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Pre stem cell transplantation evaluation
The document outlines the comprehensive evaluation process for potential stem cell transplant candidates, detailing the roles of various healthcare professionals involved, including physicians, coordinators, and nurses. It emphasizes the importance of assessing the patient's overall health, organ function, and previous medical history to determine eligibility for autologous or allogeneic transplants. Additionally, it highlights the necessity of thorough pre-transplant evaluations, including psychosocial assessments, infectious disease history, and the specific criteria that must be met to proceed with transplantation.
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Pre stem cell transplantation evaluation
- 1. Pre- stem celltransplant Evaluation Hedayati Asl A. Ped. Hemato. & Oncologist/BMT Shariati Hospital, Tehran-Iran
- 2. Initial visit During thisvisit, will meet with one of the BMT physicians, the financial coordinator and transplant coordinator. Also meet some of the BMT nurses.
- 3. Initial visit • Thephysician will take a history of disease. • All records from primary physician will also be reviewed. • Some of the same questions that were asked before will be asked again in order to ensure that evaluation will be completely accurate.
- 4. The areas thatwill require special attention include: General state of health Past blood transfusions Exposure to radiation Past and present infections Episodes of bleeding
- 5. • Identifying patientswho 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.
- 6. • Autologous transplantrecipients should have no active disease in the bone marrow and require adequate collection of hematopoietic cells from the peripheral blood prior to transplant. • 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.
- 9. Planning for Dateof Transplant • The list of patients eligible for transplant is reviewed thoroughly at the weekly BMT meeting. Patients are prioritized according to diagnosis and risk of relapse. The date of admission for transplant, and the initiation of the preparative regimen are determined by the coordinating team, as the schedules for bone marrow or peripheral blood stem cell harvest. •
- 11. Planning for Dateof Transplant • PBHSC transplantation implies that the coordinating team will make sure that the donor has a satisfactory venous access for harvest procedures. • The donor must be evaluated by the apheresis team and decisions for the need of a catheter for apheresis must be taken well in advance. Teaching about mobilization procedures is the responsibility of the coordinating team.
- 12. the case managerand the BMT coordinating team are responsible for the following: • 1. Initiate the recipient pre-transplant workup as per protocol • 2. Initiate the donor workup as per protocol • 3. Initiate intensive teaching about: • • the nature of the patient’s disease and the reason for transplantation. • • the effects of chemotherapy, including sterility • • the nature and mechanics of the transplantation itself • • the major complications of transplantation • • the importance of reverse isolation • • the importance of following recommended treatment and guidelines (urine collection, compliance to hygiene etc) • • the post-transplant follow-up (patients who live far from hospital have to stay until Day +120, weekly visits at the BMT clinic, the issue of the mask, compliance to medication, hydration, etc.).
- 13. • The patient'soverall health, age and disease stage are also extremely important considerations in evaluating patients. • Patients under consideration for HSCT require an extensive evaluation performed by a transplant physician. A comprehensive pre- transplant evaluation should: Determine the patient's health and performance status
- 14. •Determine the patient'sdisease status •Guide the informed consent process •Identify any psychiatric and/or social behaviors that may exclude the patient
- 16. Health and performancestatus • Determining 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 Organ assessment should include the following systems:
- 18. Oral cavity • Theoral cavity is a potential source of infection following transplantation. A dental exam and X-rays allow for identification and correction of potential problems prior to the immunosuppression resulting from the pre- transplant conditioning regimen.
- 19.
- 20. Lungs • Pulmonary complicationsare a significant cause of post-transplant morbidity and mortality. Some agents used in the conditioning regimen, such as BCNU, Busulfan and total body irradiation (TBI), can reduce the diffusion capacity. Pulmonary function tests including diffusion capacity (DLCO), forced expiratory volume (FEV), and forced capacity (FVC) should be performed. Abnormalities in these tests should be used in the decision-making process but are not necessarily a contraindication to transplant.
