Guides BMT/SCT workflow from conditioning through engraftment monitoring and GVHD assessment. Use when managing transplant patients, monitoring engraftment, or assessing GVHD.
Guides BMT/SCT workflow from conditioning through engraftment monitoring and GVHD assessment.
Hematopoietic stem cell transplantation (HSCT) — including bone marrow transplant (BMT), peripheral blood stem cell transplant (PBSCT), and cord blood transplant — is the definitive curative therapy for many hematologic malignancies. The procedure carries treatment-related mortality of 10–30% depending on transplant type, conditioning intensity, and patient factors. FACT (Foundation for the Accreditation of Cellular Therapy) standards mandate comprehensive documentation of every phase from donor selection through long-term follow-up.
CIBMTR (Center for International Blood and Marrow Transplant Research) requires standardized outcomes reporting for all US transplant centers. GVHD remains the leading cause of post-transplant morbidity and mortality, requiring systematic grading and evidence-based management. Engraftment monitoring with chimerism testing informs critical decisions about immunosuppression tapering and donor lymphocyte infusion. Incomplete documentation or delayed recognition of complications leads to preventable mortality and regulatory non-compliance.
HCT-CI scoring (Sorror et al.): Calculate comorbidity score (0 = low risk, 1–2 = intermediate, ≥3 = high risk):
| Comorbidity | Score |
|---|---|
| Arrhythmia | 1 |
| Cardiac (LVEF ≤50% or prior MI or CHF) | 1 |
| Inflammatory bowel disease | 1 |
| Diabetes requiring treatment | 1 |
| Cerebrovascular disease | 1 |
| Psychiatric disturbance | 1 |
| Hepatic (mild: bilirubin ULN–1.5× or AST/ALT ULN–2.5×) | 1 |
| Obesity (BMI >35) | 1 |
| Infection requiring treatment at transplant | 1 |
| Rheumatologic disease | 2 |
| Peptic ulcer | 2 |
| Moderate/severe renal (CrCl <61) | 2 |
| Moderate pulmonary (FEV1 66–80% or DLCO 66–80%) | 2 |
| Prior solid tumor | 3 |
| Heart valve disease | 3 |
| Severe pulmonary (FEV1 ≤65% or DLCO ≤65%) | 3 |
| Moderate/severe hepatic (bilirubin >1.5× or AST/ALT >2.5×) | 3 |
Disease Risk Index (DRI): Low, intermediate, high, or very high — based on diagnosis and disease status at transplant. DRI stratifies expected relapse risk and overall survival post-transplant.
Conditioning phase (Day -7 to Day -1):
Day 0 (Stem Cell Infusion):
Engraftment monitoring (Day +1 to +30):
Acute GVHD (typically within first 100 days):
| Organ | Stage 1 | Stage 2 | Stage 3 | Stage 4 |
|---|---|---|---|---|
| Skin | Rash <25% BSA | Rash 25–50% BSA | Rash >50% BSA | Generalized erythroderma with bullae |
| Liver | Bilirubin 2–3 mg/dL | Bilirubin 3.1–6 mg/dL | Bilirubin 6.1–15 mg/dL | Bilirubin >15 mg/dL |
| GI | Diarrhea 500–999 mL/day | Diarrhea 1000–1500 mL/day | Diarrhea >1500 mL/day | Severe abdominal pain ± ileus |
Overall acute GVHD grading (Glucksberg criteria):
Chronic GVHD (NIH Consensus Criteria): Assess 8 organ systems (skin, mouth, eyes, GI, liver, lungs, joints/fascia, genital tract). Score each 0–3. Classify overall severity as mild, moderate, or severe.
First-line treatment: Systemic corticosteroids (methylprednisolone 2 mg/kg/day for Grade II–IV acute GVHD). Steroid-refractory: ruxolitinib (FDA-approved for steroid-refractory acute and chronic GVHD).
Infection prophylaxis schedule:
| Pathogen | Prophylaxis | Duration |
|---|---|---|
| Bacterial | Fluoroquinolone (levofloxacin) | Neutropenic period |
| HSV/VZV | Acyclovir/valacyclovir | Minimum 1 year; longer if on immunosuppression |
| PJP | TMP-SMX or alternative | Minimum 6 months; longer if on immunosuppression |
| Fungal | Fluconazole or posaconazole | Through neutropenic period; longer for GVHD patients |
| CMV | Monitor by PCR weekly × 100 days; preemptive therapy with letermovir prophylaxis or valganciclovir if viremia detected | Per institutional protocol |
| EBV | Monitor by PCR; rituximab for PTLD | Per institutional protocol |
Other critical monitoring: