BMT and transplant service
Transplant has its own language and its own calendar. Learn the vocabulary on day one and present every patient by their transplant day.
The vocabulary
- Autologous: the patient’s own stem cells, collected and frozen, then returned after high-dose chemotherapy. Common in myeloma and relapsed lymphoma.
- Allogeneic: stem cells from a donor. The new immune system fights the disease (graft versus tumor) but can also attack the patient (graft versus host disease).
- Donor types: matched related (sibling), matched unrelated, haploidentical (half matched, often a parent or child) and cord blood.
- Conditioning: the chemotherapy, with or without total body irradiation, given before cells. Myeloablative or reduced intensity.
- Day 0: the day of cell infusion. Days before are minus, days after are plus.
- Engraftment: neutrophil engraftment is commonly defined as an ANC of at least 500 on three consecutive days.
How to present a transplant patient
“Day +12 from a matched unrelated donor allogeneic transplant with reduced-intensity conditioning for AML in first remission. GVHD prophylaxis with tacrolimus and methotrexate. Not yet engrafted, ANC 100 and rising. Grade 2 mucositis on a PCA. Afebrile on levofloxacin, acyclovir and fluconazole prophylaxis.”
Your daily checklist
- Counts: trend toward engraftment, transfusions in the last 24 hours.
- Immunosuppressant levels: tacrolimus or cyclosporine level, plus creatinine, potassium and magnesium.
- Fluids: daily weight and ins and outs. Sudden weight gain matters.
- Liver: bilirubin. Rising bilirubin with weight gain and right upper quadrant pain suggests sinusoidal obstruction syndrome (veno-occlusive disease).
- Gut: stool volume, not just number of stools. Large-volume diarrhea after engraftment may be GVHD.
- Skin: look at the palms, soles and ears every day for a GVHD rash.
- Infection: fever curve, viral monitoring (such as CMV PCR) per protocol, prophylaxis doses adjusted for kidney function.
- Mucositis and nutrition: pain control, oral intake, need for nutrition support.
Infections by phase
| Phase | Main risks |
|---|---|
| Before engraftment (first weeks) | Bacteria from gut and lines, candida, early mold, HSV reactivation |
| After engraftment (to about day +100) | CMV, molds such as aspergillus, PJP, other viruses; risk rises with GVHD and steroids |
| Late (after day +100) | Encapsulated bacteria, VZV, ongoing risk in patients with chronic GVHD |
Complications to recognize early
- Acute GVHD: skin rash, diarrhea and rising bilirubin. Staged by organ; steroids are first-line treatment.
- Engraftment syndrome: fever, rash and fluid leak around the time of count recovery.
- Sinusoidal obstruction syndrome: weight gain, hepatomegaly, jaundice, usually early.
- Neutropenic fever: treat it like any neutropenic fever, urgently.
- Graft failure: counts that never recover, or recover then fall.
Transfusion basics
- Transplant patients typically receive irradiated, leukoreduced products. Know your institution’s rules.
- Donor and recipient blood types may differ, which changes which products the patient can receive. The blood bank will guide you; just know to ask.
CAR T-cell therapy
- Cytokine release syndrome (CRS): fever, hypotension and hypoxia in the days after infusion. Graded; treated with tocilizumab and, for higher grades, steroids.
- ICANS (neurotoxicity): confusion, word-finding trouble, handwriting changes, seizures. Assessed with the ICE score several times a day; treated with steroids.
- Know where the patient is in the monitoring window and the grading scale your center uses.
See our transplant trial summaries for the evidence behind these practices.