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The MTU has a Clinical Nurse Coordinator who will be following all patients (allogeneic transplant patients more extensively) throughout your transplant process and even when you return to your referring VA. All patients will return to Seattle at the one-year anniversary of their transplant for a complete evaluation and therapeutic plan.
Prior to departing Seattle, you and your caregiver will meet with the Clinical Nurse Coordinator wherein she will review what to expect during your transition home, provide guidelines for the first year post-transplant, and contact your oncology team in order to make your transition back home go smoothly. She will also be available to your home VA providers as a liaison for answering any questions you or your follow-up team have.
Long Term Follow-up Guidelines (Allogeneic Transplant)
1. Clinical evaluation should be performed weekly for the first month, every two weeks for the next two months, and then monthly for the remainder of the year. After that visits should be scheduled at least yearly for a complete physical with chest x-ray and labs. Clinic visits should include a thorough physical assessment, with particular attention to signs of infection. Patients should also have a Complete Blood Count with differential, liver function tests creatinine and other tests as indicated. They should have chest X-rays at routine intervals and additional studies as clinically relevant.
Particular attention should be paid to monitoring for development of chronic graft-versus-host disease (GVHD). Symptoms include skin thickening, hyperpigmentation or other types of rash, nail changes, poor appetite, dry eyes, dry mouth, difficulty swallowing, and weight loss. If manifestations of chronic GVHD develop or worsen, please contact us.
2. There should be careful attention paid to renal function while taking cyclosporine or tacrolimus. If the creatinine rises to greater than 2.0, the dose should be reduced by 50% and hydration administered. When renal function returns to baseline, previous dosing may be resumed. If the creatinine continues to rise despite reducing the dose, it should be held until renal function has improved. In addition, cyclosporine and tacrolimus cause magnesium wasting, so the serum magnesium should be checked regularly with oral or IV magnesium given as necessary.
3. In the absence of toxicity, immunosuppression should continue at present doses. Additional tapers should only be made after consultation with the VA Puget Sound Marrow Transplant program.
4. All patients should take Bactrim DS bid twice weekly for Pneumocystis Carinii Pneumonia (PCP) for at least six months after transplant or until all immunosuppressive medications have been discontinued. During this time, they are still prone to sepsis and should they develop fever we suggest broad- spectrum antibiotics be instituted as quickly as possible and appropriate diagnostic workup pursued. Patients allergic to Bactrim, for whom desensitization was not successful, receive Dapsone 50 mg bid daily for at least six months after all immunosuppressive medications have been discontinued.
5. All herpes zoster infections developing in the next year should be treated with high-dose parenteral acyclovir until the lesions have crusted and then oral therapy for a total of 14 days. Oral therapy is frequently not adequate initial treatment for preventing dissemination.
6. All blood products should be irradiated (minimum 2500 cGy) prior to infusion.
7. Cytomegalovirus (CMV) negative patients whose donor was also CMV negative should receive CMV negative blood products. Any evidence of unexplained fevers, cytopenias, enteritis or pneumonitis is an indication for immediate CMV cultures and prompt consideration of therapy. We would appreciate being contacted promptly with any indication of CMV disease or increased CMV assay results. Patients at risk for CMV infections should be monitored at regular intervals using a DNA by PCR assay or antigenemia testing. Patients in this category include those who are CMV seropositive and being treated for chronic GVHD with systemic steroids.
8. Contact with live-virus vaccine or children recently vaccinated with live-virus vaccines should be avoided. The most common one being oral polio vaccine.
9. At approximately 9 months post transplant, patients with CML should have a peripheral blood specimen sent for PCR detection of the bcr-abl translocation as evidence of minimal residual disease. Please contact us when you are ready to send the sample, and we will make arrangements at that time.
10. Patients should not return to work or other environments that put them at risk for exposure to transmissible infections for at least one year.
11. Beginning one year after transplant, patients should be re-vaccinated. Because of their immunosuppression, vaccinations are unlikely to be effective before then. Generally, this should wait until after the one year post-transplant evaluation in Seattle. Please contact us for recommended guidelines when you are ready to start.
Long Term Follow-up Guidelines (Autologous Transplant)
1. Clinical evaluation should be performed weekly for the first month, every 2 weeks for the next 2 months and then monthly for the remainder of the first year. After that visits should be scheduled as clinically indicated. Clinic visits should include a thorough physical assessment, with particular attention to signs of infection. Vital signs and weight should be monitored at each clinic visit. Patients should also have a CBC with differential, liver function tests (alkaline phosphatase, SGOT, SGPT, total bilirubin, and LDH), creatinine and other tests as indicated. They should have chest X-rays at routine intervals and additional studies as clinically relevant.
2. All patients should take Bactrim DS bid twice weekly for Pneumocystis Carinii Pneumonia (PCP) for at least six months after transplant. During this time, they are still prone to sepsis and should they develop fever we suggest broad- spectrum antibiotics be instituted as quickly as possible and appropriate diagnostic workup pursued.
3. All VZV seropositive patients and those with a history of VZV infection post transplant should receive prophylaxis with acyclovir throughout the first year after transplant. All patients exposed to chickenpox or zoster during the first year after the transplant or during treatment with immunosuppressive medications should be evaluated. It is difficult to prevent VZV transmission to susceptible patients because infected individuals are contagious for 24-48 hours before the rash appears, and the incubation period of VZV is 10-21 days. Herpes zoster infections developing in the first year should be treated with valacyclovir until the lesions have crusted and for at least 14 days total to prevent dissemination. Individuals with VZV (chickenpox or shingles) remain contagious until all skin lesions have crusted.
4. All blood products should be irradiated (minimum 2500 cGy) prior to infusion. CMV negative patients should also receive CMV negative blood products. Any evidence of unexplained fevers, cytopenias, enteritis or pneumonitis is an indication for immediate CMV testing and prompt consideration of therapy. Testing should be performed by either CMV DNA by PCR or serum antigenemia (culture based assays are not appropriate for monitoring).We would appreciate being contacted promptly with any indication of positive test results or CMV disease.
5. Contact with live-virus vaccine or children recently vaccinated with live-virus vaccines should be avoided. The most common one being oral polio vaccine.
6. Patients should not return to work or other environments that put them at risk for exposure to transmissible infections for at least one year.
7. Beginning one year after transplant, patients should be re-vaccinated. Because of their immunosuppression, vaccinations are unlikely to be effective before then. Please contact us for recommended guidelines when you are ready to start.
If we can be of assistance in helping you with any aspect of post-transplant care, please do not hesitate to call. During regular weekdays, non-emergent calls should be directed to the Clinical Nurse Coordinator, Lisa Fox, R.N., at (206) 764-2139. As always, a physician can be reached 24 hours a day at (206) 764-2199.
Lisa Fox, Clinical Nurse Coordinator
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