294 Stem cell collection for autologous SCT with curative intent in diseases involving the bone marrow should be undertaken after a complete response has been achieved by initial therapy . In some settings e.g. myeloma where HDT is being used with the aim of disease control rat her than with curative intent, BM involvement up to 30% is often accepted. Comparison of autologous and allogeneic SCT Autologous Allogeneic Wide age range, generally \211 65 Age range generally \211 55 No need for donor search if BM clear Sibs have 1 in 4 chance of match Not feasible if BM involved May be used in patients with BM disease Risk of tumor cell re-infusion No tumor contamination of graft Not all patients can be mobilized Donor search may impose delay No GvHD GvHD mortality and morbidity No immunosuppression Graft-versus-leukemia (GvL) effect Low early treatment related mortality (2-5%) Higher early treatment related mortality from GvHD and infection (20-40%) Risk of long term MDS from BM injury Less risk of late MDS 09-BMT.qxd 10.12.2003 04.21 PM Page 295 Transplantation Patient receives high dose chemo \200\223( radio)therapy (conditioning) which ablates the BM and immune system. After conditioning is completed, BM or PBSC are infused IV. After a p eriod of profound myelosuppression (7 \200\22325d), engraftment occurs with production of W BCs, platelets and RBCs. Immunosuppression is required after allogeneic transplantation to prevent GvHD and graft rejection. Early complications of the transplant procedure Chemoradiotherapy 2 Nausea/vomiting. 2 Reve rsible alopecia. 2 Fatigue. 2 Dry skin. 2 Mucositis. 2 VOD* (p328). Infection 2 Bacterial (Gram \200\223ve and +ve). 2 Viral \200\224HZV. 2 CMV (particularly pneumonitis)*. 2 Fungal \200\224Candida, Aspergillus*, Mucor*. 2 Atypical organisms \200 \224Pneumocystis (PCP)*, Toxoplasma*, Mycoplasma*, 295 Legionella*. Low risk in autologous SCT; significant to high risk in allogeneic SCT Graft-versus-host disease (GvHD) May occur in recipients of allogeneic SCT due to tissue in compatibility between donor and recipient undetected by standard tissue-typing tests. Acute and chronic forms occur. Higher incidence of severe GvHD fol- lowing unrelated donor SCT a nd mismatched (haploidentical) grafts. Late complications of transplantation 2 Infertility (both sexes). 2 Hypothyroidism. 2 Secon dary malignancy. 2 Late sepsis due to hyposplenism. 2 Cataracts (where TBI used). 2 Psychol ogical disturbance. Follow up and post-transplant surveillance Life-long supervision required. The particular r isks and monitoring required depend on the type of graft and whether TBI was used. Suitable conditioning regimens are outlined on p310. 09-BMT.qxd 10.12.2003 04.21 PM Page 296 Allogeneic stem cell transplantation Patient selection 2 Recipients should be in good physical condition, and \211 55 years old . 2 Donor and recipient should be fully or closely HLA-matched to reduce the risk of life threatening GvHD or graft rejection. 2 Greatest chance of full HLA match is with siblings (small chance of full match with cousins); each sib has 1:4 chance of full HLA-match. 2 Matched-volunteer unrela ted donor (MUD) may be sought from donor registries e.g. in UK The National Blood Authority and Anthony Nolan panels. 2 Haploidentical sibling may considered as a donor for patients in whom no matched sibling or volunteer donor is available ( 40%) and the increased risks of the procedure are accepta ble (e.g. poor risk adult AML, Ph-positive adult ALL). Indications for allogeneic SCT 2 Adult AML (poor risk first CR or any second CR)1. 2 Adult ALL (poor risk first CR or any second CR)2. 2 Severe aplastic anemia. 2 Chronic myeloid leu kemia. 2 Myelodysplasia. 2 Multiple myeloma (stage II/III). 2 Primary immunodeficiency synd romes. 2 Thalassaemia major. 2 Sickle cell disease. 2 Inborn errors of metabolism. 2 Relaps ed aggressive histology NHL. 2 Relapsed Hodgkin \200\231s lymphoma. 1. Good risk adult AML should not receive SCT in first remission as out- comes are good for most patients with sta ndard treatment (p156) 2. Most children with ALL will be cured by standard chemotherapy alo ne \200\224transplantation is reserved for those who relapse. (p475) 296 Outline of allogeneic SCT procedure 2 Patient receives standard conditioning therapy with h igh dose chemoradiotherapy (e.g. cyclophosphamide (CTX) 120mg/kg + 14Gy fractionated total body irra diation (TBI)) or chemotherapy (e.g. cyclophosphamide 120mg/kg + busulfan 16mg/kg). 2 Non-myeloablative conditioning regimens use moderate doses of chemotherapy and immunosuppression to achieve engraftment and have a lower transplant-relat ed mortality and morbidity; utilized to increase age range for allogeneic SCT and permit th e use of adoptive immunotherapy with donor lymphocyte infusion (DLI) for residual disease p ost-transplant. 