bone marrow transplantation (BMT)
Jump to navigation
Jump to search
Introduction
May be obsolete procedure since hematopoietic stem cells may be harvested from peripheral blood.
Classification
Types of BMTs:
- autologous
- stem cell harvesting from patient prior to high-dose chemotherapy &/or radiation
- cryopreservation
- reinfusion into the patient after chemotherapy to restore hematopoiesis
- allogeneic
- HLA-matched donor
- HLA-identical sibling
- HLA-identical donor identified from the general population via searching international donor registries
- in some case, one antigen mismatch from a sibling may be tolerated
- allogeneic cells from fetal cord blood (rich in stem cells) may be associated with less graft-versus host disease
Phases post BMT
- pre-engraftment phase 1 (< 30 days post BMT)
- profound neutropenia distinguishes BMT from other organ transplantation
- post-engraftment phase 2 (30-100 days post BMT)
- late phase 3 (> 100 days post BMT)
Indications
- hematopoietic malignancies
- aplastic anemia
- genetic blood disorders
- support for high-dose chemotherapy in which hematopoietic toxicity limits therapy (autologous BMT)
Procedure
allogeneic hematopoietic stem cell transplantation
- whole body irradiation
- myeloablative high-dose chemotherapy
- stem cell transplantation
- immunosuppressive therapy to prevent transplant rejection & graft-vs-host disease
Complications
- graft versus host disease (GVHD) (allogeneic BMT)
- acute GVHD generally occurs within 3 months of transplantation
- chronic GVHD may occur with taper of immunosuppression
- opportunistic infections
- pancytopenic phase 1 (< 30 days post transplantation)
- phase 2 (30-100 days post transplantation)
- cytomegalovirus pneumonitis (allogeneic BMT)
- generally occurs within 3 months of transplantation
- Epstein-Barr virus*
- Staphylococcus epidermidis
- Candida
- invasive pulmonary aspergillosis
- Toxoplasma gondii*
- Strongyloides stercoralis*
- Pneumocystis jirovecii (late phase 2)
- cytomegalovirus pneumonitis (allogeneic BMT)
- phase 3, late complications (> 100 days post transplantation)
- increased risk of infection with encapsulated organism
- cytomegalovirus pneumonitis
- Varicella zoster reactivation (20-50%)
- dermatomal pain with vesicular rash
- disseminated vesicles with visceral involvement; liver, lung, brain
- Epstein-Barr virus*
- invasive pulmonary aspergillosis
- Pneumocystis jirovecii
- Toxoplasma gondii*
- BCNU-related interstitial pneumonitis with autologous BMT
- respiratory & enteric viruses (all phases post transplantation)
- bone marrow transplant nephropathy
- veno-occlusive disease of the liver, especially after chemotherapy with busulfan
- risk of secondary malignancy (allogeneic BMT)
- excess risk for adverse cardiovascular outcomes
- hazzard ratio ~ 2-3[2]
- excess risk of all-cause mortality
- hazzard ratio ~ 10[2]
* low incidence (< 10%
Management
- rapid hematologic & immunologic reconstitution is generally complete within 3-6 months
- allogeneic BMT is treated for 6-12 months after trans- plantation with immunosuppressive agents to prevent allo- recognition of the patient by donor T-cells
- prescribe new medications with caution
- anti-rejection drug effects are wide
- drug interactions are common[1]
- immunizations prior to transplantation
- reimmunizations after BMT
- prophylaxis with fluconozole & a fluoroquinolone for neutropenic patients
- CMV prophylaxis
- indicated for transplant recipients at risk for CMV
- ganciclovir, valganciclovir or high-dose acyclovir
- can reduce risk of lymphoproliferative disease
- Bactrim is used for prophylaxis against & treatment of Pneumocystis pneumonia
- treat complications
- BCNU-related interstitial pneumonitis is treated with glucocorticoids to prevent respiratory failure & death
- treatment of graft versus host disease (GVHD)
- lifelong surveillance for long-term complications
More general terms
Additional terms
- bone marrow transplant (BMT) nephropathy
- graft versus host disease (GVHD)
- vaccination after bone marrow transplantation
References
- ↑ 1.0 1.1 1.2 Medical Knowledge Self Assessment Program (MKSAP) 11, 16. American College of Physicians, Philadelphia 1998, 2012
- ↑ 2.0 2.1 2.2 Chow EJ et al. Cardiovascular hospitalizations and mortality among recipients of hematopoietic stem cell transplantation. Ann Intern Med 2011 Jul 5; 155:21 PMID: https://www.ncbi.nlm.nih.gov/pubmed/21727290
- ↑ Wingard JR, Hsu J, Hiemenz JW. Hematopoietic stem cell transplantation: an overview of infection risks and epidemiology. Infect Dis Clin North Am. 2010 Jun;24(2):257-72. PMID: https://www.ncbi.nlm.nih.gov/pubmed/20466269
- ↑ 4.0 4.1 Asano-Mori Y. Fungal infections after hematopoietic stem cell transplantation. Int J Hematol. 2010 May;91(4):576-87 PMID: https://www.ncbi.nlm.nih.gov/pubmed/20432074
- ↑ Nucci M, Anaissie E. Fungal infections in hematopoietic stem cell transplantation and solid-organ transplantation--focus on aspergillosis. Clin Chest Med. 2009 Jun;30(2):295-306, PMID: https://www.ncbi.nlm.nih.gov/pubmed/19375636
- ↑ Tomblyn M, Chiller T, Einsele H, Gress R et al Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009 Oct;15(10):1143-238 PMID: https://www.ncbi.nlm.nih.gov/pubmed/19747629
- ↑ National Heart, Lung, and Blood Institute (NHLBI) Blood and Bone Marrow Transplant https://www.nhlbi.nih.gov/health-topics/blood-and-bone-marrow-transplant