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.

1. Pre- stem cell transplant
Evaluation
Hedayati Asl A.
Ped. Hemato. & Oncologist/BMT
Shariati Hospital, Tehran-Iran

2. Initial visit
During this visit, will meet
with one of the BMT
physicians, the financial
coordinator and
transplant coordinator.
Also meet some of the
BMT nurses.

3. Initial visit
• The physician will take a history of disease.
• All records from primary physician will also be
reviewed.
• Some of the same questions that were asked
before will be asked again in order to ensure
that evaluation will be completely accurate.

4. The areas that will require special attention
include:
General state of health
Past blood transfusions
Exposure to radiation
Past and present infections
Episodes of bleeding

5. • 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.

6. • 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.
• 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.

9. Planning for Date of Transplant
• The list of patients eligible for transplant is
reviewed thoroughly at the weekly BMT meeting.
Patients are prioritized according to diagnosis and
risk of relapse. The date of admission for
transplant, and the initiation of the preparative
regimen are determined by the coordinating
team, as the schedules for bone marrow or
peripheral blood stem cell harvest.
•

11. Planning for Date of Transplant
• PBHSC transplantation implies that the
coordinating team will make sure that the
donor has a satisfactory venous access for
harvest procedures.
• The donor must be evaluated by the apheresis
team and decisions for the need of a catheter
for apheresis must be taken well in advance.
Teaching about mobilization procedures is the
responsibility of the coordinating team.

12. the case manager and the BMT coordinating
team are responsible for the following:
• 1. Initiate the recipient pre-transplant workup as per protocol
• 2. Initiate the donor workup as per protocol
• 3. Initiate intensive teaching about:
• • the nature of the patient’s disease and the reason for
transplantation.
• • the effects of chemotherapy, including sterility
• • the nature and mechanics of the transplantation itself
• • the major complications of transplantation
• • the importance of reverse isolation
• • the importance of following recommended treatment and
guidelines (urine collection, compliance to hygiene etc)
• • the post-transplant follow-up (patients who live far from hospital
have to stay until Day +120, weekly visits at the BMT clinic, the
issue of the mask, compliance to medication, hydration, etc.).

13. • The patient's overall health, age and disease
stage are also extremely important
considerations in evaluating patients.
• Patients under consideration for HSCT require
an extensive evaluation performed by a
transplant physician. A comprehensive pre-
transplant evaluation should: Determine the
patient's health and performance status

14. •Determine the patient's disease status
•Guide the informed consent process
•Identify any psychiatric and/or social
behaviors that may exclude the patient

16. 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
Organ assessment should include the following
systems:

18. Oral cavity
• 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.

19. Dental evaluation:
Panorex
Assessment by dentist

20. Lungs
• 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.

21. Pulmonary assessment:
CXR- PA, Lat
PFT's

22. Heart
• 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.

23. Cardiac assessment:
EKG
MUGA or ECHO

24. Liver
• 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.

25. Kidneys
• 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.

26. 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.

27. Performance status
• 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.

28. Eligibility Criteria for
Hematopoietic Cell Transplant
Patients
• Pulmonary function tests DLCO, FVC > 60%
• Serum Creatinine < 1.5 mg%
• Creatinine Clearance > 60 ml/min
• SGOT 1-2x normal SGPT 1-2x normal
• Serum Bilirubin < 2 mg%
• Ejection Fraction > 50%
• Karnofsky Score 70-100%

29. Disease status
• 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.

30. • 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.

31. 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.

32. Infectious disease history
• 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.

33. Previous chemotherapy/radiation
• 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.

34. 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.

35. Psychosocial evaluation
• 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.

36. Transfusion history
• 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.

37. Conclusion
• 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.
•

38. • 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.

39. Recipient Pre-Transplant Work-up
1. Complete Blood Count, differential
2. Coagulation Profile
3. Comprehensive hepatic and renal profiles, Mg, LDH
4. Urinalysis
5. HAV, HBsAg, HBcAb, HBsAb, HCV, HIV1/HTLV1, HSV, HZV, CMV, EBV, Brucellosis, PPD, Toxoplasma
6. Complete RBC phenotype
7. If ABO incompatible, do ABO ISO
8. HLA typing
9. EPBM + CBCD (Please request BMT Leukocyte Markers)
10. Bone marrow aspirate, biopsy, cytogenetics, and other bone marrow aspirate studies as necessary
11. CXR
12. ECG
13. Pulmonary function tests
14. Echocardiogram
15. Sample for STR chimerism
16. Dental consult

40. • For Hodgkin’s disease of NHL
• 1. CT scan of the chest
• 2. CT of the abdomen and pelvis

