🧬 Chapter 115: Post-Haematopoietic Stem Cell Transplant (HSCT) Care

Autologous vs allogeneic · HLA matching · Conditioning regimen (myeloablative vs RIC) · GVHD (acute skin, liver, gut; chronic) · Engraftment syndrome · VOD (veno-occlusive disease) · CMV, EBV (PTLD), Aspergillus · Immunosuppression (tacrolimus, cyclosporine, MTX) · Defibrotide

🔍 Core Concepts: Post-HSCT Care

📌 Types of HSCT
Autologous: own stem cells. Allogeneic: from donor (related/unrelated/cord). Syngeneic: identical twin. Allogeneic risk: GVHD, graft rejection.
⚠️ Acute GVHD (day 20-100)
Skin (maculopapular rash), liver (bilirubin ↑), gut (diarrhoea, cramping). Grade I-IV. Treatment: steroids, tacrolimus, ATG. Prophylaxis: tacrolimus + MTX or cyclosporine + MMF.
🫁 Chronic GVHD (>100 days)
Scleroderma-like, oral sicca, bronchiolitis obliterans. Steroids, photophoresis, rituximab.
🧪 VOD (Veno-occlusive disease)
Triad: hyperbilirubinaemia, hepatomegaly + RUQ pain, weight gain (>2%). Modified Seattle criteria. Treatment: defibrotide (fibrinolytic), supportive care.
🦠 Infections (timeline)
Pre-engraftment: bacteria, Candida, HSV, RSV. Post-engraftment: CMV (ganciclovir), EBV (PTLD → rituximab), Aspergillus (voriconazole), PJP (TMP-SMX).
💊 Engraftment Syndrome
Fever, rash, non-cardiogenic pulmonary oedema at neutrophil recovery. Steroid-responsive. Differentiate from GVHD.

🩺 Stepwise Approach: Post-HSCT Complications

1
Fever in neutropenic post-HSCT patient
Treat as febrile neutropenia: broad-spectrum antibiotics (cefepime/meropenem). Add vancomycin if catheter-related or severe mucositis. Consider antifungal if prolonged fever.
2
Suspected acute GVHD (rash, diarrhoea, jaundice)
Skin biopsy, liver biopsy, endoscopy. Grade I: topical steroids; Grade II-IV: systemic steroids (methylprednisolone 2 mg/kg/day). Steroid-refractory: ATG, ruxolitinib, extracorporeal photophoresis.
3
VOD (sinusoidal obstruction syndrome)
Clinical diagnosis (modified Seattle criteria: bilirubin >2, hepatomegaly + pain, weight gain >2%). Supportive care (fluid restriction, diuretics). Defibrotide (25 mg/kg/day) is treatment of choice.
4
Cytomegalovirus (CMV) reactivation
Monitor CMV PCR twice weekly. Preemptive therapy: ganciclovir (or valganciclovir) if rising PCR. CMV pneumonitis: ganciclovir + CMV immunoglobulin.
5
EBV reactivation / PTLD
Monitor EBV PCR. Reduce immunosuppression. Rituximab (anti-CD20) for EBV-driven PTLD. Chemotherapy for refractory disease.
6
Invasive aspergillosis
Voriconazole first-line. Liposomal amphotericin B if refractory. Surgical resection for localised disease.