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This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
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] The rate of transplant-related mortality increases with the presence of cardiac, hepatic, pulmonary, gastrointestinal, infectious, and autoimmune comorbidities, or a history of previous solid tumors (refer to Table 1).
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 predict outcomes for patients receiving reduced-intensity and nonmyeloablative regimens. It has also been combined with disease status  and Karnofsky score, leading to even better prediction of survival outcomes. In addition, high HCT-CI scores (>3) have been associated with a higher risk of grades III to IV acute graft-versus-host disease.
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 hematopoietic stem cell transplantation (HSCT) has been explored in several studies.
Evidence (use of HCT-CI score in pediatrics):
Most of the reported comorbidities in these studies were with respiratory or hepatic conditions and infections.[7,8] In the adolescent and young adult study, patients with pre-HSCT pulmonary dysfunction were at particularly high risk of comorbidity, with a 2-year OS rate of 29%, compared with 61% in those with normal lung function before HSCT.
Infectious Risks and Immune Recovery After Transplantation
Defective immune reconstitution is a major barrier to successful HSCT, regardless of graft source.[1,2] Serious infections have accounted for a significant percentage (4%–20%) of late deaths after HSCT.
Factors that can significantly slow immune recovery include the following:
Figure 1 illustrates the immune defects, contributing transplant-related factors, and types and timing of infections that occur after allogeneic transplantation.
Figure 1. 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 research into the role of prophylactic antibacterial medications during the neutropenic phase.
Guidelines for prevention of infections after HSCT have been established by a joint effort of the Centers for Disease Control and Prevention, the Infectious Disease Society of America, and the American Society of Transplantation and Cellular Therapy. Approaches include preventive or prophylactic antivirals, antifungals, and antibiotics; escalation to heightened empiric therapy for signs of infection; and continued careful monitoring through the full duration of the immunocompromised period after HSCT.
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 infections can occur in all patients after bone marrow transplants, and prophylaxis is mandatory.; [Level of evidence: 3iiiB]
After HSCT, 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:
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 HSCT 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 HSCT, and 9 months to 24 months after allogeneic HSCT without GVHD. Patients with active chronic GVHD may have persistent immunosuppression for years. Many centers monitor T-cell subset recovery after bone marrow transplants as a guide to infection risk.
Vaccination after transplantation
International transplant and infectious disease groups have developed specific guidelines for the administration of vaccines after autologous and allogeneic transplantation.[6,10,11] Comparative studies aimed at defining ideal timing of vaccination after transplantation have not been performed, but the vaccine guidelines outlined in Table 2 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 who continue to receive immunosuppressive drugs or until patients are no longer receiving immunosuppressants.
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.
Sinusoidal Obstruction Syndrome/Veno-occlusive Disease (SOS/VOD)
Pathologically, SOS/VOD of the liver 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.[13,14]
Risk factors for SOS/VOD include the following:[13,14]
SOS/VOD is defined clinically by the following:
Life-threatening SOS/VOD generally occurs soon after transplantation and is characterized by multiorgan system failure. Milder, reversible forms can occur, with full recovery expected. Pediatric patients who have severe SOS/VOD without increased bilirubin have been reported; 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. One small, retrospective, single-center study showed a benefit from corticosteroid therapy, but further validation is needed.
Another agent with demonstrated activity is defibrotide, a mixture of oligonucleotides with antithrombotic and fibrinolytic effects on microvascular endothelium. Studies of defibrotide have shown the following:
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. 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 maintains 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. However, they concluded there is insufficient evidence to support the use of tissue plasminogen activator or N-acetylcysteine.[22,26] More detailed consensus recommendations for the diagnosis and management of SOS/VOD in children after HSCT have been published by the Pediatric Blood and Marrow Transplant Consortium, which worked with the Pediatric Acute Lung Injury and Sepsis Investigators.[27,28,29]
Transplant-Associated Thrombotic Microangiopathy (TA-TMA)
Although TA-TMA 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. TA-TMA has most frequently been associated with the use of the calcineurin inhibitors tacrolimus and cyclosporine, and it has been noted to occur more frequently when either of these medications is used in combination with sirolimus.