2 In patients receiving MUD or haploidentical SCT, Campath-1H (humanized anti-CD52 monoclonal antibody) is often administered daily for 5d prior to condi tioning as an immunosuppressant to 5 the risk of graft rejection. 2 For patients with aplastic anemia less intensive conditioning is used (200mg/kg CTX combined with anti-thymocyte globulin) and because 09-BMT.qxd 10.12.2003 04.21 PM Page 297 Transplantation of sensitivity to alkylating agents in Fanconi \200\231s anemia still less intensive condit ioning is used. 2 One day after completing conditioning treatment, BM or PBSC are harvested from donor and infused IV through a central line. 2 In MUD and haploidentical SCT the graft is usually depleted of T lym- phocytes prior to infusion to reduce the risk of severe GvHD. 2 After 7 \200\22321d of severe myelosuppression, haematopoietic engraftment occurs. 2 Reverse barrier nursing in a filtered air environment, prophylactic anti- infectives (cip rofloxacin, itraconazole, acyclovir) reduce the risk of infective complications. 2 Immunosuppression is required to prevent GvHD and graft rejection; generally methotrexate (in the early engraftment phase) + cyclosporin A (for 6 months). Mechanism of cure: evidence for graft versus leukemia (GvL) effect 1. Reduced risk of relap se in patients with acute and chronic GvHD. 2. Increased risk of relapse after syngeneic SC T (no GvHD). 3. Increased risk of relapse after T-lymphocyte-depleted SCT. 4. Delayed clear ance of minimal residual disease detected post-SCT. 5. Induction of remission by donor lymp hocyte infusion (DLI) after 297 relapse post-SCT. Early complications of allogeneic SCT 2 Overall transplant related mortality for matched si bling allografts is 15 \200\22330%, for volunteer unrelated donors may reach 45%. 2 Infection: severe myelosuppression together with immune dysfunction from delayed reconsti tution or GvHD predisposes to a wide variety of potentially fatal infections with bacterial (Gram +ve and \200\223ve), viral, fungal and atypical organisms. Both HSV and HZV infecti ons are common \200\224may present with fulminant extensive lesions. Main causes of infecti ve death post-transplant are: CMV pneumonitis and invasive fungal infections with molds e.g . Aspergillus. 2 Graft versus host disease (GvHD): Acute GvHD occurs \211 100d of transplant and chronic >100d. (p324 \200\223327) 2 Other complications: \200\223 Endocrine infertility (both sexes), early menopause and occasionally hypothyroidism. \200\223 Cataract (TBI induced) >12 months post-transplant. \200\223 2 malignancies (es p. skin). \200\223 EBV associated lymphoma. \200\223 Mild psychological disturbances comm on (serious psychoses rare). Follow-up treatment and post-transplant surveillance Immunosuppression requires careful mon itoring to avoid toxicity. Unlike solid organ transplant recipients, immunosuppression not required and cyclosporin is usually discontinued at about 6 months post- transplant. Prophy laxis against pneumococcal sepsis secondary to hypos- lifelong 09-BMT.qxd 10.12.2003 04.21 PM Page 298 plenism, HZV reactivation and PCP infections required. Despite these complications, most pa tients return to an active, working life without the need for continuing medication. Future developments Molecular HLA gene loci mapping: improved DNA characterisation of HLA g ene loci should permit greater applicability and success of transplants from volunteer unre lated donors. Umbilical cord blood transplants: umbilical cord blood donation post- delivery shown to be safe for mother and child. Cord blood stem cells are immunologically immature and may be mo re permissive of HLA donor/recipient mismatches with less risk of GvHD. Successful grafts i n children; cell dose insufficient for adult grafts. 298 09-BMT.qxd 10.12.2003 04.21 PM Page 299 Transplantation 299 09-BMT.qxd 10.12.2003 04.21 PM Page 300 Autologous stem cell transplantation Patient selection Patients should good physical condition; age range for some procedures ca n be extended up to 70. BM should be uninvolved or in CR at the time of harvest/mobilizati on unless disease control rather than cure is the primary intent cf. myeloma. Accepted indications 2 Relapsed aggressive and very aggressive NHL. 2 Relapsed Hodgkin \200 \231s lymphoma. 2 Adult AML (poor risk first CR without allogeneic option or second CR without allogeneic option). 2 Adult ALL (poor risk first CR without allogeneic option or second CR without allogeneic option). 2 Multiple myeloma (stage II/III). 2 AL amyloid. Possible indications 2 Sclerosing mediastinal B-cell NHL in 1st CR. 2 Patients with aggress ive or very aggressive NHL with 2 of: stage III/IV, 300 high LDH, ECOG performance status 3 or 4, bulk disease (mass >10cm). 2 Indolent NHL (aged \211 60) relapsing after 2nd line therapy if still responsive to therapy. 2 Relapsed germ cell tumors. 2 Ewing \200\231s sarcoma. 2 Neuroblastoma. 2 Soft tissue sarc oma. 2 Autoimmune disease (multiple sclerosis, systemic sclerosis, rheumatoid arthritis, juvenile chronic arthritis, SLE). Outline of autologous SCT procedure 2 Haematopoietic stem cells harvested in CR are process ed, frozen and stored in liquid N2. 2 SCT may take place within days of harvest or several years later after treatment for recurrent disease. 2 Different conditioning chosen for underlying indication e.g. cyclophos- phamide plus busu lphan for AML or BEAM (p612) for NHL or HL. 2 After completion of conditioning (generally p lus 24 hours to allow clearance of chemotherapeutic agents), the stem cell product is thawe d rapidly and infused IV. Bags are thawed by transfer directly from liquid N2 into water at 37 \200\22343 C. Product is infused IV rapidly through indwelling central line. 2 There is period of myelosuppression (7 \200\22325d) followed by WBC, platelet and RBC engraftment. Early complications of the transplant procedure 2 Overall transplant related mortality is 5 \200\22310%. 2 Morbidity from conditioning regimens e.g. nausea from chemoradio- therapy a nd mucositis from the widespread mucosal damage to GIT: 09-BMT.qxd 10.12.2003 04.21 PM Page 301 Transplantation oral ulceration, buccal desquamation, oesophagitis, gastritis, abdominal pain and diarrhea may all be features. 2 Spectrum of infective organisms seen is similar to allografts but severity and mortality are 5. Late complications of autologous SCT 2 Single commonest long-term complication is relapse o f underlying disease. 2 Other late complications similar to allografts, but less frequent and less severe. Follow-up treatment and post-transplant surveillance 2 Regular hematological follow-up is m andatory and psychological support from the transplant team, family and friends is important for readjustment to norma l life. 2 Prophylaxis against specific infections required including Pneumococcus, HZV and PCP. Mos t patients return to an active, working life without continuing medication. 301 09-BMT.qxd 10.12.2003 04.21 PM Page 302 Investigations for BMT/PBSCT Hematology 2 FBC, reticulocytes, ESR. 2 Serum B12 and red cell folate, ferritin. 2 Blood gr oup, antibody screen and DAT. 2 Coagulation screen, PT, APTT, fibrinogen. 2 BM aspirate for morphology (cytogenetics if relevant); BM trephine biopsy. Biochemistry 2 U&Es, LFTs. 2 Ca2+, phosphate, random glucose. 2 LDH. 2 TFTs. 2 Serum and ur ine Igs. 2 EDTA clearance. Virology 2 Hepatitis BsAg. 2 Hepatitis C antibody. 2 HIV I and II antibody (counseling and consent required). 2 CMV IgG and IgM. 2 EBV, HSV and VZV IgG. 2 Parvovirus B19 titre (allog rafts only). 2 Toxoplasma titre (allografts only). 302 Immunology 2 Autoantibody screen. 2 HLA type \200\224(if not known) in case HLA matched pla telets are subse- quently required. 2 HLA and platelet antibody screen (if previously poor increments to platelet transfusions). 2 CRP. Bacteriology 2 Baseline blood cultures (peripheral blood and Hickman line). 2 Routine admis sion swabs: throat, central line site. 2 MSU, stool cultures. Cardiology 2 ECG. 2 Echocardiogram, to include measurement of systolic ejection fraction. Respiratory 2 Lung function tests. Radiology 2 CXR. 2 Sinus x-rays. Cytogenetics 2 Blood for donor/recipient polymorphisms (allografts only). 09-BMT.qxd 10.12.2003 04.21 PM Page 303 Transplantation Other 2 Consider semen storage. 2 Dental opinion if caries/gum disease. 2 Psychiatric opini on if previous history. 303 09-BMT.qxd 10.12.2003 04.21 PM Page 304 Bone marrow harvesting Pre-operative preparations Important to give advanced notice so that theater time can be bo oked if necessary and the virological screening results obtained. Within 30 days before the harvest procedure, arrange the following virological investigatio ns 1. Hepatitis B surface antigen. 2. Hepatitis C antibody. 3. HIV 1 and 2. 4. VDRL. 5. Spa re serum stored. Admit patient day before harvest. Clerk patient and arrange: 2 U&E. 2 FBC. 2 X match 2 \200 \2233 units blood (CMV \200\223ve). If harvest is on normal donor \200\224 offer autologou s blood collection to donor. If declined, arrange for genotyped, CMV negative and irradiate d X-matched blood to be avail- able for the donor. A CXR and ECG may also be arranged, if f elt clini- cally appropriate. 304 Harvest procedure 1. Give heparin 50units/kg IV at anesthetic induction. 2. Prepare harvest bag: adding ACD with a dilution factor of 1:10 for the prospective marrow volume; i.e. 100 mL of ACD if expected harvest is 1L. 3. Heparinise aspirate needles/syringes (0.9% saline containing at least 100U heparin/mL). 4. Begin with posterior superior iliac crests, limiting the number of skin entry points, th e aspirate needle should be maneuvered to collect as much marrow as possible with 5 \200 \22310mL maximum from each penetra- tion of the bone. Each aspirate should be deposited in a sterile harvest bag and syringe rinsed in the heparinised saline prior to re-use. Gently agitate bag at intervals. 5. Midway through harvest (or 500mL) a bag sample should be sent for FBC to determine the a dequacy of the harvest. The final total WBC count should be at least 2 x 108 cells/kg of th e recipient for autografts and 3 x 108 cells/kg for allografts. 09-BMT.qxd 10.12.2003 04.21 PM Page 305 Transplantation The volume of marrow required may be calculated as follows: Total volume required for autograft = 2.0 x recipient weight (kg) (bag WBC x 10) e.g. re cip. 100kg and bag WBC 20 x109/L then vol. required = (2.0 x100) (20 x10) = 1.0L Volume still needed to be harvested = total volume \200\223 volume already taken at time o f count + 10% Notes 1. The extra 10% compensates for reduced harvesting efficiency and the ACD. 2. The formula works at whatever volume you choose to do the first WBC but is a more accurate prediction at 500mL. 3. If need to harvest >1L, remember to add additional ACD in the same 1 in 10 ratio. 305 4. For allograft calculations, substitute 3.0 for 2.0 in the formula. If yield not adequate from the posterior iliac crests, other sites may be considered (e.g. anterior superior iliac crests and sternum). Review punc- ture sites the following morning for signs of local infection or continuing bleeding. For normal donors, offer out-patient f ollow-up appointment as additional safeguard and provide access to counseling services. 09-BMT.qxd 10.12.2003 04.21 PM Page 306 Peripheral blood stem cell mobilization and harvesting Properties of stem cells 2 Stem cells are defined as the most primitive haemopoietic precur sor cell. 2 Unique property is capability of both infinite self-renewal and differen- tiation to form all mature cells of the haemopoietic and immune systems. 2 In the resting state almost all stem cells reside in the bone marrow although a tiny minority circulate in peripheral blood. 2 Stem cells in marrow can migrate into the blood after treatment with chemotherapy and/or haemopoietic growth factors. 2 Once circulating, they can easily be harvested using a cell separator machine. 2 Stem cell levels in peripheral blood can be assessed by CD34 immuno- phenotype analysis. 2 More than one day of apheresis may be necessary to achieve required yield. 306 2 The yield can be assessed for engraftment potential. Protocols Mobilization and harvesting protocols differ between diseases. The fol- lowing il lustrate the principal types of schedule: 1. Mobilization after standard chemotherapy 2 No specific additional stimulus given. 2 Harv est times determined by WBC and platelet recovery, and CD34 count. 2 Yields variable. Improved by addition of G-CSF. Suitable for 2 NHL post DHAP chemotherapy. 2 AML post ADE/DAT chemotherapy. 2 ALL post high dose methotrexate. 2. Mobilization with chemotherapy and haemopoietic growth factors The commonest schedule an d the best evaluated. Harvest timing and yields more predictable. Typical protocol for NHL Day 0 cyclophosphamide 1.5g/m2 IVI with Mesna. Day +4 to day + 10 G-CSF 5 g/kg/d SC continued until last day of har- vesting. Harvest day +10 when CD34 >10 106/L and/or WBC >10 109/L Typical protocol for myeloma Day 0 cyclophosphamide 4g/m2 IVI with Mesna. Day +1 to day +10 to14, G-CSF 5 \200\22310 g/kg/d SC. Harvest day +10 to14 when CD34 > 10 106/L and/or W BC >10 109/L Mobilization with haemopoietic growth factor alone Suitable for normal volunteers e.g. allo graft donors. 09-BMT.qxd 10.12.2003 04.21 PM Page 307 Transplantation G-CSF 5 \200\22310 g/kg/d SC for 4 \200\2235d. Harvest days 4 \200\2235. Yield evaluation Common parameters are mononuclear cell counts (MNC); CD34 numbers and haem opoietic colony forming unit assays e.g. CFU-GM. All are a quantitative or functional asses sment of engraftment potential expressed per kg of recipient weight. Typical target yields Daily apheresis and daily G-CSF continue until the collection exceeds: 4 108/kg mononuclear cells or 10 104/kg CFU-GM or 3 106/kg CD34+ cells (i) (ii) (iii) 307 09-BMT.qxd 10.12.2003 04.22 PM Page 308 Microbiological screening for stem cell cryopreservation Infective agents, particularly viruses, can be transmitted through stem cell preparations a s through blood products and may cause significant mor- bidity and mortality in the recipie nt. It has been demonstrated that trans- mission of hepatitis B virus has occurred followin g common storage in a liquid nitrogen tank which contained one patient \200\231s hepatitis BsAg +ve bone marrow. The following tests should be performed on all patients in whom it is planned to cryopreser ve stem cells 2 Hepatitis B surface antigen. 2 Hepatitis B surface antibody. 2 Hepatitis B core antigen. 2 Hepatitis B core antibody. 2 Hepatitis C antibody. 2 HIV 1 and 2 antibodies . 2 HIV 1 and 2 antigen. 2 HTLV1 antibody. 2 VDRL. 2 Additional serum for storage for retro spective analysis. 308 These results must be available to transplant laboratories before cryop- reservation. Since many of these patients will be receiving blood products as part of their on-going treatmen t, they must be performed within 30 days of cryopreservation to prevent false \200\223ve a ntibody tests due to the interval between exposure and seroconversion. In practice these co n- straints dictate that samples should be taken between 7 and 30 days prior to cryopreserv ation. Patient samples shown to be \200\223ve for all the above infectious agents should have ste m cells stored in a dedicated liquid nitrogen freezer convention- ally in the liquid phase. Patient samples shown to be +ve for any of the above agents should be double bagged and sto red in a separate liquid nitrogen freezer in the vapor phase (to reduce transmissibility). Data on all stem cell product samples must be registered in a secure environment on a compu terized database with a logical inventory and retrieval system. No material should be impor ted to the freezers unless a complete negative virological audit storage trail can be demon strated. 09-BMT.qxd 10.12.2003 04.22 PM Page 309 Transplantation 309 09-BMT.qxd 10.12.2003 04.22 PM Page 310 Stem cell transplant conditioning regimens Conditioning is the treatment the patient undergoes immediately prior to a stem cell transp lant. The purpose is to reduce the burden of residual disease; in allogeneic transplant rec ipients, it also acts as an immunosup- pressant to prevent rejection of the graft. There ar e many different proto- cols using chemotherapy alone or in combination with total body irr adiation (TBI). Unrelated transplants require immunosuppression with ALG or anti-T-cell mon oclonal antibodies or total lymphoid Irradiation (TLI). Examples are AML \200\223allo and autografts 2 Cyclophosphamide 120mg/kg + 13.2Gy fractiona ted TBI or Cyclophosphamide 120mg/kg + busulfan 16 mg/kg. ALL \200\223Allo and autografts 2 Cyclophosphamide 120mg/kg + 13.2Gy fractionated TBI or Et oposide 60mg/kg + 14.4Gy fractionated TBI. 310 Non-myeloablative allografts 2 Campath-1H 100mg + fludarabine 150mg/m2 + melphalan 140mg/m2 . NHL \200\223autografts 2 BEAM (BCNU, etoposide, ara-C and melphalan; p612). Myeloma \200\223autografts 2 High dose melphalan 200mg/m2. 09-BMT.qxd 10.12.2003 04.22 PM Page 311 Transplantation 311 09-BMT.qxd 10.12.2003 04.22 PM Page 312 Infusion of cryopreserved stem cells Equipment 1. Dewar containing stem cells in liquid N2. 2. Water bath heated to 37 C \200 \22340 C. 3. Tongs. 4. Protective gloves. 5. Patient \200\231s notes. 6. Trolley with: syr inges, needles, ampoules of 0.9% saline, blood giving sets, sterile dressing towels, chlorh exidine spray, bags of 500mL N/Saline, sterile gloves. Ensure the patient has had procedure and any possible side effects explained. Method 1. Wri te up the stem cell infusion on the blood product infusion chart. 2. 30 mins before re-infu sion, ensure water bath is filled and heated to 37 C \200\22340 C and give (chlorpheniram ine) 10mg IV and paracetamol 1g PO. 3. When ready to return the stem cells take the dewar and equipment trolley to the patient \200\231s bedside. 4. Check the patient \200\231s vital signs. 5. Se t up a standard blood giving set with microaggregate filter. Never use additional filters. Prime with 500mL 0.9% saline, connect to the patient and ensure good flow before starting t o thaw any cells. 312 6. Check the water bath is 37 C \200\22340 C and using the protective gloves and large to ngs remove a bag of cells from liquid nitrogen dewar and place on the trolley. Carefully re move from the outer sleeve and place in water bath and allow one minute. DMSO cryopreservat ive is very toxic to cells once 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 to dry. Check patient identification number and DOB with the patient and if correct then co nnect to the giving set. 8. Cells should be returned as quickly as possible. Each bag conta ins approximately 100 \200\223150mL. Providing the flow is good, start thawing the next bag . Only thaw the next bag if you are able to finish the pre- vious bag within the next minut e. Check the patient \200\231s details on every bag. 9. Check the patient \200\231s observations at 15 minute intervals. 10.If the patient compl ains of abdominal pain, nausea or feeling faint, slow down the IVI for a short time. If sym ptoms persist or patient develops chest tightness or wheezing \200\224stop the infusion. O2 nebulised salbu- tamol may be required. Anaphylaxis rarely occurs. 