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2091 results in Hematology

Page 32 of 105

  • 22 - Pulmonary complications

  • Joseph H. Antin, Deborah Yolin Raley
  • Book:
    Manual of Stem Cell and Bone Marrow Transplantation
    Published online:
    05 November 2013
    Print publication:
    17 October 2013, pp 154-161

  • Summary

    Pulmonary injury is one of themost common complications of stem cell transplantation and a major cause ofmorbidity and mortality. Damage to the lungs can be multifactorial,including infection, chemotherapy toxicity, graft-versus-host disease(GVHD), radiation injury, hemorrhage, and immune reactions. Potentialetiology can be determined by carefully considering timing of pulmonarycomplications and whether the radiographic studies are focal or diffuse.Important also to consider is history including exposure to infectiousagents, current and recent prophylaxis regimen, cytomegalovirus (CMV) statusof patient and donor, prior treatment and exposure to pulmonary/cardiotoxictherapy, and current and recent immunosuppression therapy.

    All patients should havebaseline pulmonary function tests (PFTs) before transplantation, and anaggressive diagnostic approach should be taken early after transplantationif there are pulmonary problems.

    In general, patients withdyspnea and normal chest X-ray (CXR) should undergo PFTs and arterial bloodgas analysis. Restrictive physiology should prompt a chest CT (to look forinterstitial disease). In patients with normal PFTs and CXR, cardiac causessuch as pulmonary hypertension and cardiac dysfunction should beexcluded.

    Bronchoscopy withbronchoalveolar lavage (BAL) should be performed early in the search for adiagnosis. If no diagnosis is made, lung biopsy if possible should beconsidered. Patients with focal ini ltrates should be given empiricantibiotics plus or minus fungal therapy and assessed for a response beforeinvasive measures are taken.

Manual of Stem Cell and Bone Marrow Transplantation
  • 2nd edition
  • Joseph H. Antin, Deborah Yolin Raley
  • Published online:
    05 November 2013
    Print publication:
    17 October 2013
  • Fully revised throughout, the second edition of Manual of Stem Cell and Bone Marrow Transplantation is based on the in-house handbook used at the world-renowned Dana-Farber Cancer Institute. It is a practical pocket manual for all members of the stem cell and bone marrow transplant team. Written by experts at Dana-Farber, the contents are handily arranged in outline format for maximum usefulness and convenience. This essential and user-friendly manual covers all aspects of the transplantation process, from stem cell processing through management of transplant-related complications. Topics discussed thoroughly include evaluation and counselling of patients and donors, preventative care, graft-versus-host disease and conditioning regimens. A new extensive chapter on oral health in stem cell transplantation has been added. These features make the Manual of Stem Cell and Bone Marrow Transplantation an ideal resource for the entire transplant team.

  • 15 - Treatment guidelines for acute graft-versus-host disease

  • Joseph H. Antin, Deborah Yolin Raley
  • Book:
    Manual of Stem Cell and Bone Marrow Transplantation
    Published online:
    05 November 2013
    Print publication:
    17 October 2013, pp 64-78

  • Summary

    Steroids ± calcineurin inhibitor

    All other therapies areinvestigational at this time and no comparative data are available.

  • Therapy is effective 30–60% of the time.

  • Typically, therapy needs to be maintained until manifestations are completely resolved; however, be careful of the risk of opportunistic infections and EBV lymphoproliferative disorders that are associated with increased immunosuppression.

  • If GVHD develops after T-cell-depleted HSCT, CSA or tacrolimus are useful additions.

    • Steroids

    Methylprednisolone 0.5 to 2mg/kg/day. The most common dose is 1 to 2 mg/kg day in grade II to IVGVHD.

  • Conversion: Hydrocortisone (1×), prednisone (4×), Solu-Medrol® (5×), Decadron (20×). For example, a patient on 100 mg of Solu-Medrol would convert to 80 mg of prednisone.

  • There is no standard method to tapering steroids once symptoms improve. A reasonable approach is to taper by 10% of original dose per week in the absence of GVHD symptoms and after GVHD has been controlled for about 1 month.

  • 14 - Graft-versus-host disease prophylactic regimens

  • Joseph H. Antin, Deborah Yolin Raley
  • Book:
    Manual of Stem Cell and Bone Marrow Transplantation
    Published online:
    05 November 2013
    Print publication:
    17 October 2013, pp 53-63

  • Summary

    Effective prophylaxis islimited by an incomplete understanding of the pathophysiology of thedisease. Drugs are often used in combination in an attempt to block severalpathways thought to cause graft-versus-host disease (GVHD). Use ofcalcineurin inhibitors in conjunction with methotrexate is the most commoncombination regimen. Institutions use a variety of combinations. The doseand toxicity of each agent are listed individually below.

