Table Of ContentBlood and Marrow
Transplant Handbook
Blood and Marrow
Transplant Handbook
Comprehensive Guide
for Patient Care
Richard T. Maziarz, MD
Portland,Oregon,USA
Susan Slater, MN, FNP-BC
Portland,Oregon,USA
123
Editors
RichardT.Maziarz,MD SusanSlater,MN,FNP-BC
CenterforHematologic CenterforHematologic
Malignancies Malignancies
AdultBloodandMarrowStem AdultBloodandMarrowStem
CellTransplantProgram CellTransplantProgram
KnightCancerInstitute KnightCancerInstitute
OregonHealth&Science OregonHealth&Science
University University
Portland,OR97239,USA Portland,OR97239,USA
ISBN978-1-4419-7505-8 e-ISBN978-1-4419-7506-5
DOI10.1007/978-1-4419-7506-5
SpringerNewYorkDordrechtHeidelbergLondon
©SpringerScience+BusinessMedia,LLC2011
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Preface and Acknowledgments
Hematopoieticstemcelltransplantationhasexperiencedadra-
maticincreaseofactivityoverthepastdecadewithacontinued
markedescalationofproceduresprojectedoverthenexttento
fifteenyears.Thisexpansionisnotonlyareflectionofanever
changing field with increasing demand but also the pursuit of
innovation that contributes to continued improved outcomes
withlessriskofadverseeventsordeleteriouslong-termconse-
quences for the transplant patient population. Cell therapy is
a dynamic field. It requires multi-specialty input for the man-
agementofthesecomplexpatients.Inthepast,transplantation
wasthesoleresponsibilityofafewacademiccenters,andinfor-
mationresidedwithinthehandsofafewindividuals.However,
with the dissemination of technology and the ongoing prolif-
erationoftheseprocedures,therehasbeenanobligatoryneed
forthedevelopmentoftoolstoprovidestandardguidelinesand
algorithmsforthemanagementofpatients.
Most institutions have established their own set of guide-
lines and recommendations designed for consensus manage-
ment as patients are in constant need of shared care. As new
workforcedemandshaveemerged,therehavebeenchangesin
theworkplacewithrecentpredictionsofamarkedshortageof
transplant physicians. As an alternative, more non-physician
providers are being recruited to this field to provide day-to-
daycareofthetransplantpatient.Inlightofthesechanges,it
becomes imperative to provide detailed and shared consensus
guidelinestoensurethebestandmostpredictableoutcomesof
ourpatientscanbeachieved.
Thisguidetopatientmanagementistheproductoffifteen
years of evolution of patient care at our institution. Wherever
possible, the information herein has been altered to reflect
the multiple options that exist for treatment of various condi-
tions.However,itisnotmeanttodefinetheexactcarepathway
for all patients. Rather, we have provided a practical set of
guidelines that can be shared across institutions. This effort
is our contribution to the workforce shortage for transplant
physicians.Byprovidinganeasy-to-usemanualthatcoversthe
basics of care of the stem cell transplant patient which can
beutilizedtoeducatephysicianassistants,nursepractitioners,
v
vi PREFACEANDACKNOWLEDGMENTS
residents,post-doctoralfellows,andotherhospitaliststhatmay
be recruited to the day-to-day care of the patient, we have
achieved our goal. We recognize that this pocket guide is a
work in progress, and we anticipate that as time passes, even
potentiallyquitequickly,anewsetofguidelineswillneedtobe
generated.
We recognize that this manual is incomplete. We do not
discuss graft engineering to any great degree. We are not
addressing the nuances of cord blood transplantation. We are
notconsideringhaplo-identicaltransplantationorotherthera-
piesthatremaininclinicaltrialdevelopmentandmayemerge
soon into the clinical arena. Nor are we talking about regen-
eration medicine, its futures, and its overlap with hematopoi-
etic stem cell transplantation. Rather, we provide information
aboutstandardsofcareandassimilateknowledgegainedfrom
others.
The work presented within this volume represents not the
workofafew,buttheworkofmany.Anumberofourauthors
were members of the team that helped create our institution-
specific consensus guidelines. We have also recruited new
memberstoassistingeneratingtheseeverchangingsetofstan-
dards. We wish to thank the many contributors, as well as
our mentors and colleagues who have inspired us to pursue
this field and who have provided us with the energy to make
thiscontribution.WewouldliketothankThomasThomasfor
his assistance in the preparation of this manual. We specifi-
cally acknowledge the work of Florence Seelig, Peter Curtin,
Mark Brunvand, Kamar Godder, Gerald Segal, and the late
Keith Hansen among many of our former team members.
Theircontributionstoourprogramcannotbeunderestimated.
In addition, we thank our team of dedicated nurses, social
workers, CMAs, CNAs, physical therapists, nutrition special-
ists,andallprovidersthatarepresentatthepatients’bedside.
We also thank our collaborating community partners: refer-
ring physicians, mid-level providers, and nurse coordinators.
Through collaboration and shared information, we hope to
assurethebestoutcomeofourpatientsastheyreturntotheir
communitiesacrossthecountry.