Diagnostic criteria for this syndrome have been standardized and include the following:
Suggestive symptoms consistent with, but not necessary for, the diagnosis include a sudden worsening of renal function or neurologic symptoms.
Evidence (impact of TA-TMA on HSCT outcomes):
Treatment of TA-TMA
Treatment for TA-TMA includes the following:
Prognosis for normalization of kidney function when disease is caused by calcineurin inhibitors alone is generally poor; however, most TA-TMA that is associated with the combination of a calcineurin inhibitor and sirolimus has been reversed after sirolimus is discontinued, and in some cases, after both medications are stopped.
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.[34,35,36]
Idiopathic Pneumonia Syndrome (IPS)
IPS 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 conditioning regimens and occult infection leading to secretion of high levels of inflammatory cytokines into the alveoli.
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; 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:
Early assessment by bronchioalveolar lavage to rule out infection is important.
Treatment of IPS
The traditional therapy for IPS 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. A large phase II trial of this approach in pediatric patients showed promising results, with OS rates of 89% at 1 month and 63% at 12 months.
Autoimmune Cytopenias (AIC)
AIC after allogeneic HSCT can be restricted to one cell lineage (e.g., autoimmune hemolytic anemia), two cell lineages, or three cell lineages. Most data about AIC in pediatric patients after HSCT are reported from single-center experiences, with the number of cases ranging from 20 to 30, over a 10- to 20-year period.[41,42,43] The incidence of AIC is about 5% after allogeneic HSCT. Risk factors for developing AIC seem to be age younger than 10 years and having a nonmalignant disease as an HSCT indication. At least one study has identified use of serotherapy, use of cord blood as the donor source, and severe GVHD as risk factors, but this finding has not been confirmed in other studies. One study demonstrated that patients who develop AIC have inferior outcomes compared with patients who did not develop AIC. However, other studies did not demonstrate an inferior outcome.[41,42]
Treatment of AIC
The most common first-line therapy for AIC has been corticosteroids.[41,42,43] This treatment is effective in only 15% of patients, and additional immunosuppression or B-cell targeting monoclonal antibodies have been used. Intravenous immunoglobulin is used frequently as adjunct treatment for AIC and/or immunoglobulin replacement.
Epstein-Barr Virus (EBV)–Associated Lymphoproliferative Disorder
After HSCT, 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 HSCT 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).[44,45,46]
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).
Treatment of EBV-associated lymphoproliferative disorder
Isolated bloodstream reactivation of EBV 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.[47,48,49] In addition, some centers have shown efficacy in treating or preventing this complication with therapeutic or prophylactic EBV-specific cytotoxic T cells.[50,51]
Improved understanding of the risk of EBV reactivation, early monitoring, and aggressive therapy have significantly decreased the risk of mortality from this challenging complication.
GVHD is the result of immunologic activation of donor lymphocytes targeting major or minor HLA disparities present in the tissues of a recipient. 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:
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 3 and 4). 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.
Because of variation in outcomes of patients with different grades of acute GVHD, investigators have sought to define a more precise determination of acute GVHD risk based on serum biomarkers. A study that included both adults and children used a score calculated on the basis of the levels of a combination of three biomarkers (tumor necrosis factor receptor 1 [TNFR1], suppression of tumorigenicity 2 [ST2], and regenerating islet-derived 3-alpha [REG3-alpha]) measured at the onset of acute GVHD. Investigators were able to define patients with low (8%), intermediate (27%), and high (46%, P < .0001) risk of 6-month mortality. The biomarker score was more sensitive and specific for predicting survival than clinical staging. Additional refining of the prediction algorithm showed that measurement of only two biomarkers (ST2 and REG3-alpha) reliably predicted outcome. In addition, after 4 weeks of therapy, changes in the biomarker score were able to further refine prediction of survival outcomes. These findings have led to several studies targeting biomarker high-risk or low-risk subsets of patients with acute GVHD and are influencing clinicians regarding the timing and intensity of acute GVHD therapies.
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]).
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 result, most HSCT GVHD prophylaxis attempts to balance risk by giving sufficient immune suppression to prevent severe acute GVHD but not completely remove GVHD risk.
