Patient Care Post-Transplant

In the immediate period following allogeneic hematopoietic cell transplant (bone marrow, PBSC, or cord blood transplant — BMT), an immunosuppressed patient requires specialized care at a transplant center with a health care team experienced in treating post-BMT complications.

Transplant patients may still have special health care needs after returning home, and physicians assuming the care of such patients work together with the transplant center team to develop a treatment and communication plan to ensure that the patient receives appropriate monitoring — short- and long-term. The NMDP has several online and printed educational materials that can assist physicians in this process. These materials are accessible from this page.

Early patient monitoring

Patients will remain immunodeficient after transplantation. In the immediate post-transplant period, this is caused by the conditioning regimen. In later time periods, chronic GVHD may cause immunodeficiency.

The relative times of immune recovery are:

• Neutrophils and phagocytes: 1 month
• T cells: 6-12 months
• B cells: 12-24 months

Post-transplant care is typically categorized into four general time periods. Table 1 outlines possible complications and common infections in each time period.

Time period	Complication	Common infections
0-1 months	Regimen-related toxicity Graft failure Drug reactions	Most bacteria Candida, Aspergillus Herpes simplex
1-3 months	Acute graft-versus-host disease (GVHD)	Candida, other fungi Pneumocystis carinii Cytomegalovirus
3-12 months	Chronic GVHD Relapse	P. carinii Varicella-Zoster viruses Cytomegalovirus Encapsulated bacteria
> 12 months	Chronic GVHD Relapse	P. carinii Varicella-Zoster viruses Cytomegalovirus Encapsulated bacteria

Table 1. Post-transplant complications: 0-1 months, 1-3 months, 3-12 months and >12 months.

Discharge medications

Discharge medications will differ somewhat due to variations in transplant center protocols and an individual patient's condition, but a typical drug regimen may include:

• Pen VK 250 mg BID
• Sulfamethoxazole, trimethoprim
• Magnesium three times a day
• Prednisone once a day
• Famotidine twice a day
• Cyclosporine A (CSA) twice a day 10 a.m. and 10 p.m.
• Fluconazole once a day
• Ganciclovir IV three times a week

Pharmacokinetic drug interactions among BMT patients can result in either increases or decreases in serum concentrations of medications, which may reduce drug efficacy and safety. [1]

Post-transplant immunodeficient patients

To reduce the incidence of infectious complications, immunosuppressed patients must restrict their activities. The following are typical restrictions, but restrictions can differ due to variations in transplant center protocols and an individual patient's condition.

Post-discharge restrictions: Day 0-100

• Avoid crowds, use mask when in public places
• Visit doctor 1-3 times a week for the first 4 weeks with blood tests to check blood counts, renal function, liver function, CSA level
• Adhere to catheter care requirements
• Use caregiver for transportation, shopping, cooking
• Avoid contact with small children and pets

Post-discharge restrictions: 3-6 months

• No longer needs mask
• Doctor visit once a month, more frequent if patients have GVHD
• Monitor for chronic GVHD
• Continue prophylactic CSA, tacrolimus, or other immunosuppressive drug

Post-discharge restrictions: 6-12 months

• Stop immunosuppressive drugs if there is no GVHD
• May be able to return to work
• Monitor for chronic GVHD
• Still at risk for infection
• Monitor for disease status
• Some may still be taking prophylactic antibiotics

Guidelines for long-term care

Recognizing complications early, while there are more therapeutic options available and while treatments are more effective, is critical to the well-being of transplant recipients.

Recommended screening and preventive practices for transplant recipients have been developed by a consensus panel formed by members of the Center for International Blood and Marrow Transplant Research (CIBMTR), the European Group for Blood and Marrow Transplantation (EBMT) and the American Society for Blood and Marrow Transplantation (ASBMT). [2] The NMDP, in partnership with these organizations, has developed post-transplant care guidelines that patients and their physicians can use to schedule long-term follow-up care after a marrow, peripheral blood stem cell (PBSC) or cord blood transplant.

These guidelines are part of a toolkit that includes long-term screening, GVHD screening (see GVHD section, below), and Recommended Timing for Transplant Consultation.

