Stem cell transplant complications
Background
- Autologous or allogenic
- Cells harvested from bone marrow or peripherally
- Treats various malignant and benign heme/onc diseases
- Leukemia, lymphoma, multiple myeloma, myelodysplastic syndrome
- Severe aplastic anemia and bone marrow failure, inherited blood dyscrasias or immune deficiencies
- 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
- Conditioning with radiation (usually total body) and/or chemotherapy
Clinical Features/Differential
Neurologic complications
Higher risk with allogenic transplant
- Stroke
- Median time of presentation 28 days post-transplant
- Usually hemorrhagic due to thrombocytopenia
- Can also be ischemic due infection, thrombosis, endocarditis
- Infection
- Aspergillus (main cause), CMV, HSV, Toxoplasma, Candida, Cryptococcus, bacterial meningitis
- Metabolic encephalopathy
- Causes include hypoxemia, electrolyte abnormalities, metabolic acidosis, sepsis, hepatic failure, medications (sedatives and analgesics), thiamine deficiency
Cardiac complications
- Pulmonary edema
- Pericardial effusion, pericardial tamponade
- Rare, associated with cyclophosphamide toxicity, infection, chronic GVHD, renal failure
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
- Pseudo-obstruction
- Veno-occlusive disease of liver
- GI bleed
- Chemo, GVHD, or CMV/adenovirus → diffuse mucosal bleeding, ulcers, or necrosis
Renal complications
- Tumor lysis syndrome
- Hemorrhagic cystitis, veno-occlusive disease
- Hemolytic uremic syndrome
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
- increased risk due to neutropenia, mucositis, skin fragility, GI problems, indwelling lines
- Pseudomonas, klebsiella
- MRSA, strep viridans, enterococcus
- C. diff
- Pneumonia, endocarditis, UTI, colitis, meningitis, etc.
- 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
- See immunocompromised antibiotics, neutropenic fever
- See thrombocytopenia, anemia
- Patients should receive leukocyte-reduced/irradiated PRBCs
- See Graft-vs-host disease
- Treatment usually glucocorticoids
- Low threshold to consult heme/onc, infectious disease
Disposition
- Most complications will require admission
See Also
- Transplant complications
- Neutropenic fever
- Immunocompromised antibiotics
- Graft-vs-host disease
- Leukemia, lymphoma, multiple myeloma