Approaches to GVHD prevention in non–T-cell-depleted grafts have included the following:[57,58]; [Level of evidence: 3iiiA]
Steroid-refractory acute GVHD
When significant acute GVHD occurs, first-line therapy is generally methylprednisolone. Patients with acute GVHD who are 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). Ruxolitinib was approved in 2019 for the treatment of children aged 12 years and older with steroid-refractory acute GVHD, with an overall response rate of 55% and a complete response rate of 27% at day 28 after initiation of therapy. Comparative trials of these agents have not been performed; therefore, a best option for steroid-refractory GVHD has not been identified.[62,63]
Chronic GVHD is a syndrome that may involve a single organ system or several organ systems, with clinical features resembling an autoimmune disease.[1,2] Chronic GVHD is usually first noted 2 to 12 months after hematopoietic stem cell transplantation (HSCT). Traditionally, symptoms occurring more than 100 days after HSCT were considered chronic GVHD, and symptoms occurring sooner than 100 days after HSCT were considered acute GVHD. Because some approaches to HSCT can lead to late-onset acute GVHD, and manifestations that are diagnostic for chronic GVHD can occur sooner than 100 days post-HSCT, the following three distinct types of chronic GVHD have been described:
Organ Manifestations of Chronic GVHD
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).
The tissues that are commonly involved include the skin, eyes, mouth, hair, joints, liver, and gastrointestinal tract. Other tissues such as lungs, nails, muscles, urogenital system, and nervous system may also be involved. Tables 5 to 9 list organ manifestations of chronic GVHD, including 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.
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.
Risk Factors for Chronic GVHD
Chronic GVHD occurs in approximately 15% to 30% of children after sibling-donor HSCT  and in 20% to 45% of children after unrelated-donor HSCT, with a higher risk associated with peripheral blood stem cells (PBSCs) and a lower risk associated with cord blood and selected approaches to haploidentical HSCT.[6,7,8]
Risk factors for the development of chronic GVHD include the following:[5,9,10]
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 of 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.
Older literature describes chronic GVHD as either limited or extensive. A National Institutes of Health (NIH) Consensus Workshop in 2006 broadened the description of chronic GVHD to three categories to better predict long-term outcomes. The three NIH grading categories are as follows:
Thus, high-risk patients include those with severe disease of any site or extensive involvement of multiple sites, especially those with the following:
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. In another large prospective trial with central review that used the 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.
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. Topical therapy to affected areas is preferred for patients with limited disease. The following agents have been tested with some success:
Other approaches, including extracorporeal photopheresis, have been evaluated and show some efficacy in some patients.
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.
Transplant-related complications account for 70% of the deaths in patients with chronic GVHD. Guidelines concerning ancillary therapy and supportive care of patients with chronic GVHD have been published.[16,23]
The highest incidence of mortality after HSCT occurs in the first 2 years and is mostly caused by relapse. A study of late mortality (=2 years posttransplant) in children with malignancies who underwent HSCT showed that approximately 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 HSCT (median follow-up, 6.7 years; range, 2.0–22.2 years), and recurrence of the primary malignancy accounted for 88% of these deaths. Nonrelapse mortality, death caused by chronic graft-versus-host disease (GVHD), and secondary malignancies are less common in children.
Another study reviewed the causes of late mortality after second allogeneic transplantation. Of the children who were alive and relapse free 1 year after a second HSCT, 55% remained alive at 10 years. The most common cause of mortality between 1 and 10 years after HSCT 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 HSCT in children showed that mortality rates remained elevated compared with those of the general population more than 10 years after the procedure, but they 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).
Data from studies of child and adult survivors of HSCT have shown a significant impact of treatment-related exposures on survival and quality of life. In one study of patients who were alive 2 years after undergoing HSCT, survivors had a 9.9-fold increased risk of premature death compared with age- and sex-matched controls in the U.S. general population.
