BMTCN UPDATED CORRECT QUESTIONS AND
ANSWERS SURE A+
✔✔GVHD - ✔✔Immunological response that occurs when the donor lymphocytes are
infused onto the recipient and identified as foreign. this process is essentially an
exaggerated response of a normal physiologic inflammatory mechanism of the donor
lymphocytes. 20-80% incidence rate
✔✔classic acute GVHD - ✔✔erythematous, maculopapular rash, nausea, vomiting,
anorexia, profuse diarrhea, ileus or cholestatic liver disease that occurs within 100 days
after transplant or DLI in patients not meeting criteria for chronic GVHD
often seen during taper or withdrawal of immunosuppressants
✔✔persistent, recurrent, or late-onset acute GVHD - ✔✔includes erythematous,
maculopapular rash, nausea, vomiting, anorexia, profuse diarrhea, ileus or cholestatic
liver disease that occurs beyond 100 days post transplant or DLI and without criteria for
diagnosis chronic GVHD
✔✔chronic GVHD - ✔✔Manifestations of autoimmune disease and no features
characteristics of acute gvhd, it is a syndrome that involves multiple organs including
the skin, the eyes oral mucosa, lung, gi tact and liver.
most cases are diagnose 4-6 m after HSCT but 5-10% of cases are initially diagnosed
beyond the first year post transplant
✔✔Overlap syndrome - ✔✔a subcategory of chronic GVHD occurs when features of
both chronic and acute appear together
✔✔pt who present overlap syndrom with chronic GVHD - ✔✔may resolved the acute
features but chronic GVHD features persist.
✔✔hyperacute GVHD is a - ✔✔severe form of acute GVHD that ca be fatal
,✔✔hyperacute GVHD is diagnosed based on - ✔✔1-fever greater than 100.4 f on two
occasions for more hat 3 days prior to engraftment with lack of resolution after treatment
with ABO and antifungal agents including amphotericin B.
2-rapid development of skin rash engraftment, generalized erythroderma and progress
to desquamation.
3-hepatic dysfunction especially alkaline-phosphate and bilirubin before engraftment
(excluding causes such as veno occlusive , drug induce hepatitis or Right sided heart
failure)
4- development of mucoid, greenish diarrhea with more that five stool per day
(excluding etiology of mucositis)
✔✔preferred treatment for GVHD - ✔✔high dose of steroids
✔✔the dame degree of human leukocytes antigen (HLA) mismatch results in -
✔✔lowers risk for acute GVHD using UCB grafts
✔✔risk factors for GVHD - ✔✔1-degree of hla mismatch
2-pbsc as the graft source
3-sex mismatch
4-recipient and donors older than 40
5-high doses of TBI
6-conditioning intensity higher risk with myeloablative conditioning regimens than non
myeloablative regimens
7-higher CD34+ cell dose
8-GVHD prophylaxis (single agent or reduce dose)
9-unmanipulated graft (not depleted of T cells)
10-donor transfusion status (previously transfused)
11-related versus unrelated : most severe GVHD occurs with HLA mismatched or
unrelated donors, compares with hla matched sibling.
✔✔requirements for GVHD - ✔✔1-graft must contain immunocompetent cells
2-histoincompatibility must exist between the donor and the recipient
3-the recipient must be incapable of mounting an effective immunologic reaction against
the graft, this would eliminate the foreign transplanted cells.
✔✔pathophysiology of GvHD phase I - ✔✔occur prior to the transplant when the
preparative or conditioning regimen of chemotherapy (with and without radiation) may
damage host tissues, including intestinal ,ucosa, skin, and liver and the mucosa
becomes permeable.
✔✔pathophysiology of GvHD phase II - ✔✔Donor T cell activation
host APCs (antigen-presenting cells) come into contact with donors and activate T cells
t-cell activated expand and differentiate producing specific cytokines that recruit
cytotoxic T lymphocytes and natural killer cells to cause cell and tissue destruction of
target organs.
