reactivation, particularly CMV. Classifi ed according to the Seattle system by a staging for each organ involved (skin, liv er, gut) and overall clinical grading based on the organ staging (Table 9.11). Skin involved in >90% cases. May be mild and unremarkable maculo- papular rash (esp. palms of hands and soles of feet, but can aff ect any part of the body). May be pruritic and/or p ainful. In more severe cases, erythroderma and extensive desquamation and exfoliation can o ccur. Liver typical pattern of LFT abnormalities is intrahepatic cholestasis with i bilirubin and alkaline phosphatase (relative sparing of transaminases). Note: this picture often does no t discriminate between other causes of post-transplant liver dysfunction (e.g. drugs, infec tion \200\224particularly CMV and fungal). Gut may occasionally be only organ involved, with anorexia, nausea and vomiting. Diarrhea, typically green and watery. In severe cases can contain fresh blood and mucosa and is accom panied by abdominal pain and on occasion paralytic ileus. Diagnosis \200 Skin biopsy. Do not delay treatment if strong clinical suspicion. \200 S igmoid/rectal biopsy; helpful to distinguish infective from pseudo-membranous colitis but beware risk of bleeding and bacteraemia \200\224 perform only if it will alter management. Where GI symptoms are predominantly upper GI, gastroscopy with oesophageal, gastric, and du odenal biopsies may be helpful (e.g. to distinguish between CMV and fungal oesophagitis and gastritis). Liver biopsy is hazardous and should only be performed where other convincing diagnostic gu ides are not available. It should be performed only by the transjugular route by an experie nced operator and covered appropriately with blood products. 429 ACUTE GvHD Table 9.11 Consensus criteria for grading acute GvHD Stage Skin Liver Gut Rash <25% body surface Bilirubin 34 \200\22350micromol/L Diarrhea >0.5L/day 1 Rash 25 \200\22350% body surface Bilirubin Diarrhea 1 \200\2231.5L/day 2 51 \200\223102micromol/L Generalized erythroderma (>50%) Bilirubin 103 \200\223255micromol/L Diarrhea >1.5L/day 3 Bilirubin >255micromol/L Severe abdominal pain ileus Generalized erythroderma with bullae and desquamation 4 Overall clinical grading for the patient Grade Stage 1 \200\2232 None None I IIa IIIb IVc Stage 1-3 Stage 1 Stage 1 and/or Stage 2 \200\2233 Stage 2 \200\2233 Stage 2-3 and/or Stage 2 \200\2234 Stage 2 \200\2234 Stage 2 \200\2234 and/or a Mild decrease in clinical performance. b Marked decrease in clinical performance. c Extre me decrease in clinical performance. Treatment General measures Good nutrition and weight maintenance important. TPN may be nec- essary. IV antibiotics and antifungals often necessary in the absence of neutropenia and s igns of infection may be masked by steroids. Continue ciclosporin during acute GvHD. CMV-PC R to exclude reactivation. Speci \201 c treatment Should always be discussed with an experienced transplant haema- to logist. Mild GvHD confers a GvL eff ect; hence in mild forms GvHD may require no treatment. Patient will require very close monitoring and must be instructed to contact the transplan t center instantly if symp- toms worsen or new symptoms arise. 1st-line treatment Steroid treatment is the mainstay of acute GvHD management If there is g ut GvHD or diarrhea switch ongoing ciclosporin IV. \200 Patients with grade IIa GVHD (not progressing rapidly): methyl- prednisolone (MP) 1 mg/kg beclometasone, 1 \200\2232mg 4 times a day, budesonide 3mg twice a day. Grades IIb to IV GVHD: 2mg/kg ( beclometasone and budesonide). \200 Continue 7 \200\223 14 days then tapered slowly. \200 If no response consider adding other agent (no evidence for higher doses of steroids). 