H e m a t o lo g y E d u c a t io n - European Hematology Association

G. Socié 1
A. Tichelli 2
1 Hematology/Transplantation,
Hospital Saint Louis, Paris;
2 Hematology, University Hospital,
Basel, Switzerland
Hematology Education:
the education program for the
annual congress of the European
Hematology Association
2011;5:342-348
Supportive care of transplants
Late complications after hematopoietic stem cell
transplant in adult patients
Introduction
Allogeneic hematopoietic stem cell transplantation
(HSCT) is the treatment of choice
for defined malignant and non-malignant
hematological disorders. 1 Overall survival has
improved substantially, and the number of
long term survivors is continuously increasing.
2 Thus, the general health status and quality
of life in the long-term has become a
major issue in the 21st century. Still, HSCT
remains associated with late treatment-related
morbidity and mortality. Compared to
general population, late mortality is increased
after HSCT. 3,4 Complications can appear
within the first year, and other events will
become apparent only years or even decades
after HSCT. Late complications can be separated
into delayed events, late events, and
very late events. 5 Most of current literature is
orientated toward late effect after allogeneic
HSCT and very few involved patients after
autologous HSCT only. Only main complications
will be summarized here and limited to
adulthood; readers can find extended reviews
elsewhere. 6 Main key issues in late effects
after HSCT are summarized (Table 1).
Non-malignant late effects
Non-malignant late effects are heterogeneous
in their presentation and clinical manifestation.
Any organ can be the target, and
frequently multiple causes are involved. 7
Chronic Graft-versus-Host disease
Chronic GVHD is the most common and
clinically significant problem affecting longterm
survivors. Up to 60% of patients receiving
HLA-identical sibling grafts and 70% of
A B S T R A C T
More than 40,000 HSCT are performed yearly worldwide. Therefore, the number of long-term survivors,
free of the disease is continuously increasing. Despite improved prognosis, long-term outcome
may be impaired by transplant associated morbidity and mortality. Long-term survivors can present a
variety of malignant and non-malignant complications, impairing physical and psychological performance,
normal integration in family and social life, and quality of life. Conditioning regimen and chronic
graft-versus-host disease are key risk factors in the development of late effects. With increasing follow-up
new types of late effects have emerged. Awareness on long-term effects after HSCT is crucial
to provide adapted pre-transplant counseling, and recommendations for post-transplant screening,
prevention and early treatment.
those receiving alternative donor develop
chronic GVHD. Chronic GVHD is the leading
cause of non-relapse mortality more than
2 years after allogeneic transplantation. 8
Chronic GVHD is associated with decreased
quality of life, impaired functional status, and
ongoing need for immunosuppressive medications.
7 The incidence of chronic GVHD is
increasing because of increasing use of alternative
donors, older recipient age, and use of
peripheral blood cells as the graft source.
Even if reduced intensity conditioning seems
to decrease the incidence and severity of
acute GVHD, there is little evidence that
chronic GVHD is reduced in this setting. 2,9
Many excellent reviews have been published
recently on chronic GVHD and its
clinical consequences. 10–13 This review focuses
on late effects, which arise predominantly
as a result of chronic GVHD and its treatment.
14 Often it is not possible to determine
whether chronic GVHD itself or its treatment
is responsible for complication.
Chronic GVHD causes profound immune
dysfunction, 13 and most chronic GVHD
deaths are attributable to infection. Defects
in mucosal integrity, immunosuppressive
medications, and reduced number and function
of mature T and B cells contribute to the
high fatality rate from bacterial, fungal, and
viral pathogens. Functional asplenia with an
increased susceptibility to encapsulated bacteria,
particularly pneumococcal infection, is
common. According to the European guidelines,
vaccination against Streptococcus
pneumonia and Haemophilus Influenza are
strongly recommended and vaccination
against Varicella Zoster can increase survival.
15 Patients are also at high risk for
Pneumocystis carinii pneumonia.
Although classical, these late infections
have been poorly reported in the literature.
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