11.At the end of re-infusion ensure no more bags of stem cells in the dewar and clear away all equipment. 12.Write the infusion details in the patient \200\231s notes in red ink. Special considerations iIf 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 air not re moved from the bag before freezing. A sterile needle may be used to pierce the bag if relea se of pressure appears essential. 09-BMT.qxd 10.12.2003 04.22 PM Page 313 Transplantation ii Acute anaphylaxis is very rare but epinephrine (adrenaline) (1mL of 1:1000 ) should be a vailable in the patient \200\231s room for SC or IM administration. 313 09-BMT.qxd 10.12.2003 04.22 PM Page 314 Infusion of fresh non-cryopreserved stem cells Explain procedure and side effects to patient. In general, bone marrow 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 first 30 minutes. 2. Prime blood giving set without an in-line filter with 500mL 0.9% saline and connect to the patient \200\224check there is a good flow. 3. Check BP, pulse and chest auscultation before the infusion. 4. Give paracetamol 1g PO and chlorpheniramine 10mg IV a t beginning of infusion. 5. Give stem cells as slowly as possible for the first 15 minutes, then increase the rate t o 100mL in 60 minutes. If after 2h the patient is toler- ating infusion without problems, i ncrease to 200mL/h until completion. 6. Watch for fluid overload \200\224give diuretic if necessary. 7. Nursing staff should mon itor BP and pulse every 15 \200\22330 mins. 8. Write infusion details in the patient \200 \231s notes in red ink. 314 Complications of stem cell infusion 2 Microemboli occasionally cause dyspnoea and cyanosis. O2 should be available. Slow down or stop the stem cell infusion if dyspnoea. 2 Pyrexia, rash and rigors can occur \200\224treat with hydrocortisone 100mg IV and chlorpheniramine 10mg IV. 2 Hypertension may occur (especially if patient fluid overloaded). Usually responds to diuretic. ii Acute anaphylaxis is very rare but adrenalin (1mL of 1:1000 ) should be available in the patient \200\231s room for SC or IM administration. Daily ward management Each day check patient for 2 Fever. 2 Nausea and vomiting. 2 Diarrhea . 2 Bleeding. 2 Rashes. 2 Fatigue. 2 Dyspnoea. 2 Pain. 2 Weight loss. 2 Jaundice. 2 Mucosit is. 2 Skin surveillance needed to observe for signs of acute and chronic GvHD, HSV, HZV and drug related problems. 2 Hickman line infections are common post-transplant. If any signs of infection and fever, line cultures and exit site swab should be taken. Remove line as soon as infusional support no longer needed. 09-BMT.qxd 10.12.2003 04.22 PM Page 315 Transplantation 315 09-BMT.qxd 10.12.2003 04.22 PM Page 316 Blood product support for stem cell transplantation All cellular blood products, i.e. red cells and platelets, must be irradiated. Irradiation 2 All cellular blood products given to allogeneic and autologous SCT patients m ust be irradiated to prevent transfusion associated GvHD due to transfused T lymphocytes. 2 Transfusion associated GvHD is usually fatal particularly in allografts. 2 Fatality can s ometimes be avoided by immediate administration of anti- lymphocyte globulin or Campath antibody. 2 Irradiation protocol is standard 2500cGy. 2 Commence blood product irradiation two weeks prior to allogeneic SCT until one year post-SCT or off all immunosuppression whichever is later. 2 Commence blood product irradiation two weeks prior to autologous SCT until six months post-SCT. 2 Cell-free blood products e.g. FFP, cryoprecipitate or albumin do not need to be irradiated. 316 2 Marrow or blood stem cell transplant itself is never irradiated. CMV status of blood products 2 CMV is not destroyed by irradiation. 2 All transplant recipi ents should ideally receive CMV \200\223ve red cells and platelet transfusions regardless of their own CMV status if sufficient CMV \200\223ve blood products available. This is bec ause of good evidence that transfused CMV carried in donor white cells may cause disease po st-transplant regardless of the CMV status of the patient. CMV \200\223ve recipients must always have \200\223ve products. 2 Should CMV negative platelets not be available at any time, it is acceptable to use unscreened leucodepleted red cells or platelets. This is because CMV is c arried predominantly in leucocytes. 2 For allograft recipients, additional preventive measures are taken against CMV reactivation (see p334). Indications for RBC and platelet transfusions Identical to those for patients undergoing in tensive chemotherapy (see, pp546 \200\223650). Management of ABO incompatibility ABO incompatibility between donor and recipient does not affect the long-term success of the transplant nor the incidence of graft failure or GvHD. However, major ABO incompatibility transfusion reactions will occur unless specific steps a re 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 product s. ABO mismatched definitions 1. 