430 CHAPTER 9 Haematopoietic stem cell transplantation Side eff ects of steroid treatment \200 Gastric/peptic ulceration; proton pump inhibitor preferred over H2 blocker. Hyperglycaemia, particularly when TPN in use. Monitor blood sugars closely. Hypertension may be potentiated by ciclosporin and by fl uid retention; treat with diuretics. Insomnia and psychosis. Supportive care \200 Very important; can include GI rest, parenteral nutrition, replaceme nt of enteral fl uid loss, pain control and infection prophylaxis. Very close monitoring. \200 Requires antifungal prophylaxis. Failure of response to high-dose methylprednisolone Defi ned by: \200 Progression after 3 d. \200 No change after 7d. \200 Incomplete response after 14d. The prognosis of steroid refractory GvHD is very poor. Response to 2nd-line therapy ranges from 35 \200\22370% but 6 \200\22312-month survival is poor because of infectious complicat ions and/or recurrence of GvHD. Long- term survival 25 \200\22335%. There are no systematic randomized studies; various alternative/2nd-line treatments have been and are used. There is no consensus on standard 2nd-line treatment. Options for treatment of steroid refractory GvHD are listed in Table 9.12 Extracorporeal photopheresis (ECP) Photodynamic treatment: blood is initially treated with 8-methoxypso- ralen (a photoactivable agent) which binds to DNA of nucleated cells followin g photoactivation. Via an apheresis technique the blood leaves the patient and is exposed t o UV light (the photoactivation) before returning back into the patient; this photoactivati on leads to photo- chemically damaged T cells, hence treating GvHD. Used in treatment of sk in and liver GvHD. Prognosis Skin involvement is more likely to respond than liver or gut acute GvHD. Viral, b acterial, and fungal infections are the most common cause of death in patients with severe acute GvHD. The outcome depends on: \200 Overall grade of acute GvHD. \200 Time of onse t. \200 Response to treatment. 431 ACUTE GvHD Table 9.12 Treatments used in steroid refractory acute GvHD1 2 therapy Organ with predominant GVHD manifestation Skin ATG Denileukin diftitox Monoclonal antibodies (anti-CD25, anti-CD3, anti-CD52) Phototherapy (PUVA, ECP) Chemotherapy (MMF, calcineurin inhibitors, pentostatin, sirolimus) Liver ATG Denileukin diftitox Monoclonal antibodies Chemotherapy (sirolimus, pentostatin, calcine urin inhibitors) Phototherapy (ECP) GI tract Non-absorbable steroids (beclomethasone, budesonide) ATG TNF blockade (infl iximab, etane rcept) Chemotherapy (sirolimus, pentostatin, calcineurin inhibitors) Octreotide Reference 1. Deeg J. (2007). How I treat GVHD. Blood, 109, 4119 \200\22326. 432 CHAPTER 9 Haematopoietic stem cell transplantation Chronic GvHD The 1 cause of late morbidity and mortality after an allograft. By defi - ni tion occurs >100d post-allogeneic transplant (most frequently d100 \200\223 300). Median in cidence 30 \200\22345%. The major risk factor is previous acute GvHD. Other risk factors ar e increasing recipient age (children less fre- quently aff ected), prior acute GvHD, CMV se ropositivity of recipient and/or donor, higher degree of mismatch, donor age, \231\200 don or to \231\202 recipient, inadequate prophylaxis, busulfan conditioning, graft T-cell dose , and donor lymphocyte infusion (DLI). Preceding acute GvHD not always seen; acute GvHD may have resolved prior to onset of chronic GvHD. Diagnosis \200 Diagnosis of chronic GvHD requires at least 1 diagnostic manifestation or at least 1 distinctive manifestation confi rmed by the pertinent biopsy or test. See Table 9.13. Conventionally subdivided into limited or extensive chronic GvHD. Major clinical features a re debility, weight loss with malabsorption, sclerodermatous reaction due to excessive coll agen deposition, severe immunosuppression, and features of autoimmune disease. See Table 9. 14. Limited chronic GvHD \200\224clinical features \200 Localized skin involvement <50% total surface. \200 Hepatic dysfunction \200\224portal lesions but lacking necrosis, aggressiv e hepatitis, or cirrhosis. Other localized involvement of eyes, salivary glands, and mouth. Extensive chronic GvHD \200\224clinical features \200 Generalized skin involvement >50% o f surface \200\224may include sclerodermatous changes and ulceration. Abnormal liver function \200\224histology shows centro-lobular changes, chronic aggressive hepatitis, bridging necrosis, or cirrhosis. Liver dysfunction localized skin GvHD with involvement of eyes, salivary glands, or oral mucosa on labial biopsy. \200 Involvement of any other major org an system. 