Ver el código de «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

==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]]
**Risk factors: low EF, venooclussive disease, severe sepsis, anemia, high-dose chemo
*[[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]]
**abdominal pain, nausea/vomiting, diarrhea, GI bleeding +/- peritonitis, hepatitis, rash
*Pseudo-obstruction
*Veno-occlusive disease of liver
**common
**usually first 21 days after transplant
**high dose chemo-->endothelial damage of central hepatic venules--> thrombosis 
**[[RUQ pain]], [[jaundice]], weight gain
*[[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 recieve 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]]

==External Links==

==References==
<references/>

[[Category:Heme/Onc]]