- 21. Pulmonary assessment: CXR- PA,Lat PFT's
- 22. Heart • An EKGand two-dimensional echocardiogram or multiple gated acquisition (MUGA) scan should be performed. A reduced ejection fraction and a history of congestive heart failure have a strong association with cardiotoxicity following transplant.
- 23.
- 24. Liver • Liver functiontests should be performed, because an elevation in the transaminases is a predictor for veno-occlusive disease (VOD). It is important for the transplant physician to know if the patient has a history of VOD or has received gemtuzumab ozogamicin, as this places the patient at increased risk for VOD following transplant.
- 25. Kidneys • Serum creatinineand creatinine clearance are routinely performed pre-transplant. Adequate renal function is important due to the potential for exposure to many nephrotoxic agents such as cyclosporine, tacrolimus, aminoglycosides and amphotericin following transplant.
- 26. Central nervous system(CNS) • A neurologic exam to detect primary neurologic disorders should be performed. A lumbar puncture with cytologic exam is important in patients with leukemia and lymphoma to rule out meningeal involvement. • Patients with meningeal involvement will require intrathecal chemotherapy and/or cranial radiation prior to proceeding to transplant. Parenchymal CNS disease may be a contraindication to transplant because of the risk of cerebral bleeding.
- 27. Performance status • Theperformance status is a useful tool in evaluating the transplant candidate's overall condition. The Karnofsky performance scoring system is used in many centers and is often used throughout the transplant procedure.
- 28. Eligibility Criteria for HematopoieticCell Transplant Patients • Pulmonary function tests DLCO, FVC > 60% • Serum Creatinine < 1.5 mg% • Creatinine Clearance > 60 ml/min • SGOT 1-2x normal SGPT 1-2x normal • Serum Bilirubin < 2 mg% • Ejection Fraction > 50% • Karnofsky Score 70-100%
- 29. Disease status • Thestatus 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.
- 30. • The specificdisease 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.
- 31. Infectious disease history Acomplete 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.
- 32. Infectious disease history •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.
- 33. Previous chemotherapy/radiation • Manypatients 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.
- 34. The chemotherapy and/orradiation 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.
- 35. Psychosocial evaluation • Athorough 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.
- 36. Transfusion history • Thepatient'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.
- 37. Conclusion • The pre-transplantevaluation 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. •
- 38. • Developments insupportive 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.
- 39. Recipient Pre-Transplant Work-up 1.Complete Blood Count, differential 2. Coagulation Profile 3. Comprehensive hepatic and renal profiles, Mg, LDH 4. Urinalysis 5. HAV, HBsAg, HBcAb, HBsAb, HCV, HIV1/HTLV1, HSV, HZV, CMV, EBV, Brucellosis, PPD, Toxoplasma 6. Complete RBC phenotype 7. If ABO incompatible, do ABO ISO 8. HLA typing 9. EPBM + CBCD (Please request BMT Leukocyte Markers) 10. Bone marrow aspirate, biopsy, cytogenetics, and other bone marrow aspirate studies as necessary 11. CXR 12. ECG 13. Pulmonary function tests 14. Echocardiogram 15. Sample for STR chimerism 16. Dental consult
- 40. • For Hodgkin’sdisease of NHL • 1. CT scan of the chest • 2. CT of the abdomen and pelvis
- 41. Lab evaluation a) Hematology: CBCwith differential PT/INR/PTT ABO group and Rh type antibody screen
- 42. b) Chemistry: Sodium, Potassium,Chloride, Bicarbonate Glucose Calcium, Albumin Magnesium Phosphate BUN, Creatinine Total Bilirubin (direct and indirect if total bilirubin is elevated) Alkaline Phosphatase AST, ALT Total Protein LDH, Uric Acid
- 43. c) Serology: (mustbe documented within 30 days prior to first day of stem cell collection) • Cytomegalovirus serology (*Anti-CMV IgG) • Herpes simplex virus serology (HSV I & II) • Varicella zoster virus (VZV) serology • HIV serology (*Anti-HIV-1, *Anti-HIV-2) • *HIV-1 Antigen • *Anti-HTLV 1 and 2 • Serologic test for syphylis: • *RPR • Hepatitis A: • Anti-HAV IgM and IgG • Hepatitis B: • *HbsAg - surface antigen • *Anti-HBc • Anti-HBs - surface antibody • Hepatitis C: • *Anti-HCV • (* FACT specified)
- 44. Renal evaluation: Urine analysis 24hour urine for creatinine clearance
- 45.