433 CHRONIC GvHD Table 9.13 Signs and symptoms of chronic GvHD1 Organ/site \200\230Diagnostic \200\231 \200\230Distinctive \200\231 Other Common (both acute and chronic) Depigmentation Sweat impairment, hypopigmentation, hyperpigmentation Erythema, maculopopular rash, pruritis Skin Poikiloderma, lichen planus-like features, sclerotic features Nails Dystrophy, Brittle features Scalp Alopecia Premature gray hair Mouth Lichen planus Xerostomia Mucositis Photophobia, blepharitis Eyes Dry eyes, kerato- conjunctivitis, sicca Genitalia Lichen planus Erosions, fi ssures, ulcers Anorexia, weight loss, nausea, vomiting Exocrine pancreatic insuffi ciency GI tract Oesophageal web, strictures of esophagus Liver Bilirubin or ALP/ALT >2 \227 ULN Lung Bronchiolitis obliterans BOOP: bronchiolitis obliterans organizing pneumonia Myositis, polymyositis Oedema, muscle cramps, arthralgia, arthritis Muscles, fascia, joints Fasciitis, joint stiff ness sec to sclerosis Haemopoietic and immune Thrombocytopenia, eosinophilia, lym- phopenia, hypo- or hyper gamma- globulin aemia Other Peripheral neuropathy, myasthenia gravis, ascites, pericardial or pleural eff usion 434 CHAPTER 9 Haematopoietic stem cell transplantation Table 9.14 Criteria for classifi cation of chronic GvHD Classi \201 cation Criteria Subclinical Histological evidence on screening biopsies without clinical signs or symptoms Limited Localized skin or single organ involvement not requiring systemic therapy Platelet count >1 00 \227 109/L and extensive skin disease or other organ involvement requiring systemic the rapy Platelet count <100 \227 109/L and extensive skin disease or other organ involvement requiring systemic therapy Extensive low risk Extensive high risk Grading of chronic GvHD The NIH Working Group2 consensus for global grading of chronic GvHD encompasses both the number of organs/sites involved and the severity of chronic GvHD with in each organ. See Table 9.15. Mild cGvHD = only 1 or 2 sites involved (except lung) with a maximum severity score of 1. Moderate cGvHD = 1 or 2 sites involved with score 2, or \211 3 organs with score 1, or lun g involvement with score 1. Severe cGvHD = score 3 in any number of sites or score 3 in lung. Table 9.15 NIH Consensus for global grading of cGvHD Number of organs/sites Mild Moderate Severe 1 site Score 1 Score 2 Score 3 2 sites Score 1 Score 2 Score 3 \211 3 sites Score 1 Score 3 Lung involvement Score 1 Score 2 Score 0 = no symptoms. Score 1 = mild symptoms. Score 2 = moderate symptoms. Score 3 = severe symptoms. Treatment Always discuss with a senior member of transplant team. Limited chronic GvHD is m uch easier to treat than extensive chronic GvHD. Localized mucosal or skin involvement ofte n responds to topical steroids. 435 CHRONIC GvHD General measures \200 Adequate nutrition, vitamin/calorie supplements may be required and severe cases may require TPN. Pneumococcal prophylaxis must be continued lifelong (infection with S. pneumoniae and H. infl uenzae common). Restart conventional prophylaxis with antiviral (aciclovir) and antibacterial agents. Antifungal prophylaxis essential in patients treated with prolonged courses of immunosuppression. Posaconazole superior to other agents. CMV surveillance is critical as reactivation is more common. \200 P. jirovecii prophylaxi s must be commenced with co-trimoxazole or nebulized pentamidine and continued for 6 months after immunosuppressive therapy is discontinued. Ursodeoxycholic acid may be given for cholestasis in patients with hepatic chronic GvHD. Artifi cial tears for patients with ocular involvement. \200 Skin hydration/emollients to lubricate skin; avoid perfume and sun-exposure. Regular dental care for patients with oropharyngeal involvement as caries i. Bisphosphonates for patients on long-term steroids to prevent osteoporosis. Psychological support may be required to adjust to chronic disability. Speci \201 c treatment \200 Commonest protocol used is the Seattle regimen using prednis olone and ciclosporin. If disease