  • Tacrolimus/methotrexate (MTX) or cyclosporine/MTX is superior to single-agent prophylaxis. When calcineurin inhibitors are used with lower doses of MTX, so-called “mini methotrexate” may attenuate mucositis caused by MTX.

  • Tacrolimus/mycophenolate mofetil (MMF) or cyclosporine/MMF are alternatives for patients who are unable to take MTX.

  • Sirolimus/tacrolimus/MTX or sirolimus/tacrolimus may allow for lower doses or the elimination of MTX, although there is an increased risk of veno-occlusive disease (VOD) if myeloablative conditioning is used.

    • Agents used for prophylaxis

    Methotrexate

    Mechanism of action

    Blocks the enzymedihydrofolate reductase, which inhibits the conversion of folic acid totetrahydrofolic acid, resulting in inhibition of the key precursors of DNA,RNA, and cellular protein.

  • 4 - Stem cell source

  • Joseph H. Antin, Deborah Yolin Raley
  • Book:
    Manual of Stem Cell and Bone Marrow Transplantation
    Published online:
    05 November 2013
    Print publication:
    17 October 2013, pp 9-14

  • Summary

    Hematopoietic progenitor cell products

    Hematopoietic progenitor cell(HPC) products contain hematopoietic stem and lineage-committed progenitorcells capable of providing hematopoietic and immune reconstitution aftermyeloablative, nonmyeloablative, or reduced-intensity preparative regimens.There is no unanimity on the terminology.

  • Since stem cells are difficult to identify specifically, some authors prefer the term hematopoietic cell transplantation (HCT).

  • Others call the procedure hematopoietic stem cell transplantation (HSCT) to acknowledge that most transplantations are not successful unless stem cells are transplanted.

  • The Foundation for the Accreditation of Cellular Therapy (FACT) focuses on progenitors. Cellular therapy products can be broadly categorized as being either minimally manipulated products or more than minimally manipulated products.

    • Hematopoietic progenitor cell function

    Hematopoietic progenitor cellsadministered intravenously migrate to the marrow, where they adhere, expand,self-renew (stem cells only), and differentiate. The differentiated cellsare released into the blood, restoring blood counts and immunity. The timefrom administration of HPCs to recovery of adequate or normal blood countsis variable (see Chapter 9, Engraftment).

  • 26 - Neurologic complications

  • Joseph H. Antin, Deborah Yolin Raley
  • Book:
    Manual of Stem Cell and Bone Marrow Transplantation
    Published online:
    05 November 2013
    Print publication:
    17 October 2013, pp 172-176

  • Summary

    Neurologic toxicity is commonand often multifactorial. The primary causes of neurologic injury are (1)drug toxicity, (2) infection, (3) toxic metabolic encephalopathy, and (4)hemorrhage. It is convenient to consider neurologic injury occurring earlyafter transplantation and that occurring late after transplantationseparately. Early toxicity tends to be related to immediate problems withconditioning regimen effects. Preexisting neurological problems related tomalignancy or metabolic encephalopathy are likely to increase the risk ofimmediate post-transplantation neurologic symptoms. Later events are oftenrelated to prolonged immunoincompetence and the effects of calcineurininhibitors.

    Calcineurin inhibitors

  • CNI use (cyclosporine and tacrolimus) is probably the single most frequent cause of neurologic toxicity. The most common manifestations are tremor and burning palmar and plantar dysesthesias. However, headache, depression, confusion, somnolence, and nystagmus may also be observed. Seizures may occur, especially in association with hypomagnesemia, hypertension, hypocholesterolemia, infections, and high blood levels of CNIs.

  • A unique complication of CNIs is cortical blindness and posterior leukoencephalopathy. This syndrome is known as PRES – posterior reversible encephalopathy syndrome. It is often observed in association with the new onset of hypertension, suggesting that there is cerebral edema due to abnormalities of pressure regulation in the posterior circulation. Many of the radiologic manifestations are similar to those seen in hypertensive encephalopathy. The most common pattern is white matter edema in the posterior circulation, which may or may not persist despite continued use of the drug. Although there are reports to the contrary, most clinicians believe that cyclosporine and tacrolimus are cross-reactive; therefore, substitution of one for the other may not be useful. Newer agents such as sirolimus or mycophenolate mofetil have no known neurological toxicity and may be appropriate substitutes for CNIs. Establishing a successful immunosuppressive regimen in this setting can be quite difficult, and may require persistent use of the offending agent with an effort to maintain excellent blood pressure control.

  • A frequent complication of the use of CNIs is the development of thrombotic microangiopathy. These microangiopathies are associated with evidence of hemolysis; typically, schistocytes are observed on the blood smear and there is a reduction in haptoglobin. Because of renal vascular involvement, hypertension and azotemia are generally concomitantly observed.

