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Evaluating Adult Patients Prior to Hematopoietic Cell TransplantClaire Keller, R.N., M.N., O.C.N. On this page:Identifying patients who may benefit from a hematopoietic cell transplant is complex and involves many factors. Some considerations are specific to whether the patients receive an autologous or allogeneic transplant. Autologous transplant recipients should have no active disease in the bone marrow and require adequate collection of hematopoietic cells from the peripheral blood prior to transplant. For allogeneic transplant recipients, the human leukocyte antigens (HLA) of the donor or cord blood unit must match the patient as closely as possible, and some donor factors, such as the donor's age, CMV status and pregnancies may affect outcomes. The patient's overall health, age and disease stage are also extremely important considerations in evaluating adult patients. Patients under consideration for hematopoietic cell transplantation require an extensive evaluation performed by a transplant physician. A comprehensive pre-transplant evaluation should:
Health and performance statusDetermining the patient's health and performance status starts with a history and physical examination along with an evaluation of the major organ function. It is important to thoroughly evaluate the major organ systems so that any decrease in organ reserve can be identified (Table 1).The chemotherapy and/or radiation that a transplant recipient receives as part of the pre-transplant conditioning regimen can result in damage to various organ systems. A decrease in organ function prior to transplant may not necessarily make a patient ineligible for the procedure, but the increased risk for complications needs to be addressed in the informed consent process.
 Disease statusThe status of the patient's disease is an important factor in determining eligibility for hematopoietic cell transplantation. In addition, this information allows the transplant physician to outline recommendations for additional treatment that may be needed prior to transplant. The extent of underlying disease and response to previous treatment influence the decision to proceed with transplant and the selection of the conditioning regimen.The specific disease will determine the testing necessary to evaluate the current extent of the disease. Appropriate diagnostic procedures include X-rays, scans, biopsies, bone marrow aspiration and biopsy, and cytogenetic and molecular studies. It is also important for the transplant physician to review previous diagnostic information so a comparison can be made. Other considerationsInfectious disease historyA complete history of previous infections provides important information to the transplant physician. Transplant physicians should be informed of previous fungal infections, especially with Aspergillus, so that active infection can be ruled out.Systemic aspergillosis has an extremely high mortality rate in transplant recipients. Patients with a significant infection history are at greater risk of reactivating infections. This information can also help detect viruses for which there is effective prophylaxis, such as CMV and HSV. The pre-transplant evaluation should include a search for any signs of active infection. Patients with active infections at the time of hematopoietic cell transplant have a very high mortality rate. Most centers do not consider patients with HIV to be transplant candidates. However, some centers have special autologous protocols to treat patients with HIV and non-Hodgkins lymphoma. Previous chemotherapy/radiationMany patients under consideration for hematopoietic cell transplantation have a history of previous treatment. Multiple cycles of cytotoxic drugs and previous radiation, especially to the chest or mediastinum, are known to affect post-transplant complications. The transplant physician needs to know the lifetime dose of anthracyclines a patient has received.While previous treatment is not a reason to exclude a patient, it is important to identify the increased risk to organ systems. Knowledge of the toxicity resulting from previous treatment helps to determine if there is a risk for overlapping toxicity from the transplant conditioning regimen. Psychosocial evaluationA thorough psychosocial evaluation is important in assessing the patient's ability to undergo the transplant procedure. This evaluation provides information about the patient's and family's or caregiver's ability to comply and cope with the treatment plan. A diagnosis of a psychiatric disorder may not be a contraindication to transplant, but it requires thorough psychiatric evaluation and follow-up. A history of substance abuse is also an indication for psychiatric evaluation and can have a serious negative impact on the transplant procedure.Transfusion historyThe patient's transfusion history can provide important information to the transplant physician. Detailed information about red blood cell and platelet transfusion — particularly any adverse reactions and the response to the transfusion — can assist the physician in post-transplant care. Patients with aplastic anemia referred for transplant should receive minimal transfusions to decrease the risk of graft failure.ConclusionThe pre-transplant evaluation provides the transplant physician the opportunity to identify conditions that can affect the patient's ability to successfully undergo the procedure. There are few absolute contraindications to transplant; each transplant center has developed its own eligibility criteria based on treatment protocols and experience with high-risk patients.Developments in supportive care and new approaches such as reduced-intensity conditioning regimens have made transplantation safer and well tolerated by older and higher-risk patients. Patients with increased risk factors should be thoroughly evaluated, and the risks, benefits and treatment options should be discussed and decisions made on a case-by-case basis. References
The information in this article is also available at a more basic level in an article written for patients, Evaluating Your Health Before Transplant
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