General Information About Hematopoietic Cell Transplantation (HCT)

Rationale for HCT

Blood and marrow transplantation, or HCT, is a procedure that involves infusion of hematopoietic stem cells (hematopoietic progenitor cells) to reconstitute the hematopoietic system of a patient. The infusion of hematopoietic stem cells generally follows a preparative regimen consisting of agents designed to do the following:

• Create marrow space.
• Suppress the patient's immune system to prevent rejection.
• Eradicate malignant cells in patients with cancer.

HCT is currently used in the following three clinical scenarios:

1. Treatment of malignancies.
2. Replacement or modulation of an absent or poorly functioning hematopoietic or immune system.
3. Treatment of genetic diseases in which an insufficient expression of the affected gene product can be partially or completely overcome by circulating hematopoietic cells transplanted from a donor with normal gene expression.

Autologous Versus Allogeneic HCT

The two major transplant approaches currently in use are the following:

• Autologous (using the patient's own hematopoietic stem cells).
• Allogeneic (using related- or unrelated-donor hematopoietic stem cells).

An autologous transplant treats cancer by exposing patients to high-dose therapy with the intent of overcoming chemotherapy resistance in tumor cells, followed by infusion of the patient's previously stored hematopoietic stem cells. The transplant can be performed in a single procedure or tandem sequential procedures. For autologous transplants to work for malignancies, the following must apply:

• A dose-intensified chemotherapy/radiation therapy regimen with hematopoietic stem cell support is used to achieve a significantly higher cell kill than could be achieved without the use of hematopoietic stem cell support. This may include increased tumor kill in areas where standard-dose chemotherapy has less penetration (central nervous system).
• Meaningful percentages of cure or long-term remission from the disease must occur without significant nonhematopoietic toxicities that would otherwise limit the therapeutic benefit achieved.

Autologous transplants have also been used to reset the immune system in patients with severe autoimmune disorders.

Current pediatric indications for autologous transplant include patients with certain lymphomas, neuroblastoma, and brain tumors. Autologous transplant techniques are also being used to enable engraftment of genetically modified autologous hematopoietic stem cell progenitors to correct/ameliorate inherited disorders (e.g., immunodeficiencies, metabolic disorders, and hemoglobinopathies).

Allogeneic transplant approaches to cancer treatment also may involve high-dose therapy, but because of immunologic differences between the donor and recipient, an additional graft-versus-tumor (GVT) or graft-versus-leukemia (GVL) treatment effect can occur. Although autologous approaches are associated with less short-term mortality, many malignancies are resistant to even high doses of chemotherapy and/or involve the bone marrow, thus requiring allogeneic approaches for optimal outcome.

Determining When HCT Is Indicated: Comparison of HCT and Chemotherapy Outcomes

Because the outcomes using chemotherapy and HCT treatments have been changing over time, regular comparisons between these approaches should be performed to continually redefine optimal therapy for a given patient. For some diseases, randomized trials or intent-to-treat using an HLA-matched sibling donor have established the benefit of HCT by direct comparison.[1 ,2 ] However, for very high-risk patients such as those with early relapse of acute lymphoblastic leukemia (ALL), randomized trials have not been feasible because of investigator bias.[3 ,4 ]

In general, HCT typically offers benefit only to children at high risk of relapse with standard chemotherapy approaches. Accordingly, treatment schemas that accurately identify these high-risk patients and offer HCT if reasonably HLA-matched donors are available have come to be the preferred approach for many diseases.[5 ] Less well-established, higher-risk approaches to HCT are generally reserved for only the very highest-risk patients. However, higher-risk approaches such as haploidentical transplantation are becoming safer and more efficacious and are increasingly being used interchangeably with fully matched allogeneic approaches.[6 ,7 ,8 ,9 ] (Refer to the Haploidentical HCT section of this summary for more information.)

When comparisons of similar patients treated with HCT or chemotherapy are made in the setting where randomized or intent-to-treat studies are not feasible, the following issues should be considered:

1. Remission/disease status: Comparisons between HCT and chemotherapy should include only patients who obtain remission, preferably after similar approaches to salvage therapy, because patients failing to obtain remission do very poorly with any therapy.[10 ]

   To account for time-to-transplant bias, the chemotherapy comparator arm should include only patients who maintained remission until the median time to HCT. The HCT comparator arm should also include only patients who achieved the initial remission mentioned above and maintained that remission until the time of HCT.[10 ]

   High-risk and intermediate-risk patient groups should not be combined because a benefit for HCT in the high-risk group can be masked when outcomes are similar to those achieved in the intermediate-risk group.[10 ]

2. Therapy approaches used for comparison: Comparisons should be made with the best or most commonly used chemotherapy and HCT approaches utilized during the time frame under study.
3. HCT approach: HCT approaches that are very high risk or have documented lower rates of survival should not be combined for analysis with standard-risk HCT approaches.
4. Criteria for relapse: Risk factors for relapse should be carefully defined, and analysis should be based on the most current knowledge of risk.
5. Selection bias: Attempts should be made to understand and eliminate or correct for selection bias. Examples include the following:
   • Higher-risk patients preferentially undergoing HCT (i.e., patients who take several rounds to achieve remission or who relapse after obtaining remission and go back into a subsequent remission before HCT).
   • Sicker patients deferred from HCT because of comorbidities.
   • Related to the time-to-transplant bias noted above, patients who undergo HCT after relapse or recurrence are a subset of all patients with a disease recurrence and will be selected from those who are able to obtain a remission and remain healthy enough to undergo HCT.
   • Patient or parent refusal.
   • Lack of or inability to obtain insurance approval for HCT.
   • Lack of access to HCT because of distance or inability to travel.

One source of bias difficult to control for or detect is physician bias for or against HCT. The effects of access to HCT and therapeutic bias on outcomes of pediatric malignancies for which HCT may be indicated have been poorly studied to date.

References:

1. Matthay KK, Villablanca JG, Seeger RC, et al.: Treatment of high-risk neuroblastoma with intensive chemotherapy, radiotherapy, autologous bone marrow transplantation, and 13-cis-retinoic acid. Children's Cancer Group. N Engl J Med 341 (16): 1165-73, 1999.
2. Woods WG, Neudorf S, Gold S, et al.: A comparison of allogeneic bone marrow transplantation, autologous bone marrow transplantation, and aggressive chemotherapy in children with acute myeloid leukemia in remission. Blood 97 (1): 56-62, 2001.
3. Lawson SE, Harrison G, Richards S, et al.: The UK experience in treating relapsed childhood acute lymphoblastic leukaemia: a report on the medical research council UKALLR1 study. Br J Haematol 108 (3): 531-43, 2000.
4. Gaynon PS, Harris RE, Altman AJ, et al.: Bone marrow transplantation versus prolonged intensive chemotherapy for children with acute lymphoblastic leukemia and an initial bone marrow relapse within 12 months of the completion of primary therapy: Children's Oncology Group study CCG-1941. J Clin Oncol 24 (19): 3150-6, 2006.
5. Schrauder A, von Stackelberg A, Schrappe M, et al.: Allogeneic hematopoietic SCT in children with ALL: current concepts of ongoing prospective SCT trials. Bone Marrow Transplant 41 (Suppl 2): S71-4, 2008.
6. Bertaina A, Merli P, Rutella S, et al.: HLA-haploidentical stem cell transplantation after removal of αβ+ T and B cells in children with nonmalignant disorders. Blood 124 (5): 822-6, 2014.
7. Handgretinger R, Chen X, Pfeiffer M, et al.: Feasibility and outcome of reduced-intensity conditioning in haploidentical transplantation. Ann N Y Acad Sci 1106: 279-89, 2007.
8. Huang XJ, Liu DH, Liu KY, et al.: Haploidentical hematopoietic stem cell transplantation without in vitro T-cell depletion for the treatment of hematological malignancies. Bone Marrow Transplant 38 (4): 291-7, 2006.
9. Luznik L, Fuchs EJ: High-dose, post-transplantation cyclophosphamide to promote graft-host tolerance after allogeneic hematopoietic stem cell transplantation. Immunol Res 47 (1-3): 65-77, 2010.
10. Pulsipher MA, Peters C, Pui CH: High-risk pediatric acute lymphoblastic leukemia: to transplant or not to transplant? Biol Blood Marrow Transplant 17 (1 Suppl): S137-48, 2011.

Autologous HCT

Collection and Storage of Autologous Hematopoietic Stem Cells

Autologous procedures require collection of growth-factor–mobilized peripheral blood stem cells (PBSCs) from patients by the process of leukapheresis. Bone marrow can be used for autologous transplants, but PBSCs have been shown to lead to quicker blood count recovery and cause less toxicity.

Patients being considered for autologous hematopoietic cell transplantation (HCT) are generally given chemotherapy to determine tumor responsiveness and minimize the risk of tumor contamination in their bone marrow. After a number of rounds of chemotherapy, patients undergo the leukapheresis procedure, either as their blood counts recover from chemotherapy or during a break between chemotherapy treatments. Growth factors such as granulocyte colony-stimulating factor (G-CSF) are used to increase the number of circulating stem and progenitor cells (CD34+ cells). Collection centers monitor the CD34-positive number in the patient and product each day to determine the best time to begin collection and when collection is complete. Patients with poorly mobilized CD34-positive cells can often have their cells successfully collected using alternative mobilization approaches (e.g., plerixafor).[1 ] The collected PBSCs are cryopreserved for later use. After completion of an intensive preparative regimen using high-dose chemotherapy, which varies according to the tumor type, the PBSCs are administered back into the patient at the time of transplant.

General Indications for Autologous Procedures/Preparative Regimens/Tumor Purging

In pediatrics, the most common autologous transplant indications are the following:

• High-risk neuroblastoma. (Refer to the PDQ summary on Neuroblastoma Treatment for more information.)
• Relapsed Hodgkin lymphoma and non-Hodgkin lymphoma. (Refer to the PDQ summaries on Childhood Hodgkin Lymphoma Treatment and Childhood Non-Hodgkin Lymphoma Treatment for more information.)
• High-risk and relapsed brain tumors.
• Relapsed or resistant germ cell tumors. (Refer to the PDQ summaries on Childhood Central Nervous System Germ Cell Tumors Treatment and Childhood Extracranial Germ Cell Tumors Treatment for more information.)

Tumor-specific regimens are described in disease-specific PDQ treatment summaries.

The tumor-specific activity and intensity of agents used for autologous regimens have been shown to be important in improving survival. This is not the case for allogeneic procedures.

One concern with autologous approaches for these and other tumor types has been the contamination of the collected stem cell product by persistent tumor cells. Although many techniques have been developed to remove or purge tumor cells from products, most studies have shown no benefit to tumor purging.[2 ]

References:

1. Patel B, Pearson H, Zacharoulis S: Mobilisation of haematopoietic stem cells in paediatric patients, prior to autologous transplantation following administration of plerixafor and G-CSF. Pediatr Blood Cancer 62 (8): 1477-80, 2015.
2. Kreissman SG, Seeger RC, Matthay KK, et al.: Purged versus non-purged peripheral blood stem-cell transplantation for high-risk neuroblastoma (COG A3973): a randomised phase 3 trial. Lancet Oncol 14 (10): 999-1008, 2013.

Allogeneic HCT

Improved Outcomes After Allogeneic Transplantation

Over the past one to two decades, significant advances have led to improved outcomes after allogeneic hematopoietic cell transplantation (HCT).[1 ,2 ,3 ] The most significant improvements in survival occurred in unrelated and alternative donor procedures.[4 ,5 ,6 ] Possible explanations for these improvements in survival include improved patient selection, better supportive care, refined treatment regimens, improved approaches specific to stem cell sources, and better HLA typing. All of these factors may have contributed to better outcomes; however, the section below focuses on modifiable aspects of HCT (i.e., optimization of HLA typing and selection of stem cell sources).

HLA Matching and Hematopoietic Stem Cell Sources

HLA overview

Appropriate matching between donor and recipient HLA in the major histocompatibility complex located on chromosome 6 is essential to successful allogeneic HCT (refer to Figure 1 and Tables 1 and 2).

Figure 1. HLA Complex. Human chromosome 6 with amplification of the HLA region. The locations of specific HLA loci for the class I B, C, and A alleles and the class II DP, DQ, and DR alleles are shown.

HLA class I (A, B, C, etc.) and class II (DRB1, DQB1, DPB1, etc.) alleles are highly polymorphic; therefore, finding appropriately matched unrelated donors is a challenge for some patients, especially those of certain racial groups (e.g., African Americans and Hispanics).[7 ,8 ] Full siblings of cancer patients have a 25% chance of being HLA matched.

Early serologic techniques of HLA assessment defined a number of HLA antigens, but more precise DNA methodologies have shown HLA allele-level mismatches in up to 40% of serologic HLA antigen matches. These differences are clinically relevant because the use of donors with allele-level mismatches affects survival and rates of graft-versus-host disease (GVHD) to a degree similar to that in patients with antigen-level mismatches.[9 ] Because of this, DNA-based allele-level HLA typing is standard when unrelated donors are being chosen.

Table 1. Level of HLA Typing Currently Used for Different Hematopoietic Stem Cell Sources^a,b,c

	Class I Antigens			Class II Antigens
BM = bone marrow; PBSCs = peripheral blood stem cells.
a HLA antigen: A serologically defined, low-resolution method of defining an HLA protein. Differs from allele-level typing half of the time. Designated by the first two numbers (i.e., HLA B 35:01—antigen is HLA B 35).
b HLA allele: A higher-resolution method of defining unique HLA proteins by typing their gene through sequencing or other DNA-based methods that detect unique differences. Designated by at least four numbers (i.e., HLA B 35:01—35 is the antigen and 01 is the allele).
c Consensus recommendations for HLA typing, including extended class II typing of mismatched donors, have been published by the National Cancer Institute/National Heart, Lung, and Blood Institute–sponsored Blood and Marrow Transplant Clinical Trials Network.[10 ]
d Siblings need confirmation that they have fully matched haplotypes with no crossovers in the A to DRB1 region. If parental typing is performed and haplotypes are established, antigen-level typing of class I is adequate. With no parental haplotypes, allele-level typing of eight alleles is recommended.
e Parent, cousin, etc., with a phenotypic match or near-complete HLA match.
Stem Cell Source	HLA A	HLA B	HLA C	HLA DRB1	HLA DQB1; HLA DPB1; HLA DR3,4,5
Matched siblingd BM/PBSCs	Antigen or allele	Antigen or allele	Optional	Allele
Mismatched sibling/other related-donore BM/PBSCs	Allele	Allele	Allele	Allele	Recommended, if mismatches are present
Unrelated-donor BM/PBSCs	Allele	Allele	Allele	Allele	Recommended, if mismatches are present
Unrelated-donor cord blood	Antigen (allele recommended)	Antigen (allele recommended)	Allele recommended	Allele

Table 2. Definitions of the Numbers Describing HLA Antigens and Alleles Matching

If These HLA Antigens and Alleles Match:	Then the Donor Is Considered to be This Type of Match:
A, B, and DRB1	6/6
A, B, C, and DRB1	8/8
A, B, C, DRB1, and DQB1	10/10
A, B, C, DRB1, DQB1, and DPB1	12/12

HLA matching considerations for sibling and related donors

The most commonly used related donor is a sibling from the same parents who, at a minimum, is HLA matched for HLA A, HLA B, and HLA DRB1 at the antigen level. Given the distance between HLA A and HLA DRB1 on chromosome 6, there is approximately a 1% possibility of a crossover event occurring in a possible sibling match. Because a crossover event could involve the HLA C antigen and because parents may share HLA antigens that actually differ at the allele level, many centers perform allele-level typing of possible sibling donors at all of the key HLA antigens (HLA A, B, C, and DRB1). Any related donor that is not a full sibling should have full HLA typing because similar haplotypes from different parents could differ at the allele level.

Although single-antigen mismatched related donors (5/6 antigen matched) were used interchangeably with matched sibling donors in some studies, a large Center for International Blood and Marrow Transplant Research (CIBMTR) study in pediatric HCT recipients showed that the use of 5/6 antigen-matched related donors resulted in rates of GVHD and overall survival (OS) equivalent to rates in 8/8-allele-level-matched unrelated donors and slightly inferior survival than in fully matched siblings.[11 ] Any siblings with single mismatches should have extended typing to ensure that if the mismatch is caused by a crossover, it only occurs with one antigen. If clinicians choose siblings with multiple antigen mismatches as donors, haploidentical approaches may be warranted.

HLA matching considerations for unrelated donors

Optimal outcomes are achieved in unrelated allogeneic marrow transplantation when the pairs of antigens at HLA A, B, C, and DRB1 are matched between the donor and the recipient at the allele level (termed an 8/8 match) (refer to Table 2).[12 ] A single antigen/allele mismatch at any of these antigens (7/8 match) lowers the probability of survival between 5% and 10%, with a similar increase in the amount of significant (grades III–IV) acute GVHD.[12 ] Of these four antigen pairs, different reports have shown HLA A, C, and DRB1 mismatches to potentially be more highly associated with mortality than the other antigens,[9 ,12 ,13 ] but the differences in outcome are small and inconsistent, making it very difficult to conclude that one can pick a more favorable mismatch by choosing one type of antigen mismatch over another. Many groups are attempting to define specific antigens or pairs of antigens that are associated with either good or poor outcomes. For example, a specific HLA C mismatch (HLA-C*03:03/03:04) has outcomes similar to a match; therefore, selection of this mismatch is desirable in an otherwise matched donor/pair combination.[14 ]

It is well understood that class II antigen DRB1 mismatches increase GVHD incidence and worsen survival.[13 ] Subsequent data have also shown that multiple mismatches of DQB1, DPB1, and DR3,4,5 lead to worse outcomes in the setting of less than 8/8 matches.[15 ] DPB1 mismatches have been extensively studied and classified as permissive or nonpermissive based on T-cell epitope matching. Patients with 10/10 matches and nonpermissive DPB1 mismatches have more transplant-related mortality but have survival rates similar to those with DPB1 matches or permissive matches. Those with 9/10 matches who have nonpermissive DPB1 mismatches had worse survival than did those with permissive mismatches or DPB1 matches.[16 ,17 ,18 ]

With these findings in mind, although a 7/8- or 8/8-matched unrelated donor can be used routinely, centers may be able to further improve outcomes by the following:

• Extended typing of DQB1, DPB1, and DR3,4,5, especially in the context of a less-than-8/8-matched donor.[16 ,17 ,18 ]
• Extended HLA testing to select appropriate donors in the context of HLA-sensitized patients to avoid the potential risk of graft failure.[19 ,20 ] HLA sensitization is detected by testing for the presence of specific anti-HLA antibodies and avoidance of donors who have any HLA antigens associated with the antibodies present in the recipient.
• Use of younger donors.[10 ]
• Matching cytomegalovirus (CMV)-positive or CMV-negative recipients with positive or negative donors.[21 ]
• Use of blood type–compatible unrelated donors.[10 ]

Figure 2. HLA allele duplication in a donor or recipient results in a half match and a mismatch that will either occur in a direction that promotes GVHD (GVH-O) or a direction that promotes rejection (R-O).

If a donor or recipient has a duplication of one of their HLA alleles, they will have a half match and a mismatch only in one direction. Figure 2 illustrates that these mismatches will occur in either a direction that promotes GVHD (GVH-O) or a direction that promotes rejection (R-O). When 8/8-matched unrelated donors are compared with 7/8 donors mismatched in the GVH-O direction, 7/8 mismatched in the R-O direction, or 7/8 mismatched in both directions, the mismatch in the R-O direction leads to rates of grades III and IV acute GVHD similar to rates in the 8/8 matched and better than in the other two combinations. The 7/8 mismatched in only the R-O direction is preferred over GVH-O and bidirectional mismatches.[22 ] It is important to note that this observation in unrelated donors differs from observations in cord blood recipients, outlined below.

HLA matching and cell dose considerations for unrelated cord blood HCT

Another commonly used hematopoietic stem cell source is that of unrelated umbilical cord blood, which is harvested from donor placentas moments after birth. The cord blood is processed, HLA typed, cryopreserved, and banked.

Unrelated cord blood transplantation has been successful with less stringent HLA matching requirements compared with standard related or unrelated donors, probably because of limited antigen exposure experienced in utero and different immunological composition. Cord blood matching has traditionally been performed at an intermediate level for HLA A and B and at an allele level (high resolution) for DRB1. This means that until just recently, attempted matching of only six antigens has been necessary to choose units for transplantation.

