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Short Term Complications of Transplant

Infections

After completing chemotherapy and radiation and the transplant has taken place the weeks following, prior to engraftment, are a time when patients are at high risk for several complications including infections and bleeding. 

Infectious complications may be bacterial, viral or fungal. Usually patients receive prophylaxis against most common organisms. However, due to patients overwhelming immuno-compromised state, patients are still at risk for developing infections. Normal bacteria may enter a patients bloodstream a number of different ways. Common sites of infection in transplant patients include: gastrointestinal tract, lungs, mouth and nose, urinary tract, vascular access device or catheter site, and blood. Pneumocystis carnii is a single celled micro-organism, often found in the trachea of healthy persons, may cause pneumonia in transplant patients. It is likely that a medication will be prescribed during and after transplant to avoid this infection. Antibiotics are usually effective at treating bacterial infections, however some bacterial infections may be resistant and are more difficult to treat. 

Often viral infections seen with transplant patients are related to previous exposures of viruses patients have had in the past but may be related to new exposures. Common viruses include; Cytomegalovirus (CMV), Herpes simplex virus (HSV) and Varicella Zoster virus. Due to the patients decreased ability to fight infections, a virus may occur. Viruses may be mild and easy to treat or may be life-threatening and more difficult to treat. There are medications available to treat these common viral infections. Often patients receive prophylaxis for these viruses, especially in the allogeneic setting. 

Candida and Aspergillus are two common fungal infections seen in transplant patients. Most fungi are harmless and may be encountered daily. Candida is a yeast that is normally found in our bodies. Aspergillus is a fungus that is common in the enviroment. Aspergillus infections invade the tissues of the lungs and sinuses and may disseminate to other organs in an invasive infection. A healthy person's normal bacteria, found on our skin, GI tract, and sinuses, keep fungus from proliferating and causing infections. Transplant patients are more susceptible to fungal infections due to the prolonged use of antibiotics and their pronounced immunocompromised state. Fungal infections may be difficult to detect and difficult to treat. There are medications to treat these fungi and patients may receive these medications prophylactically, especially in the allogeneic setting. 

Bleeding

Another potential complication of transplant is bleeding. Ninety-five percent of blood cell production is thought to take place in the bone marrow. When the marrow is destroyed during conditioning, and engraftment has not yet occurred, patients may develop bleeding. Bleeding may be mild and include the gums or maybe severe and involve other organs. A Complete Blood Count (CBC) will be monitored at least daily, until engraftment occurs, and patients transfused with red blood cells and platelets as needed. 

Mouth Sores

Mouth Sores (mucositis) are a common side effect of radiation and chemotherapy. Mouth sores may range from mild to severe and may cause discomfort. Medication can be prescribed to alleviate any pain related to mouth sores. A mouth care regimen is important and may vary according to the facility where the transplant is being performed.

Nausea, Vomiting and Diarrhea

Nausea, Vomiting and Diarrhea may also occur as a result of the conditioning regimen and other medications used during transplant. Medications and intravenous fluids may be used to minimize these symptoms.

Acute Graft-Versus-Host Disease

Graft-versus-host disease (GVHD) is a common complication after allogeneic transplant. Graft refers to the donated bone marrow/stem cells and host is the transplant recipient. GVHD may be acute or chronic and ranges from mild disease to life-threatening disease. The risk for GVHD increases as the disparity between the donors HLA markers and the recipient's HLA markers increases ( how well donor and recipient are matched) . Although patients and donors are matched immunologically prior to transplant there are still mismatches at minor markers that are only avoided if the patient and donor are identical twins.

Acute Graft-versus-host disease typically occurs in the first three months following transplant. T-lymphocytes or T-cells are a type of white cell that play an important role in the immune response by recognizing foreign organisms in the body. The donor's T-cells are harvested along with the other stem cells at collection and are transplanted into the recipient. Acute GVHD occurs when the donor's T-cells recognize the recipient's blood cells as foreign and forge an attack on the recipient's tissue and organs. Acute GVHD can affect the skin, liver and gastrointestinal tract and may include one or all three. There are four stages of Acute GVHD, mild, moderate, severe, and life-threatening, and are graded by the number of organs involved and the severity of each affected. A skin rash is usually the first manifestation of acute GVHD and typically appears on the palms of hands, soles of feet, and/or face. The rash may progress to other areas of the body and appear similar to a sunburn or may progress to blistering of the skin. Watery or bloody diarrhea with cramping is the typical manifestation of GVHD of the gastrointestinal tract. Symptoms of liver GVHD may include jaundice, bleeding problems, and enlargement of the liver. Liver enzymes in the blood will be monitored closely beginning with the first suspicion of liver GVHD. A biopsy of the affected area may be done to assist with diagnosis. Immunosuppressive medications will likely be prescribed prior to transplant to avoid GVHD. 

T-Cell Depletion

T-cell depletion is a technique used in some facilities to decrease the risk of GVHD. The rationale for T-cell depletion is that if T-cells are recognizing the donor's cells as foreign and attacking the donor's tissues by removing the donor's T-cells the incidence of GVHD will be decreased. 

Veno-Occlusive Disease (VOD) 

Veno-Occulsive disease is a potentially life-threatening liver complication that may occur during the first three months post-transplant. Veno-Occlusive disease is caused by the chemotherapy and/or radiation that patients receive during the conditioning regimen prior to transplant. VOD is described as the blood vessels of the liver become swollen and congested, therefore diminishing the liver's ability to remove toxins and waste from the blood. Fluids may build up in the liver causing additional swelling and pain/tenderness of the liver. Other symptoms may include; jaundice, weight gain, ascites (fluid in abdomen), elevated bilirubin, elevated liver enzymes, and confusion. VOD can be difficult to diagnose however, a number of tests may be done to assist in diagnosis. Some of these tests may include; blood levels of bilirubin and liver enzymes, an approximate measurement of the size of the liver by the physician, an ultrasound or CT scan, and liver biopsy. Management of VOD may include a restriction and close monitoring of fluids, the use of diuretics, dialysis, and transfusions with red blood cells.