Bone Marrow Transplant Flashcards
(37 cards)
Fludarabine
- class
- use
- CIs
Class: purine analogue
Use: mainly in CLL….
CIs: CrCl <30, haemolytic anaemia, pregnancy, lactation
BMT Conditioning regimens
Myeloablative, reduced intensity and nonmyeloablative
Cyclophosphamide
Class
Uses
Class - alkylating agent
Uses - myelo/lympho proliferative disorders and other cancers
In AML, what prognosis is conferred by the involvement of the following genes? A. FLT3-ITD B. EVI-1 C. WT1 D. NPM1 alone
A. very poor prognosis
B & C - no associated prognosis
D. Good prognosis
Flu/mel is an example of which of the following
- myeloablative
- Reduced intensity conditioning
- non myeloablative
RIC
Which of the following could NOT be attributed to endothelial dysfunction? A. Engraftment syndrome B. Haemorrhagic cystitis C. Veno-occlusive disease of the liver D. Thrombotic microangiopathy
B - haemorrhagic cystitis - is a complication of cyclophosphamide (given with mesna to reduce risk)
Out of bone marrow and peripheral blood SCT, which has:
A. Better engraftment
B. Less GvHD
C. Better survival
A. Peripheral blood SCT is associated with better engraftment
B. Traditional BM biopsy is associated with reduced GvHD (hence why we still tend to do this in paediatrics - don’t want to commit a young person to GvHD for the rest of their life)
C. Neither has proven to be associated with better survival
Which cell populations recover the earliest post alloSCT?
First are monocytes, granulocytes, and NK cells
T and B cells take 1-2 years to recover and a proportion of patients will have ongoing deficits
Why do we discharge patients on phenoxymethylpenicillin?
GvHD gives patients functional asplenism
We discharge on phenoxymethylpenicillin as prophylaxis for invasive pneumococcal disease, which is the most likely infection associated with hyposplenism
First line treatment for mild C diff infection
PO metronidazole
Why do we give acyclovir prophylaxis post alloSCT?
Prevent reactivation of HSV-1 and 2.
AS WELL
As prophylaxis against VZV. VZV can cause severe (potentially fatal) disease including hepatitis & meningoencephalitis late after alloSCT even in the absence of skin lesions. Risk of reactivation is high especially later i.e. >3 months, post transplantation.
CMV in alloSCT?
Highest risk for reactivation?
How do we detect and prevent?
Common for either donor or recipient, or both, to be seropositive.
Highest risk of reactivation when donor is negative and recipient is positive (because you delete your own immune cells and the CMV you already have can reactivate).
Do CMV viral loads weekly. Prophylactic valganciclovir is given until D-2, then ceased and switched to valaciclovir until engraftment (count recovery), then switched back to valganciclovir to D+100. Not given whilst counts low because it can cause BM suppression/failure, hence the reason for the switch.
PJP prophylaxis surrounding BMT?
Give bactrim until D-2, withhold until neutrophil count recovers >1.0 – can cause pancytopenia (withhold whilst counts low)
The HLA locus with the least evidence for the importance of matching on clinical outcome is: A/ HLA-A B/ HLA-C C/ HLA-DRB1 D/ HLA-DQB1
D. HLA DQB1 is the least important
HLA-A and C and both MHC class I
The others are both MHC class II
GvHD is the main risk factor for which of the following: A. Cataract formation B. Bronchiolitis obliterans syndrome C. Secondary breast cancer D. Thyroid dysfunction
B - bronchiolitis obliterans
Causes of haemorrhagic cystitis in BMT patients?
Cyclophosphamide
and
BK (polyoma) virus - latent virus in uroepithelium. GvHD is a risk factor for BK-associated haemorrhagic cystitis.
What is bronchiolitis obliterans?
Clinical syndrome associated with small airways injury. Can be caused by inhalational, infectious, drug exposures AND following lung or haematopoietic SCT
Symptoms: dyspnoea, airflow limitation (obstructive pictures)
What is engraftment post BMT defined as?
Absolute neutrophil count >1.0 OR 3 consecutive days with a count above 0.5
DDx for pulmonary complications BEFORE engraftment (i.e. in the first 30 days)
- Infection
- Pulmonary oedema
- Sepsis
- Aspiration
- Engraftment syndrome
DDx for pulmonary complications AFTER engraftment (i.e. 30 days onwards)
- Infection
- Pulmonary oedema less common although can occur
- Diffuse alveolar haemorrhage
- Idiopathic pneumonia syndrome (non infectious widespread alveolar injury)
- Pulmonary alveolar proteinosis
What is engraftment syndrome?
Timeframe?
Symptoms?
What test may predict engraftment syndrome?
Non infectious complication of alloSCT seen in about 15-20% of recipients
- Develops approx 10 days post alloSCT in time of neutrophil recovery (within 3 days of engraftment)
- Symptoms are typically mild and include fever, rash (diffuse erythema), with variable presence of dyspnoea/hypoxemia, weight gain, diarrhoea and altered mental status
A rapid fall in phosphate may predict engraftment syndrome
Engraftment syndrome radiological appearances
Bilateral ground glass
Hilar or peribronchial consolidation
Thickening of septa
What are the diagnostic criteria for engraftment syndrome?
How do we treat it
Three major or two major AND one minor criteria
Three major:
- Non infectious fever > 38
- Erythematous maculopapular rash (not due to drug/acute GvHD)
- Diffuse pulmonary opacities consistent with non cardiogenic pulmonary oedema
Minor criteria:
- Liver dysfunction
- Renal failure
- Transient encephalopathy
TREATMENT: STEROIDS
Hyperacute and acute GVHD timeframe
- Hyperacute - within the first 2/52 post transplant. 88% have skin involvement and non-cardiogenic pulmonary oedema
- Acute - in first 100 days following alloSCT. Rarely affects lungs directly.