Methodological Challenges in the Study of Late Effects After HSCT
Although the main cause of death in patients who have undergone HSCT is from relapse of the primary disease, a sizeable number of these patients die from infections related to graft-versus-host disease (GVHD), second malignancies, or cardiac or pulmonary issues.[2,3,4,5] In addition, other studies have revealed that up to 40% of HSCT survivors experience severe, disabling, and/or life-threatening events or die because of an adverse event associated with primary or previous cancer treatment.[6,7]
Before studies aimed at decreasing the incidence and severity of these effects are initiated, it is important to understand what leads to the development of these complications:
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-HSCT settings, less is known about the incidence and predictors of congestive heart failure following HSCT in childhood. Potentially cardiotoxic exposures unique to HSCT include the following:
HSCT 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 HSCT or related to other health conditions (e.g., hypothyroidism or growth hormone deficiency).[7,11] In a study of 661 pediatric patients who survived at least 2 years after allogeneic HSCT, 52% of patients were obese or overweight at their most recent examination, 18% of patients had dyslipidemia (associated with pre-HSCT anthracycline or cranial or chest irradiation), and 7% of patients were diagnosed with diabetes.
Rates of cardiovascular outcomes were examined among nearly 1,500 transplant survivors (surviving =2 years) who were treated in Seattle from 1985 to 2006. The survivors and a population-based comparison group were matched by age, year, and sex. 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]). Survivors also had an increased cumulative incidence of the following:
Survivors also had an increased cumulative incidence of related conditions that increased their risk of developing more serious cardiovascular disease (i.e., hypertension, renal disease, dyslipidemia, and diabetes).
In addition, cardiac function and pre-HSCT exposures to chemotherapy and radiation therapy have been shown to significantly impact post-HSCT cardiac function. In evaluating post-HSCT patients for long-term issues, it is important to consider levels of pre-HSCT anthracycline and chest irradiation. Although more specific studies are needed to verify this approach, current evidence suggests that the risk of late-occurring cardiovascular complications after HSCT may largely result from pre-HSCT 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.)
Neurocognitive Late Effects
A preponderance of studies report normal neurodevelopment after HSCT, 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 research group reported poorer outcomes in patients who underwent unrelated-donor transplant when the patients received TBI and when they experienced GVHD. But these effects on outcomes were small compared with the much larger effects of socioeconomic status on cognitive function. 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-HSCT. Stable cognitive function was also noted in a large cohort monitored from pretransplant to 2 years post-HSCT. A smaller study reported similar normal functioning and the absence of declines over time in HSCT survivors. HSCT 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. On the basis of the findings to date, it appears that HSCT 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 HSCT.[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-HSCT, deficits that were maintained at 3 years post-HSCT.[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. Patients who received TBI had a significantly lower IQ at 5 years (P = .05) than did those who did not receive TBI.
(Refer to the Hematopoietic stem cell transplantation [HSCT] 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 10). (Refer to the Hepatobiliary 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. Viral serology and polymerase chain reaction should be performed to differentiate these from GVHD presenting with hepatocellular injury.
Iron overload occurs in almost all patients who undergo HSCT, especially if the procedure is for a condition associated with transfusion dependence before HSCT (e.g., thalassemia, bone marrow failure syndromes) or pre-HSCT treatments requiring transfusions after myelotoxic chemotherapy (e.g., acute leukemias). Inflammatory conditions such as GVHD also increase gastrointestinal iron absorption. Non-HSCT conditions leading to iron overload can lead to cardiac dysfunction, endocrine disorders (e.g., pituitary insufficiency, hypothyroidism), diabetes, neurocognitive effects, and second malignancies.
The effects of iron overload on morbidity post-HSCT have not been well studied; however, reducing iron levels after HSCT for thalassemia has been shown to improve cardiac function.
Although data supporting iron reduction therapies (such as phlebotomy or chelation after HSCT) 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)  should be addressed by iron reduction therapy.
Endocrine System Late Effects
Studies show that rates of thyroid dysfunction in children after myeloablative HSCT 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 who underwent HSCT 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. Early studies showed very high rates of thyroid dysfunction after high single-dose fractions of TBI, 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 prophylaxis than with three-drug GVHD prophylaxis. Increased rates of thyroid dysfunction occur after unrelated-donor HSCT than after related-donor HSCT (36% vs. 9%), suggesting a role for alloimmune damage in causing thyroid dysfunction.[69,76]
Growth impairment is generally multifactorial. Factors that play a role in failure to achieve expected adult height in young children who have undergone HSCT include the following:
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]
Patients younger than 10 years at the time of HSCT are at the highest risk of growth impairment, but they 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.