,✔✔Organs most commonly affected by acute GVHD - ✔✔SKIN
LIVER
GI TRACT
✔✔pathophysiology of GvHD phase III - ✔✔Cellular and inflammatory effector phase
(target tissue destruction)
an inflammatory cascade initiated a number of cytotoxic pathways targeting and
attacking host cells in multiple organs system (cytokine storm).
the entire process becomes cyclical more tissue damage lead to more cytokines
production with causes a greater risk of GVHD.
✔✔biomarkers for diagnosing GVHD - ✔✔1-regenerating islet-derived 3- alpha for lower
GI
2-Elafin for skin
3-b- cell activating factor(known as BAFF) for chronic GVHD
✔✔prevention of GVHD - ✔✔1-Depletion of T cells in the graft
2-immunosuppressant therapy (given prior to the transplant)
✔✔immunosuppressive drugs mechanism of action - ✔✔blocking TNF, IL-2 pathways
and therefore are often use in combination
✔✔immunosuppresive drug for GVHD - ✔✔-calcineurin inhibitors(CNIs) cyclosporine or
tacrolimus
-a short dose of MTX is the standard for acute phase prophylaxis.
-combination of sirolimus and tacrolimus use to prevent gvhd
✔✔the administration of epstein-barr virus (EBV) cytotoxic T lymphocytes has been
found to be feasible therapeutic option in which medicated disease process? -
✔✔Lymphoproliferative disease
✔✔donor leukocytes infusion is an appropriate treatment option for a patient who has
relapsed post allogeneic transplant with - ✔✔chronic myelogenous leukemia
✔✔which of the following is most important prognosis elements for a patient being
treated for pulmonary aspergillosis post-transplant? - ✔✔granulocyte recovery
✔✔the foundation for the accreditation of cellular therapy requires notification of positive
microbial culture results on cellular therapy products to the - ✔✔recipient
✔✔a patient is undergoing peripheral blood stem cell mobilization for an autologous
transplant and starts to experience fever, fatigue and bone pain. this most likely due to ?
- ✔✔growth factors
, ✔✔28 y old with acute myeloid leukemia
plan: myeloablation (busulfan/cyclophosphamide) and immunosuppression with
tacrolimus and MTX on days 1.3.6.& 11 she did not received day 11 because of severe
mucositis. day 50 revealed a new maculopapular rash covering 40% . she is stage
grade 2 what is the initial management ? - ✔✔check tacrolimus level and start topical
steroids (grade 2)
✔✔tacrolimus level therapeutic at 11 (5.0-15.0) pt report watery diarrhea fives times per
day. she is admitted to the hospital how would she be managed - ✔✔-add antidiarrheal
agents
-rule out infections etiology of diarrhea
-change medication from po to iv
-request gi consult
-obtain accurate measurement of stool volume
✔✔stage 2 gvhd diarrhea of 1000 ml treatment? - ✔✔systemic steroids
(methylprednisolone 1-2 mg/kg per day)
✔✔one week later volumen of diarrhea of 3000 ml how should be treated? - ✔✔add
infliximab or ATG and attempt to taper steroids
✔✔what is the standard regimen of immunosuppression for myeloablative transplant -
✔✔tacrolimus and MTX
✔✔C.W presents to the clinic on day 30 after allogeneic transplant (matched unrelated
donor) with a rash on her arms and chest. using the rule of nines, what stage is the
patient? - ✔✔stage 1-2
✔✔2 moths status post allogeneic bone marrow using unrelated donor. complains of
itchy rash on her chest and arms. her immunosuppression regimen is cyclosporine ad
mycophenolic acid what would be the initial treatment? - ✔✔check cyclosporine level
and using hydrocortisone and have her return in 3 days
✔✔unrelated transplant from 40 y man, the graft is 9/10 hla matched. both donor and
recipient are CMV positive. what is the biggest risk factor for ot developing GVHD? -
✔✔HLA mismatch
✔✔cyclosporine and tacrolimus have many drugs-drug interaction. a major interaction is
with voriconazole. when calculating dose of calcineurin inhibitors (CNIs) for
immunosuppression, what should be done? - ✔✔give drugs at least four hours apart to
avoid interaction, dose reduce CNI by one third to one-quarter and follow levels closely.