Although better outcomes occur when 6/6 or 5/6 HLA-matched units are used,[23 ] successful HCT has occurred even with 4/6 or less HLA-matched units in many patients. In a large CIBMTR/Eurocord study, better matching at the allele level using eight antigens (matching for HLA A, B, C, and DRB1) resulted in less transplant-related mortality and improved survival. Best outcome was noted with 8/8 allele matching versus 4/8 to 7/8 matches, with poor survival in patients with five or more allele mismatches. Patients receiving 8/8-matched cord blood did not require higher cell doses for better outcomes; however, those with one to three allele mismatches had less transplant-related mortality with total nucleated cell counts higher than 3 × 10⁷ /kg, and those with four allele mismatches required a total nucleated cell count higher than 5 × 10⁷ /kg to decrease transplant-related mortality.[24 ] This observation was noted to be especially important in cord blood transplantation for nonmalignant disorders, where any mismatching below 7/8 alleles led to inferior survival.[25 ] Many centers will type additional alleles and use the best match possible, but the impact of DQB1, DPB1, and DR3,4,5 mismatches has not been studied in detail.

As in unrelated peripheral blood stem cells (PBSCs) or bone marrow donors, extended HLA testing can support the selection of appropriate cord blood units in HLA-sensitized patients to avoid the potential risk of graft failure.[26 ,27 ] Evidence also suggests that selecting a mismatched cord blood unit, where the mismatch involves a noninherited maternal antigen, may improve survival.[28 ,29 ]

As with unrelated donors, individuals can occasionally have duplicate HLA antigens (e.g., the HLA A antigen is 01 on both chromosomes). When this occurs in a donor product and the antigen is matched to one of the recipient antigens, the recipient immune response will see the donor antigens as matched (matched, in the rejection direction), but the donor immune response will see a mismatch in the recipient (mismatched in the GVHD direction). This variation of partial mismatching has been shown to be important in cord blood transplant outcomes. Mismatches that are only in the GVHD direction (GVH-O) lead to lower transplant-related mortality and overall mortality than in those with recipient direction only (R-O) mismatches.[30 ] R-O mismatches have outcomes similar to those of bidirectional mismatches.[31 ] Although these studies suggest that using unidirectional mismatching as a criteria for cord blood selection may be beneficial, a Eurocord–European Society for Blood and Marrow Transplantation analysis disputes the value of this type of mismatching.[32 ]

Two aspects of umbilical cord blood HCT have made the practice more widely applicable. First, because a successful procedure can occur with multiple HLA mismatches, more than 95% of patients from a wide variety of ethnicities are able to find at least a 4/6-matched cord blood unit.[7 ,33 ] Second, as mentioned above, adequate cell dose (minimum 2–3 × 10⁷ total nucleated cells/kg and 1.7 × 10⁵ CD34+ cells/kg) has been shown to be associated with improved survival.[34 ,35 ] Total nucleated cells are generally used to judge units because techniques to measure CD34-positive doses have not been standardized. Because even large single umbilical cord blood units are only able to supply these minimum doses to recipients weighing up to 40 kg to 50 kg, early umbilical cord blood HCT focused mainly on smaller children. Later studies showed that barriers of this size could be overcome by using two umbilical cord blood units, as long as each of the units is at least a 4/6 HLA match with the recipient; because two cords provide higher cell doses, umbilical cord blood transplantation is now used widely for larger children and adults.[36 ]

If a single unit provides an adequate cell dose, there may be disadvantages to adding a second unit.[37 ][Level of evidence: 1iiA] Two randomized trials showed that in children who had adequately sized single units, the addition of a second unit did not alter relapse, transplant-related mortality, or survival rates, but was associated with higher rates of extensive chronic GVHD.[37 ,38 ]

Investigators have shown that by using combinations of cytokines and other compounds to expand cord blood for a period of time before infusion, engraftment of cord blood cells can occur more rapidly than after standard approaches.[39 ,40 ,41 ,42 ] Although some studies using multiple units or split units have shown that expanded units will engraft early and then give way to nonexpanded units for long-term reconstitution,[43 ] other studies are showing persistence of expanded cells, implying preservation of stem cells through the expansion process.[41 ,42 ] A number of these approaches are currently under investigation; their effect on efficacy and survival of children using cord blood as a stem cell source has yet to be established and none are approved by the U.S. Food and Drug Administration (FDA).

Comparison of stem cell products

Currently, the following three stem cell products are used from both related and unrelated donors:

• Bone marrow.
• PBSCs.
• Cord blood.

In addition, bone marrow or PBSCs can be T-cell depleted by several methods, and the resultant stem cell product has very different properties. Finally, partially HLA-matched (half or more antigens [haploidentical]) related bone marrow or PBSCs can be used after in vitro or in vivo T-cell depletion, and this product also behaves differently from other stem cell products. A comparison of stem cell products is presented in Table 3.

Table 3. Comparison of Hematopoietic Stem Cell Products

	PBSCs	BM	Cord Blood	T-cell–Depleted BM/PBSCs	Haploidentical T-cell–Depleted BM/PBSCs
BM = bone marrow; EBV-LPD = Epstein-Barr virus–associated lymphoproliferative disorder; GVHD = graft-versus-host disease; HCT = hematopoietic cell transplantation; PBSCs = peripheral blood stem cells.
a Assuming no development of GVHD. If patients develop GVHD, immune reconstitution is delayed until resolution of the GVHD and discontinuation of immune suppression.
b If a haploidentical donor is used, longer times to immune reconstitution may occur.
T-cell content	High	Moderate	Low	Very low	Very low
CD34+ content	Moderate–high	Moderate	Low (but higher potency)	Moderate–high	Moderate–high
Time to neutrophil recovery	Rapid: median, 16 d (11–29 d)[44 ]	Moderate: median, 21 d (12–35 d)[44 ]	Slower: median, 23 d (11–133 d)[38 ]	Rapid: median, 16 d (9–40 d)[45 ]	Rapid: median, 13 d (10–20 d)[46 ]
Early post-HCT risk of infections, EBV-LPD	Low–moderate	Moderate	High	Very High	Very High
Risk of graft rejection	Low	Low–moderate	Moderate–high	Moderate–high	Moderate–high
Time to immune reconstitutiona	Rapid (6–12 mo)	Moderate (6–18 mo)	Slow (6–24 mo)	Slow (6–24 mo)	Slow (9–24 mo)b
Risk of acute GVHD	Moderate	Moderate	Moderate	Low	Low
Risk of chronic GVHD	High	Moderate	Low	Low	Low

The main differences between the products are associated with the numbers of T cells and CD34-positive progenitor cells present; very high levels of T cells are present in PBSCs, intermediate numbers in bone marrow, and low numbers in cord blood and T-cell–depleted products. Patients receiving T-cell–depleted products or cord blood generally have slower hematopoietic recovery, increased risk of infection, late immune reconstitution, higher risks of nonengraftment, and increased risk of Epstein-Barr virus (EBV)–associated lymphoproliferative disorder. This is countered by lower rates of GVHD and an ability to offer transplantation to patients where full HLA matching is not available. Higher doses of T cells and other cells in PBSCs result in rapid neutrophil recovery and immune reconstitution, but also increase rates of chronic GVHD.

Only a few studies directly compared outcomes of different stem cell sources/products in pediatric patients.

Evidence (comparison of outcomes of stem cell sources/products in children):

1. A retrospective registry study of pediatric patients who underwent HCT for acute leukemia compared those who received related-donor bone marrow with those who received related-donor PBSCs.[47 ]
   • Although the bone marrow and PBSC recipient cohorts differed some in their risk profiles, after statistical correction, increased risk of GVHD and transplant-related mortality associated with PBSCs led to poorer survival in the PBSC group.
2. A retrospective study of Japanese children with acute leukemia compared 90 children who received PBSCs with 571 children who received bone marrow.[48 ]
   • The study confirmed higher transplant-related mortality caused by GVHD and inferior survival among the children who received PBSCs.

These reports, combined with a lack of prospective studies comparing bone marrow and PBSCs, have led most pediatric transplant protocols to prefer bone marrow over PBSCs from related donors.

For those requiring unrelated donors, a large Blood and Marrow Transplant Clinical Trials Network (BMT CTN) trial that included a number of pediatric patients randomly assigned enrollees to receive either bone marrow or PBSCs. This trial demonstrated that OS was identical using either source, but rates of chronic GVHD were significantly higher in the PBSC arm, with a small increase in rejection in the bone marrow arm.[49 ] Rejections were rare in pediatric patients, and there was an insufficient number of patients to draw specific conclusions about rejection risk in children who received bone marrow.

Published studies comparing unrelated cord blood and bone marrow have been retrospective, with weaknesses inherent in such analyses.

Evidence (comparison of unrelated cord blood versus bone marrow outcomes):

1. In one study, pediatric patients with acute lymphoblastic leukemia (ALL) who underwent HCT and received 8/8-HLA-allele–matched unrelated-donor bone marrow were compared with those who received unrelated cord blood.[23 ]
   • The analysis showed that the best survival occurred in recipients of 6/6 HLA-matched cord blood; survival after 8/8 HLA-matched unrelated bone marrow was slightly less and was statistically identical to survival for patients receiving 5/6 and 4/6 HLA-matched cord blood units.
2. In a second study from a single center consisting of mostly adult patients with acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), and ALL, outcomes for cord blood recipients were compared with outcomes for recipients of matched and mismatched unrelated-donor bone marrow/PBSCs.[50 ]
   • Better survival because of less relapse was noted in cord blood recipients, mainly resulting from superior survival in patients with minimal residual disease (MRD) present just before transplant.
   • No difference was seen in relapse and survival between patients with pre-HCT MRD and patients without pre-HCT MRD if they received cord blood.
   • This result is controversial because it contradicts many other studies that showed that the presence of pre-HCT MRD in cord blood recipients led to increased relapse and inferior survival.[51 ,52 ,53 ,54 ]

On the basis of these studies, most transplant centers consider matched sibling bone marrow to be the preferred stem cell source/product. If a sibling donor is not available, fully matched unrelated-donor bone marrow or PBSCs or HLA-matched (4/6 to 6/6) cord blood leads to similar survival rates. Although adult studies of T-cell–depleted unrelated bone marrow or PBSCs have shown outcomes similar to non–T-cell–depleted approaches, large pediatric trials or retrospective studies comparing T-cell–depleted matched or haploidentical bone marrow or PBSCs have not been conducted.

Haploidentical HCT

Early HCT studies demonstrated progressively higher percentages of patients experiencing severe GVHD and lower survival rates as the number of donor/recipient HLA mismatches increased.[55 ] Other studies showed that even with very high numbers of donors in unrelated-donor registries, patients with rare HLA haplotypes and patients with certain ethnic backgrounds (e.g., Hispanic, African American, Asian-Pacific Islander, etc.) have a low chance of achieving desired levels of HLA matching (7/8 or 8/8 match at the allele level).[8 ]

To allow access to HCT for patients without fully HLA-matched donor options, investigators have developed techniques allowing the use of siblings, parents, or other relatives who share only a single haplotype of the HLA complex with the patient and are thus half matches. Most approaches developed to date rely on intense T-cell depletion of the product before infusion into the patient. The main challenge associated with this approach is intense immune suppression with delayed immune recovery, which can result in lethal infections,[56 ] increased risk of EBV-associated lymphoproliferative disorder, and high rates of relapse.[57 ] This has generally led to inferior survival compared with matched HCT and has resulted in the procedure being practiced mainly at larger academic centers with a specific research focus on studying and developing this approach.

Current approaches, however, are rapidly evolving, resulting in improved outcomes, with some pediatric groups reporting survival similar to that of standard approaches.[58 ,59 ] These approaches include the following:

• Newer techniques of T-cell depletion and add-back of specific cell populations (e.g., CD3 or alpha-beta CD3/CD19-negative selection) may decrease transplant-related mortality.[60 ]; [61 ,62 ][Level of evidence: 3iiiDii]
• Reduced toxicity regimens have led to improved survival.
• Better supportive care has decreased the chance of morbidity from infection or EBV-associated lymphoproliferative disorder.[63 ]
• Some patient-donor combinations that have specific killer immunoglobulin-like receptor mismatches have shown decreased likelihood of relapse (refer to the Role of killer immunoglobulin-like receptor mismatching in HCT section of this summary for more information).
• Certain techniques, such as using combinations of granulocyte colony-stimulating factor (G-CSF)–primed bone marrow and PBSCs with posttransplant antibody–based T-cell depletion [64 ] or post-HCT cyclophosphamide (chemotherapeutic T-cell depletion),[65 ]; [66 ][Level of evidence: 3iiiA] have made these procedures more accessible to centers because the expensive and complicated processing necessary for traditional T-cell depletion are not used.

Reported rates of survival using many different types of haploidentical approaches varies between 25% and 80%, depending on the technique used and the risk of the patient undergoing the procedure.[57 ,58 ,64 ,65 ]; [66 ][Level of evidence: 3iiiA] Whether haploidentical approaches are superior to cord blood or other stem cell sources for a given patient group has not been determined because comparative studies have yet to be performed.[57 ]

Even more than with other stem cell sources, patients undergoing haploidentical procedures can develop anti-HLA antibodies that, if directed against nonshared haploidentical antigens, can greatly increase the risks of rejection. Clinicians should choose donors with HLA types against whom the recipient does not have an antibody present, if possible. Guidelines on how to best approach this issue have been published.[67 ]

Other donor characteristics associated with outcome

Although HLA matching has consistently been the most important factor associated with improved survival in nonhaploidentical allogeneic HCT, a number of other characteristics of the donor have been shown in studies to affect key outcomes. Higher cell dose from the donor (refer to the HLA matching and cell dose considerations for unrelated cord blood HCT section of this summary for more information) has also been shown to be important when related, unrelated, or haploidentical bone marrow or PBSC donors are used.[68 ,69 ] The effects of donor age, blood type, CMV status, sex, and parity of female donors have also been studied.

Ideally, after HLA matching, transplant centers should select donors based on the following characteristics:

• Donor age. The youngest donor available is preferred.[70 ,71 ]
• CMV status of the recipient. CMV-negative donor matched to CMV-negative recipient and CMV-positive donor matched to CMV-positive recipient are preferred.[72 ]
• Matched donor blood type.[73 ,74 ,75 ]
• Donor sex and parity of female donors. Male or nonparous female donors are preferred over parous female donors.[71 ,76 ]

Rarely can a donor/recipient pair fit perfectly into this algorithm, and determining which of these characteristics should be chosen over others has been controversial. A CIBMTR study involving 6,349 patients who underwent transplant for hematological malignancies from 1988 to 2006, with a confirmation cohort of 4,690 patients who underwent transplant between 2007 and 2011, tested the effect of donor characteristics while adjusting for disease risk and other key transplant characteristics.[71 ,77 ]

• The earlier data set showed that in addition to HLA mismatching, older donor age and major or minor ABO blood-type mismatching increased overall mortality; parous female graft recipients experienced lower rates of relapse; recipients of younger donor grafts had lower rates of acute GVHD; and recipients of parous female grafts had higher rates of chronic GVHD. Recipient CMV status was more important than donor CMV status (recipients who are CMV-positive are at higher risk of mortality independent of the donor CMV status), although a CMV-negative donor to a CMV-negative recipient combination improves survival.[71 ]
• The more recent confirmation cohort was tested by a multivariate analysis for independent predictors of survival in an EBMT study. Older donor age was confirmed to be independently associated with worse OS; every 10 years of donor age increased the risk of mortality by 5.5%. HLA matching continued to have the most important effect on survival; ABO mismatching was not confirmed to have a continuing effect.[77 ]

Thus, after HLA matching, donor age is likely the most important second factor to optimize, unless the recipient is CMV negative, at which point finding a CMV-negative donor would take priority.

A number of studies have attempted to identify characteristics of the best donors for haploidentical procedures. As with conventional bone marrow transplantation, use of younger donors appears to be beneficial, but data regarding donor sex are inconclusive. Studies involving intense T-cell depletion have noted better outcomes using maternal donors,[78 ] but studies using posttransplant cyclophosphamide or intense immune suppression seem to favor male donors.[79 ,80 ] Further study is needed to clarify this important issue. One large comparison of haploidentical donors showed an effect of ABO incompatibility on engraftment (risk of rejection doubling from 6% to 12%, ABO match vs. ABO major mismatch), and patients receiving bidirectionally mismatched donors had a 2.4-fold increase in grades II to IV acute GVHD.[81 ]

Immunotherapeutic Effects of Allogeneic HCT

Graft-versus-leukemia (GVL) effect

Early studies in HCT focused on the delivery of intense myeloablative preparative regimens followed by rescue of the hematopoietic system with either an autologous or allogeneic bone marrow. Investigators quickly showed that allogeneic approaches led to a decreased risk of relapse caused by an immunotherapeutic reaction of the new bone marrow graft against tumor antigens. This phenomenon came to be termed the GVL or graft-versus-tumor (GVT) effect, and has been shown to be associated with mismatches to both major and minor HLA antigens.

The GVL effect is challenging to use therapeutically because of a strong association between GVL and clinical GVHD. For standard approaches to HCT, the highest survival rates have been associated with mild or moderate GVHD (grades I to II in AML and grades I to III in ALL), compared with patients who have no GVHD and experience more relapse or patients with severe GVHD who experience more transplant-related mortality.[82 ,83 ]; [84 ][Level of evidence: 3iDi]

Understanding when GVL occurs and how to use GVL optimally is challenging. One method of study is comparing rates of relapse and survival between patients undergoing myeloablative HCT with either autologous or allogeneic donors for a given disease.

• Leukemia and MDS: A clear advantage has been noted when allogeneic approaches are used for ALL, AML, chronic myelogenous leukemia (CML), and MDS. For ALL and AML specifically, autologous HCT approaches for most high-risk patient groups have shown results similar to those obtained with chemotherapy, while allogeneic approaches produced superior results.[85 ,86 ]
• Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL): Patients with HL or NHL generally fare better with autologous approaches, although there may be a role for allogeneic approaches in relapsed lymphoblastic lymphoma, lymphoma that is poorly responsive to chemotherapy, or lymphoma that has relapsed after autologous HCT.[87 ]

Further insights into the therapeutic benefit of GVL/GVT for given diseases have come from the use of reduced-intensity preparative regimens (refer to the Principles of Allogeneic HCT Preparative Regimens section of this summary for more information). This approach to transplantation relies on GVL because, in most cases, the intensity of the preparative regimen is not sufficient for cure. Although studies have shown benefit for patients pursuing this approach when they are ineligible for standard transplantation,[88 ] this approach has not been used for most children with cancer who require HCT because pediatric cancer patients can generally undergo myeloablative approaches safely.

Using donor lymphocyte infusions (DLI) or early withdrawal of immune suppression to enhance GVL

GVL can be delivered therapeutically through the infusion of cells after transplant that either specifically or nonspecifically target the tumor. The most common approach is the use of DLI. This approach relies on the persistence of donor T-cell engraftment after transplant to prevent rejection of donor lymphocytes infused to induce the GVL.

Therapeutic DLI results in potent responses in patients with CML who relapse after transplant (60%–80% enter into long-term remission),[89 ] but responses in patients with other diseases (AML and ALL) have been less potent, with only 20% to 30% long-term survival.[90 ] DLI works poorly in patients with acute leukemia who relapse early and who have high levels of active disease. Late relapse (>6 months after transplant) and the treatment of patients into complete remission with chemotherapy before DLI have been associated with improved outcomes.[91 ] Infusions of DLI modified to enhance GVL or other donor cells (natural killer [NK] cells, etc.) have also been studied, but have yet to be generally adopted.

Another method of delivering GVL therapeutically is the rapid withdrawal of immune suppression after HCT. Some studies have scheduled more rapid immune suppression tapers based on donor type (related donors are tapered more quickly than are unrelated donors because of less GVHD risk), and others have used sensitive measures of either low levels of persistent recipient cells (recipient chimerism [from the Greek chimera, a mythical animal with parts from various animals]) or MRD to assess the risk of relapse and trigger rapid taper of immune suppression.

