Chronic effects may loosely be termed those that occur after day +100. Recipients are at risk of complications related to:
- organ damage from the conditioning regimen
- chronic GVHD
- immune dysfunction and effects of immunosuppressive therapy.
Quality of life
While many HSCT recipients have a good quality of life at one year and have resumed part or full time employment, a significant proportion of survivors experience persistent anxiety and depressive symptoms, fatigue, sexual dysfunction, and fertility concerns.42
Chronic graft-versus-host disease
Chronic GVHD (cGVHD) is a syndrome of immune dysfunction that results in immunodeficiency and autoimmunity. cGVHD has been reported in at least 30-50% of recipients of transplants from HLA-matched siblings, and at least 60-70% of recipients from unrelated donors.43
Any organ may be involved and many symptoms resemble those of spontaneously occurring autoimmune disorders. The skin, liver, and mouth are the most frequent targets. Opportunistic infections are common, including invasive fungal infections and Pneumocystis jiroveci pneumonia. Decreased quality of life and depression have also been associated with cGVHD.43
Transplant recipients, especially allogeneic recipients with cGVHD, have an increased risk of infection for up to five years after transplantation. Contributing factors include persistent hypogammaglobinaemia, impaired cellular immunity, and splenic hypofunction.30
Recurrent sinopulmonary infections (sinusitis, pneumonia, bronchitis) are common in the first two years.
Reactivation of latent varicella zoster virus occurs in almost 50% of survivors.
Reactivation of cytomegalovirus (CMV) is most common in allogeneic recipients who are taking corticosteroids for GVHD.
Antibody titres to vaccine-preventable diseases decline during the first four years after transplantation, requiring revaccination.30
Causes of death
In recipients of allogeneic transplants carried out in Australia and New Zealand between 1998 and 2011, the most common primary causes of death in the first year included:2
- relapse / recurrence / persistent disease – 34.1%
- infection - 19.1%
- graft-versus-host disease - 15.7%
- multiple organ failure – 5.3%.
- interstitial pneumonitis – 3.7%.
In recipients of autologous transplants, the primary causes of death in the first year included:2
- relapse / progression / persistent disease – 72.6%
- infection – 9.3%.
The majority of deaths in the second year post allogeneic transplantation in Australia and New Zealand between 1998 and 2007 were caused by:2
- relapse / recurrence / persistent disease– 59.7%
- infection - 16.5%
- graft-versus-host disease – 8.4%.
The majority of deaths in the second year after autologous transplantation were caused by:2
- relapse / progression / persistent disease – 78.3%
- infection – 4.3%
- new malignancy – 1.9%.
Access a current text and/or literature and watch the Coping with chronic graft-versus-host disease presentation44, and:
- Distinguish between acute and chronic graft-versus-host disease
- Describe the pathology of chronic graft-versus-host disease
- Identify the clinical manifestations of chronic graft-versus-host disease
- Outline the treatment options for chronic graft-versus-host disease
- Review common psychosocial experiences for the individual with graft-versus-host disease
- Discuss the role of the SCN in the functional and psychosocial support of the individual with graft-versus-host disease.
Identify the pharmacological approaches used prophylactically in the management of infection risk in transplant recipients post discharge and explain the rationale for the use of the drug / strategy.
Discuss the implications of a diagnosis of herpes zoster (shingles) in a transplant recipient, considering:
- Infection control
- Symptom management
- Occupational health and safety.
- Discuss the role of vaccination in recipients after allogeneic and autologous HSCT
- Outline the suggested schedule of vaccinations.