(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 and metabolic syndrome
After HSCT, adult survivors have a 2.3-fold higher risk of premature cardiovascular-related death 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 HSCT has been suggested.[85,86,87]
In studies of conventionally treated leukemia survivors compared with those who underwent HSCT, 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 HSCT will be at higher risk of 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.)
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 HSCT. However, despite having a normal BMI, HSCT 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, termed sarcopenic obesity, 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 adult survivors and 81 healthy sibling controls found that HSCT survivors had significantly lower weight but no differences in BMI or waist circumference when compared with siblings. HSCT survivors had a significantly higher percent fat mass and lower lean body mass than did controls. HSCT 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 HSCT 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 for multivariate analysis to test the relative importance of each factor.[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 HSCT;[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 and Fractures section in the PDQ summary on Late Effects of Treatment for Childhood Cancer for more information.)
Reported incidence of osteonecrosis in children after HSCT has been 1% to 14%; however, these studies were retrospective and underestimated actual incidence because patients may have been asymptomatic early in the course of the disease.[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 HSCT, 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-HSCT 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 HSCT. 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.
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. 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
Delayed, absent, or incomplete pubertal development commonly occurs after HSCT. 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 who received 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.
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 HSCT.[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 HSCT 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%). 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.
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. After HSCT, 48% to 85% of men 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. (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, or 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, reduced-toxicity, or nonmyeloablative regimens will likely lead to a higher chance of preserved fertility after HSCT. Because 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. In addition, a single-center study compared myeloablative busulfan/cyclophosphamide with reduced-intensity fludarabine/melphalan.[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 HSCT with reduced-intensity conditioning approaches.
A second study compared serum concentrations of antimüllerian hormone (AMH) and inhibin B in 121 children who survived more than 1 year following a single HSCT and received a treosulfan-based regimen (treosulfan; low-toxicity), a fludarabine/melphalan regimen (Flu/Mel; reduced-intensity), or a busulphan/cyclophosphamide regimen (Bu/Cy; myeloablative). Mean age at HSCT was 3.6 years; mean age at follow-up was 11.8 years. Mean length of follow-up was 9.9 years. Mean AMH standard deviation scores (SDS) were significantly higher after treosulfan (-1.047) and Flu/Mel (-1.255) than after Bu/Cy (-1.543), suggesting less ovarian reserve impairment after treosulfan and Flu/Mel than after Bu/Cy. Mean serum AMH concentration was significantly better with treosulfan (>1.0 µg/l) than with Flu/Mel or Bu/Cy. In males, mean inhibin B SDS was significantly higher after treosulfan (-0.506) than after Flu/Mel (-2.53) or some Bu/Cy (-1.23). The authors concluded that treosulfan-based regimens may confer a more favorable outlook for gonadal reserve in both sexes than Flu/Mel or Bu/Cy regimens.
Respiratory System Late Effects
Chronic pulmonary dysfunction
The following two forms of chronic pulmonary dysfunction are observed after HSCT:[133,134,135,136,137,138]
The incidence of both forms of lung toxicity can range from 10% to 40%, depending on donor source, the time interval after HSCT, 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.
Obstructive lung disease
The most common form of obstructive lung disease after allogeneic HSCT is bronchiolitis obliterans.[135,138,140,141] This condition is an inflammatory process resulting in bronchiolar obliteration, fibrosis, and progressive obstructive lung disease.
Historically, the term bronchiolitis obliterans has been used to describe chronic GVHD of the lung and begins 6 to 20 months after HSCT. 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:[133,140]
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. 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.
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 HSCT and has been reported in 25% to 45% of patients by day 100. Importantly, declines in TLC or FVC occurring at 100 days and 1 year after HSCT 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 HSCT.
The most recognizable form of restrictive lung disease is bronchiolitis obliterans organizing pneumonia (BOOP), more recently called cryptogenic organizing pneumonia (COP). 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 HSCT recipients, the development of BOOP/COP is strongly associated with previous acute and chronic GVHD.
Patients with restrictive lung disease have limited responses to multiple agents such as corticosteroids, cyclosporine, tacrolimus, and azathioprine. 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.