A combination of early withdrawal of immune suppression after HCT with addition of DLI to prevent relapse in patients at high risk of relapse due to persistent/progressive recipient chimerism has been tested in patients who underwent transplant for both ALL and AML.[92 ][Level of evidence: 2A]; [93 ][Level of evidence: 3iiDii]

• ALL: For patients with ALL, one study found increasing recipient chimerism in 46 of 101 patients. Thirty-one of those patients had withdrawal of immune suppression, and a portion went on to receive DLI if GVHD did not occur. This group had a 37% survival rate, compared with 0% in the 15 patients who did not undergo this approach (P < .001).[94 ]
• AML: For patients with AML after HCT, about 20% experienced mixed chimerism after HCT and were identified as high risk. Of these, 54% survived if they underwent withdrawal of immune suppression with or without DLI; there were no survivors among those who did not receive this therapy.[95 ]

Other immunological and cell therapy approaches under evaluation

The role of killer immunoglobulin-like receptor (KIR) mismatching in HCT

Donor-derived NK cells in the post-HCT setting have been shown to promote the following:[96 ,97 ,98 ]

• Engraftment.
• Decreased GVHD.
• Fewer relapses of hematological malignancies.
• Improved survival.

NK-cell function is modulated by interactions with a number of receptor families, including activating and inhibiting KIR. The KIR effect in the allogeneic HCT setting hinges on the expression of specific inhibitory KIR on donor-derived NK cells and either the presence or the absence of their matching HLA class I molecules (KIR ligands) on recipient leukemic and normal cells. Normally, the presence of specific KIR ligands interacting with paired inhibitory KIR molecules prevents NK cell attack on healthy cells. In the allogeneic transplant setting, recipient leukemia cells genetically differ from donor NK cells, and they may not have the appropriate inhibitory KIR ligand. Mismatch of ligand and receptor allows NK-cell–based killing of recipient leukemia cells to proceed for certain donor-recipient genetic combinations.

The original observation of decreased relapse with certain KIR-ligand combinations was made in the setting of T-cell–depleted haploidentical transplantation and was strongest after HCT for AML.[97 ,99 ] Along with decreasing relapse, these studies have suggested a decrease in GVHD with appropriate KIR-ligand combinations. Many subsequent studies did not detect survival effects for KIR-incompatible HCT using standard transplantation methods,[100 ,101 ] which has led to the conclusion that T-cell depletion may be necessary to remove other forms of inhibitory cellular interactions.

Decreased relapse and better survival have been noted with donor/recipient KIR-ligand incompatibility after cord blood HCT, a relatively T-cell–depleted procedure.[102 ,103 ] In contrast to this notion, one study demonstrated that some KIR mismatching combinations (activating receptor KIR2DS1 with the HLA C1 ligand) can lead to decreased relapse after AML HCT without T-cell depletion.[104 ] The role of KIR incompatibility in sibling donor HCT and in diseases other than AML is controversial, but in pediatrics, at least two groups have found better outcomes with specific types of KIR mismatching in ALL.[58 ,105 ,106 ]

A current challenge associated with studies of KIR is that several different approaches have been used to determine what is KIR compatible and incompatible.[99 ,107 ] The standardization of classification and prospective studies should help clarify the utility and importance of this approach. Because a limited number of centers perform haploidentical HCT and the results of the data in cord blood HCT are preliminary, most transplant programs do not use KIR mismatching as part of their strategy for choosing a donor. Full HLA matching is considered most important for outcome, with considerations of KIR incompatibility remaining secondary.

NK-cell transplantation

With a low risk of GVHD and demonstrated efficacy in decreasing relapse in post-haploidentical HCT settings, NK-cell infusions as a method of treating high-risk patients and consolidating patients in remission have been studied:

Evidence (NK-cell transplantation outcomes):

1. The University of Minnesota group initially failed to demonstrate efficacy with autologous NK cells, but found that intense immunoablative therapy followed by purified haploidentical NK cells and interleukin-2 (IL-2) maintenance led to remission in 5 of 19 high-risk AML patients.[108 ]
2. Researchers at St. Jude Children's Research Hospital treated ten intermediate-risk AML patients who had completed chemotherapy and were in remission with lower-dose immunosuppression followed by haploidentical NK-cell infusions and IL-2 for consolidation.[109 ] Expansion of NK cells was noted in all nine of the KIR-incompatible donor/recipient pairs. All ten children remained in remission at 2 years. A follow-up phase II study is under way, as are many investigations into NK-cell therapy for a number of cancer types.

   Other investigators have used expanded/activated NK cells before and after HCT.[110 ] One approach that included the culturing of haploidentical NK cells with membrane-bound IL-21 showed marked expansion and high activity. These cells were then infused just before haploidentical HCT, followed by additional infusions on day +7 and +28 after HCT.[110 ]

3. Although early survival rates in this high-risk AML cohort are high, multicenter confirmatory studies will be necessary to establish the efficacy of these types of NK-cell approaches.

Chimeric antigen receptor (CAR) T-cell therapy

For T cells to attack cellular targets (viruses or cancer cells), they must bind to class I major histocompatibility complex (MHC) molecules on the surface of the target cells and avoid suppressor signals sent by regulatory T cells and other surface molecule interactions. Gene transfer technologies can modify T cells to express MHC-independent antibody-binding domains (CAR molecules) aimed at specific target proteins on the surface of tumors. To minimize the chance of suppressor mechanisms affecting CAR T-cell function and to create a cytokine milieu conducive to CAR T-cell expansion,[111 ] lymphodepleting chemotherapy is generally given before CAR T-cell infusions. CAR T-cell–mediated responses are further enhanced by the addition of intracellular costimulatory domains (e.g., CD28, 4-1BB), which cause significant CAR T-cell expansion and may increase the lifespan of these cells in the recipient.[111 ]

Investigators using this technology have targeted a variety of tumors/surface molecules, but the best-studied example in pediatric patients is CAR T cells aimed at CD19, a surface receptor on B cells. Several groups have reported significant rates of remission (70%–90%) in children and adults with refractory B-cell ALL,[112 ,113 ,114 ,115 ] and several groups have reported persistence of CAR T cells and remission beyond 6 months in most patients studied.[115 ,116 ] Early loss of the CAR T cells is associated with relapse, and the best use of this therapy (bridge to transplant vs. definitive therapy) is under study.

Responses have been associated with a significant increase in inflammatory cytokines (termed cytokine release syndrome), which presents as a sepsis-like picture that can be successfully treated with anti–interleukin-6 receptor (IL-6R) therapies (tocilizumab), often in combination with steroids.[117 ,118 ] Cytokine release syndrome presents as fever, headache, myalgias, hypotension, capillary leak, hypoxia, and renal dysfunction. Neurotoxicity, including aphasia, altered mental status, and seizures, has also been observed with CAR T-cell therapy and the symptoms usually resolve spontaneously. Central nervous system symptoms have not responded to IL-6R–targeting agents or other approaches. Other CAR T-cell therapy side effects include coagulopathy, hemophagocytic lymphohistiocytosis–like laboratory changes, and cardiac dysfunction. Between 20% and 40% of patients require treatment in the intensive care unit, mostly pressor support, with 10% to 20% of patients requiring intubation and/or dialysis.[112 ,115 ,116 ]

An international trial in children led to FDA approval of tisagenlecleucel for multiply relapsed or refractory CD19-positive B-cell ALL for patients aged 1 to 25 years.[119 ] Tisagenlecleucel has also been approved for adults with B-cell lymphoma, as has a second agent, axicabtagene ciloleucel.[120 ,121 ]

Principles of Allogeneic HCT Preparative Regimens

In the days just before infusion of the stem cell product (bone marrow, peripheral blood stem cells, or cord blood), HCT recipients receive chemotherapy/immunotherapy, sometimes combined with radiation therapy. This is called a preparative regimen, and the original intent of this treatment was to:

• Create bone marrow space in the recipient for the donor cells to engraft.
• Suppress the immune system or eliminate the recipient T cells to minimize risks of rejection.
• Intensely treat cancer (if present) with high doses of active agents, with the intent to overcome therapy resistance.

With the recognition that donor T cells can facilitate engraftment and kill tumors through GVL effects (obviating the need to create bone marrow space and intensely treat cancer), reduced-intensity or minimal-intensity HCT approaches focusing on immune suppression rather than myeloablation have been developed. The resultant lower toxicity associated with these regimens has led to lower rates of transplant-related mortality and an expanded eligibility for allogeneic HCT to older individuals and younger patients with pre-HCT comorbidities that put them at risk of severe toxicity after standard HCT approaches.[122 ]

The preparative regimens available now vary tremendously in the amount of immunosuppression and myelosuppression that they cause, with the lowest-intensity regimens relying heavily on a strong GVT effect (refer to Figure 3).

Figure 3. Selected preparative regimens frequently used in pediatric HCT categorized by current definitions as nonmyeloablative, reduced-intensity, or myeloablative. Although FLU plus treosulfan and FLU plus busulfan (full-dose) are considered myeloablative approaches, some refer to them as reduced-toxicity regimens.

Although these regimens lead to varying degrees of myelosuppression and immune suppression, they have been grouped clinically into the following three major categories (refer to Figure 4):[123 ]

• Myeloablative: Intense approaches that cause irreversible pancytopenia that requires stem cell rescue for restoration of hematopoiesis.
• Nonmyeloablative: Regimens that cause minimal cytopenias and do not require stem cell support.
• Reduced-intensity conditioning: Regimens that are of intermediate intensity and do not meet the definitions of nonmyeloablative or myeloablative regimens.

Figure 4. Classification of conditioning regimens in 3 categories, based on duration of pancytopenia and requirement for stem cell support. Myeloablative regimens (MA) produce irreversible pancytopenia and require stem cell support. Nonmyeloablative regimens (NMA) produce minimal cytopenia and would not require stem cell support. Reduced-intensity regimens (RIC) are regimens which cannot be classified as MA nor NMA. Reprinted from Biology of Blood and Marrow Transplantation, Volume 15 (Issue 12), Andrea Bacigalupo, Karen Ballen, Doug Rizzo, Sergio Giralt, Hillard Lazarus, Vincent Ho, Jane Apperley, Shimon Slavin, Marcelo Pasquini, Brenda M. Sandmaier, John Barrett, Didier Blaise, Robert Lowski, Mary Horowitz, Defining the Intensity of Conditioning Regimens: Working Definitions, Pages 1628-1633, Copyright 2009, with permission from Elsevier.

For a number of years, retrospective studies showed similar outcomes using reduced-intensity and myeloablative approaches.[68 ,124 ] However, a Blood and Marrow Transplant Clinical Trials Network (BMT CTN) trial of adults with AML and MDS that randomly assigned patients to receive either myeloablative or reduced-intensity HCT approaches demonstrated the importance of regimen intensity.[125 ]

• At 18 months, relapse was markedly higher in the reduced-intensity cohort (48% vs. 13.5%, P < .001).
• Although treatment-related mortality was higher in the myeloablative arm (16% vs. 4%, P = .002), relapse-free survival was superior in the myeloablative arm (69% vs. 47%, P < .01) and overall survival was higher (76% vs. 68%), with a nonsignificant P value of .07.

With this in mind, the use of reduced-intensity conditioning and nonmyeloablative regimens is well established in older adults who cannot tolerate more intense myeloablative approaches,[126 ,127 ,128 ] but these approaches have been studied in a limited number of younger patients with malignancies.[129 ,130 ,131 ,132 ,133 ] A large Pediatric Blood and Marrow Transplant Consortium study identified patients at high risk of transplant-related mortality with myeloablative regimens (e.g., history of previous myeloablative transplant, severe organ system dysfunction, or active invasive fungal infection) and successfully treated them with a reduced-intensity regimen.[88 ] Transplant-related mortality was low in this high-risk group, and long-term survival occurred in most patients with minimal or no detectable disease at the time of transplantation. Because the risks of relapse are higher with these approaches, their use in pediatric cancer is currently limited to patients ineligible for myeloablative regimens and is most likely to be successful when patients have achieved MRD-negative remissions.[88 ]

Establishing donor chimerism

Intense myeloablative approaches almost invariably result in rapid establishment of hematopoiesis derived completely from donor cells upon count recovery within weeks of the transplant. The introduction of reduced-intensity conditioning and nonmyeloablative approaches into HCT practice has resulted in a slower pace of transition to donor hematopoiesis (gradually increasing from partial to full donor hematopoiesis over months) that is sometimes only partial. DNA-based techniques have been established to differentiate donor and recipient hematopoiesis, applying the word chimerism to describe whether all or part of hematopoiesis after HCT is from the donor or recipient.

There are several implications for the pace and extent of donor chimerism eventually achieved by an HCT recipient. For patients receiving reduced-intensity conditioning or nonmyeloablative regimens, rapid progression to full donor chimerism is associated with less relapse but more GVHD.[134 ] The delayed pace of obtaining full donor chimerism after reduced-intensity regimens has led to late-onset acute GVHD, occurring as long as 6 months to 7 months after HCT (generally within 100 days after myeloablative approaches).[135 ] A portion of patients achieve stable mixed chimerism of both donor and recipient. Mixed chimerism is associated with more relapse after HCT for malignancies and less GVHD; however, this condition is often advantageous for nonmalignant HCT, where usually only a percentage of normal hematopoiesis is needed to correct the underlying disorder and GVHD is not beneficial.[136 ] Finally, serially measured decreasing donor chimerism, especially T-cell–specific chimerism, has been associated with increased risk of rejection.[137 ]

Because of the implications of persistent recipient chimerism, most transplant programs test for chimerism shortly after engraftment and continue testing regularly until stable full donor hematopoiesis has been achieved. Investigators have defined two approaches to treat the increased risks of relapse and rejection associated with increasing recipient chimerism: rapid withdrawal of immune suppression and DLI. (Refer to the Using donor lymphocyte infusions (DLI) or early withdrawal of immune suppression to enhance GVL section of this summary for more information.) These approaches are frequently used to address this issue, and have been shown in some cases to decrease relapse risk and stop rejection.[94 ,138 ,139 ] The timing of tapers of immune suppression and doses and approaches to the administration of DLI to increase or stabilize donor chimerism vary tremendously among transplant regimens and institutions.