41. Lab evaluation
a) Hematology:
CBC with differential
PT/INR/PTT
ABO group and Rh type
antibody screen

42. b) Chemistry:
Sodium, Potassium, Chloride, Bicarbonate
Glucose
Calcium, Albumin
Magnesium
Phosphate
BUN, Creatinine
Total Bilirubin (direct and indirect if total
bilirubin is elevated)
Alkaline Phosphatase
AST, ALT
Total Protein
LDH, Uric Acid

43. c) Serology: (must be documented within 30
days prior to first day of stem cell collection)
• Cytomegalovirus serology (*Anti-CMV IgG)
• Herpes simplex virus serology (HSV I & II)
• Varicella zoster virus (VZV) serology
• HIV serology (*Anti-HIV-1, *Anti-HIV-2)
• *HIV-1 Antigen
• *Anti-HTLV 1 and 2
• Serologic test for syphylis:
• *RPR
• Hepatitis A:
• Anti-HAV IgM and IgG
• Hepatitis B:
• *HbsAg - surface antigen
• *Anti-HBc
• Anti-HBs - surface antibody
• Hepatitis C:
• *Anti-HCV
• (* FACT specified)

44. Renal evaluation:
Urine analysis
24 hour urine for creatinine
clearance

45. HLA-typing (A, B, DR)

46. Staging studies (as
appropriate for specific disease):
Bone scan
CT scans: head, neck, chest, abdomen, pelvis
Bone marrow studies:
Morphology
Immunophenotype
Cytogenetics
DNA Studies (PCR)
FISH
Gallium Scan
MRI
Tumor markers
Skeletal survey
SPEP, SPIEP, Ig’s, Beta-2 microglobulin

47. Inpatient Nurses
Each transplant physician closely
coordinates care with a clinical nurse to
ensure optimum care throughout the
transplant process. Clinical nurses not
only provide expert care for the many
complex issues transplant patients often
experience, but also serve as a reliable
and knowledgeable source of
information for patients and their
families.
Our highly skilled inpatient clinical
nurses provide expert care and serve as
sources of education and information for
patients and their families. They
participate in daily rounds at the
bedside, and provide timely, accurate
and comprehensive clinical information
to the entire medical team.

48. Research Nurses
Clinical Study Coordinators
Each of our clinical trials has an assigned
research nurse or clinical study
coordinator to assist the physician.
They explain the proposed treatment, potential
side effects and required follow-up, and help the
physician with the consent
process and with conducting the study to ensure
that protocol requirements

52. Dietitians
A clinical dietitian determines
nutritional needs and develops
a nutrition care plan
during a patient’s treatment
and recovery. A dietitian and
diet specialist meet patients
several times during their
hospital stay to learn of any
eating problems and to suggest
alternatives when necessary.

53. I. Infections in first 30 days post-
transplantation
A. Bacteremia
Gram-positive
organisms:
Staphylococcus
epidermidis
Gram-negative
aerobes and
anaerobes
B. Invasive fungal
infections: Aspergillus,
Candida
C. Reactivation of
herpes simplex I

54. II. Infections 30–120 days
post-transplantation
A. Protozoal infections
Pneumocystis carinii
Toxoplasma
B. Viral infections
Cytomegalovirus (CMV)
Adenovirus
Epstein–Barr virus (EBV)
Human herpesvirus 6 (HHV-6)
C. Fungal infections
Candida (C. albicans and C. tropicalis)
Aspergillus
Trichosporon
Fusarium
Candida krusei

55. III. Infections after 120 days
post-transplantation
• A. Sinopulmonary infections with
encapsulated organisms
• B. Viral infections
• Cutaneous herpes zoster

56. • Transplant donors must
be in generally good
health without other
comorbid conditions. The
donor must have a
performance status that
will permit the safe
collection of the cells,
either by bone marrow
(BM) or peripheral blood
progenitor cell (PBPC)
collection.

57. • Thus, the donor must be able to tolerate
anesthesia (either general or regional) and
have adequate cardiac, pulmonary, hepatic
and renal function. Pediatric donors are only
utilized for autologous collection or donation
to siblings. Donors with ongoing malignancies
or a history of a malignant condition other
than minor skin cancers (eg, basal cell
carcinomas) are generally excluded from
further consideration.

58. • Viral serologic studies are performed on all donors,
who must be negative for both anti-HIV antibodies and
HIV RNA.
• Serologic tests for hepatitis B and C are also required at
most transplant centers. Donors with active viral
hepatitis are usually excluded although exceptions are
occasionally made with sibling donors, depending upon
the clinical urgency. In certain circumstances, antiviral
therapy may be considered if time permits for an
adequate course . Additional testing, such as for sickle
cell disease, exposure to syphilis, West Nile virus, and
other potential pathogens are required by some States
and Regions.