ANSWERS SURE A+
✔✔GVHD - ✔✔Immunological response that occurs when the donor lymphocytes are
infused onto the recipient and identified as foreign. this process is essentially an
exaggerated response of a normal physiologic inflammatory mechanism of the donor
lymphocytes. 20-80% incidence rate
✔✔classic acute GVHD - ✔✔erythematous, maculopapular rash, nausea, vomiting,
anorexia, profuse diarrhea, ileus or cholestatic liver disease that occurs within 100 days
after transplant or DLI in patients not meeting criteria for chronic GVHD
often seen during taper or withdrawal of immunosuppressants
✔✔persistent, recurrent, or late-onset acute GVHD - ✔✔includes erythematous,
maculopapular rash, nausea, vomiting, anorexia, profuse diarrhea, ileus or cholestatic
liver disease that occurs beyond 100 days post transplant or DLI and without criteria for
diagnosis chronic GVHD
✔✔chronic GVHD - ✔✔Manifestations of autoimmune disease and no features
characteristics of acute gvhd, it is a syndrome that involves multiple organs including
the skin, the eyes oral mucosa, lung, gi tact and liver.
most cases are diagnose 4-6 m after HSCT but 5-10% of cases are initially diagnosed
beyond the first year post transplant
✔✔Overlap syndrome - ✔✔a subcategory of chronic GVHD occurs when features of
both chronic and acute appear together
✔✔pt who present overlap syndrom with chronic GVHD - ✔✔may resolved the acute
features but chronic GVHD features persist.
✔✔hyperacute GVHD is a - ✔✔severe form of acute GVHD that ca be fatal
,✔✔hyperacute GVHD is diagnosed based on - ✔✔1-fever greater than 100.4 f on two
occasions for more hat 3 days prior to engraftment with lack of resolution after treatment
with ABO and antifungal agents including amphotericin B.
2-rapid development of skin rash engraftment, generalized erythroderma and progress
to desquamation.
3-hepatic dysfunction especially alkaline-phosphate and bilirubin before engraftment
(excluding causes such as veno occlusive , drug induce hepatitis or Right sided heart
failure)
4- development of mucoid, greenish diarrhea with more that five stool per day
(excluding etiology of mucositis)
✔✔preferred treatment for GVHD - ✔✔high dose of steroids
✔✔the dame degree of human leukocytes antigen (HLA) mismatch results in -
✔✔lowers risk for acute GVHD using UCB grafts
✔✔risk factors for GVHD - ✔✔1-degree of hla mismatch
2-pbsc as the graft source
3-sex mismatch
4-recipient and donors older than 40
5-high doses of TBI
6-conditioning intensity higher risk with myeloablative conditioning regimens than non
myeloablative regimens
7-higher CD34+ cell dose
8-GVHD prophylaxis (single agent or reduce dose)
9-unmanipulated graft (not depleted of T cells)
10-donor transfusion status (previously transfused)
11-related versus unrelated : most severe GVHD occurs with HLA mismatched or
unrelated donors, compares with hla matched sibling.
✔✔requirements for GVHD - ✔✔1-graft must contain immunocompetent cells
2-histoincompatibility must exist between the donor and the recipient
3-the recipient must be incapable of mounting an effective immunologic reaction against
the graft, this would eliminate the foreign transplanted cells.
✔✔pathophysiology of GvHD phase I - ✔✔occur prior to the transplant when the
preparative or conditioning regimen of chemotherapy (with and without radiation) may
damage host tissues, including intestinal ,ucosa, skin, and liver and the mucosa
becomes permeable.
✔✔pathophysiology of GvHD phase II - ✔✔Donor T cell activation
host APCs (antigen-presenting cells) come into contact with donors and activate T cells
t-cell activated expand and differentiate producing specific cytokines that recruit
cytotoxic T lymphocytes and natural killer cells to cause cell and tissue destruction of
target organs.