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54. Sanchez-Garcia J, Serrano J, Serrano-Lopez J, et al.: Quantification of minimal residual disease levels by flow cytometry at time of transplant predicts outcome after myeloablative allogeneic transplantation in ALL. Bone Marrow Transplant 48 (3): 396-402, 2013.
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65. Luznik L, Fuchs EJ: High-dose, post-transplantation cyclophosphamide to promote graft-host tolerance after allogeneic hematopoietic stem cell transplantation. Immunol Res 47 (1-3): 65-77, 2010.
66. Berger M, Lanino E, Cesaro S, et al.: Feasibility and Outcome of Haploidentical Hematopoietic Stem Cell Transplantation with Post-Transplant High-Dose Cyclophosphamide for Children and Adolescents with Hematologic Malignancies: An AIEOP-GITMO Retrospective Multicenter Study. Biol Blood Marrow Transplant 22 (5): 902-9, 2016.
67. Ciurea SO, Cao K, Fernadez-Vina M, et al.: The European Society for Blood and Marrow Transplantation (EBMT) Consensus Guidelines for the Detection and Treatment of Donor-specific Anti-HLA Antibodies (DSA) in Haploidentical Hematopoietic Cell Transplantation. Bone Marrow Transplant 53 (5): 521-534, 2018.
68. Pulsipher MA, Chitphakdithai P, Logan BR, et al.: Donor, recipient, and transplant characteristics as risk factors after unrelated donor PBSC transplantation: beneficial effects of higher CD34+ cell dose. Blood 114 (13): 2606-16, 2009.
69. Aversa F, Terenzi A, Tabilio A, et al.: Full haplotype-mismatched hematopoietic stem-cell transplantation: a phase II study in patients with acute leukemia at high risk of relapse. J Clin Oncol 23 (15): 3447-54, 2005.
70. Kollman C, Howe CW, Anasetti C, et al.: Donor characteristics as risk factors in recipients after transplantation of bone marrow from unrelated donors: the effect of donor age. Blood 98 (7): 2043-51, 2001.
71. Kollman C, Spellman SR, Zhang MJ, et al.: The effect of donor characteristics on survival after unrelated donor transplantation for hematologic malignancy. Blood 127 (2): 260-7, 2016.
72. Boeckh M, Nichols WG: The impact of cytomegalovirus serostatus of donor and recipient before hematopoietic stem cell transplantation in the era of antiviral prophylaxis and preemptive therapy. Blood 103 (6): 2003-8, 2004.
73. Seebach JD, Stussi G, Passweg JR, et al.: ABO blood group barrier in allogeneic bone marrow transplantation revisited. Biol Blood Marrow Transplant 11 (12): 1006-13, 2005.
74. Logan AC, Wang Z, Alimoghaddam K, et al.: ABO mismatch is associated with increased nonrelapse mortality after allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 21 (4): 746-54, 2015.
75. Stussi G, Muntwyler J, Passweg JR, et al.: Consequences of ABO incompatibility in allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 30 (2): 87-93, 2002.
76. Loren AW, Bunin GR, Boudreau C, et al.: Impact of donor and recipient sex and parity on outcomes of HLA-identical sibling allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 12 (7): 758-69, 2006.
77. Canaani J, Savani BN, Labopin M, et al.: ABO incompatibility in mismatched unrelated donor allogeneic hematopoietic cell transplantation for acute myeloid leukemia: A report from the acute leukemia working party of the EBMT. Am J Hematol 92 (8): 789-796, 2017.
78. Stern M, Ruggeri L, Mancusi A, et al.: Survival after T cell-depleted haploidentical stem cell transplantation is improved using the mother as donor. Blood 112 (7): 2990-5, 2008.
79. Ciurea SO, Champlin RE: Donor selection in T cell-replete haploidentical hematopoietic stem cell transplantation: knowns, unknowns, and controversies. Biol Blood Marrow Transplant 19 (2): 180-4, 2013.
80. Wang Y, Chang YJ, Xu LP, et al.: Who is the best donor for a related HLA haplotype-mismatched transplant? Blood 124 (6): 843-50, 2014.
81. Canaani J, Savani BN, Labopin M, et al.: Impact of ABO incompatibility on patients' outcome after haploidentical hematopoietic stem cell transplantation for acute myeloid leukemia - a report from the Acute Leukemia Working Party of the EBMT. Haematologica 102 (6): 1066-1074, 2017.
82. Pulsipher MA, Langholz B, Wall DA, et al.: The addition of sirolimus to tacrolimus/methotrexate GVHD prophylaxis in children with ALL: a phase 3 Children's Oncology Group/Pediatric Blood and Marrow Transplant Consortium trial. Blood 123 (13): 2017-25, 2014.
83. Neudorf S, Sanders J, Kobrinsky N, et al.: Allogeneic bone marrow transplantation for children with acute myelocytic leukemia in first remission demonstrates a role for graft versus leukemia in the maintenance of disease-free survival. Blood 103 (10): 3655-61, 2004.
84. Boyiadzis M, Arora M, Klein JP, et al.: Impact of Chronic Graft-versus-Host Disease on Late Relapse and Survival on 7,489 Patients after Myeloablative Allogeneic Hematopoietic Cell Transplantation for Leukemia. Clin Cancer Res 21 (9): 2020-8, 2015.
85. Woods WG, Neudorf S, Gold S, et al.: A comparison of allogeneic bone marrow transplantation, autologous bone marrow transplantation, and aggressive chemotherapy in children with acute myeloid leukemia in remission. Blood 97 (1): 56-62, 2001.
86. Ribera JM, Ortega JJ, Oriol A, et al.: Comparison of intensive chemotherapy, allogeneic, or autologous stem-cell transplantation as postremission treatment for children with very high risk acute lymphoblastic leukemia: PETHEMA ALL-93 Trial. J Clin Oncol 25 (1): 16-24, 2007.
87. Gross TG, Hale GA, He W, et al.: Hematopoietic stem cell transplantation for refractory or recurrent non-Hodgkin lymphoma in children and adolescents. Biol Blood Marrow Transplant 16 (2): 223-30, 2010.
88. Pulsipher MA, Boucher KM, Wall D, et al.: Reduced-intensity allogeneic transplantation in pediatric patients ineligible for myeloablative therapy: results of the Pediatric Blood and Marrow Transplant Consortium Study ONC0313. Blood 114 (7): 1429-36, 2009.
89. Porter DL, Collins RH Jr, Shpilberg O, et al.: Long-term follow-up of patients who achieved complete remission after donor leukocyte infusions. Biol Blood Marrow Transplant 5 (4): 253-61, 1999.
90. Levine JE, Barrett AJ, Zhang MJ, et al.: Donor leukocyte infusions to treat hematologic malignancy relapse following allo-SCT in a pediatric population. Bone Marrow Transplant 42 (3): 201-5, 2008.
91. Warlick ED, DeFor T, Blazar BR, et al.: Successful remission rates and survival after lymphodepleting chemotherapy and donor lymphocyte infusion for relapsed hematologic malignancies postallogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant 18 (3): 480-6, 2012.
92. Horn B, Petrovic A, Wahlstrom J, et al.: Chimerism-based pre-emptive immunotherapy with fast withdrawal of immunosuppression and donor lymphocyte infusions after allogeneic stem cell transplantation for pediatric hematologic malignancies. Biol Blood Marrow Transplant 21 (4): 729-37, 2015.
93. Horn B, Wahlstrom JT, Melton A, et al.: Early mixed chimerism-based preemptive immunotherapy in children undergoing allogeneic hematopoietic stem cell transplantation for acute leukemia. Pediatr Blood Cancer 64 (8): , 2017.
94. Bader P, Kreyenberg H, Hoelle W, et al.: Increasing mixed chimerism is an important prognostic factor for unfavorable outcome in children with acute lymphoblastic leukemia after allogeneic stem-cell transplantation: possible role for pre-emptive immunotherapy? J Clin Oncol 22 (9): 1696-705, 2004.
95. Rettinger E, Willasch AM, Kreyenberg H, et al.: Preemptive immunotherapy in childhood acute myeloid leukemia for patients showing evidence of mixed chimerism after allogeneic stem cell transplantation. Blood 118 (20): 5681-8, 2011.
96. Ruggeri L, Capanni M, Urbani E, et al.: Effectiveness of donor natural killer cell alloreactivity in mismatched hematopoietic transplants. Science 295 (5562): 2097-100, 2002.
97. Giebel S, Locatelli F, Lamparelli T, et al.: Survival advantage with KIR ligand incompatibility in hematopoietic stem cell transplantation from unrelated donors. Blood 102 (3): 814-9, 2003.
98. Bari R, Rujkijyanont P, Sullivan E, et al.: Effect of donor KIR2DL1 allelic polymorphism on the outcome of pediatric allogeneic hematopoietic stem-cell transplantation. J Clin Oncol 31 (30): 3782-90, 2013.
99. Ruggeri L, Mancusi A, Capanni M, et al.: Donor natural killer cell allorecognition of missing self in haploidentical hematopoietic transplantation for acute myeloid leukemia: challenging its predictive value. Blood 110 (1): 433-40, 2007.
100. Davies SM, Ruggieri L, DeFor T, et al.: Evaluation of KIR ligand incompatibility in mismatched unrelated donor hematopoietic transplants. Killer immunoglobulin-like receptor. Blood 100 (10): 3825-7, 2002.
101. Farag SS, Bacigalupo A, Eapen M, et al.: The effect of KIR ligand incompatibility on the outcome of unrelated donor transplantation: a report from the center for international blood and marrow transplant research, the European blood and marrow transplant registry, and the Dutch registry. Biol Blood Marrow Transplant 12 (8): 876-84, 2006.
102. Cooley S, Trachtenberg E, Bergemann TL, et al.: Donors with group B KIR haplotypes improve relapse-free survival after unrelated hematopoietic cell transplantation for acute myelogenous leukemia. Blood 113 (3): 726-32, 2009.
103. Willemze R, Rodrigues CA, Labopin M, et al.: KIR-ligand incompatibility in the graft-versus-host direction improves outcomes after umbilical cord blood transplantation for acute leukemia. Leukemia 23 (3): 492-500, 2009.
104. Venstrom JM, Pittari G, Gooley TA, et al.: HLA-C-dependent prevention of leukemia relapse by donor activating KIR2DS1. N Engl J Med 367 (9): 805-16, 2012.
105. Leung W: Use of NK cell activity in cure by transplant. Br J Haematol 155 (1): 14-29, 2011.
106. Oevermann L, Michaelis SU, Mezger M, et al.: KIR B haplotype donors confer a reduced risk for relapse after haploidentical transplantation in children with ALL. Blood 124 (17): 2744-7, 2014.
107. Leung W, Iyengar R, Triplett B, et al.: Comparison of killer Ig-like receptor genotyping and phenotyping for selection of allogeneic blood stem cell donors. J Immunol 174 (10): 6540-5, 2005.
108. Miller JS, Soignier Y, Panoskaltsis-Mortari A, et al.: Successful adoptive transfer and in vivo expansion of human haploidentical NK cells in patients with cancer. Blood 105 (8): 3051-7, 2005.
109. Rubnitz JE, Inaba H, Ribeiro RC, et al.: NKAML: a pilot study to determine the safety and feasibility of haploidentical natural killer cell transplantation in childhood acute myeloid leukemia. J Clin Oncol 28 (6): 955-9, 2010.
110. Ciurea SO, Schafer JR, Bassett R, et al.: Phase 1 clinical trial using mbIL21 ex vivo-expanded donor-derived NK cells after haploidentical transplantation. Blood 130 (16): 1857-1868, 2017.
111. Kalos M, Levine BL, Porter DL, et al.: T cells with chimeric antigen receptors have potent antitumor effects and can establish memory in patients with advanced leukemia. Sci Transl Med 3 (95): 95ra73, 2011.
112. Grupp SA, Kalos M, Barrett D, et al.: Chimeric antigen receptor-modified T cells for acute lymphoid leukemia. N Engl J Med 368 (16): 1509-18, 2013.
113. Lee DW, Kochenderfer JN, Stetler-Stevenson M, et al.: T cells expressing CD19 chimeric antigen receptors for acute lymphoblastic leukaemia in children and young adults: a phase 1 dose-escalation trial. Lancet 385 (9967): 517-28, 2015.
114. Davila ML, Riviere I, Wang X, et al.: Efficacy and toxicity management of 19-28z CAR T cell therapy in B cell acute lymphoblastic leukemia. Sci Transl Med 6 (224): 224ra25, 2014.
115. Gardner RA, Finney O, Annesley C, et al.: Intent-to-treat leukemia remission by CD19 CAR T cells of defined formulation and dose in children and young adults. Blood 129 (25): 3322-3331, 2017.
116. Maude SL, Frey N, Shaw PA, et al.: Chimeric antigen receptor T cells for sustained remissions in leukemia. N Engl J Med 371 (16): 1507-17, 2014.
117. Lee DW, Gardner R, Porter DL, et al.: Current concepts in the diagnosis and management of cytokine release syndrome. Blood 124 (2): 188-95, 2014.
118. Maude SL, Barrett D, Teachey DT, et al.: Managing cytokine release syndrome associated with novel T cell-engaging therapies. Cancer J 20 (2): 119-22, 2014 Mar-Apr.
119. Maude SL, Laetsch TW, Buechner J, et al.: Tisagenlecleucel in Children and Young Adults with B-Cell Lymphoblastic Leukemia. N Engl J Med 378 (5): 439-448, 2018.
120. Chow VA, Shadman M, Gopal AK: Translating anti-CD19 CAR T-Cell therapy into clinical practice for relapsed/refractory diffuse large B-Cell lymphoma. Blood : , 2018.
121. Neelapu SS, Locke FL, Bartlett NL, et al.: Axicabtagene Ciloleucel CAR T-Cell Therapy in Refractory Large B-Cell Lymphoma. N Engl J Med 377 (26): 2531-2544, 2017.
122. Deeg HJ, Sandmaier BM: Who is fit for allogeneic transplantation? Blood 116 (23): 4762-70, 2010.
123. Bacigalupo A, Ballen K, Rizzo D, et al.: Defining the intensity of conditioning regimens: working definitions. Biol Blood Marrow Transplant 15 (12): 1628-33, 2009.
124. Luger SM, Ringdén O, Zhang MJ, et al.: Similar outcomes using myeloablative vs reduced-intensity allogeneic transplant preparative regimens for AML or MDS. Bone Marrow Transplant 47 (2): 203-11, 2012.
125. Scott BL, Pasquini MC, Logan BR, et al.: Myeloablative Versus Reduced-Intensity Hematopoietic Cell Transplantation for Acute Myeloid Leukemia and Myelodysplastic Syndromes. J Clin Oncol 35 (11): 1154-1161, 2017.
126. Giralt S, Estey E, Albitar M, et al.: Engraftment of allogeneic hematopoietic progenitor cells with purine analog-containing chemotherapy: harnessing graft-versus-leukemia without myeloablative therapy. Blood 89 (12): 4531-6, 1997.
127. Slavin S, Nagler A, Naparstek E, et al.: Nonmyeloablative stem cell transplantation and cell therapy as an alternative to conventional bone marrow transplantation with lethal cytoreduction for the treatment of malignant and nonmalignant hematologic diseases. Blood 91 (3): 756-63, 1998.
128. Storb R, Yu C, Sandmaier BM, et al.: Mixed hematopoietic chimerism after marrow allografts. Transplantation in the ambulatory care setting. Ann N Y Acad Sci 872: 372-5; discussion 375-6, 1999.
129. Bradley MB, Satwani P, Baldinger L, et al.: Reduced intensity allogeneic umbilical cord blood transplantation in children and adolescent recipients with malignant and non-malignant diseases. Bone Marrow Transplant 40 (7): 621-31, 2007.
130. Del Toro G, Satwani P, Harrison L, et al.: A pilot study of reduced intensity conditioning and allogeneic stem cell transplantation from unrelated cord blood and matched family donors in children and adolescent recipients. Bone Marrow Transplant 33 (6): 613-22, 2004.
131. Gómez-Almaguer D, Ruiz-Argüelles GJ, Tarín-Arzaga Ldel C, et al.: Reduced-intensity stem cell transplantation in children and adolescents: the Mexican experience. Biol Blood Marrow Transplant 9 (3): 157-61, 2003.
132. Pulsipher MA, Woolfrey A: Nonmyeloablative transplantation in children. Current status and future prospects. Hematol Oncol Clin North Am 15 (5): 809-34, vii-viii, 2001.
133. Roman E, Cooney E, Harrison L, et al.: Preliminary results of the safety of immunotherapy with gemtuzumab ozogamicin following reduced intensity allogeneic stem cell transplant in children with CD33+ acute myeloid leukemia. Clin Cancer Res 11 (19 Pt 2): 7164s-7170s, 2005.
134. Baron F, Baker JE, Storb R, et al.: Kinetics of engraftment in patients with hematologic malignancies given allogeneic hematopoietic cell transplantation after nonmyeloablative conditioning. Blood 104 (8): 2254-62, 2004.
135. Vigorito AC, Campregher PV, Storer BE, et al.: Evaluation of NIH consensus criteria for classification of late acute and chronic GVHD. Blood 114 (3): 702-8, 2009.
136. Marsh RA, Vaughn G, Kim MO, et al.: Reduced-intensity conditioning significantly improves survival of patients with hemophagocytic lymphohistiocytosis undergoing allogeneic hematopoietic cell transplantation. Blood 116 (26): 5824-31, 2010.
137. McSweeney PA, Niederwieser D, Shizuru JA, et al.: Hematopoietic cell transplantation in older patients with hematologic malignancies: replacing high-dose cytotoxic therapy with graft-versus-tumor effects. Blood 97 (11): 3390-400, 2001.
138. Horn B, Soni S, Khan S, et al.: Feasibility study of preemptive withdrawal of immunosuppression based on chimerism testing in children undergoing myeloablative allogeneic transplantation for hematologic malignancies. Bone Marrow Transplant 43 (6): 469-76, 2009.
139. Haines HL, Bleesing JJ, Davies SM, et al.: Outcomes of donor lymphocyte infusion for treatment of mixed donor chimerism after a reduced-intensity preparative regimen for pediatric patients with nonmalignant diseases. Biol Blood Marrow Transplant 21 (2): 288-92, 2015.

Complications After HCT

Pre-HCT Comorbidities That Affect the Risk of Transplant-Related Mortality: Predictive Power of the HCT-Specific Comorbidity Index

Because of the intensity of therapy associated with the transplant process, the pretransplant clinical status of recipients (e.g., age, presence of infections or organ dysfunction, and functional status) is associated with a risk of transplant-related mortality.

The best tool to assess the impact of pretransplant comorbidities on outcomes after transplant was developed by adapting an existing comorbidity scale, the Charlson Comorbidity Index (CCI). Investigators at the Fred Hutchinson Cancer Research Center systematically defined which of the CCI elements were correlated with transplant-related mortality in adult and pediatric patients. They also determined several additional comorbidities that have predictive power specific to transplant patients.

Successful validation defined what is now termed the hematopoietic cell transplantation–specific comorbidity index (HCT-CI).[1 ,2 ] Transplant-related mortality increases with cardiac, hepatic, pulmonary, gastrointestinal, infectious, and autoimmune comorbidities, or a history of previous solid tumors (refer to Table 4).

Table 4. Definitions of Comorbidities Included in the Hematopoietic Cell Transplantation–Specific Comorbidity Index (HCT-CI)^a

HCT-CI Score
1	2	3
AST/ALT = aspartate aminotransferase/alanine aminotransferase; DLCO = diffusion capacity of carbon monoxide; FEV1 = forced expiratory volume in one second; ULN = upper limit of normal.
a Adapted from Sorror et al.[1 ]
b One-or-more–vessel coronary artery stenosis requiring medical treatment, stent, or bypass graft.
Arrhythmia: Atrial fibrillation or flutter, sick sinus syndrome, or ventricular arrhythmias	Moderate pulmonary: DLCO and/or FEV1 66%–80% or dyspnea on slight activity	Heart valve disease: Excluding mitral valve prolapse
Cardiac: Coronary artery disease,b congestive heart failure, myocardial infarction, or ejection fraction ≤50%	Moderate/severe renal: Serum creatinine >2 mg/dL, on dialysis, or prior renal transplantation	Moderate/severe hepatic: Liver cirrhosis, bilirubin >1.5 × ULN, or AST/ALT >2.5 × ULN
Cerebrovascular disease: Transient ischemic attack or cerebrovascular accident	Peptic ulcer: Requiring treatment	Prior solid tumor: Treated at any time in the patient's history, excluding nonmelanoma skin cancer
Diabetes: Requiring treatment with insulin or oral hypoglycemic agents but not diet alone	Rheumatologic: Systemic lupus erythematosus, rheumatoid arthritis, polymyositis, mixed connective tissue disease, or polymyalgia rheumatica	Severe pulmonary: DLCO and/or FEV1 <65% or dyspnea at rest or requiring oxygen
Hepatic, mild: Chronic hepatitis, bilirubin >ULN or AST/ALT >ULN to 2.5 × ULN
Infection: Requiring continuation of antimicrobial treatment after day 0
Inflammatory bowel disease: Crohn disease or ulcerative colitis
Obesity: Body mass index >35 kg/m2
Psychiatric disturbance: Depression or anxiety requiring psychiatric consult or treatment

The predictive power of this index for both transplant-related mortality and overall survival (OS) is strong, with a hazard ratio of 3.54 (95% confidence interval [CI], 2.0–6.3) for nonrelapse mortality and 2.69 (95% CI, 1.8–4.1) for survival for patients with a score of 3 or higher, compared with those who have a score of 0. Although the original studies were performed with patients receiving intense myeloablative approaches, the HCT-CI has also been shown to be predictive of outcome for patients receiving reduced-intensity and nonmyeloablative regimens.[3 ] It has also been combined with disease status [4 ] and Karnofsky score,[5 ] leading to even better prediction of survival outcomes. In addition, high HCT-CI scores (>3) have been associated with a higher risk of grades 3 to 4 acute graft-versus-host disease (GVHD).[6 ]

Most patients assessed in the HCT-CI studies have been adults, and the comorbidities listed are skewed toward adult diseases. The relevance of this scale for pediatric and young adult recipients of HCT has been explored in the following studies:

• A retrospective cohort study was conducted at four large centers of pediatric patients (median age, 6 years) with a wide variety of both malignant and nonmalignant disorders.[7 ] The HCT-CI was predictive of both nonrelapse mortality and survival, with 1-year nonrelapse mortality of 10%, 14%, and 28% and 1-year OS of 88%, 67%, and 62% for patients with scores of 0, 1 to 2, and 3 or higher, respectively.
• A second study included young adults (aged 16–39 years) and demonstrated similar increases in mortality with higher HCT-CI scores (nonrelapse mortality of 24% and 38% and OS of 46% and 28% for patients with scores of 0–2 and 3+, respectively).[8 ]
• As part of a prospective validation of the HCT-CI through the Center for International Blood and Marrow Transplant Research, 23,876 patients—including 1,755 children—who underwent transplant between 2007 and 2009 were scored and outcomes were tracked. Although adults treated with myeloablative regimens had increased mortality with scores of 1 or 2, pediatric patients did not have increased mortality until a score of 3 or higher was noted.[9 ]

Most of the reported comorbidities in these studies were with respiratory or hepatic conditions and infection.[7 ,8 ] In the adolescent and young adult study, patients with pre-HCT pulmonary dysfunction were at particularly high risk of comorbidity, with a 2-year OS of 29%, compared with 61% in those with normal lung function before HCT.[8 ]

Selected HCT-Related Acute Complications

Infectious risks and immune recovery after transplantation

Defective immune reconstitution is a major barrier to successful HCT, regardless of graft source.[10 ,11 ] Serious infections have been shown to account for a significant percentage (4%–20%) of late deaths after HCT.[12 ]

Factors that can significantly slow immune recovery include the following:[13 ]

• Graft manipulation (removal of T cells).
• Stem cell source (slow recovery with cord blood).
• Chronic GVHD.

Figure 5 illustrates the immune defects, contributing transplant-related factors, and types and timing of infections that occur after allogeneic transplantation.[14 ]

Figure 5. Phases of predictable immune suppression with their opportunistic infections among allogeneic hematopoietic stem cell transplantation recipients. Adapted from Burik and Freifeld. This figure was published in Clinical Oncology, 3rd edition, Abeloff et al., Chapter: Infection in the severely immunocompromised patient, Pages 941–956, Copyright Elsevier (2004).

Bacterial infections tend to occur in the first few weeks after transplant during the neutropenic phase, when mucosal barriers are damaged from the conditioning regimen; there is significant ongoing study about the role of prophylactic antibacterial medications during the neutropenic phase.[15 ]

Prophylaxis against fungal infections is standard during the first several months after transplantation and may be considered for patients with chronic GVHD who are at high risk of fungal infection. Antifungal prophylaxis must be tailored to the patient's underlying immune status. Pneumocystis infection can occur in all patients post–bone marrow transplant, and prophylaxis is mandatory.[15 ]; [16 ][Level of evidence: 3iiiB]

After HCT, viral infections can be a major source of mortality, especially after T-cell–depleted or cord blood procedures. Types of viral infections include the following:

• Cytomegalovirus (CMV). CMV infection has been a major cause of mortality in the past, but effective drugs to treat CMV are available, and preventive strategies, including quantitative polymerase chain reaction (PCR) monitoring followed by preemptive therapy with ganciclovir, have been developed.
• Epstein-Barr virus (EBV). EBV rarely causes lymphoproliferative disease and is generally associated with intensive, multidrug GVHD therapy or T-cell–depleted HCT.
• Adenovirus. Adenovirus infection is a major issue in T-cell–depleted transplantation, and monitoring by quantitative blood PCR followed by therapy with cidofovir or brincidofovir (available through a compassionate-use protocol) has led to a major decrease in morbidity.[17 ]
• Other. Other viruses have been implicated in hemorrhagic cystitis (BK virus), encephalitis and poor count recovery (human herpes virus 6), and other clinical issues.[15 ]

Careful viral monitoring is essential during high-risk allogeneic procedures.