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. 09-BMT.qxd 10.12.2003 04.22 PM Page 317 Transplantation 2. Minor ABO mismatch. This is where the donor has antibodies to recip- ient ABO antigens e.g. group A recipient with group O donor. 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 supportive transfusions 2 Transfuse packed group O red cell s only for all major mismatch donor \200\223recipient pairs. 2 The choice of platelet group is less critical and may be affected by availability. First, second and third choice groups for platelet transfu- sions are shown i n the table below. Management of minor ABO mismatch Manipulation of donor stem cells: prior to infusion, the p roduct will have been plasma reduced in the transplant laboratory by centrifugation to remo ve antibody that could be passively transferred. Delayed immune haemolysis, which may be se vere and intravascular, can occur after minor ABO mismatch due to active production of anti body by engrafting donor lymphocytes. Maximum haemolysis occurs 9 \200\22316 days post-tran splant. 317 Choice of red cell and platelet transfusions 2 Always transfuse packed O red cells, i.e. th e same as in major ABO mismatch. 2 Platelet transfusions first, second and third choice group is shown in the table below. Choice of ABO group of blood/platelets in ABO mismatch BMT Platelets Donor Major ABO mismatch A B AB A B AB AB Recipient Red cells 1st choice 2nd choice 3rd choice O O O B A A B O O O O O O O A B A B A A B B A B A* B* B* A* O O O O* O* O* O* Minor ABO mismatch O O O A B A B AB AB AB O O O O O A B A* A* B* B* A* B* B* A* O* O* O* O* O* (*Risk of haemolysis but do not withhold) 09-BMT.qxd 10.12.2003 04.22 PM Page 318 Rhesus (D) mismatch Anti-D is not a naturally occurring antibody but may be induced by sens i- tisation with D +ve cells through pregnancy or previous incompatible transfusion. Import ant to screen both recipient and donor serum for the presence of anti-D. 2 When either dono r or recipient serum contains anti-D, rhesus D \200\223ve blood products should always be given post-transplant. Note: in the sit- uation where a rhe sus D +ve recipient receives a graft from a donor whose serum contains anti-D, immune haemo lysis may occur despite plasma reduction of the donor marrow due to active production of do nor lymphocyte derived anti-D. Cannot be prevented but is rarely severe. 2 Provided neither donor nor recipient have anti-D in the serum, specific pre-transplant ma nipulation of the product is only required in the situ- ation of rhesus D +ve donor going i nto rhesus D \200\223ve recipient where red cell depletion is required pre-transplant. 2 It will occasionally be necessary to give rhesus D +ve platelet support when rhesus D \200\223ve is preferable simply due to lack of abundant avail- ability of rhesus \200\223v e platelet products. 2 If rhesus D +ve platelets have to be given, give anti-D 250iu SC imme- diately post-transfusion. 318 09-BMT.qxd 10.12.2003 04.22 PM Page 319 Transplantation 319 09-BMT.qxd 10.12.2003 04.22 PM Page 320 GvHD prophylaxis In vitro T-cell depletion of graft or in vivo T-cell depletion with Campath- 1H or anti-lym phocyte globulin (ALG) are successful in reducing both the incidence and severity of GvHD i n graft recipients. The former is associ- ated with an increased risk of relapse. Both are used in MUD and hap- loidentical grafts where the risk of severe GvHD is increased. The \200\230Seattle protocol \200\231 is most commonly used post graft infusion: consists of a combi- nation of stat pulses of IV methotrexate (MTX) with bd infusions of cyclosporin: Met hotrexate MTX (IV bolus) 15mg/m2 on day +1, then 10mg/m2 days +3, +6 and +11. Folinic acid rescue 15mg/m2 IV tds may be given 24 hours after each MTX injection for 24 hours (rescue p rotocol designed to reduce mucositis). Dosage reductions 2 If renal/hepatic impairment 5 MTX dose as follows: Creatinine ( mol/L) MTX dose (%) <145 146 \200\223165 166 \200\223180 >180 100 50 25 omit dose 320 Bilirubin ( mol/L) MTX dose (%) <35 36 \200\22350 51 \200\22385 >85 100 50 25 omit dose Side effects although reduced by folinic acid rescue mucositis may remain severe and requir e IV diamorphine. Cyclosporin administration Powerful immunosuppressant with profound effects on T-cell suppressor function. Available f or IV and oral use. Intravenous regimen \200\224commence on day \200\2231 at 1.5mg/kg IV bd as IVI in 100mL 0. 9% saline/2h. If flushing, nausea or pronounced tremor, slow infusion rate 4 \200\2236h/dos e. Following loading, on day +3 onwards, adjust cyclosporin dosage based on plasma cyclospo rin A level together with renal and hepatic function. Oral regimen \200\224switch intraveno us7oral when patient can tolerate oral medication and is eating (usually day +10 to +20). D osage on conversion is 1.5 \200\2232.0 IV dose (still bd). Monitoring cyclosporin levels 2 Cyclosporin is toxic and renal impairment is the most frequ ent dose limiting toxicity. 