  • Other less common manifestations of these agents include coma, optic disc edema, aphasia, paralysis, insomnia, somnolence, and rigidity.

  • 16 - Therapeutic decision making in BMT/SCT for congenital immunodeficiencies

  • Edited by Reinhold Munker, Louisiana State University, Shreveport, Gerhard C. Hildebrandt, University of Utah, Hillard M. Lazarus, Kerry Atkinson, University of Queensland
  • Book:
    The BMT Data Book
    Published online:
    05 August 2013
    Print publication:
    21 February 2013, pp 172-178

  • Summary

    Introduction

    Among the early successes of allogeneic BMT were those achieved in the area of congenital immunodeficiencies. In certain diseases and certain donor–recipient combinations, over 90% of patients can be cured by allogeneic transplantation. Worldwide, over 3000 patients with congenital immunodeficiencies have been treated by allogeneic transplantation. The following table gives a list of the current indications. Patients with congenital immunodeficiencies generally manifest as severe infections within the first year of life. In the absence of a hematopoietic SCT or BMT, most severe immunodeficiencies are fatal. The European Society for Immunodeficiencies (ESID) in collaboration with the EBMT provides guidelines for the conditioning regimens in use for primary immunodeficiencies (www.esid.org and www.ebmt.org). For reviews related to BMT and congenital immunodeficiencies, see Buckley, 2003; Buckley et al., 1999; and Steward and Jarisch, 2005. Szabolcs et al. (2010) gave a very detailed overview of the primary immunodeficiencies treated by BMT/SCT.

    With the advent of genetic mapping, SCID is now increasingly classified on a genetic basis. This gives a more precise characterization of the immunological defects. Thus, it is becoming clear which types have the best cure rate, allowing the stratification of therapy. For example, patients with a mutation in the antigen receptor gene Artemis (resulting in a T-B- NK+ phenotype) were described as having a worse prognosis.

  • 23 - Pathobiology of graft-versus-host disease

  • Edited by Reinhold Munker, Louisiana State University, Shreveport, Gerhard C. Hildebrandt, University of Utah, Hillard M. Lazarus, Kerry Atkinson, University of Queensland
  • Book:
    The BMT Data Book
    Published online:
    05 August 2013
    Print publication:
    21 February 2013, pp 297-310

  • Summary

    Introduction

    The number of allogeneic HCTs has continued to increase, with more than 20 000 allogeneic transplantations performed annually. The GVL/GVT effect during allogeneic HCT effectively eradicates many hematologic malignancies (Appelbaum, 2001). The development of novel strategies that use DLI, non-myeloablative conditioning, and CBT have helped expand the indications for allogeneic HCT over the last several years, especially among older patients (Welniak et al., 2007). Improvements in infectious prophylaxis, immunosuppressive medications, supportive care and DNA-based tissue typing have also contributed to improved outcomes after allogeneic HCT (Appelbaum, 2001). Yet the major complication of allogeneic HCT, GVHD, remains lethal and limits wider application (Ferrara & Reddy, 2006; Welniak et al., 2007). Depending on the time at which it occurs after HCT, GVHD can be either acute or chronic (Deeg, 2007; Lee, 2005; Weiden et al., 1979; Weiden et al., 1981). Acute GVHD is responsible for 15%–40% of mortality and is the major cause of morbidity after allogeneic HCT, while chronic GVHD occurs in up to 50% of patients who survive three months after HCT (Appelbaum, 2001; Lee, 2005).

    The GVH reaction was first noted when irradiated mice were infused with allogeneic BM and spleen cells (van Bekkum & De Vries, 1967). Although mice recovered from radiation injury and BM aplasia, they later died with “secondary disease” (van Bekkum & De Vries, 1967), a phenomenon subsequently recognized as acute GVHD. Three requirements for the development of GVHD were formulated by Billingham (Billingham, 1966). First, the graft must contain immunologically competent cells, now recognized as mature T-cells. In both experimental and clinical allogeneic BMT, the severity of GVHD correlates with the number of donor T-cells transfused (Kernan et al., 1986; Korngold & Sprent, 1987). The precise nature of these cells and the mechanisms they use are now understood in greater detail (discussed later). Second, the recipient must be incapable of rejecting the transplanted cells, that is, immunocompromised.