Late bacterial infections can occur in patients who have central lines or patients with significant chronic GVHD. These patients are susceptible to infection with encapsulated organisms, particularly pneumococcus. Despite reimmunization, these patients can sometimes develop significant infections, and continued prophylaxis is recommended until a serological response to immunizations has been documented. Occasionally, postallogeneic HCT patients can become functionally asplenic, and antibiotic prophylaxis is recommended. Patients should remain on infection prophylaxis (e.g., Pneumocystis jirovecii pneumonia prophylaxis) until immune recovery. Time to immune recovery varies, but ranges from 3 months to 9 months after autologous HCT and 9 months to 24 months after allogeneic HCT without GVHD. Patients with active chronic GVHD may have persistent immunosuppression for years. Many centers monitor T-cell subset recovery post–bone marrow transplant as a guide to infection risk.[15 ]

Vaccination after transplantation

Specific guidelines have been developed by international transplant and infectious disease groups for administration of vaccinations after autologous and allogeneic transplantation.[15 ] Comparative studies aimed at defining ideal timing of vaccination after transplantation have not been performed, but the vaccine guidelines outlined in Table 5 result in protective titers in most patients who receive vaccinations. These guidelines recommend that autologous transplant recipients receive immunizations beginning at 6 months after stem cell infusion and receive live vaccines 24 months after the transplant. Patients undergoing allogeneic procedures can begin immunizations as soon as 6 months after transplant. However, many groups prefer to wait either until 12 months after the procedure for patients remaining on immune suppression or until patients are off immune suppression.

Vaccination recommendations should be reconsidered at times of local endemic or epidemic disease outbreaks. In those settings, earlier vaccination with killed vaccines may be implemented, acknowledging limited host responses.

Table 5. Vaccination Schedule for Hematopoietic Stem Cell Transplantation (HSCT) Recipients^a

Autologous HSCT	6 Mob	8 Mob	12 Mob	24 Mob
Allogeneic HSCT (if not immunized before 12 mo post-HSCT; start regardless of GVHD status or immunosuppression)	12 mob(sooner if off immunosuppression)	14 mob(or 2 mo after first dose)	18 mob(or 6 mo after first dose)	24 mob
GVHD = graft-versus-host disease; IM = intramuscular; PO = orally.
a Adapted from Tomblyn et al.,[15 ]Centers for Disease Control and Prevention,[18 ]and Kumar et al.[19 ]
b Times indicated are times posttransplant (day 0).
c Use of Tdap is acceptable if DTap is not available.
d Titers may be considered for pediatric patients and patients with GVHD who received immunizations while on immune suppression (minimum 6–8 weeks after last vaccination).
e May start as soon as 4 months post-HSCT or sooner for patients with CD4 counts >200/mcL or at any time during an epidemic. If given <6 months after HSCT, may require second dose. Children younger than 9 years require second dose, separated by 1 month.
f Consider pre- or postvaccine (at least 6–8 weeks after) titers.
g PCV 7 at 24 months only for patients with GVHD; all other patients can get PPV 23.
h Pediatric patients should receive two doses at least 1 month apart.
Inactivated Vaccines
Diphtheria, tetanus, acellular pertussis (DTap)	Xc	Xc	Xc,d
Haemophilus influenzae (Hib)	X	X	Xd
Hepatitis B (HepB)	X	X	Xd
Inactive polio (IPV)	X	X	Xd
Influenza—seasonal injection (IM)	Xe
Pneumococcal conjugate (PCV 7, PCV 13)	Xf	X	Xd,f,g
Pneumococcal polysaccharide (PPV 23)			Xd,f,g
Live Attenuated Vaccines(contraindicated in patients with active GVHD or on immunosuppression)
Measles, mumps, rubella				Xd,h
Optional Inactivated Vaccines
Hepatitis A			Optional
Meningococcal			Xd(for high-risk patients)
Optional Live Vaccines(contraindicated in patients with active GVHD or on immunosuppression)
Chicken pox (varicella vaccine)				Optional
Rabies			May be considered at 12–24 mo if exposed
Yellow fever, tick-borne encephalitis (TBE), Japanese B encephalitis				For travel in endemic areas
Contraindicated Vaccines
Intranasal influenza (trivalent live-attenuated influenza vaccine) —household contacts and caregivers should not receive within 2 weeks before contact with HSCT recipient;shingles;bacillus Calmette-Guerin (BCG);oral polio vaccine (OPV);cholera;typhoid vaccine (PO, IM);rotavirus.

Sinusoidal obstruction syndrome/veno-occlusive disease

Pathologically, sinusoidal obstructive syndrome/veno-occlusive disease of the liver (SOS/VOD) is the result of damage to the hepatic sinusoids, resulting in biliary obstruction. This syndrome has been estimated to occur in 15% to 40% of pediatric myeloablative transplantation patients.[20 ,21 ]

Risk factors include the following:[20 ,21 ]

• Use of busulfan (especially before therapeutic pharmacokinetic monitoring).
• Total-body irradiation.
• Serious infection.
• GVHD.
• Pre-existing liver dysfunction due to hepatitis or iron overload.

SOS/VOD is defined clinically by the following:

• Right upper quadrant pain with hepatomegaly.
• Fluid retention (weight gain and ascites).
• Hyperbilirubinemia.

Life-threatening SOS/VOD generally occurs soon after transplantation and is characterized by multiorgan system failure.[22 ] Milder, reversible forms can occur, with full recovery expected. Pediatric patients who have severe SOS/VOD without increased bilirubin have been reported;[23 ] therefore, it is important to be vigilant about monitoring patients who have other symptoms without increased bilirubin.

Prevention and treatment of SOS/VOD

Approaches to both prevention and treatment with agents such as heparin, protein C, and antithrombin III have been studied, with mixed results.[24 ] One small, retrospective, single-center study showed a benefit from corticosteroid therapy, but further validation is needed.[25 ] Another agent with demonstrated activity is defibrotide, a mixture of oligonucleotides with antithrombotic and fibrinolytic effects on microvascular endothelium. Defibrotide has demonstrated the following:

• Decreased mortality in the treatment of severe SOS/VOD.[26 ,27 ,28 ,29 ]; [30 ][Level of evidence: 3iiiA]
• Decreased SOS/VOD mortality associated with the early initiation of defibrotide treatment soon after diagnostic criteria for SOS/VOD were met.[31 ][Level of evidence: 2A]
• Efficacy in decreasing SOS/VOD incidence when used prophylactically.[32 ][Level of evidence: 1iiA]

Defibrotide is approved by the U.S. Food and Drug Administration (FDA) for the treatment of patients who have hepatic SOS/VOD with renal or pulmonary dysfunction after HSCT.

The British Society for Blood and Marrow Transplantation (BSBMT) published evidence-guided recommendations for the diagnosis and management of SOS/VOD.[29 ] They recommend that biopsy be reserved for difficult cases and be performed using the transjugular approach. The BSBMT supports the use of defibrotide for the prevention of SOS/VOD (defibrotide prophylaxis is not currently part of the FDA indication), but concluded there is insufficient data to support the use of prostaglandin E1, pentoxifylline, or antithrombin. For treatment of SOS/VOD, they recommend aggressive fluid balance management, early involvement of critical care and gastroenterology specialists, and the use of defibrotide and possibly methylprednisolone, but concluded there is insufficient evidence to support the use of tissue plasminogen activator or N-acetylcysteine.[29 ,33 ] More detailed consensus recommendations for the diagnosis and management of SOS/VOD in children after HCT have been published by the Pediatric Blood and Marrow Transplant Consortium (PBMTC), who worked with the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI).[34 ,35 ,36 ]

Transplant-associated microangiopathy

Although transplant-associated microangiopathy clinically mirrors hemolytic uremic syndrome, its causes and clinical course differ from those of other hemolytic uremic syndrome–like diseases. Studies have linked this syndrome with dysregulation of complement pathways.[37 ] Transplant-associated microangiopathy has most frequently been associated with the use of the calcineurin inhibitors tacrolimus and cyclosporine, and has been noted to occur more frequently when either of these medications are used in combination with sirolimus.[38 ]

Diagnostic criteria for this syndrome have been standardized and include the following:[39 ]

• Presence of schistocytes on a peripheral smear.
• Increased lactic dehydrogenase.
• Decreased haptoglobin.
• Thrombocytopenia with or without anemia.

Suggestive symptoms consistent with but not necessary for the diagnosis include a sudden worsening of renal function or neurologic symptoms.

Treatment of transplant-associated microangiopathy

Treatment for transplant-associated microangiopathy includes the following:

• Cessation of the calcineurin inhibitor and substitution with other immune suppressants, if necessary.
• Careful management of hypertension and renal damage by dialysis, if necessary, is vital.

Prognosis for normalization of kidney function when disease is caused by calcineurin inhibitors alone is generally poor; however, most transplant-associated microangiopathy associated with the combination of a calcineurin inhibitor and sirolimus has been reversed after sirolimus is stopped, and in some cases, after both medications are stopped.[38 ]

Some evidence suggests a role for complement modulation (c5, eculizumab therapy) in preserving renal function; further assessment of the role of this medication in treating this complication is ongoing.[40 ,41 ]

Idiopathic pneumonia syndrome

Idiopathic pneumonia syndrome is characterized by diffuse, noninfectious lung injury that occurs from 14 to 90 days after the infusion of donor cells. Possible etiologies include direct toxic effects of the conditioning regimens and occult infection leading to secretion of high levels of inflammatory cytokines into the alveoli.[42 ]

The incidence of this complication appears to be decreasing, possibly because of less intensive preparative regimens, better HLA matching, and better definition of occult infections through PCR testing of blood and bronchioalveolar specimens. Mortality rates of 50% to 70% have been reported;[42 ] however, these estimates are from the mid-1990s, and outcomes may have improved.

Diagnostic criteria include the following signs and symptoms in the absence of documented infectious organisms:[43 ]

• Pneumonia.
• Evidence of nonlobar radiographic infiltrates.
• Abnormal pulmonary function.

Early assessment by bronchioalveolar lavage to rule out infection is important.

Treatment of idiopathic pneumonia syndrome

Traditional therapy has been high-dose methylprednisolone and pulmonary support.

Etanercept is a soluble fusion protein that joins the extracellular ligand-binding domain of the tumor necrosis factor (TNF)–alpha receptor to the Fc region of the immunoglobulin G1 antibody. It acts by blocking TNF-alpha signaling. The addition of etanercept to steroid therapies has shown promising short-term outcomes (extubation, improved short-term survival) in single-center studies.[44 ] A large phase II trial of this approach in pediatrics showed promising results, with overall survival rates of 89% at 1 month and 63% at 12 months.[45 ]

Epstein-Barr virus (EBV)–associated lymphoproliferative disorder

After HCT, EBV infection incidence increases through childhood, from approximately 40% in children aged 4 years to more than 80% in teenagers. Patients with a history of previous EBV infection are at risk of EBV reactivation when undergoing HCT procedures that result in intense, prolonged lymphopenia (T-cell–depleted procedures, use of antithymocyte globulin or alemtuzumab, and to a lesser degree, use of cord blood).[46 ,47 ,48 ]

Features of EBV reactivation can vary from an isolated increase in EBV titers in the bloodstream as measured by PCR, to an aggressive monoclonal disease with marked lymphadenopathy presenting as lymphoma (lymphoproliferative disorder).

Isolated bloodstream reactivation can improve in some cases without therapy as immune function improves; however, lymphoproliferative disorder requires more aggressive therapy. Treatment of EBV–associated lymphoproliferative disorder has relied on decreasing immune suppression and treatment with chemotherapy agents such as cyclophosphamide. CD20-positive EBV–associated lymphoproliferative disorder and EBV reactivation have been shown to respond to therapy with the CD20 monoclonal antibody therapy rituximab.[49 ,50 ,51 ] In addition, some centers have shown efficacy in treating or preventing this complication with therapeutic or prophylactic EBV-specific cytotoxic T cells.[52 ,53 ]

Improved understanding of the risk of EBV reactivation, early monitoring, and aggressive therapy have significantly decreased the risk of mortality from this challenging complication.

Acute graft-versus-host disease (GVHD)

GVHD is the result of immunologic activation of donor lymphocytes targeting major or minor HLA disparities present in the tissues of a recipient.[54 ] Acute GVHD usually occurs within the first 3 months posttransplantation, although delayed acute GVHD has been noted in reduced-intensity conditioning and nonmyeloablative approaches where achieving a high level of full donor chimerism is sometimes delayed.

Typically, acute GVHD presents with at least one of the following three manifestations:

• Skin rash.
• Hyperbilirubinemia.
• Secretory diarrhea.

Acute GVHD is classified by staging the severity of skin, liver, and gastrointestinal involvement and further combining the individual staging of these three areas into an overall grade that is prognostically significant (refer to Tables 6 and 7).[55 ] Patients with grade III or grade IV acute GVHD are at higher risk of mortality, generally resulting from organ system damage caused by infections or progressive acute GVHD that is sometimes resistant to therapy.

Table 6. Staging of Acute Graft-Versus-Host Disease (GVHD)^a

Stage	Skin	Liver (bilirubin)b	GI/Gut (stool output per day)c
			Adult	Child
BSA = body surface area; GI = gastrointestinal.
a Adapted from Harris et al.[56 ]
b There is no modification of liver staging for other causes of hyperbilirubinemia.
c For GI staging: Theadult stool output values should be used for patients weighing >50 kg. Use 3-day averages for GI staging based on stool output. If stool and urine are mixed, stool output is presumed to be 50% of total stool/urine mix.
d If results of colon or rectal biopsy are positive, but stool output is <500 mL/day (<10 mL/kg/day), then consider as GI stage 0.
e For stage 4 GI: the termsevere abdominal pain will be defined as having both (a) pain control requiring treatment with opioids or an increased dose in ongoing opioid use; and (b) pain that significantly impacts performance status, as determined by the treating physician.
0	No GVHD rash	<2 mg/dL	<500 mL or <3 episodes/day	<10 mL/kg or <4 episodes/day
1	Maculopapular rash <25% BSA	2–3 mg/dL	500–999 mLd or 3–4 episodes/day	10–19.9 mL/kg or 4–6 episodes/day; persistent nausea, vomiting, or anorexia, with a positive result from upper GI biopsy
2	Maculopapular rash 25%–50% BSA	3.1–6 mg/dL	1,000–1,500 mL or 5–7 episodes/day	20–30 mL/kg or 7–10 episodes/day
3	Maculopapular rash >50% BSA	6.1–15 mg/dL	>1,500 mL or >7 episodes/day	>30 mL/kg or >10 episodes/day
4	Generalized erythroderma plus bullous formation and desquamation >5% BSA	>15 mg/dL	Severe abdominal paine with or without ileus, or grossly bloody stool (regardless of stool volume)	Severe abdominal paine with or without ileus, or grossly bloody stool (regardless of stool volume)

Table 7. Overall Clinical Grade (Based on the Highest Stage Obtained)

GI = gastrointestinal.
Grade 0:	No stage 1–4 of any organ
Grade I:	Stage 1–2 skin and no liver or gut involvement
Grade II:	Stage 3 skin and/or stage 1 liver involvement and/or stage 1 GI
Grade III:	Stage 0–3 skin, with stage 2–3 liver and/or stage 2–3 GI
Grade IV:	Stage 4 skin, liver, or GI involvement

Prevention and treatment of acute GVHD

Morbidity and mortality from acute GVHD can be reduced through immune suppressive medications given prophylactically or T-cell depletion of grafts, either ex vivo by actual removal of cells from a graft or in vivo with antilymphocyte antibodies (antithymocyte globulin or anti-CD52 [alemtuzumab]).

Approaches to GVHD prevention in non–T-cell-depleted grafts have included the following:[57 ,58 ]; [59 ][Level of evidence: 3iiiA]

• Intermittent methotrexate.
• Calcineurin inhibitor (e.g., cyclosporine or tacrolimus).
• Combination of a calcineurin inhibitor with methotrexate (currently the most commonly used approach in pediatrics).
• Various combinations of a calcineurin inhibitor with steroids or mycophenolate mofetil.
• Non–calcineurin inhibitor (intensive T-cell depletion, posttransplant cyclophosphamide, etc.). Non–calcineurin inhibitor approaches have been developed and are becoming more widely used.

When significant acute GVHD occurs, first-line therapy is generally methylprednisolone.[60 ] Patients with acute GVHD resistant to this therapy have a poor prognosis, but a good percentage of cases respond to second-line agents (e.g., mycophenolate mofetil, infliximab, pentostatin, sirolimus, or extracorporeal photopheresis).[61 ]

Complete elimination of acute GVHD with intense T-cell depletion has generally resulted in increased relapse, more infectious morbidity, and increased EBV-associated lymphoproliferative disorder. Because of this, most HCT GVHD prophylaxis is given in an attempt to balance risk by giving sufficient immune suppression to prevent severe acute GVHD but not completely remove GVHD risk.

Chronic GVHD

Chronic GVHD is a syndrome that may involve a single organ system or several organ systems, with clinical features resembling an autoimmune disease.[62 ,63 ] Chronic GVHD is usually first noted 2 to 12 months after HCT. Traditionally, symptoms occurring more than 100 days after HCT were considered to be chronic GVHD, and symptoms occurring sooner than 100 days post-HCT were considered to be acute GVHD. Because some approaches to HCT can lead to late-onset acute GVHD, and manifestations that are diagnostic for chronic GVHD can occur sooner than 100 days post-HCT, the following three distinct types of chronic GVHD have been described:

• Classic chronic GVHD: Occurs with diagnostic and/or distinct features of chronic GVHD (refer to Tables 8–12) after a previous history of resolved acute GVHD.
• Overlap syndrome: An ongoing GVHD process when manifestations diagnostic for chronic GVHD occur while symptoms of acute GVHD persist.
• De novo chronic GVHD: New-onset GVHD generally occurring at least 2 months after transplant, with diagnostic and/or distinct features of chronic GVHD and no history or features of acute GVHD.

Chronic GVHD occurs in approximately 15% to 30% of children after sibling donor HCT [64 ] and in 20% to 45% of children after unrelated-donor HCT, with a higher risk associated with peripheral blood stem cells (PBSCs) and a lower risk associated with cord blood.[65 ,66 ] The tissues that are commonly involved include skin, eyes, mouth, hair, joints, liver, and gastrointestinal tract. Other tissues such as lungs, nails, muscles, urogenital system, and nervous system may be involved.

Risk factors for the development of chronic GVHD include the following:[64 ,67 ,68 ]

• Patient's age.
• Type of donor.
• Use of PBSCs.
• History of acute GVHD.
• Conditioning regimen.