2 Cyclosporin A levels should be monitored at least twice weekly. 2 Never take blood for cy closporin A levels from the central catheter through which cyclosporin has been given as cy closporin adheres to 09-BMT.qxd 10.12.2003 04.22 PM Page 321 Transplantation plastic and falsely high levels will be obtained. One lumen should be marked for cyclospori n administration and another lumen marked for blood levels testing. 2 12h pre-dose trough whole blood levels are measured. Instruct patient to delay the morning dose of cyclosporin until after the blood level has b een taken. The optimum blood cyclosporin level is not known. Target range: 100 \200\223300n g/mL. Aim towards the top of the thera- peutic range in the early post-transplant period an d lower part of the range at other times. In practice, the dose is often limited by a rise in serum creatinine. If serum creatinine >130 mol/L \200\224adjust dose. Do not give cyclo sporin if serum creatinine >180 mol/L. Dosage adjustment \200\224cyclosporin has a very long t 1 \201\2042 so dosage adjustment si milar to warfarin adjustment. 1. To 5 cyclosporin level omit 1 \200\2232 doses and make a 2 5 \200\22350% reduction 321 in ongoing maintenance dose, recheck levels at 48h. 2. To 4 levels, give 1 additional dose, increase maintenance dose by 25 \200\22350%, recheck level in 48h. 3. Monitor renal function and LFTs daily. Check serum calcium and mag- nesium twice weekly. Cyclosporin toxicity 2 Nephrotoxicity (see above). Worse with concurrent use of aminoglyco- sides, vancomycin and amphotericin. 2 Hypertension \200\224often associated with fluid retention and potentiated by steroids. T reat initially with diuretic to baseline weight and then nifedipine if persists. Sub-lingua l nifedipine useful where emergency reduction of blood pressure is required. 2 Neurological syndromes, esp. grand mal seizures (usually if untreated hypertension/fluid retention). 2 Anorexia, nausea, vomiting, tremor (almost always occurs \200\224if severe suggests overdosage). 2 Hirsutism and gum hypertrophy with prolonged usage. 2 Hepatotoxicity \200\224less common than nephrotoxicity. Usually intrahep- atic cholestatic picture on LFTs. Potentiated by concurrent drug administration e.g. macrol ide antibiotics, norethisterone and the azole antifungals. 2 Hypomagnesaemia commonly occurs. Potentiated by combination with amphotericin. Give 20mmo l IVI if levels <0.5 mol/L or if symptoms develop. Note: only one orally absorbed preparation of magnesium. For hypomag- nesaemia persisting o n cyclosporin post-discharge, consider magnesium glycerophosphate tablets qds. 09-BMT.qxd 10.12.2003 04.22 PM Page 322 Cyclosporin drug interactions There are substantial and important drug interactions with cy closporin: Drugs that 4cyclosporin A levels Azole antifungals Digoxin Macrolide antibiotics, especiall y erythromycin Imipenem/meropenem Calcium channel blockers Oral contraceptives Drugs that 5cyclosporin levels Rifampicin 7 major effect Phenytoin 7 major effect Sulphonam ides Carbamazepine Drugs WORSENING cyclosporin nephrotoxicity 2 Aminoglycosides. 2 Amphotericin B. 2 Ciproflox acin. 2 Cotrimoxazole. 2 ACE inhibitors. 322 Note: This is not an exhaustive list. Check cyclosporin levels 48h after any drug addition or cessation. Tacrolimus 2 Calcineurin inhibitor that prevents early T-cell activation; mechanism of acti on, pharmacology, drug interactions and toxicity similar to cyclosporin. 2 Superior to cyclosporin in three randomized trials when used in com- bination with methotrexate as GvHD prophylaxis. 2 Dosage: 0.03mg/kg/day by continuous IV infusion from day \200\2232; taper 20% every 2 we eks from day 180; monitor blood level and toxicities and modify dose accordingly; used with standard dose MTX or mini- MTX (5mg/m2 IV days +1, +3, +6 and +11). 09-BMT.qxd 10.12.2003 04.22 PM Page 323 Transplantation 323 09-BMT.qxd 10.12.2003 04.22 PM Page 324 Acute GvHD Risk factors for acute GvHD include: older recipients, older donors, male recipient of fema le SCT (4 risk with previous donor pregnancies), matched unrelated donors, haploidentical s ibling donor. Defined as GvHD occurring within first 100d post-transplant (usually starts b etween day 7 and 28 post-transplant). Ranges from mild self-limiting condition to exten- si ve disease (may be fatal). Characterized by fever, rash, abnormal LFTs, diarrhea, suppressi on of engraftment and viral reactivation, particularly CMV. Classified according to the Seattle system by a staging for each organ involved (skin, live r, gut) and overall clinical grading based on the organ staging.