LWBK1006-42 LWW-Govindan-Review December 12, 2011 20:38
Chapter 42•Stem Cell Transplantation 533the first 2 to 3 weeks posttransplant. Diarrhea is not typically associated
with VOD but may be present concurrently because of other causes in
the immediate posttransplant period. The diagnosis of VOD can often be
reliably made solely on the basis of clinical grounds, although in com-
plicated clinical scenarios, a liver biopsy may be helpful, demonstrating
sinusoidal congestion, fibrin deposition, fibrosis, and surrounding hepa-
tocyte damage.Answer 42.12. The answer is B.
This scenario, with pulmonary infiltrates, hypoxia, and culture-negative
hemorrhagic lavage, is most consistent with idiopathic pneumonitis with
diffuse alveolar hemorrhage, a complication of allogeneic HCT generally
observed in the first several weeks posttransplant. High-dose corticos-
teroids, and more recently recombinant Factor VII, have been used with
some success, although mortality remains high.Answer 42.13. The answer is B.
Although HLA-A, B, C, and DR mismatches have been associated with an
increased risk of GVHD, the impact of mismatches at HLA-DP (and -DQ)
is minimal. Compared with T cell-depleted grafts, T cell-replete grafts
confer a higher risk of GVHD. Older recipient age is also associated with
an increased risk of acute GVHD.Answer 42.14. The answer is D.
Knowledge of the types of opportunistic infections that patients with allo-
geneic HCT are at risk for at various time points allows for a rational,
targeted strategy for prophylaxis. Patients with chronic GVHD requiring
ongoing immunosuppression remain at increased risk for various oppor-
tunistic infections, including pneumocystis, fungal, and viral infections,
as well as CMV. The routine use of ganciclovir as prophylaxis is not indi-
cated, however, because of its significant myelosuppression, and instead
a more rational approach to preventing CMV disease involves periodic
monitoring of peripheral blood with CMV PCR and reserving ganciclovir
for preemptive use in the event of detectable CMV viremia.Answer 42.15. The answer is C.
Graft failure remains a relatively uncommon complication (2% to 3%)
of matched sibling allogeneic HSC, although the risk is increased in the
setting of an HLA-mismatched or unrelated donor, marginal CD34+cell
dose, or T depletion. Cell doses are often limiting in cord blood products,
particularly for adult recipients, which are associated with a higher risk
of graft failure.Answer 42.16. The answer is B.
The risk of developing CMV infection with a CMV-negative donor and
recipient is negligible. Among CMV-positive recipients, a CMV-positive
donor confers a lower risk of reactivation because of the transfer of