The diagnosis of chronic GVHD is based on clinical features (at least one diagnostic clinical sign, e.g., poikiloderma) or distinctive manifestations complemented by relevant tests (e.g., dry eye with positive results of a Schirmer test).[69 ] Tables 8 to 12 list organ manifestations of chronic GVHD with a description of findings that are sufficient to establish the diagnosis of chronic GVHD. Biopsies of affected sites may be needed to confirm the diagnosis.[70 ]

Table 8. Chronic Graft-versus-Host Disease (GVHD) Symptoms in the Skin, Nails, Scalp, and Body Hair^a

Organ or Site	Diagnosticb	Distinctivec	Other Featuresd	Common (Seen with Both Acute and Chronic GVHD)
a Reprinted fromBiology of Blood and Marrow Transplantation, Volume 11 (Issue 12), Alexandra H. Filipovich, Daniel Weisdorf, Steven Pavletic, Gerard Socie, John R. Wingard, Stephanie J. Lee, Paul Martin, Jason Chien, Donna Przepiorka, Daniel Couriel, Edward W. Cowen, Patricia Dinndorf, Ann Farrell, Robert Hartzman, Jean Henslee-Downey, David Jacobsohn, George McDonald, Barbara Mittleman, J. Douglas Rizzo, Michael Robinson, Mark Schubert, Kirk Schultz, Howard Shulman, Maria Turner, Georgia Vogelsang, Mary E.D. Flowers, National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. Diagnosis and Staging Working Group Report, Pages 945-956, Copyright 2005, with permission from American Society for Blood and Marrow Transplantation and Elsevier.[69 ]
b Sufficient to establish the diagnosis of chronic GVHD.
c Seen in chronic GVHD, but insufficient alone to establish a diagnosis of chronic GVHD.
d Can be acknowledged as part of the chronic GVHD symptomatology if the diagnosis is confirmed.
e In all cases, infection, drug effects, malignancy, or other causes must be excluded.
f Diagnosis of chronic GVHD requires biopsy or radiology confirmation (or Schirmer test for eyes).
Skin	Poikiloderma	Depigmentation	Sweat impairment	Pruritus
	Lichen planus–like features		Ichthyosis	Erythema
	Sclerotic features		Keratosis pilaris	Maculopapular rash
	Morphea-like features		Hypopigmentation
	Lichen sclerosus–like features		Hyperpigmentation
Nails		Dystrophy
		Longitudinal ridging, splitting, or brittle features
		Onycholysis
		Pterygium unguis
		Nail loss (usually symmetric; affects most nails)e
Scalp and body hair		New onset of scarring or nonscarring scalp alopecia (after recovery from chemoradiotherapy)	Thinning scalp hair, typically patchy, coarse, or dull (not explained by endocrine or other causes)
		Scaling, papulosquamous lesions	Premature gray hair

Table 9. Chronic Graft-versus-Host Disease (GVHD) Symptoms in the Mouth and GI Tract^a

Organ or Site	Diagnosticb	Distinctivec	Other Featuresd	Common (Seen with Both Acute and Chronic GVHD)
ALT = alanine aminotransferase; AST = aspartate aminotransferase; GI = gastrointestinal; ULN = upper limit of normal.
Refer to Table 8footers for definitions ofa throughe.
Mouth	Lichen-type features	Xerostomia		Gingivitis
	Hyperkeratotic plaques	Mucocele		Mucositis
	Restriction of mouth opening from sclerosis	Pseudomembranese		Erythema
		Mucosal atrophy		Pain
		Ulcerse
GI Tract	Esophageal web		Exocrine pancreatic insufficiency	Anorexia
	Strictures or stenosis in the upper to mid third of the esophaguse			Nausea
				Vomiting
				Diarrhea
				Weight loss
				Failure to thrive (infants and children)
				Total bilirubin, alkaline phosphatase >2 × ULNe
				ALT or AST >2 × ULNe

Table 10. Chronic Graft-versus-Host Disease (GVHD) Symptoms in the Eyes^a

Organ or Site	Diagnosticb	Distinctivec	Other Featuresd	Common (Seen with Both Acute and Chronic GVHD)
Refer to Table 8footers for definitions ofa throughf.
Eyes		New onset dry, gritty, or painful eyesf	Blepharitis (erythema of the eyelids with edema)
		Cicatricial conjunctivitis
		Keratoconjunctivitis siccaf	Photophobia
		Confluent areas of punctate keratopathy	Periorbital hyperpigmentation

Table 11. Chronic Graft-versus-Host Disease (GVHD) Symptoms in the Genitalia^a

Organ or Site	Diagnosticb	Distinctivec	Other Featuresd	Common (Seen with Both Acute and Chronic GVHD)
Refer to Table 8footers for definitions ofa throughe.
Genitalia	Lichen planus–like features	Erosionse
		Fissurese
	Vaginal scarring or stenosis	Ulcerse

Table 12. Chronic Graft-versus-Host Disease (GVHD) Symptoms in the Lung, Muscles, Fascia, Joints, Hematopoietic and Immune Systems, and Other Symptoms^a

Organ or Site	Diagnosticb	Distinctivec	Other Featuresd	Common (Seen with Both Acute and Chronic GVHD)
AIHA = autoimmune hemolytic anemia; BOOP = bronchiolitis obliterans–organizing pneumonia; ITP = idiopathic thrombocytopenic purpura; PFTs = pulmonary function tests.
Refer to Table 8footers for definitions ofa throughf.
Lung	Bronchiolitis obliterans diagnosed with lung biopsy	Bronchiolitis obliterans diagnosed with PFTs and radiologyf		BOOP
Muscles, fascia, joints	Fasciitis	Myositis or polymyositisf	Edema
			Muscle cramps
			Arthralgia or arthritis
Hematopoietic and immune			Thrombocytopenia
			Eosinophilia
			Lymphopenia
			Hypo- or hypergammaglobulinemia
			Autoantibodies (AIHA and ITP)
Other			Pericardial or pleural effusions
			Ascites
			Peripheral neuropathy
			Nephrotic syndrome
			Myasthenia gravis
			Cardiac conduction abnormality or cardiomyopathy

Common skin manifestations include alterations in pigmentation, texture, elasticity, and thickness, with papules, plaques, or follicular changes. Patient-reported symptoms include dry skin, itching, limited mobility, rash, sores, or changes in coloring or texture. Generalized scleroderma may lead to severe joint contractures and debility. Associated hair loss and nail changes are common. Other important symptoms that should be assessed include dry eyes and oral changes such as atrophy, ulcers, and lichen planus. In addition, joint stiffness along with restricted range of motion, weight loss, nausea, difficulty swallowing, and diarrhea should be noted.

Several factors have been associated with increased risk of nonrelapse mortality in children who develop significant chronic GVHD. Children who received HLA-mismatched grafts, received PBSCs, were older than 10 years, or had platelet counts lower than 100,000/µL at diagnosis of chronic GVHD have an increased risk of nonrelapse mortality. Nonrelapse mortality was 17% at 1 year, 22% at 3 years, and 24% at 5 years after diagnosis with chronic GVHD. Many of these children required long-term immune suppression. By 3 years after diagnosis of chronic GVHD, about a third of children had died of either relapse or nonrelapse mortality, a third were off immune suppression, and a third still required some form of immune suppressive therapy.[71 ]

Older literature describes chronic GVHD as either limited or extensive. A National Institutes of Health (NIH) Consensus Workshop in 2006 proposed broadening the description of chronic GVHD to three categories to better predict long-term outcomes.[72 ] The three NIH grading categories are as follows:[69 ]

• Mild disease: Involving only one or two sites, with no significant functional impairment (maximum severity score of 1 on a scale of 0 to 3).
• Moderate disease: Either involving more sites (>2) or associated with higher severity score (maximum score of 2 in any site).
• Severe disease: Indicating major disability (a score of 3 in any site or a lung score of 2).

Thus, high-risk patients include those with severe disease of any site or extensive involvement of multiple sites, especially those with the following:

• Symptomatic lung involvement.
• Skin involvement greater than 50%.
• Platelet count lower than 100,000/µL.
• Poor performance score (<60%).
• Weight loss of more than 15%.
• Chronic diarrhea.
• Progressive-onset chronic GVHD.
• History of steroid treatment with more than 0.5 mg of prednisone per kilogram per day for acute GVHD.

One study demonstrated a much higher chance of long-term GVHD-free survival and lower treatment-related mortality in children with mild and moderate chronic GVHD than in children with severe chronic GVHD. At 8 years, the probability of continued chronic GVHD in children with mild, moderate, and severe chronic GVHD was 4%, 11%, and 36%, respectively.[73 ] In another large prospective trial with central review that used the National Institutes of Health (NIH) consensus criteria, about 28% of patients were misclassified as having chronic GVHD when they actually had late-acute GVHD. Additionally, there were significant challenges when using the NIH consensus criteria for bronchiolitis obliterans in children.[74 ]

Treatment of chronic GVHD

Steroids remain the cornerstone of chronic GVHD therapy; however, many approaches have been developed to minimize steroid dosing, including the use of calcineurin inhibitors.[75 ] Topical therapy to affected areas is preferred for patients with limited disease.[76 ] The following agents have been tested with some success:

• Mycophenolate mofetil.[77 ]
• Pentostatin.[78 ]
• Sirolimus.[79 ]
• Rituximab.[80 ]
• Ibrutinib.[81 ]

Other approaches, including extracorporeal photopheresis, have been evaluated and show some efficacy in a percentage of patients.[82 ]

Besides significantly affecting organ function, quality of life, and functional status, infection is the major cause of chronic GVHD–related death. Therefore, all patients with chronic GVHD receive prophylaxis against Pneumocystis jirovecii pneumonia, common encapsulated organisms, and varicella by using agents such as trimethoprim/sulfamethoxazole, penicillin, and acyclovir. While disease progression is the primary cause of death seen in long-term follow-up of hematopoietic stem cell transplantation patients with no chronic GVHD, transplant-related complications account for 70% of the deaths in patients with chronic GVHD.[64 ] Guidelines concerning ancillary therapy and supportive care of patients with chronic GVHD have been published.[76 ]

Late Mortality After HCT

The highest incidence of mortality after HCT occurs in the first 2 years, mostly caused by relapse. A study of late mortality (≥2 years) after HCT showed that about 20% of the 479 patients who were alive at 2 years suffered a late death. Late mortality in the allogeneic group was 15% (median follow-up, 10.0 years; range, 2.0–25.6 years), mainly caused by relapse (65%). A total of 26% of patients suffered a late death after autologous HCT (median follow-up, 6.7 years; range, 2.0–22.2 years),[83 ] and recurrence of the primary malignancy accounted for 88% of these deaths. In contrast to studies of adult patients, nonrelapse mortality is less common in children, and death caused by chronic GVHD and secondary malignancies is less common. Another study reviewed the causes of late mortality after second allogeneic transplantation.[84 ] Of the children who were alive and relapse free 1 year after second HCT, 55% remained alive at 10 years. The most common cause of mortality at 10 years in this group was relapse (77% of deaths), generally occurring in the first 3 years after transplantation. The cumulative incidence of nonrelapse mortality for this cohort at 10 years was 10%. Chronic GVHD occurred in 43% of children in this study and was the leading cause of nonrelapse mortality.

A study focused on late mortality after autologous HCT in children showed that mortality rates remained elevated from those of the general population more than 10 years after the procedure, but approached the rates of the general population at 15 years. The study also showed a decrease in late mortality in the more current treatment eras (before 1990: 35.1%; 1990–1999: 25.6%; 2000–2010: 21.8%; P = .05).[85 ]

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18. Centers for Disease Control and Prevention, Infectious Disease Society of America, American Society of Blood and Marrow Transplantation: Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Recomm Rep 49 (RR-10): 1-125, CE1-7, 2000.
19. Kumar D, Chen MH, Welsh B, et al.: A randomized, double-blind trial of pneumococcal vaccination in adult allogeneic stem cell transplant donors and recipients. Clin Infect Dis 45 (12): 1576-82, 2007.
20. Reiss U, Cowan M, McMillan A, et al.: Hepatic venoocclusive disease in blood and bone marrow transplantation in children and young adults: incidence, risk factors, and outcome in a cohort of 241 patients. J Pediatr Hematol Oncol 24 (9): 746-50, 2002.
21. Cesaro S, Pillon M, Talenti E, et al.: A prospective survey on incidence, risk factors and therapy of hepatic veno-occlusive disease in children after hematopoietic stem cell transplantation. Haematologica 90 (10): 1396-404, 2005.
22. Bearman SI: The syndrome of hepatic veno-occlusive disease after marrow transplantation. Blood 85 (11): 3005-20, 1995.
23. Myers KC, Dandoy C, El-Bietar J, et al.: Veno-occlusive disease of the liver in the absence of elevation in bilirubin in pediatric patients after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 21 (2): 379-81, 2015.
24. Ruutu T, Eriksson B, Remes K, et al.: Ursodeoxycholic acid for the prevention of hepatic complications in allogeneic stem cell transplantation. Blood 100 (6): 1977-83, 2002.
25. Myers KC, Lawrence J, Marsh RA, et al.: High-dose methylprednisolone for veno-occlusive disease of the liver in pediatric hematopoietic stem cell transplantation recipients. Biol Blood Marrow Transplant 19 (3): 500-3, 2013.
26. Richardson PG, Murakami C, Jin Z, et al.: Multi-institutional use of defibrotide in 88 patients after stem cell transplantation with severe veno-occlusive disease and multisystem organ failure: response without significant toxicity in a high-risk population and factors predictive of outcome. Blood 100 (13): 4337-43, 2002.
27. Corbacioglu S, Kernan N, Lehmann L, et al.: Defibrotide for the treatment of hepatic veno-occlusive disease in children after hematopoietic stem cell transplantation. Expert Rev Hematol 5 (3): 291-302, 2012.
28. Richardson PG, Soiffer RJ, Antin JH, et al.: Defibrotide for the treatment of severe hepatic veno-occlusive disease and multiorgan failure after stem cell transplantation: a multicenter, randomized, dose-finding trial. Biol Blood Marrow Transplant 16 (7): 1005-17, 2010.
29. Dignan FL, Wynn RF, Hadzic N, et al.: BCSH/BSBMT guideline: diagnosis and management of veno-occlusive disease (sinusoidal obstruction syndrome) following haematopoietic stem cell transplantation. Br J Haematol 163 (4): 444-57, 2013.
30. Strouse C, Richardson P, Prentice G, et al.: Defibrotide for Treatment of Severe Veno-Occlusive Disease in Pediatrics and Adults: An Exploratory Analysis Using Data from the Center for International Blood and Marrow Transplant Research. Biol Blood Marrow Transplant 22 (7): 1306-1312, 2016.
31. Richardson PG, Smith AR, Triplett BM, et al.: Earlier defibrotide initiation post-diagnosis of veno-occlusive disease/sinusoidal obstruction syndrome improves Day +100 survival following haematopoietic stem cell transplantation. Br J Haematol 178 (1): 112-118, 2017.
32. Corbacioglu S, Cesaro S, Faraci M, et al.: Defibrotide for prophylaxis of hepatic veno-occlusive disease in paediatric haemopoietic stem-cell transplantation: an open-label, phase 3, randomised controlled trial. Lancet 379 (9823): 1301-9, 2012.
33. Ruutu T, Juvonen E, Remberger M, et al.: Improved survival with ursodeoxycholic acid prophylaxis in allogeneic stem cell transplantation: long-term follow-up of a randomized study. Biol Blood Marrow Transplant 20 (1): 135-8, 2014.
34. Bajwa RPS, Mahadeo KM, Taragin BH, et al.: Consensus Report by Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplantation Consortium Joint Working Committees: Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents, Part 1: Focus on Investigations, Prophylaxis, and Specific Treatment. Biol Blood Marrow Transplant 23 (11): 1817-1825, 2017.
35. Mahadeo KM, McArthur J, Adams RH, et al.: Consensus Report by the Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplant Consortium Joint Working Committees on Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents: Part 2-Focus on Ascites, Fluid and Electrolytes, Renal, and Transfusion Issues. Biol Blood Marrow Transplant 23 (12): 2023-2033, 2017.
36. Ovchinsky N, Frazier W, Auletta JJ, et al.: Consensus Report by the Pediatric Acute Lung Injury and Sepsis Investigators and Pediatric Blood and Marrow Transplantation Consortium Joint Working Committees on Supportive Care Guidelines for Management of Veno-Occlusive Disease in Children and Adolescents, Part 3: Focus on Cardiorespiratory Dysfunction, Infections, Liver Dysfunction, and Delirium. Biol Blood Marrow Transplant 24 (2): 207-218, 2018.
37. Jodele S, Licht C, Goebel J, et al.: Abnormalities in the alternative pathway of complement in children with hematopoietic stem cell transplant-associated thrombotic microangiopathy. Blood 122 (12): 2003-7, 2013.
38. Cutler C, Henry NL, Magee C, et al.: Sirolimus and thrombotic microangiopathy after allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 11 (7): 551-7, 2005.
39. Ho VT, Cutler C, Carter S, et al.: Blood and marrow transplant clinical trials network toxicity committee consensus summary: thrombotic microangiopathy after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 11 (8): 571-5, 2005.
40. Jodele S, Fukuda T, Vinks A, et al.: Eculizumab therapy in children with severe hematopoietic stem cell transplantation-associated thrombotic microangiopathy. Biol Blood Marrow Transplant 20 (4): 518-25, 2014.
41. Jodele S, Fukuda T, Mizuno K, et al.: Variable Eculizumab Clearance Requires Pharmacodynamic Monitoring to Optimize Therapy for Thrombotic Microangiopathy after Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 22 (2): 307-315, 2016.
42. Kantrow SP, Hackman RC, Boeckh M, et al.: Idiopathic pneumonia syndrome: changing spectrum of lung injury after marrow transplantation. Transplantation 63 (8): 1079-86, 1997.
43. Clark JG, Hansen JA, Hertz MI, et al.: NHLBI workshop summary. Idiopathic pneumonia syndrome after bone marrow transplantation. Am Rev Respir Dis 147 (6 Pt 1): 1601-6, 1993.
44. Yanik GA, Ho VT, Levine JE, et al.: The impact of soluble tumor necrosis factor receptor etanercept on the treatment of idiopathic pneumonia syndrome after allogeneic hematopoietic stem cell transplantation. Blood 112 (8): 3073-81, 2008.
45. Yanik GA, Grupp SA, Pulsipher MA, et al.: TNF-receptor inhibitor therapy for the treatment of children with idiopathic pneumonia syndrome. A joint Pediatric Blood and Marrow Transplant Consortium and Children's Oncology Group Study (ASCT0521). Biol Blood Marrow Transplant 21 (1): 67-73, 2015.
46. Gerritsen EJ, Stam ED, Hermans J, et al.: Risk factors for developing EBV-related B cell lymphoproliferative disorders (BLPD) after non-HLA-identical BMT in children. Bone Marrow Transplant 18 (2): 377-82, 1996.
47. Shapiro RS, McClain K, Frizzera G, et al.: Epstein-Barr virus associated B cell lymphoproliferative disorders following bone marrow transplantation. Blood 71 (5): 1234-43, 1988.
48. Brunstein CG, Weisdorf DJ, DeFor T, et al.: Marked increased risk of Epstein-Barr virus-related complications with the addition of antithymocyte globulin to a nonmyeloablative conditioning prior to unrelated umbilical cord blood transplantation. Blood 108 (8): 2874-80, 2006.
49. Blaes AH, Cao Q, Wagner JE, et al.: Monitoring and preemptive rituximab therapy for Epstein-Barr virus reactivation after antithymocyte globulin containing nonmyeloablative conditioning for umbilical cord blood transplantation. Biol Blood Marrow Transplant 16 (2): 287-91, 2010.
50. Kuehnle I, Huls MH, Liu Z, et al.: CD20 monoclonal antibody (rituximab) for therapy of Epstein-Barr virus lymphoma after hemopoietic stem-cell transplantation. Blood 95 (4): 1502-5, 2000.
51. Styczynski J, Gil L, Tridello G, et al.: Response to rituximab-based therapy and risk factor analysis in Epstein Barr Virus-related lymphoproliferative disorder after hematopoietic stem cell transplant in children and adults: a study from the Infectious Diseases Working Party of the European Group for Blood and Marrow Transplantation. Clin Infect Dis 57 (6): 794-802, 2013.
52. Liu Z, Savoldo B, Huls H, et al.: Epstein-Barr virus (EBV)-specific cytotoxic T lymphocytes for the prevention and treatment of EBV-associated post-transplant lymphomas. Recent Results Cancer Res 159: 123-33, 2002.
53. Bollard CM, Heslop HE: T cells for viral infections after allogeneic hematopoietic stem cell transplant. Blood 127 (26): 3331-40, 2016.
54. Ferrara JL, Levine JE, Reddy P, et al.: Graft-versus-host disease. Lancet 373 (9674): 1550-61, 2009.
55. Przepiorka D, Weisdorf D, Martin P, et al.: 1994 Consensus Conference on Acute GVHD Grading. Bone Marrow Transplant 15 (6): 825-8, 1995.
56. Harris AC, Young R, Devine S, et al.: International, Multicenter Standardization of Acute Graft-versus-Host Disease Clinical Data Collection: A Report from the Mount Sinai Acute GVHD International Consortium. Biol Blood Marrow Transplant 22 (1): 4-10, 2016.
57. Kanakry CG, O'Donnell PV, Furlong T, et al.: Multi-institutional study of post-transplantation cyclophosphamide as single-agent graft-versus-host disease prophylaxis after allogeneic bone marrow transplantation using myeloablative busulfan and fludarabine conditioning. J Clin Oncol 32 (31): 3497-505, 2014.
58. Bertaina A, Merli P, Rutella S, et al.: HLA-haploidentical stem cell transplantation after removal of αβ+ T and B cells in children with nonmalignant disorders. Blood 124 (5): 822-6, 2014.
59. Jacoby E, Chen A, Loeb DM, et al.: Single-Agent Post-Transplantation Cyclophosphamide as Graft-versus-Host Disease Prophylaxis after Human Leukocyte Antigen-Matched Related Bone Marrow Transplantation for Pediatric and Young Adult Patients with Hematologic Malignancies. Biol Blood Marrow Transplant 22 (1): 112-8, 2016.
60. Jacobsohn DA: Acute graft-versus-host disease in children. Bone Marrow Transplant 41 (2): 215-21, 2008.
61. Deeg HJ: How I treat refractory acute GVHD. Blood 109 (10): 4119-26, 2007.
62. Shlomchik WD, Lee SJ, Couriel D, et al.: Transplantation's greatest challenges: advances in chronic graft-versus-host disease. Biol Blood Marrow Transplant 13 (1 Suppl 1): 2-10, 2007.
63. Bolaños-Meade J, Vogelsang GB: Chronic graft-versus-host disease. Curr Pharm Des 14 (20): 1974-86, 2008.
64. Zecca M, Prete A, Rondelli R, et al.: Chronic graft-versus-host disease in children: incidence, risk factors, and impact on outcome. Blood 100 (4): 1192-200, 2002.
65. Eapen M, Logan BR, Confer DL, et al.: Peripheral blood grafts from unrelated donors are associated with increased acute and chronic graft-versus-host disease without improved survival. Biol Blood Marrow Transplant 13 (12): 1461-8, 2007.
66. Eapen M, Rubinstein P, Zhang MJ, et al.: Outcomes of transplantation of unrelated donor umbilical cord blood and bone marrow in children with acute leukaemia: a comparison study. Lancet 369 (9577): 1947-54, 2007.
67. Leung W, Ahn H, Rose SR, et al.: A prospective cohort study of late sequelae of pediatric allogeneic hematopoietic stem cell transplantation. Medicine (Baltimore) 86 (4): 215-24, 2007.
68. Arora M, Klein JP, Weisdorf DJ, et al.: Chronic GVHD risk score: a Center for International Blood and Marrow Transplant Research analysis. Blood 117 (24): 6714-20, 2011.
69. Filipovich AH, Weisdorf D, Pavletic S, et al.: National Institutes of Health consensus development project on criteria for clinical trials in chronic graft-versus-host disease: I. Diagnosis and staging working group report. Biol Blood Marrow Transplant 11 (12): 945-56, 2005.
70. Shulman HM, Kleiner D, Lee SJ, et al.: Histopathologic diagnosis of chronic graft-versus-host disease: National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: II. Pathology Working Group Report. Biol Blood Marrow Transplant 12 (1): 31-47, 2006.
71. Jacobsohn DA, Arora M, Klein JP, et al.: Risk factors associated with increased nonrelapse mortality and with poor overall survival in children with chronic graft-versus-host disease. Blood 118 (16): 4472-9, 2011.
72. Pavletic SZ, Martin P, Lee SJ, et al.: Measuring therapeutic response in chronic graft-versus-host disease: National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: IV. Response Criteria Working Group report. Biol Blood Marrow Transplant 12 (3): 252-66, 2006.
73. Inagaki J, Moritake H, Nishikawa T, et al.: Long-Term Morbidity and Mortality in Children with Chronic Graft-versus-Host Disease Classified by National Institutes of Health Consensus Criteria after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 21 (11): 1973-80, 2015.
74. Cuvelier GDE, Nemecek ER, Wahlstrom JT, et al.: Benefits and challenges with diagnosing chronic and late acute GvHD in children using the NIH consensus criteria. Blood : , 2019.
75. Koc S, Leisenring W, Flowers ME, et al.: Therapy for chronic graft-versus-host disease: a randomized trial comparing cyclosporine plus prednisone versus prednisone alone. Blood 100 (1): 48-51, 2002.
76. Couriel D, Carpenter PA, Cutler C, et al.: Ancillary therapy and supportive care of chronic graft-versus-host disease: national institutes of health consensus development project on criteria for clinical trials in chronic Graft-versus-host disease: V. Ancillary Therapy and Supportive Care Working Group Report. Biol Blood Marrow Transplant 12 (4): 375-96, 2006.
77. Martin PJ, Storer BE, Rowley SD, et al.: Evaluation of mycophenolate mofetil for initial treatment of chronic graft-versus-host disease. Blood 113 (21): 5074-82, 2009.
78. Jacobsohn DA, Gilman AL, Rademaker A, et al.: Evaluation of pentostatin in corticosteroid-refractory chronic graft-versus-host disease in children: a Pediatric Blood and Marrow Transplant Consortium study. Blood 114 (20): 4354-60, 2009.
79. Jurado M, Vallejo C, Pérez-Simón JA, et al.: Sirolimus as part of immunosuppressive therapy for refractory chronic graft-versus-host disease. Biol Blood Marrow Transplant 13 (6): 701-6, 2007.
80. Cutler C, Miklos D, Kim HT, et al.: Rituximab for steroid-refractory chronic graft-versus-host disease. Blood 108 (2): 756-62, 2006.
81. Miklos D, Cutler CS, Arora M, et al.: Ibrutinib for chronic graft-versus-host disease after failure of prior therapy. Blood 130 (21): 2243-2250, 2017.
82. González Vicent M, Ramirez M, Sevilla J, et al.: Analysis of clinical outcome and survival in pediatric patients undergoing extracorporeal photopheresis for the treatment of steroid-refractory GVHD. J Pediatr Hematol Oncol 32 (8): 589-93, 2010.
83. Schechter T, Pole JD, Darmawikarta D, et al.: Late mortality after hematopoietic SCT for a childhood malignancy. Bone Marrow Transplant 48 (10): 1291-5, 2013.
84. Duncan CN, Majhail NS, Brazauskas R, et al.: Long-term survival and late effects among one-year survivors of second allogeneic hematopoietic cell transplantation for relapsed acute leukemia and myelodysplastic syndromes. Biol Blood Marrow Transplant 21 (1): 151-8, 2015.
85. Holmqvist AS, Chen Y, Wu J, et al.: Late mortality after autologous blood or marrow transplantation in childhood: a Blood or Marrow Transplant Survivor Study-2 report. Blood 131 (24): 2720-2729, 2018.