Editors,2011 RichardT.Maziarz,MD
SusanSlater,MN,FNP-BC
Contents
PartI The Nuts and Bolts of Stem Cell
Transplant
1 Overview of Hematopoietic Stem Cell
Transplantation . . . . . . . . . . . . . . . . . . . . 3
RichardT.Maziarz
2 The Business of Cellular Therapy and
HematopoieticStemCellTransplantation . . . 9
PeggyAppelandRichardT.Maziarz
3 StemCellSources . . . . . . . . . . . . . . . . . . 21
JoseLeis
4 Pre-transplantEvaluation . . . . . . . . . . . . . 27
AndyChen
5 ConditioningRegimens . . . . . . . . . . . . . . . 39
JosephBubalo
6 SupportiveCare . . . . . . . . . . . . . . . . . . . . 51
BryonAllen
7 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . 63
StaceyEvert
8 InfectionProphylaxis . . . . . . . . . . . . . . . . 71
LynneStrasfeld
9 Graft-Versus-HostDiseaseProphylaxis . . . . . 83
ErinCorella
10 TransfusionMedicine . . . . . . . . . . . . . . . . 101
JamesGajewskiandSusanSlater
11 AntithromboticGuidelines . . . . . . . . . . . . . 111
ThomasDeLoughery
12 Engraftment . . . . . . . . . . . . . . . . . . . . . . 119
SaraMurray
13 Follow-UpCare . . . . . . . . . . . . . . . . . . . . 125
CarolJacoby
vii
viii CONTENTS
PartII TransplantComplications
14 InfectiousComplications . . . . . . . . . . . . . . 143
LynneStrasfeld
15 AcuteGraft-Versus-HostDisease . . . . . . . . . 167
SusanSlater
16 ChronicGraft-Versus-HostDisease . . . . . . . . 189
RichardT.MaziarzandFarnoushAbar
17 OralComplications . . . . . . . . . . . . . . . . . . 213
KimberlyBrennanTyler
18 GastrointestinalComplications . . . . . . . . . . 223
EneidaNemecek
19 PulmonaryComplications . . . . . . . . . . . . . 233
TarekEidandAlanF.Barker
20 CardiovascularComplications . . . . . . . . . . . 245
ChristopherGreenman
21 AcuteKidneyInjury . . . . . . . . . . . . . . . . . 253
AnujaMittalhenkle
22 ThromboticMicroangiopathies . . . . . . . . . . 261
ThomasDeLoughery
23 GraftFailure . . . . . . . . . . . . . . . . . . . . . . 265
GabrielleMeyers
24 Post-transplantRelapse . . . . . . . . . . . . . . . 271
RichardT.MaziarzandSusanSlater
25 PalliativeCare . . . . . . . . . . . . . . . . . . . . . 277
MaryDeniseSmithandAmyGuthrie
26 Survivorship . . . . . . . . . . . . . . . . . . . . . . 281
LisaHansenandBrandonHayes-Lattin
Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
Contributors
FarnoushAbar,MD
CenterforHematologicMalignancies,AdultBloodand
MarrowStemCellTransplantProgram,OregonHealthand
ScienceUniversity,Portland,OR,USA
BryonAllen,MSN,FNP-BC
CenterforHematologicMalignancies,AdultBloodand
MarrowStemCellTransplantProgram,OregonHealthand
ScienceUniversity,Portland,OR,USA
PeggyAppel,MHA
NorthwestMarrowTransplantProgram,OregonHealthand
ScienceUniversity,Portland,OR,USA
AlanF.Barker,MD
PulmonaryandCriticalCareMedicine,OregonHealthand
ScienceUniversity,Portland,OR,USA
JosephBubalo,PharmD,BCPS,BCOP
ClinicalOperationsManagerandOncologyClinical
Pharmacist,PharmacyServices,OregonHealthandScience
University,Portland,OR,USA
AndyChen,MD,PhD
CenterforHematologicMalignancies,AdultBloodand
MarrowStemCellTransplantProgram,OregonHealthand
ScienceUniversity,Portland,OR,USA
ErinCorella,PharmD,BCPS,BCOP
PharmacyServices,OregonHealthandScienceUniversity,
Portland,OR,USA
ThomasDeLoughery,MD
DivisionsofHematology/OncologyandLaboratoryMedicine,
OregonHealthandScienceUniversity,Portland,OR,USA
TarekEid,MD
PulmonaryandCriticalCareMedicine,OregonHealthand
ScienceUniversity,Portland,OR,USA
ix
x CONTRIBUTORS
StaceyEvert,RD,CSO,LD
BoneMarrowTransplant/OncologyDietitian,Foodand
NutritionServices,OregonHealthandScienceUniversity,
Portland,OR,USA
JamesGajewski,MD
CenterforHematologicMalignancies,AdultBloodand
MarrowStemCellTransplantProgram,OregonHealthand
ScienceUniversity,Portland,OR,USA
ChristopherGreenman,MD
DepartmentofMedicine,OregonHealthandScience
University,Portland,OR,USA
AmyGuthrie,MSN,CNS,ACHPN
PalliativeMedicine/ComfortCareTeam,OregonHealthand
ScienceUniversity,Portland,OR,USA
LisaHansen,RN,MS,CNS,AOCN
AutologousStemCellTransplantation,LegacyGood
SamaritanHospital,Portland,OR,USA
BrandonHayes-Lattin,MD
CenterforHematologicMalignancies,AdultBloodand
MarrowStemCellTransplantProgram,OregonHealthand
ScienceUniversity,Portland,OR,USA
CarolJacoby,MSN,ACNP-BC
CenterforHematologicMalignancies,AdultBloodand
MarrowStemCellTransplantProgram,OregonHealthand
ScienceUniversity,Portland,OR,USA
JoseLeis,MD,PhD
AdultBloodandMarrowTransplantProgram,MayoClinic,
Phoenix,AZ,USA
RichardT.Maziarz,MD
CenterforHematologicMalignancies,AdultBloodand
MarrowStemCellTransplantProgram,OregonHealthand
ScienceUniversity,Portland,OR,USA
GabrielleMeyers,MD
CenterforHematologicMalignancies,AdultBloodand
MarrowStemCellTransplantProgram,OregonHealthand
ScienceUniversity,Portland,OR,USA