- 46. Staging studies (as appropriatefor specific disease): Bone scan CT scans: head, neck, chest, abdomen, pelvis Bone marrow studies: Morphology Immunophenotype Cytogenetics DNA Studies (PCR) FISH Gallium Scan MRI Tumor markers Skeletal survey SPEP, SPIEP, Ig’s, Beta-2 microglobulin
- 47. Inpatient Nurses Each transplantphysician closely coordinates care with a clinical nurse to ensure optimum care throughout the transplant process. Clinical nurses not only provide expert care for the many complex issues transplant patients often experience, but also serve as a reliable and knowledgeable source of information for patients and their families. Our highly skilled inpatient clinical nurses provide expert care and serve as sources of education and information for patients and their families. They participate in daily rounds at the bedside, and provide timely, accurate and comprehensive clinical information to the entire medical team.
- 48. Research Nurses Clinical StudyCoordinators Each of our clinical trials has an assigned research nurse or clinical study coordinator to assist the physician. They explain the proposed treatment, potential side effects and required follow-up, and help the physician with the consent process and with conducting the study to ensure that protocol requirements
- 52. Dietitians A clinical dietitiandetermines nutritional needs and develops a nutrition care plan during a patient’s treatment and recovery. A dietitian and diet specialist meet patients several times during their hospital stay to learn of any eating problems and to suggest alternatives when necessary.
- 53. I. Infections infirst 30 days post- transplantation A. Bacteremia Gram-positive organisms: Staphylococcus epidermidis Gram-negative aerobes and anaerobes B. Invasive fungal infections: Aspergillus, Candida C. Reactivation of herpes simplex I
- 54. II. Infections 30–120days post-transplantation A. Protozoal infections Pneumocystis carinii Toxoplasma B. Viral infections Cytomegalovirus (CMV) Adenovirus Epstein–Barr virus (EBV) Human herpesvirus 6 (HHV-6) C. Fungal infections Candida (C. albicans and C. tropicalis) Aspergillus Trichosporon Fusarium Candida krusei
- 55. III. Infections after120 days post-transplantation • A. Sinopulmonary infections with encapsulated organisms • B. Viral infections • Cutaneous herpes zoster
- 56. • Transplant donorsmust be in generally good health without other comorbid conditions. The donor must have a performance status that will permit the safe collection of the cells, either by bone marrow (BM) or peripheral blood progenitor cell (PBPC) collection.
- 57. • Thus, thedonor must be able to tolerate anesthesia (either general or regional) and have adequate cardiac, pulmonary, hepatic and renal function. Pediatric donors are only utilized for autologous collection or donation to siblings. Donors with ongoing malignancies or a history of a malignant condition other than minor skin cancers (eg, basal cell carcinomas) are generally excluded from further consideration.
- 58. • Viral serologicstudies are performed on all donors, who must be negative for both anti-HIV antibodies and HIV RNA. • Serologic tests for hepatitis B and C are also required at most transplant centers. Donors with active viral hepatitis are usually excluded although exceptions are occasionally made with sibling donors, depending upon the clinical urgency. In certain circumstances, antiviral therapy may be considered if time permits for an adequate course . Additional testing, such as for sickle cell disease, exposure to syphilis, West Nile virus, and other potential pathogens are required by some States and Regions.