Late Effects After HCT in Children

Data from studies of child and adult survivors of hematopoietic cell transplantation (HCT) have shown a significant impact from treatment-related exposures on survival and quality of life.[1 ] Of patients alive at 2 years after HCT, a 9.9-fold increased risk of premature death has been noted.[2 ]

Methodological Challenges Specific to HCT

Although the main cause of death in this cohort is from relapse of the primary disease, a sizeable number of these patients die from graft-versus-host disease (GVHD)–related infections, second malignancies, or cardiac or pulmonary issues.[2 ,3 ,4 ,5 ] In addition, other studies have revealed that up to 40% of HCT survivors experience severe, disabling, and/or life-threatening events or die because of an adverse event associated with primary/previous cancer treatment.[6 ,7 ]

Before studies aimed at decreasing the incidence or severity of these effects are initiated, it is important to understand what leads to the development of these complications:

• Pretransplant therapy: Pretransplant therapy plays an important role, but the details of significant exposures associated with pre-HCT therapy are not included in many studies.[8 ]
• Preparative regimen: The transplant preparative regimen itself, including total-body irradiation (TBI) and high-dose chemotherapy, has often been studied, but this intense therapy is only a small part of a long course of therapy filled with potential causes of late effects.
• Allogenicity: The effect of allogenicity—differences in major and minor HLA antigens that lead to GVHD, autoimmunity, chronic inflammation, and, sometimes, undetected organ damage—also contributes to these late effects.

Individuals differ in their susceptibility to specific organ damage from chemotherapy or in their risk of GVHD on the basis of genetic differences in both the donor and recipient.[8 ,9 ,10 ]

Cardiovascular System Late Effects

Although cardiac dysfunction has been studied extensively in non-HCT settings, less is known about the incidence and predictors of congestive heart failure following HCT in childhood. Potentially cardiotoxic exposures unique to HCT include the following:[11 ]

• Conditioning with high-dose chemotherapy, especially cyclophosphamide.
• TBI.

HCT survivors are at increased risk of developing cardiovascular risk factors such as hypertension and diabetes, partly as a result of exposure to TBI and prolonged immunosuppressive therapy after allogeneic HCT, or related to other health conditions (e.g., hypothyroidism or growth hormone deficiency).[7 ,11 ] A study of 661 pediatric patients surviving at least 2 years after allogeneic HCT showed that 52% of patients were obese or overweight at their most recent examination, 18% of patients had dyslipidemia (associated with pre-HCT anthracycline or cranial or chest irradiation), and 7% of patients were diagnosed with diabetes.[12 ]

Rates of cardiovascular outcomes were examined among nearly 1,500 transplant survivors (surviving ≥2 years) treated in Seattle from 1985 to 2006. The survivors and a population-based comparison group were matched by age, year, and sex.[13 ] Survivors experienced increased rates of cardiovascular death (adjusted incidence rate difference, 3.6 per 1,000 person-years [95% confidence interval, 1.7–5.5]) and had an increased cumulative incidence of the following:

• Ischemic heart disease.
• Cardiomyopathy/heart failure.
• Stroke.
• Vascular diseases.
• Rhythm disorders.

Survivors also had an increased cumulative incidence of related conditions that predispose towards more serious cardiovascular disease (i.e., hypertension, renal disease, dyslipidemia, and diabetes).[13 ]

In addition, cardiac function and pre-HCT exposures to chemotherapy and radiation therapy have been shown to have significant impact on post-HCT cardiac function. In evaluating post-HCT patients for long-term issues, it is important to consider levels of pre-HCT anthracycline and chest irradiation.[14 ] Although more specific work needs to be done to verify this, current evidence suggests that the risk of late-occurring cardiovascular complications after HCT may largely result from pre-HCT therapeutic exposures, with little additional risk from conditioning-related exposures or GVHD.[15 ,16 ]

(Refer to the Late Effects of the Cardiovascular System section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

Central Nervous System Late Effects

Neurocognitive outcomes

A preponderance of studies report normal neurodevelopment after HCT, with no evidence of decline.[17 ,18 ,19 ,20 ,21 ,22 ,23 ,24 ]

Researchers from St. Jude Children's Research Hospital have reported on the largest longitudinal cohort to date, describing remarkable stability in global cognitive function and academic achievement during 5 years of posttransplant follow-up.[20 ,21 ,22 ] This group reported poorer outcomes in patients undergoing unrelated-donor transplant when the patients received TBI and when they experienced GVHD, but these effects were small compared with the much larger effects seen on the basis of differences in socioeconomic status.[21 ] Most published studies report similar outcomes. Normal cognitive function and academic achievement were reported in a cohort of 47 patients monitored prospectively through 2 years post-HCT.[24 ] Stable cognitive function was also noted in a large cohort monitored from pretransplant to 2 years post-HCT.[19 ] A smaller study reported similar normal functioning and the absence of declines over time in HCT survivors.[17 ] HCT survivors did not differ from their siblings in cognitive and academic function, with the exception that survivors performed better than siblings on measures of perceptual organization.[18 ] On the basis of the findings to date, it appears that HCT poses low to minimal risk of late cognitive and academic deficits in survivors.

A number of studies, however, have reported some decline in cognitive function after HCT.[25 ,26 ,27 ,28 ,29 ,30 ,31 ] These studies tended to include samples with a high percentage of very young children. One study reported a significant decline in IQ in their cohort at 1 year post-HCT, and these deficits were maintained at 3 years post-HCT.[26 ,27 ] Similarly, studies from Sweden have reported deficits in visual-spatial domains and executive functioning in very young children who underwent transplant with TBI.[29 ,30 ] Another study from St. Jude Children's Research Hospital reported that while all children younger than 3 years had a decline in IQ at 1 year after transplant, patients who did not receive TBI during conditioning recovered later. However, patients who received TBI had a significantly lower IQ at 5 years (P = .05) than did those who did not receive TBI.[31 ]

(Refer to the Stem cell transplantation section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

Digestive System Late Effects

Gastrointestinal, biliary, and pancreatic dysfunction

Most gastrointestinal late effects are related to protracted acute GVHD and chronic GVHD (refer to Table 13). (Refer to the Hepatobiliary Complications section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

As GVHD is controlled and tolerance is developed, most symptoms resolve. Major hepatobiliary concerns include the consequences of viral hepatitis acquired before or during the transplant, biliary stone disease, and focal liver lesions.[32 ] Viral serology and polymerase chain reaction should be performed to differentiate these from GVHD presenting with hepatocellular injury.[33 ]

Table 13. Causes of Gastrointestinal (GI), Hepatobiliary, and Pancreatic Problems in Long-Term Transplant Survivors^a

Problem Areas	Common Causes	Less Common Causes
ALT = alanine transaminase; AP = alkaline phosphatase; CMV = cytomegalovirus; GGT = gamma glutamyl transpeptidase; GVHD = graft-versus-host disease; HSV = herpes simplex virus; Mg++ = magnesium; VZV = varicella zoster virus.
a Reprinted fromBiology of Blood and Marrow Transplantation, Volume 17 (Issue 11), Michael L. Nieder, George B. McDonald, Aiko Kida, Sangeeta Hingorani, Saro H. Armenian, Kenneth R. Cooke, Michael A. Pulsipher , K. Scott Baker, National Cancer Institute–National Heart, Lung and Blood Institute/Pediatric Blood and Marrow Transplant Consortium First International Consensus Conference on Late Effects After Pediatric Hematopoietic Cell Transplantation: Long-Term Organ Damage and Dysfunction, Pages 1573–1584, Copyright 2011, with permission from American Society for Blood and Marrow Transplantation and Elsevier.[33 ]
Esophageal symptoms: heartburn, dysphagia, painful swallowing[34 ,35 ,36 ,37 ,38 ,39 ]	Oral chronic GVHD (mucosal changes, poor dentition, xerostomia)	Chronic GVHD of the esophagus (webs, rings, submucosal fibrosis and strictures, aperistalsis)
	Reflux of gastric fluid	Hypopharyngeal dysmotility (myasthenia gravis, cricopharyngeal incoordination)
		Squamous > adenocarcinoma
		Pill esophagitis
		Infection (fungal, viral)
Upper gut symptoms: anorexia, nausea, vomiting[40 ,41 ,42 ,43 ,44 ]	Protracted acute GI GVHD	Secondary adrenal insufficiency
	Activation of latent infection (CMV, HSV, VZV)	Acquisition of infection (enteric viruses, Giardia, cryptosporidia,Haemophilus pylori)
	Medication adverse effects	Gut dysmotility
Mid gut and colonic symptoms: diarrhea and abdominal pain[45 ,46 ]	Protracted acute GI GVHD	Acquisition of infection (enteric viruses, bacteria, parasites)
	Activation of latent CMV, VZV	Pancreatic insufficiency
	Drugs (mycophenolate mofetil, Mg++, antibiotics)	Clostridium difficilecolitis
		Collagen-encased bowel (GVHD)
		Rare: inflammatory bowel disease, sprue;[46 ]bile salt malabsorption; disaccharide malabsorption
Liver problems[32 ,47 ,48 ,49 ,50 ,51 ,52 ,53 ,54 ,55 ,56 ]	Cholestatic GVHD	Hepatitic GVHD
	Chronic viral hepatitis (B and C)	VZV or HSV hepatitis
	Cirrhosis	Fungal abscess
	Focal nodular hyperplasia	Nodular regenerative hyperplasia
	Nonspecific elevation of liver enzymes in serum (AP, ALT, GGT)	Biliary obstruction
		Drug-induced liver injury
Biliary and pancreatic problems [57 ,58 ,59 ,60 ]	Cholecystitis	Pancreatic atrophy/insufficiency
	Common duct stones/sludge	Pancreatitis/edema, stone or sludge related
	Gall bladder sludge (calcium bilirubinate)	Pancreatitis, tacrolimus related
	Gallstones

Iron overload

Iron overload occurs in almost all patients who undergo HCT, especially if the procedure is for a condition associated with transfusion dependence before HCT (e.g., thalassemia, bone marrow failure syndromes) or pre-HCT treatments requiring transfusions after myelotoxic chemotherapy (e.g., acute leukemias). Inflammatory conditions such as GVHD also increase gastrointestinal iron absorption. The effects of iron overload on morbidity post-HCT have not been well studied; however, reducing iron levels after HCT for thalassemia has been shown to improve cardiac function.[61 ] Non-HCT conditions leading to iron overload can lead to cardiac dysfunction, endocrine disorders (e.g., pituitary insufficiency, hypothyroidism), diabetes, neurocognitive effects, and second malignancies.[33 ]

Although data supporting iron reduction therapies such as phlebotomy or chelation after HCT have not identified specific levels at which iron reduction should be performed, higher levels of ferritin and/or evidence of significant iron overload by liver biopsy or T2-weighted magnetic resonance imaging (MRI) [62 ] should be addressed by iron reduction therapy.[63 ]

Endocrine System Late Effects

Thyroid dysfunction

Studies show that rates of thyroid dysfunction in children after myeloablative HCT vary, with larger series reporting an average incidence of about 30%.[64 ,65 ,66 ,67 ,68 ,69 ,70 ,71 ,72 ,73 ] A lower incidence in adults (on average, 15%) and a notable increase in incidence in children younger than 10 years undergoing HCT suggest that a developing thyroid gland may be more susceptible to damage.[64 ,66 ,70 ]

Pretransplant local thyroid radiation contributes to high rates of thyroid dysfunction in patients with Hodgkin lymphoma.[64 ] Early studies showed very high rates of thyroid dysfunction after high single-dose fractions of TBI,[74 ] but traditional fractionated TBI/cyclophosphamide compared with busulfan/cyclophosphamide showed similar rates of thyroid dysfunction, suggesting a role for high-dose chemotherapy in thyroid damage.[67 ,68 ,69 ] Rates of thyroid dysfunction associated with newer combinations of busulfan/fludarabine or reduced-intensity regimens have yet to be reported. (Refer to the Posttransplant thyroid dysfunction section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

Higher rates of thyroid dysfunction occur with single-drug versus three-drug GVHD prophylaxis,[75 ] along with increased rates of thyroid dysfunction after unrelated-donor versus related-donor HCT (36% vs. 9%),[65 ] suggesting a role for alloimmune damage in causing thyroid dysfunction.[69 ,76 ]

Growth impairment

Growth impairment is generally multifactorial. Factors that play a role in failure to achieve expected adult height in young children who have undergone HCT include the following:

• Diminished growth hormone level.
• Thyroid dysfunction.
• Disruption of pubertal sex hormone production.
• Steroid therapy.
• Poor nutritional status.

The incidence of growth impairment varies from 20% to 80%, depending on age, risk factors, and the definition of growth impairment used by reporting groups.[71 ,72 ,77 ,78 ,79 ,80 ] Risk factors include the following:[67 ,68 ,78 ,81 ]

• TBI.
• Cranial irradiation.
• Younger age.
• Undergoing HCT for acute lymphoblastic leukemia.
• HCT occurring during a pubertal growth spurt.[82 ]

Patients younger than 10 years at the time of HCT are at the highest risk of growth impairment, but also respond best to growth hormone replacement therapy. Early screening and referral of patients with signs of growth impairment to endocrinology specialists can result in significant restoration of height in younger children.[80 ]

(Refer to the Growth hormone deficiency section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

Abnormal body composition/metabolic syndrome

After HCT, adult survivors have a risk of premature cardiovascular-related death that is increased 2.3-fold compared with the general population.[83 ,84 ] The exact etiology of cardiovascular risk and subsequent death is largely unknown, although the development of metabolic syndrome (a constellation of central obesity, insulin resistance, glucose intolerance, dyslipidemia, and hypertension), especially insulin resistance, as a consequence of HCT has been suggested.[85 ,86 ,87 ]

In studies of conventionally treated leukemia survivors compared with those who underwent HCT, transplant survivors are significantly more likely to manifest metabolic syndrome or multiple adverse cardiac risk factors, including central adiposity, hypertension, insulin resistance, and dyslipidemia.[33 ,88 ,89 ] The concern over time is that survivors who develop metabolic syndrome after HCT will be at higher risk of experiencing significant cardiovascular-related events and/or premature death from cardiovascular-related causes.

(Refer to the Metabolic Syndrome section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

Sarcopenic obesity

The association of obesity with diabetes and cardiovascular disease risk in the general population is well established, but obesity as determined by body mass index (BMI) is uncommon in long-term survivors after HCT.[89 ] However, despite having a normal BMI, HCT survivors develop significantly altered body composition that results in both an increase in total percent fat mass and a reduction in lean body mass. This finding is termed sarcopenic obesity and results in a loss of myocyte insulin receptors and an increase in adipocyte insulin receptors; the latter are less efficient in binding insulin and clearing glucose, ultimately contributing to insulin resistance.[90 ,91 ,92 ]

Preliminary data from 119 children and young adults and 81 healthy sibling controls found that HCT survivors had significantly lower weight but no differences in BMI or waist circumference when compared with siblings.[93 ] HCT survivors had a significantly higher percent fat mass and lower lean body mass than did controls. HCT survivors were significantly more insulin resistant than were controls, and they also had a higher incidence of other cardiovascular risk factors such as elevated total cholesterol, low-density lipoprotein cholesterol, and triglycerides; these differences were found only in patients who had received TBI as part of their transplant conditioning regimen.