• View Recommended post-transplant care: Long-term screening (PDF)
• Order printed copy
• Order patient version

These guidelines list recommended tests and procedures for patients’ six-month, one-year and annual post-transplant check-ups. The checklist indicates which tests and procedures are applicable to all transplant recipients and which are applicable to autologous or allogeneic recipients only.

Screening for chronic graft-versus-host disease (GVHD)

Early detection of chronic graft-versus-host disease (GVHD) can help prevent irreversible organ damage, improve survival, and increase the quality of life of transplant recipients.

Chronic GVHD, an immune response of the donor-derived T cells against recipient tissues, occurs in approximately 30-70% of patients receiving an allogeneic transplant. It is a serious, potentially life-threatening post-transplant complication. However, with ongoing surveillance, judicious management and coordination of care, most cases of chronic GVHD resolve within five years and the median duration of treatment is 2-3 years.

Important care principles for treating chronic GVHD include:

• Early detection and definitive diagnosis
• Involvement of multidisciplinary team
• Administration of topical and/or systemic treatment
• Infection prophylaxis and prompt and effective management of infections
• Long-term follow-up to monitor for late sequelae

The NMDP, in consultation with members of the National Institutes of Health (NIH) Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease, has developed a toolkit to help physicians identify the early stages of chronic GVHD. This toolkit is based on published diagnostic criteria from the NIH. [3]

The Screening for chronic GVHD publication contains a chart of organ sites where chronic GVHD can develop, accompanied by descriptions of clinical manifestations and patient symptoms. This information is cross-referenced to a photo atlas of early-stage chronic GVHD.

 

• View Recommended post-transplant care: Screening for chronic GHVD (PDF)
• Order printed copy

These guidelines are part of a toolkit that includes long-term screening, GVHD screening, and Recommended Timing for Transplant Consultation.

Special considerations for pediatric patients

Growth retardation is frequent in transplanted pediatric patients receiving total body irradiation (TBI). Approximately 45% of children receiving transplants will have markedly reduced growth rates for two years post-transplant. [4] Chemotherapy-only regimens for pre-pubertal children are preferred for this reason. Growth hormone deficiency is common; early diagnosis and treatment with synthetic growth hormone achieves the best response.

Hypothyroidism can occur in patients receiving irradiation to the head, and therefore should be avoided in children whenever possible. In some cases this may not be possible, as with a cancer with CNS involvement (e.g., in acute lymphoblastic leukemia). Transplant recipients with hypothyroidism should receive replacement hormones.

In pediatric BMT patients, there is the potential for radiation to interfere with the development of the teeth and face. Underdevelopment of the mandible is of particular concern. Changes in dental and facial development are most severe in children under the age of seven when transplanted. Avoiding conditioning regimens with radiation is the major preventative measure available, but increased diligence to oral hygiene can also minimize dental complications. [4]

References

1. Leather HL. Drug interactions in the hematopoietic stem cell transplant (HSCT) recipient: what every transplanter needs to know. Bone Marrow Transplant. 2004; 33(2):137-152.
   http://www.nature.com/bmt/journal/v33/n2/abs/1704316a.html
2. Rizzo JD, Wingard JR, Tichelli A, et al. Recommended screening and preventive practices for long-term survivors after hematopoietic cell transplantation: joint recommendations of the European Group for Blood and Marrow Transplantation, Center for International Blood and Marrow Transplant Research, and the American Society for Blood and Marrow Transplantation (EBMT/CIBMTR/ASBMT). Bone Marrow Transplantation. 2006; 37(3):249–261. (Published concurrently in Biology of Blood and Marrow Transplantation. 2006; 12(2):138-151.)
   http://www.nature.com/bmt/journal/v37/n3/abs/1705243a.html
3. Filipovich AH, Weisdorf D, Pavletic S, et al. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. Diagnosis and Staging Working Group Report. Biol Blood Marrow Transplant. 2005; 11(12):945-956.
   http://www.bbmt.org/article/PIIS1083879105006312/fulltext
4. Sanders JE. Growth and Development after hematopoietic cell transplantation. In Blume KG, Forman SJ, Appelbaum FR, editors: Thomas' Hematopoietic Cell Transplantation, 3rd ed. Oxford, England: Blackwell, 2004:929-943.