Stem cell transplant complications

Background

  • Autologous or allogenic
  • Cells harvested from bone marrow or peripherally
  • Treats various malignant and benign heme/onc diseases
  • Phases of recipient transplant process
    • Conditioning with radiation (usually total body) and/or chemotherapy
      • Goals: eliminate underlying malignancy, prevent rejection
    • Infusion
    • Neutropenic phase (weeks 2-4): no functioning immune system
    • Engraftment phase: highest risk of acute GVHD, lasts several weeks
    • Post-engraftment phase

Clinical Features/Differential

Neurologic complications

Higher risk with allogenic transplant

Cardiac complications

Pulmonary complications

  • Engraftment syndrome
    • Due to rapid return of neutrophils
    • Features: fever, rash, pulmonary edema, weight gain, liver and renal dysfunction, and/or encephalopathy
  • Diffuse alveolar hemorrhage
  • Bronchiolitis obliterans with or without organizing pneumonia

GI complications

  • Intestinal GVHD
    • abdominal pain, nausea/vomiting, diarrhea, GI bleeding +/- peritonitis, hepatitis, rash
  • Pseudo-obstruction
  • Veno-occlusive disease of liver
    • common
    • usually first 21 days after transplant
    • high dose chemo→endothelial damage of central hepatic venules→ thrombosis
    • RUQ pain, jaundice, weight gain
  • GI bleed
    • Chemo, GVHD, or CMV/adenovirus → diffuse mucosal bleeding, ulcers, or necrosis

Renal complications

Graft-vs-host disease

  • Acute (<100 days post-transplant) or chronic
  • rash, mucositis, diarrhea, fever, +/- hepatitis, polyneuropathy, polymyositis, GI bleed, pancreatitis

Infection

See also neutropenic fever and Immunocompromised antibiotics

  • Viral
    • CMV: pneumonitis most fatal, can also cause CNS infection, retinitis, hepatitis, pancreatitis, esophagitis, colitis
    • RSV
    • Adenovirus
    • HHV-6: pneumonitis, bone marrow suppression, enteritis, encephalitis
    • HSV: pneumonia, hepatitis, rash, encephalitis, DIC
  • Bacterial
  • Fungal
    • Aspergillus: pulmonary, hepatic, endocarditis, CNS infection (main cause of CNS infection)
    • Candida: pneumonia, hepatic, CNS infection, endophthalmitis, esophagitis
    • Pneumocystis: pneumonia
    • Cryptococcus: CNS, pneumonia
  • Toxoplasmosis: CNS infection, pneumonia
  • Causative organisms by time after transplant:
    • early (<30 days): bacteria, candida, aspergillus, HHV, RSV
    • mid (30-100 days): CMV, PCP, adenovirus, HSV, aspergillus
    • late (>100 days): CMV

Treatment adverse effects

  • Prednisone
    • Hyperglycemia, psychiatric symptoms, poor wound healing, edema, hypertension, ulcers
  • Tacrolimus, cyclosporine
    • Neurotoxicity, tremor, hyperkalemia, nephrotoxicity, hypertension, hyperglycemia, gout, cardiotoxicity
  • Mycophenolate mofetil, methotrexate
    • Cytopenias, GI distress
  • Azathioprine
    • Cytopenias, pancreatitis, hepatitis
  • Also consider toxicities related to other medications, including prophylactic or broad spectrum antibiotics

Evaluation

  • CBC, BMP, Mg/Phos
  • Low threshold for infectious workup
  • Additional evaluation dependent on presentation

Management

Disposition

  • Most complications will require admission

See Also

External Links

References