Musculoskeletal System Late Effects

Low bone mineral density

A limited number of studies have addressed low bone mineral density after HCT in children.[94 ,95 ,96 ,97 ,98 ,99 ,100 ] A significant portion of children experienced reduction in total-body bone mineral density or lumbar Z-scores showing osteopenia (18%–33%) or osteoporosis (6%–21%). Although general risk factors have been described (female sex, inactivity, poor nutritional status, white or Asian ethnicity, family history, TBI, craniospinal irradiation, corticosteroid therapy, GVHD, cyclosporine, and endocrine deficiencies [e.g., growth hormone deficiency, hypogonadism]), most reported populations have been too small to perform multivariate analysis to test the relative importance of each of these factors.[101 ,102 ,103 ,104 ,105 ,106 ,107 ,108 ,109 ,110 ,111 ]

Some studies in adults have shown improvement over time in low bone mineral density after HCT;[99 ,112 ,113 ] however, this has yet to be shown in children.

Treatment for children has generally included a multifactorial approach, with vitamin D and calcium supplementation, minimization of corticosteroid therapy, participation in weight-bearing exercise, and resolution of other endocrine problems. The role of bisphosphonate therapy in children with this condition is unclear.

(Refer to the Osteoporosis/fractures section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

Osteonecrosis

Reported incidence of osteonecrosis in children after HCT has been 1% to 14%; however, these studies were retrospective and underestimated actual incidence because patients may be asymptomatic early in the course.[114 ,115 ,116 ] Two prospective studies showed an incidence of 30% and 44% with routine MRI screening of possible target joints.[98 ,117 ] Osteonecrosis generally occurs within 3 years after HCT, with a median onset of about 1 year. The most common locations include knees (30%–40%), hips (19%–24%), and shoulders (9%). Most patients experience osteonecrosis in two or more joints.[74 ,114 ,118 ,119 ]

In one prospective report, risk factors by multivariate analysis included age (markedly increased in children older than 10 years; odds ratio, 7.4) and presence of osteonecrosis at the time of transplant. It is important to note that pre-HCT factors such as corticosteroid exposure are very important in determining patient risk. In this study, 14 of 44 children who developed osteonecrosis had the disease before HCT.[117 ] A Center for International Blood and Marrow Transplant Research (CIBMTR) retrospective nested control study of 160 cases and 478 control children suggested older age (>5 years), female sex, and the presence of chronic GVHD as risk factors for developing osteonecrosis.[120 ]

Treatment has generally consisted of minimization of corticosteroid therapy and surgical joint replacement. Most patients are not diagnosed until they present with symptoms. In one study of 44 patients with osteonecrosis lesions in whom routine yearly MRI was performed, 4 resolved completely, and 2 had resolution of one of multiply involved joints.[117 ] The observation that some lesions can heal over time suggests caution in the surgical management of asymptomatic lesions.

(Refer to the Osteonecrosis section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

Reproductive System Late Effects

Pubertal development

Delayed, absent, or incomplete pubertal development occurs commonly after HCT. Two studies showed pubertal delay or failure in 16% of female children who received cyclophosphamide alone, 72% of those who received busulfan/cyclophosphamide, and 57% of those who underwent fractionated TBI. In males, incomplete pubertal development or failure was noted in 14% of those who received cyclophosphamide alone, 48% of those who received busulfan/cyclophosphamide, and 58% of those who underwent TBI.[73 ,121 ] Boys receiving more than 24 Gy of radiation to the testicles developed azoospermia and also experienced failure of testosterone production, requiring supplementation to develop secondary sexual characteristics.[122 ]

Fertility

Women

Pretransplant and transplant cyclophosphamide exposure is the best-studied agent affecting fertility. Postpubertal women younger than 30 years can tolerate up to 20 g/m² of cyclophosphamide and have preserved ovarian function; prepubertal females can tolerate as much as 25 g/m² to 30 g/m². Although the additional effect added by pretransplant exposures to cyclophosphamide and other agents has not been specifically quantitated in studies, these exposures plus transplant-related chemotherapy and radiation therapy lead to ovarian failure in 65% to 84% of females undergoing myeloablative HCT.[123 ,124 ,125 ,126 ] The use of cyclophosphamide, busulfan, and TBI as part of the preparative regimen are associated with worse ovarian function. Younger age at the time of HCT is associated with a higher chance of menarche and ovulation.[127 ,128 ] (Refer to the Ovarian function after HSCT section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

Studies of pregnancy are challenging because data seldom indicate whether individuals are trying to conceive. Nonetheless, a large study of pregnancy in pediatric and adult survivors of myeloablative transplantation demonstrated conception in 32 of 708 patients (4.5%).[123 ] Of those trying to conceive, patients exposed to cyclophosphamide alone (total dose 6.7 g/m² with no pretransplant exposure) had the best chance of conception (56 of 103, 54%), while those receiving myeloablative busulfan/cyclophosphamide (0 of 73, 0%) or TBI (7 of 532, 1.3%) had much lower rates of conception.

Men

The ability of men to produce functional sperm decreases with exposure to higher doses and specific types of chemotherapy. Most men will become azoospermic at a cyclophosphamide dose of 300 mg/kg.[129 ] After HCT, 48% to 85% will experience gonadal failure.[123 ,129 ,130 ] One study showed that men who received cyclophosphamide conceived only 24% of the time, compared with 6.5% of men who received busulfan/cyclophosphamide and 1.3% of those who underwent TBI.[123 ] (Refer to the Testicular function after HSCT section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

Effect of reduced-toxicity/reduced-intensity/nonmyeloablative regimens

On the basis of clear evidence of dose effect and the lowered gonadotoxicity of some reduced-toxicity chemotherapy regimens, the use of reduced-intensity/toxicity and nonmyeloablative regimens will likely lead to a higher chance of preserved fertility after HCT. Because the use of these regimens is relatively new and mostly confined to older or sicker patients, most reports have consisted of single cases. Registry reports are beginning to describe pregnancies after these procedures.[126 ] In addition, a single-center study compared myeloablative busulfan/cyclophosphamide with reduced-intensity fludarabine/melphalan.[131 ][Level of evidence: 3iiiC] Spontaneous puberty occurred in 56% of girls and 89% of boys after busulfan/cyclophosphamide, whereas 90% of girls and all of the boys in the fludarabine/melphalan group entered puberty spontaneously (P = .012). Significantly more girls (61%) conditioned with busulfan/cyclophosphamide required hormone replacement than did girls in the fludarabine/melphalan group (10.5%; P = .012). In boys, no difference was noted between the two conditioning groups in time to follicle-stimulating hormone elevation (median, 4 years in the fludarabine/melphalan group vs. 6 years in the busulfan/cyclophosphamide group). While the two regimens have similar effects on testicular function, ovarian function seems to be better preserved in girls undergoing stem cell transplantation with reduced-intensity conditioning approaches.

Respiratory System Late Effects

Chronic pulmonary dysfunction

The following two forms of chronic pulmonary dysfunction are observed after HCT:[132 ,133 ,134 ,135 ,136 ,137 ]

• Obstructive lung disease.
• Restrictive lung disease.

The incidence of both forms of lung toxicity can range from 10% to 40%, depending on donor source, the time interval after HCT, definition applied, and presence of chronic GVHD. In both conditions, collagen deposition and the development of fibrosis in either the interstitial space (restrictive lung disease) or the peribronchiolar space (obstructive lung disease) are believed to underlie the pathology.[138 ]

Obstructive lung disease

The most common form of obstructive lung disease post–allogeneic HCT is bronchiolitis obliterans.[134 ,137 ,139 ,140 ] This condition is an inflammatory process resulting in bronchiolar obliteration, fibrosis, and progressive obstructive lung disease.[132 ]

Historically, the term bronchiolitis obliterans has been used to describe chronic GVHD of the lung and begins 6 to 20 months after HCT. Pulmonary function tests show obstructive lung disease with general preservation of forced vital capacity (FVC), reductions in forced expiratory volume in 1 second (FEV1), and associated decreases in the FEV1/FVC ratio with or without significant declines in the diffusion capacity of the lung for carbon monoxide (DLCO).

Risk factors for bronchiolitis obliterans include the following:[132 ,139 ]

• Lower pretransplant FEV1/FVC values.
• Concomitant pulmonary infections.
• Chronic aspiration.
• Acute and chronic GVHD.
• Older recipient age.
• Use of mismatched donors.
• High-dose (vs. reduced-intensity) conditioning.

The clinical course of bronchiolitis obliterans is variable, but patients frequently develop progressive and debilitating respiratory failure despite the initiation of enhanced immunosuppression.

Standard treatment for obstructive lung disease combines enhanced immunosuppression with supportive care, including antimicrobial prophylaxis, bronchodilator therapy, and supplemental oxygen, when indicated.[141 ] The potential role for tumor necrosis factor-alpha in the pathogenesis of obstructive lung disease suggests that neutralizing agents such as etanercept may have promise.[142 ]

Restrictive lung disease

Restrictive lung disease is defined by reductions in FVC, total lung capacity (TLC), and DLCO. In contrast to obstructive lung disease, the FEV1/FVC ratio is maintained near 100%. Restrictive lung disease is common after HCT and has been reported in 25% to 45% of patients by day 100.[132 ] Importantly, declines in TLC or FVC occurring at 100 days and 1 year after HCT are associated with an increase in nonrelapse mortality. Early reports suggested that the incidence of restrictive lung disease increases with advancing recipient age, but subsequent studies have revealed significant restrictive lung disease in children receiving HCT.[143 ]

The most recognizable form of restrictive lung disease is bronchiolitis obliterans organizing pneumonia. Clinical features include dry cough, shortness of breath, and fever. Radiographic findings show diffuse, peripheral, fluffy infiltrates consistent with airspace consolidation. Although reported in fewer than 10% of HCT recipients, the development of bronchiolitis obliterans organizing pneumonia is strongly associated with previous acute and chronic GVHD.[138 ]

The response in patients with restrictive lung disease to multiple agents such as corticosteroids, cyclosporine, tacrolimus, and azathioprine is limited.[141 ] The potential role for tumor necrosis factor-alpha in the pathogenesis of restrictive lung disease suggests that neutralizing agents such as etanercept may have promise.[142 ]

(Refer to the Respiratory complications associated with HSCT section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)

Urinary System Late Effects

Renal disease

Chronic kidney disease is frequently diagnosed after transplant. There are many clinical forms of chronic kidney disease, but the most commonly described ones include thrombotic microangiopathy, nephrotic syndrome, calcineurin inhibitor toxicity, acute kidney injury, and GVHD-related chronic kidney disease. Various risk factors associated with the development of chronic kidney disease have been described; however, recent studies suggest that acute and chronic GVHD may be a proximal cause of renal injury.[33 ]

In a systematic review of 9,317 adults and children from 28 cohorts who underwent HCT, approximately 16.6% of patients (range, 3.6% to 89%) developed chronic kidney disease, defined as a decrease in estimated glomerular filtration rate of at least 24.5 mL/min/1.73 m² within the first year after transplant.[144 ] The cumulative incidence of chronic kidney disease developing approximately 5 years after transplant ranges from 4.4% to 44.3%, depending on the type of transplant and stage of chronic kidney disease.[145 ,146 ] Mortality rates among patients with chronic kidney disease in this setting are higher than those in transplant recipients who retain normal renal function, even when studies have controlled for comorbidities.[147 ]

It is important to aggressively treat hypertension in patients post-HCT, especially in those treated with prolonged courses of calcineurin inhibitors. Whether post-HCT patients with albuminuria and hypertension benefit from treatment with angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers requires further study, but careful control of hypertension with captopril, an ACE inhibitor, did show a benefit in a small study.[148 ]

Quality of Life

Health-related quality of life (HRQL)

HRQL is a multidimensional construct, incorporating a subjective appraisal of one's functioning and well-being, with reference to the impact of health issues on overall quality of life.[149 ,150 ]. Many studies have shown that HRQL varies according to the following:[151 ]

• Time after HCT: HRQL is worse with more recent HCT.
• Transplant type: Unrelated-donor HCT has worse HRQL than does autologous or allogeneic related-donor HCT.
• Presence or absence of HCT-related sequelae: HRQL is worse with chronic GVHD.

Pre-HCT factors, such as family cohesion and a child's adaptive functioning, have been shown to affect HRQL.[152 ] Several groups have also identified the importance of pre-HCT parenting stress on parental ratings of children's HRQL post-HCT.[152 ,153 ,154 ,155 ,156 ] A report of the trajectories of HRQL over the 12 months after HCT noted that the poorest HRQL was seen at 3 months post-HCT, with steady improvement thereafter. Recipients of unrelated-donor transplants had the steepest declines in HRQL from baseline to 3 months. Another study reported that compromised emotional functioning, high levels of worry, and reduced communication during the acute recovery period had a negative impact on HRQL at 1-year post-HCT.[157 ] Longitudinal studies identified an association of the following additional baseline risk factors with the trajectory of HRQL after HCT:

• Child's age (older children, worse HRQL).[152 ,158 ,159 ]
• Child's sex (females, worse HRQL).[159 ]
• Rater (mothers report lower HRQL than do fathers; parents report lower HRQL than do children).[160 ,161 ]
• Concordance by primary language or by sex of the raters (concordant pairs, higher HRQL).[162 ]
• Parental emotional distress (greater parental distress, worse HRQL).[158 ]
• Child's race (African American children, better HRQL).[159 ]

A report on the impact of specific HCT complications on children's HRQL indicated that HRQL was worse among children with severe end-organ toxicity, systemic infection, or GVHD.[153 ] Cross-sectional studies report that the HRQL among pediatric HCT survivors of 5 years or longer is reasonably good, although psychological, cognitive, or physical problems appear to negatively influence HRQL. Female sex, causal diagnosis for HCT (acute myelogenous leukemia, worse HRQL), and intensity of pre-HCT therapy were all identified as affecting HRQL post-HCT.[163 ,164 ] Finally, another cross-sectional study of children 5 to 10 years post-HCT cautioned that parental concerns about the child's vulnerability may induce overprotective parenting.[156 ]

Functional outcomes

Physician-reported physical performance

Clinician reports of long-term disability among childhood HCT survivors suggest that the prevalence and severity of functional loss is low.

• A study from the European Society for Blood and Marrow Transplantation used the Karnofsky performance scale to report outcomes among 647 HCT survivors (surviving ≥5 years).[165 ] In this cohort, 40% of survivors were younger than 18 years when they underwent transplant; only 19% had Karnofsky scores lower than 100. Seven percent had scores lower than 80, defined as the inability to work. Similar low rates of clinician-graded poor functional outcome were reported by two other groups.[163 ,166 ]
• Among 50 survivors of childhood allogeneic HCT treated at the City of Hope National Medical Center and Stanford University Hospital, all had Karnofsky scores of 90 or 100.[166 ]
• Among 73 young adults (mean age, 26 years) treated at the Karolinska University Hospital, the median Karnofsky score at 10 years post-HCT was 90.[163 ]

Self-reported physical performance

Self-reported and proxy data among survivors of childhood HCT indicated similar low rates of functional loss in the following studies:

• One study evaluated 22 survivors of childhood allogeneic HCT (mean age at HCT, 11 years; mean age at questionnaire, 25 years) and reported no differences between survivors' scores and population-expected values on standardized physical performance scales.[167 ]
• Another study compared a group of survivors who underwent transplant for childhood leukemia (n = 142) with a group of childhood leukemia survivors treated with chemotherapy alone (n = 288).[168 ] There were no differences between the groups on the physical function and leisure scales using multiple standardized measures.

Other studies that have reported functional limitations include the following:

• In the Bone Marrow Transplant Survivors Study (BMTSS), among 235 survivors of childhood HCT, 17% reported long-term physical performance limitations, compared with 8.7% of a sibling comparison group.[169 ]
• A Seattle study evaluated physical function in 214 young adults (median age at questionnaire, 28.7 years; 118 males) who underwent transplant at a median age of 11.9 years. When compared with age- and sex-matched controls, the HCT survivors in this cohort scored one-half standard deviation lower on the physical component score of the SF-36 and the physical function and role physical subscales, quality-of-life measures.[164 ]
• A Swedish study also identified lower self-reported physical health among 73 young adult (median age, 26 years) HCT survivors who were a median of 10 years from transplant. HCT survivors scored significantly below population normative values on physical functioning (90.2 for HCT survivors vs. 95.3 for population), satisfaction with physical health (66.0 for HCT survivors vs. 78.7 for population), and role limitation because of physical health (72.7 for HCT survivors vs. 84.9 for population).[163 ]

Measured physical performance

Objective measurements of function in the pediatric HCT patient and survivor population hints that loss of physical capacity may be a bigger problem than revealed in studies that rely on either clinician or self-report data. Studies measuring cardiopulmonary fitness have observed the following:

• One study used exercise capacity with cycle ergometry in a group of 20 children and young adults before HCT, 31 patients at 1 year post-HCT, and 70 healthy controls.[170 ] The average peak oxygen consumption was 21 mL/kg/min in the pre-HCT group, 24 mL/kg/min in the post-HCT group, and 34 mL/kg/min in the healthy controls. Among the HCT survivors, 62% of those with cancer diagnoses scored in the lowest fifth percentile for peak oxygen consumption, compared with healthy controls.
• Another study examined exercise capacity with a Bruce treadmill protocol in 31 survivors of pediatric HCT. In this cohort, 25.8% of HCT survivors had exercise capacities in the 70% to 79% of predicted category, and 41.9% had exercise capacities in the lower than 70% of predicted category.[171 ]
• In a third study of exercise capacity among 33 HCT survivors who underwent transplant at a mean age of 11.3 years, at the 5-year post-HCT time point, only 4 of 33 survivors scored above the 75th percentile on a serial cycle ergometry test.[172 ]

Predictors of poor physical performance

In the BMTSS, associations were found between chronic GVHD, cardiac conditions, immune suppression, or treatment for a second malignant neoplasm and poor physical performance outcomes.[173 ] In a study from the Fred Hutchison Cancer Research Center, poor performance was associated with myeloid disease.[164 ]

Published Guidelines for Long-term Follow-up

A number of organizations have put forward consensus guidelines for follow-up for late effects after HCT. The CIBMTR, along with the American Society of Blood and Marrow Transplant (ASBMT) and in cooperation with five other international transplant groups, published consensus recommendations for screening and preventive practices for long-term survivors of HCT.[174 ]

Although some pediatric-specific challenges are addressed in these guidelines, many important pediatric issues are not. Some of these issues have been partially covered by general guidelines published by the Children's Oncology Group (COG) and other children's cancer groups (United Kingdom, Scotland, and Netherlands). The COG has also published more specific recommendations for late effects surveillance after HCT.[175 ] To address the lack of detailed pediatric-specific late effects data and guidelines for long-term follow-up after HCT, the Pediatric Blood and Marrow Transplant Consortium (PBMTC) published six detailed papers outlining existing data and summarizing recommendations from key groups (CIBMTR/ASBMT, COG, and the United Kingdom), along with expert recommendations for pediatric-specific issues.[8 ,33 ,63 ,176 ,177 ,178 ]

Although international efforts at further standardization and harmonization of pediatric-specific follow-up guidelines are under way, the PBMTC summary and guideline recommendations provide the most current outline for monitoring children for late effects after HCT.[63 ]

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Complications After Hematopoietic Cell Transplantation (HCT)

Added text to state that in a large prospective trial with central review that used the National Institutes of Health (NIH) consensus criteria, about 28% of patients were misclassified as having chronic graft-versus-host disease (GVHD) when they actually had late-acute GVHD. Additionally, there were significant challenges when using the NIH consensus criteria for bronchiolitis obliterans in children (cited Cuvelier et al. as reference 74).

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About This PDQ Summary

Purpose of This Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the use of hematopoietic cell transplantation in treating childhood cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

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• Michael A. Pulsipher, MD (Children's Hospital Los Angeles)

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PDQ® Pediatric Treatment Editorial Board. PDQ Childhood Hematopoietic Cell Transplantation. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/types/childhood-cancers/child-hct-hp-pdq. Accessed <MM/DD/YYYY>. [PMID: 26389503]

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Last Revised: 2019-08-06