Background
- Evaluation of a possible BMT complication is most aided by knowledge of the time since transplant, type of transplant, and previous complications.
- The periods, as broken down more precisely below, may be divided into pre-engraftment, early engraftment, and stable engraftment.
- However, failure to engraft may prolong the first phase, and any graft-vs-host disease may prolong the second, particularly if intensification of immunosuppression is required.
|
Days post-BMT |
Complication |
|---|---|
|
-7 to 21 |
Toxicity of preparative regimens (nausea, vomiting, diarrhea, alopecia, mucositis, renal failure, skin breakdown, ARDS, cardiomyopathy) |
|
0 to 21 |
HSV reactivation, hepatic veno-occlusive disease |
|
0 to 28 |
Diffuse alveolar hemorrhage, particularly at engraftment |
|
0 to 49 |
Bacterial and fungal infections |
|
28 to 70 |
CMV infection |
|
14 to 100 |
Acute GVHD |
|
49 to 100 |
Interstitial pneumonitis |
|
100 to 180 |
Chronic GVHD, VZV, PCP |
Acute Graft vs. Host Disease
|
Stage |
Skin |
Liver (total bilirubin) |
GI |
|---|---|---|---|
|
1+ |
maculopapular rash on <25% of BSA |
2-3 mg/dl |
diarrhea 500 – 1000 cc/day |
|
2+ |
maculopapular rash on 25-50% of BSA |
3-6 mg/dl |
diarrhea 1000 – 1500 cc/day |
|
3+ |
generalized erythroderma |
6-15 mg/dl |
diarrhea >1500 cc/day |
|
4+ |
generalized erythroderma and desquamation |
>15 mg/dl |
severe abdominal pain ± ileus |
Use staging information above to determine clinical grade on chart below:
|
Clinical grade |
Skin |
Liver |
GI |
Decrease in clinical performance |
|---|---|---|---|---|
|
I |
1+ to 2+ |
0 |
0 |
None |
|
II |
1+ to 3+ |
1+ |
1+ |
Mild |
|
III |
1+ to 3+ |
2+ to 3+ |
2+ to 3+ |
Marked |
|
IV |
2+ to 4+ |
2+ to 4+ |
2+ to 4+ |
Extreme |
Copelan EA. Medical progress: Bone marrow transplantation. N Engl J Med 2006;354:1813-1826.
Wingard JR, Hsu J, Hiemenz JW. Hematopoietic stem cell transplantation: an overview of infection risks and epidemiology. Infect Dis Clin North Am. 2010 24(2):257-72.