Loading
There are now around half a million people alive worldwide who have had a blood or marrow transplant. Most of them have at least one lasting health problem from it, and many have several. The list is long and reads heavily, but almost every item on it is either preventable or detectable early, which is the reason to know what is on it rather than to avoid knowing.
A review of late effects after blood and marrow transplantation opens with the scale: advances in transplantation have reduced early transplant-related mortality and widened who can be transplanted, so management of late effects matters for a growing number of long-term survivors estimated at half a million worldwide. It names the territory: diseases of the cardiovascular, pulmonary and endocrine systems, dysfunction of the thyroid gland, gonads, liver and kidneys, infertility, iron overload, bone diseases, infection, solid cancer and neuropsychological effects. The leading causes of late mortality it lists are recurrent malignancy, lung disease, infection, secondary cancers and chronic graft-versus-host disease.
The structure underneath that list is worth stating plainly, because it determines what can be done. Late effects after transplant have four sources, and most problems have more than one.
The disease and the treatment before transplant. Anthracyclines given years earlier, radiotherapy fields, and the cumulative alkylating agent dose all arrive at the transplant already spent. A cardiovascular risk model built in 1,828 transplant recipients and validated in a second cohort of 580 used age, anthracycline dose, chest radiation, hypertension, diabetes and smoking, and reached an area under the curve of 0.74 for cardiovascular disease: three of its six variables are pre-transplant exposures.
The conditioning. Total body irradiation accounts for a disproportionate share of what follows: cataract, second solid cancers in those irradiated young, thyroid and gonadal failure, renal impairment, and the body composition changes behind later metabolic disease. Chemotherapy-only conditioning avoids some of these and brings others.
Chronic GvHD and its treatment. Chronic GvHD is itself a late effect, and the years of corticosteroids and other immunosuppression it requires produce bone loss, avascular necrosis, cataract, diabetes, muscle loss and infection. Chronic GvHD was an independent risk factor for solid cancers in the largest registry study, and active chronic GvHD carried a hazard ratio of 4.0 (95 per cent CI 1.1 to 14.7) for cardiovascular death in a 1,379-patient cohort.
A lastingly altered immune system. Covered in its own records below: altered reconstitution, lost vaccine memory, and the infection risk that follows.
The international societies published updated screening and preventive practice recommendations for long-term survivors covering both autologous and allogeneic transplant and both adults and children. The point of that document is that nearly every item on the list above has a scheduled test, a modifiable risk factor or both, so the right response to a long list is a schedule rather than alarm. The records that follow take the items one at a time: the survival curves, second cancers, iron overload, bone, eyes, kidneys and lungs, and the endocrine and cardiometabolic cluster.
A transplant compresses several distinct injuries into a few weeks: cytotoxic conditioning, total body irradiation in many regimens, a period of profound immune deficiency, and in allogeneic recipients a permanent alloimmune relationship with a new immune system. Each injures stem and progenitor pools, endothelium, endocrine glands and epithelium. Late effects are the slow expression of that damage, which is why they emerge over years and why risk does not plateau.
Query for this technology: (TITLE:"Late effects after a stem cell transplant" OR ABSTRACT:"Late effects after a stem cell transplant" OR TITLE:"transplant late effects" OR ABSTRACT:"transplant late effects" OR TITLE:"post-transplant survivorship" OR ABSTRACT:"post-transplant survivorship" OR TITLE:"long-term complications of HSCT" OR ABSTRACT:"long-term complications of HSCT") AND (cancer OR tumor OR tumour OR oncology OR carcinoma OR lymphoma OR leukemia OR leukaemia OR myeloma OR sarcoma OR melanoma OR glioma). Results are unfiltered search hits about Late effects after a stem cell transplant, not a curated reading list.
Shares Total body and total marrow irradiation, Bone, eyes, kidneys and lungs after transplant, Who is supposed to be watching: EBMT, CIBMTR, FACT-JACIE, and what a survivor is actually offered, Chronic graft-versus-host disease and the tags rejuvenation, survivorship, transplant.
Shares Bone, eyes, kidneys and lungs after transplant, Second cancers after allogeneic transplant, Chronic graft-versus-host disease, After a transplant or cell therapy: what to ask for and the tags rejuvenation, survivorship, transplant.
Shares Quality of life, Survivorship care and late-effects surveillance, Late effects and survivorship toxicity, Survivorship and late effects are neglected and the tags rejuvenation, survivorship, late-effects.
Shares Who is supposed to be watching: EBMT, CIBMTR, FACT-JACIE, and what a survivor is actually offered, After a transplant or cell therapy: what to ask for, Secondary malignancy (therapy-related cancer), Late effects and survivorship toxicity and the tags rejuvenation, survivorship, transplant.
Shares Late effects and survivorship toxicity, Survivorship and late effects are neglected, Toxicity and quality of life are undervalued and the tags rejuvenation, survivorship, late-effects.
Shares Second cancers after allogeneic transplant, After a transplant or cell therapy: what to ask for, Secondary malignancy (therapy-related cancer), Late effects and survivorship toxicity and the tags rejuvenation, survivorship, transplant.
Shares Conditioning regimen (myeloablative, reduced-intensity), Chronic graft-versus-host disease, After a transplant or cell therapy: what to ask for, Allogeneic stem cell transplantation and the tags rejuvenation, survivorship, transplant.
Shares Quality of life after transplant and cell therapy, After a transplant or cell therapy: what to ask for, Quality of life, Late effects and survivorship toxicity and the tags rejuvenation, survivorship, transplant.