(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
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.
In a systematic review of 9,317 adults and children from 28 cohorts who underwent HSCT, 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. The cumulative incidence of chronic kidney disease developing approximately 5 years after transplant ranged from 4.4% to 44.3%, depending on the type of transplant and stage of chronic kidney disease.[146,147] Mortality rates among patients with chronic kidney disease in this setting were higher than those in transplant recipients who retained normal renal function, even when studies controlled for comorbidities.
It is important to aggressively treat hypertension in patients post-HSCT, especially in those treated with prolonged courses of calcineurin inhibitors. Whether post-HSCT 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.
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.[150,151] Many studies have shown that HRQL varies according to the following:
Pre-HSCT factors, such as family cohesion and a child's adaptive functioning, have been shown to affect HRQL. Several groups have also identified the importance of pre-HSCT parenting stress on parental ratings of children's HRQL post-HSCT.[153,154,155,156,157] A report of the trajectories of HRQL over the 12 months after HSCT noted that the poorest HRQL was seen at 3 months post-HSCT, 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-HSCT. Longitudinal studies identified an association of the following additional baseline risk factors with the trajectory of HRQL after HSCT:
A report that investigated the impact of specific HSCT complications indicated that HRQL was worse among children with severe end-organ toxicity, systemic infection, or GVHD. Cross-sectional studies reported that the HRQL among pediatric HSCT survivors of 5 years or longer was reasonably good, although psychological, cognitive, or physical problems appeared to negatively influence HRQL. Female sex, causal diagnosis for HSCT (e.g., acute myelogenous leukemia patients had worse HRQL), and intensity of pre-HSCT therapy were all identified as affecting HRQL post-HSCT.[164,165] Finally, another cross-sectional study of children 5 to 10 years post-HSCT cautioned that parental concerns about the child's vulnerability may induce overprotective parenting.
Physician-reported physical performance
Clinician reports of long-term disability among childhood HSCT survivors suggest that the prevalence and severity of functional loss is low, as described in the following studies:
Self-reported physical performance
Self-reported and proxy data among survivors of childhood HSCT indicated similar low rates of functional loss in the following studies:
Other studies that have reported functional limitations include the following:
Measured physical performance
Objective measurements of function in the pediatric HSCT patient and survivor population hint that loss of physical capacity may be a bigger problem than revealed in studies that rely on clinician or self-report data. Studies measuring cardiopulmonary fitness have observed the following:
Predictors of poor physical performance
The BMTSS found associations between poor physical performance outcomes and chronic GVHD, cardiac conditions, immune suppression, or treatment for a second malignant neoplasm. In a study from the Fred Hutchison Cancer Research Center, poor performance was associated with myeloid disease.
Published Guidelines for Long-term Follow-up
Several organizations have published consensus guidelines for follow-up for late effects after HSCT. 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 HSCT.
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 HSCT. To address the lack of detailed, pediatric-specific, late-effects data and guidelines for long-term follow-up after HSCT, 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.[8,33,63,177,178,179]
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 HSCT.
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
This is a new summary.
Hematopoietic Stem Cell Transplantation (HSCT)–Related Acute Complications
Added text about the results of a trial of 614 sequential patients who underwent allogeneic or autologous HSCT, including the rates of transplant-associated thrombotic microangiopathy and survival outcomes for these patients.
This summary is written and maintained by the PDQ Pediatric Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ® - NCI's Comprehensive Cancer Database pages.
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the complications, graft-versus-host disease, and late effects after hematopoietic stem cell transplantation for the treatment of pediatric cancer. It is intended as a resource to inform and assist clinicians in the care of their patients. It does not provide formal guidelines or recommendations for making health care decisions.
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PDQ® Pediatric Treatment Editorial Board. PDQ Complications, Graft-Versus-Host Disease, and Late Effects After Pediatric Hematopoietic Stem Cell Transplantation. Bethesda, MD: National Cancer Institute. Updated <MM/DD/YYYY>. Available at: https://www.cancer.gov/types/childhood-cancers/hp-stem-cell-transplant/gvhd. Accessed <MM/DD/YYYY>.
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Last Revised: 2022-02-11
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