,✔✔Organs most commonly affected by acute GVHD - ✔✔SKIN
LIVER
GI TRACT
✔✔pathophysiology of GvHD phase III - ✔✔Cellular and inflammatory effector phase
(target tissue destruction)
an inflammatory cascade initiated a number of cytotoxic pathways targeting and
attacking host cells in multiple organs system (cytokine storm).
the entire process becomes cyclical more tissue damage lead to more cytokines
production with causes a greater risk of GVHD.
✔✔biomarkers for diagnosing GVHD - ✔✔1-regenerating islet-derived 3- alpha for lower
GI
2-Elafin for skin
3-b- cell activating factor(known as BAFF) for chronic GVHD
✔✔prevention of GVHD - ✔✔1-Depletion of T cells in the graft
2-immunosuppressant therapy (given prior to the transplant)
✔✔immunosuppressive drugs mechanism of action - ✔✔blocking TNF, IL-2 pathways
and therefore are often use in combination
✔✔immunosuppresive drug for GVHD - ✔✔-calcineurin inhibitors(CNIs) cyclosporine or
tacrolimus
-a short dose of MTX is the standard for acute phase prophylaxis.
-combination of sirolimus and tacrolimus use to prevent gvhd
✔✔the administration of epstein-barr virus (EBV) cytotoxic T lymphocytes has been
found to be feasible therapeutic option in which medicated disease process? -
✔✔Lymphoproliferative disease
✔✔donor leukocytes infusion is an appropriate treatment option for a patient who has
relapsed post allogeneic transplant with - ✔✔chronic myelogenous leukemia
✔✔which of the following is most important prognosis elements for a patient being
treated for pulmonary aspergillosis post-transplant? - ✔✔granulocyte recovery
✔✔the foundation for the accreditation of cellular therapy requires notification of positive
microbial culture results on cellular therapy products to the - ✔✔recipient
✔✔a patient is undergoing peripheral blood stem cell mobilization for an autologous
transplant and starts to experience fever, fatigue and bone pain. this most likely due to ?
- ✔✔growth factors
, ✔✔28 y old with acute myeloid leukemia
plan: myeloablation (busulfan/cyclophosphamide) and immunosuppression with
tacrolimus and MTX on days 1.3.6.& 11 she did not received day 11 because of severe
mucositis. day 50 revealed a new maculopapular rash covering 40% . she is stage
grade 2 what is the initial management ? - ✔✔check tacrolimus level and start topical
steroids (grade 2)
✔✔tacrolimus level therapeutic at 11 (5.0-15.0) pt report watery diarrhea fives times per
day. she is admitted to the hospital how would she be managed - ✔✔-add antidiarrheal
agents
-rule out infections etiology of diarrhea
-change medication from po to iv
-request gi consult
-obtain accurate measurement of stool volume
✔✔stage 2 gvhd diarrhea of 1000 ml treatment? - ✔✔systemic steroids
(methylprednisolone 1-2 mg/kg per day)
✔✔one week later volumen of diarrhea of 3000 ml how should be treated? - ✔✔add
infliximab or ATG and attempt to taper steroids
✔✔what is the standard regimen of immunosuppression for myeloablative transplant -
✔✔tacrolimus and MTX
✔✔C.W presents to the clinic on day 30 after allogeneic transplant (matched unrelated
donor) with a rash on her arms and chest. using the rule of nines, what stage is the
patient? - ✔✔stage 1-2
✔✔2 moths status post allogeneic bone marrow using unrelated donor. complains of
itchy rash on her chest and arms. her immunosuppression regimen is cyclosporine ad
mycophenolic acid what would be the initial treatment? - ✔✔check cyclosporine level
and using hydrocortisone and have her return in 3 days
✔✔unrelated transplant from 40 y man, the graft is 9/10 hla matched. both donor and
recipient are CMV positive. what is the biggest risk factor for ot developing GVHD? -
✔✔HLA mismatch
✔✔cyclosporine and tacrolimus have many drugs-drug interaction. a major interaction is
with voriconazole. when calculating dose of calcineurin inhibitors (CNIs) for
immunosuppression, what should be done? - ✔✔give drugs at least four hours apart to
avoid interaction, dose reduce CNI by one third to one-quarter and follow levels closely.