  • 19 - Therapeutic decision making in BMT/SCT for autoimmune disorders

  • Edited by Reinhold Munker, Louisiana State University, Shreveport, Gerhard C. Hildebrandt, University of Utah, Hillard M. Lazarus, Kerry Atkinson, University of Queensland
  • Book:
    The BMT Data Book
    Published online:
    05 August 2013
    Print publication:
    21 February 2013, pp 205-208

  • Summary

    Introduction

    Severe autoimmune disorders often have a chronic relapsing course characterized by flare-ups, remissions, further progression, and finally incapacitation. Autoimmune disorders may target many different organ systems. Multiple sclerosis is characterized by inflammation and an autoimmune attack on myelin fibers, resulting in demyelination and later axonal loss. Rheumatoid arthritis is characterized by an autoimmune attack against the synovial membrane, resulting in chronic inflammation and joint destruction. In severe cases, autoimmune disorders may cause death from multiorgan involvement. A common principle for the treatment of most autoimmune disorders is immunosuppression. The evidence for the value of high-dose chemotherapy with stem cell support comes from three lines of evidence: (a) it was speculated that higher dose immunosuppression or immunoablation could eliminate the pathogenic autoreactive cells more thoroughly; (b) in a number of case reports, patients who underwent a BMT/SCT for a hematologic malignancy and had a coincidental autoimmune disorder came into remission of both diseases (Drachman & Brodsky, 2005); and (c) it could be demonstrated in animal experiments that the transfer of syngeneic stem cells following immunoablation may cure several autoimmune disorders (Sykes & Nikolic, 2005).) In the European data base, 900 patients underwent an auto-SCT between 1996 and 2007 for a variety of autoimmune conditions (Farge et al., 2010). In this chapter I will review the treatment results for multiple sclerosis, rheumatoid arthritis, and systemic lupus erythematosus (SLE), as well as discuss future developments.

  • Preface

  • Edited by Reinhold Munker, Louisiana State University, Shreveport, Gerhard C. Hildebrandt, University of Utah, Hillard M. Lazarus, Kerry Atkinson, University of Queensland
  • Book:
    The BMT Data Book
    Published online:
    05 August 2013
    Print publication:
    21 February 2013, pp xi-xii

  • Summary

    The last 15 years have seen a major change, expansion, and improvement in the discipline of clinical bone marrow and blood stem cell transplantation. Unifying bone marrow and peripheral blood stem cell transplants, the term hematopoietic cell transplantation has been proposed. New data have become available to support the decision for or against transplantation. The future has started already. Basic science has made progress: new genes and microRNAs have been characterized as risk factors in the outcomes of hematologic malignancies. The involvement of natural killer cells in the graft-versus-tumor reactions has been recognized. New cell populations like dendritic cells and mesenchymal stem cells have been characterized. Clinical science has made progress. New indications for transplants have been developed and evaluated. Examples are renal cell cancer, autoimmune disorders, and amyloidosis. New stem cell sources (e.g., from cord blood) were implemented. Owing to sophisticated typing methods, unrelated transplants have become safer. Because of increased donor numbers, matched unrelated transplants can now be offered to more than 70% of patients who do not have a family match. Old indications (breast cancer) have become obsolete or are being reevaluated (chronic myelogenous leukemia) because of advances in the nontransplant arena. In the first edition of this book, transplant for multiple myeloma was put into context against “conventional” treatments. Now, autologous transplant has become the standard of care for multiple myeloma, which has to compete and will join forces with antiangiogenic agents or proteasome inhibitors. New treatment protocols for older patients or those who have significant comorbidities were introduced (reduced-intensity conditioning).

  • 1 - Hematopoietic cell transplantation: past, present, and future

  • Edited by Reinhold Munker, Louisiana State University, Shreveport, Gerhard C. Hildebrandt, University of Utah, Hillard M. Lazarus, Kerry Atkinson, University of Queensland
  • Book:
    The BMT Data Book
    Published online:
    05 August 2013
    Print publication:
    21 February 2013, pp 1-6

  • Summary

    The transplantation of hematopoietic stem cells (derived from the bone marrow of healthy donors) in the 1970s was considered a highly experimental procedure and was offered only to patients with late-stage leukemia. Later, it was recognized that only a small fraction of the transplanted cells were true stem cells and that the cure effected by allogeneic transplant was mediated by an immune reaction (graft-versus-leukemia reaction). In the last 20 or 30 years, hematopoietic cell transplantation (HCT) became a routine procedure both in the United States and worldwide. It is estimated that currently 60 000 or more patients globally undergo HCT every year. Overall, both allogeneic and autologous transplants have found their indications in the everyday practice of hematology/oncology. As can been seen in the following figures, allogeneic and autologous transplants have enjoyed a huge increase both in the United States and worldwide. In this book, the terms HCT, HSCT (hematopoietic stem cell transplantation), and HPCT (hematopoietic progenitor cell transplantation) will be used interchangeably.

    Although the reporting of autologous transplants is voluntary, all accredited transplant centers in the United States submit data to the CIBMTR. Since 2007, when a Stem Cell Transplant Outcomes Database was created, the reporting of allogeneic transplants is mandatory in the United States. In previous years, unrelated transplants facilitated by the National Marrow Donor Program (NMDP) were reported through the NMDP. It was estimated by the CIBMTR that currently more than half of autologous transplants in the United States are reported to a registry.

Page 32 of 105