Claire Keller, R.N., M.N., O.C.N.
Chatchada Karanes, M.D.
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Identifying patients who 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. Autologous transplant recipients should have no active disease in the bone marrow and require adequate collection of hematopoietic cells from the peripheral blood prior to transplant.
For 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.
The patient's overall health, age and disease stage are also extremely important considerations in evaluating adult patients. Patients under consideration for hematopoietic cell transplantation require an extensive evaluation performed by a transplant physician. A comprehensive pre-transplant evaluation should:
- Determine the patient's health and performance status
- Determine the patient's disease status
- Guide the informed consent process
- Identify any psychiatric and/or social behaviors that may exclude the patient
Health and performance status
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 (Table 1).
The chemotherapy and/or radiation 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.
Organ assessment should include the following systems:
The oral 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.
Pulmonary complications are 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.
An EKG and 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.
Liver function tests 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.
Serum creatinine and 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.
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.
The performance 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 (Table 2).
|Eligibility Criteria for Adult Hematopoietic Cell Transplant Patients
|Pulmonary function tests
||DLCO, FVC > 60%
||< 1.5 mg%
||> 60 ml/min
||< 2 mg%
Table 1. Eligibility Criteria for Adult Hematopoietic Cell Transplant Patients
|Karnofsky Performance Score
|Able to carry on normal activity, no evidence of disease
|Able to carry on normal activity, minor signs or symptoms of disease
|Normal activity with effort, some signs and symptoms of disease
|Cares for self, unable to carry on normal activity or to work
|Requires occasional assistance from others but able to care for most needs
|Requires considerable assistance from others and frequent medical care
|Disabled, requires special care and assistance
|Severely disabled, hospitalization indicated, death not imminent
|Very sick, hospitalization indicated, active support treatment necessary
Table 2. Karnofsky Performance Score
The status 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.
The specific disease 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.
Infectious disease history
A complete 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. 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.
Most centers do not consider patients with HIV to be transplant candidates. However, some centers have special autologous protocols to treat patients with HIV and non-Hodgkins lymphoma.
Many patients 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.
A thorough 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. A history of substance abuse is also an indication for psychiatric evaluation and can have a serious negative impact on the transplant procedure.
The patient'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.
The pre-transplant evaluation 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.
Developments in supportive 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.
- Blume KG, Amylon MD. The evaluation and counseling of candidates for hematopoietic cell transplantation. In: Blume KG, Forman SJ, Appelbaum FR, eds. Thomas' Hematopoietic Cell Transplantation. 3rd ed. Malden, Mass: Blackwell; 2004:449-467.
- Oblon DJ. Evaluation of patients before hematopoietic stem cell transplantation. In: Ball ED, Lister J, Law P, eds. Hematopoietic Stem Cell Therapy. New York: Churchill Livingstone, 2001:225-232.