stable or improved after 2 weeks taper prednisolone by 25 % per week to target dose of 1mg/kg every other day to minimize side eff ects. After successful completion of steroid taper, reduce ciclosporin slowly. \200 If resolved completely at 9 months, slowly wean patient from both medications. Incomplete responses should be re-evaluated after 3 months more therapy; if fail to respond or progress then salvage therapy required. \200 2nd-line therapy includes ECP, azathiopr ine, thalidomide, tacrolimus, sirolimus inhibitors, mycophenolate, etanercept, imatinib and TLI. Effi cacy remains limited and clinical trials remain urgently needed. Prognostic factors Thrombocytopenia is an adverse prognostic factor for survival from diagn osis of chronic GvHD. Other factors associated with poor outcome are progressive onset, lic henoid skin rash, elevated bilirubin, poor performance status, and sex mismatched donor. Di ff erent prog- nostic models for chronic GvHD survival exist. Prognosis In a retrospective series only 10 \200\22330% of patients with extensive chronic GvHD became long-term survivors. Prompt introduction of eff ec- tive immunosuppressive ther apy has improved the outcome for these patients. 436 CHAPTER 9 Haematopoietic stem cell transplantation References 1. Apperley, J. et al. (2012). The EBMT-ESH Handbook on Haemopoietic Stem Cell Transplantation, revised ed. Paris: EBMT. 2. Filipovich, A.H. et al. (2005). National Institute of Health consensus development proje ct on criteria for clinical trials in chronic graft versus host disease: I Diagnosis and st aging Working Group report. Blood Marrow Transplant II: 945 \200\22356 Further reading Deeg, J. (2007). How I treat GVHD. Blood, 109, 4119 \200\22326. Hildebrandt , G.C. (2011). Diagnosis and treatment of pulmonary chronic GVHD: report from the consensus conference on clinical practice in chronic GVHD. Bone Marrow Transplant, 46(10), 1283 \200 \22395. Jagasia, M. (2013). Extracorporeal photopheresis versus anticytokine therapy as a s econd-line treatment for steroid-refractory acute GVHD: a multicenter comparative analysis. Blood Marrow Transplant, 19(7), 1129 \200\22333. Ullmann, A.J. et al. (2007). Posaconazole or fl uconazole for prophylaxis in severe graft-versus- host disease. N Engl J Med, 356(4) , 335 \200\22347. Erratum in: N Engl J Med, 357(4), 428. 437 CHRONIC GvHD 438 CHAPTER 9 Haematopoietic stem cell transplantation Veno-occlusive disease (syn. sinusoidal obstruction syndrome) Presents clinically early pos t-transplant (usually within the fi rst 14d). Pathophysiology poorly understood, probably d ue to damage to hepatic sinusoidal endothelial cells leading to venous occlusion and liver failure. A procoagulant state develops with low antithrombin and protein C levels, consumpt ion of FVII, and i levels of plasminogen activator inhibitor-1 (PAI-1). Multiorgan failure and death may follow. Mortality is very high. Risk factors for severe VOD include: intensive/myeloablative condi- tioning regimens, pre-t ransplant hepatitis, and 2nd/subsequent trans- plants. VOD is characterized by a triad of h epatomegaly, jaundice and ascites. In addition there is fl uid retention and weight gain as a result of this. It is much more commonly seen in allografts compared to autografts. Diagnosis is largely and initially clinical, but may be supported by typical fi ndings on D oppler ultrasound study of hepatic arterial and venous fl ows, or by elevated PAI-1 levels. The only defi nitive diagnostic inves- tigation is transjugular liver biopsy, the risks of which must be weighed against the importance of the information obtained. Diagnostic crite ria vary and are listed in Table 9.16. Diff erential diagnosis \200 Acute GvHD. \200 Sepsis with hepatic failure. \200 Chole stasis due to medication or TPN. \200 Haemolysis. \200 CCF. Table 9.16 Criteria for diagnosis of VOD (SOS) McDonald (Seattle) 2 out of 3 Jones (Baltimore) hyperbilirubinaemia plus 2 out of 3 Hepatomegaly or right upper quadrant pain + + Weight gain (>2% from pre- transplant baseline) + + Hyperbilirubinaemia (>2mg/dL or 34 micromol/L) + + Ascites \210\222 +