Post-transplant care and early HCT complications

Guidance to support hematology/oncology practices providing long-term care for patients after transplant

When your patient returns to your care after hematopoietic cell transplantation (HCT), your ongoing support is critical to their long-term recovery and survival. This page provides quick access to post-transplant care guidelines designed for your busy hematology/oncology team. NMDP^SM developed the guidelines in partnership with leading transplant organizations and using peer-reviewed publications. [1-7]

Get point-of-care access to long-term screening guidelines, vaccination schedules and GVHD assessment tools on any device.

Access web-based post-transplant care guidelines

Long-term screening
View long-term screening and preventive care practices to support ongoing treatment planning for patients after bone marrow transplant.
Access long-term screening guidelines
Vaccinations
Access timing and recommendations for routine vaccinations in allogeneic and autologous hematopoietic stem cell transplant recipients.
View vaccine schedule
GVHD screening
Identify and evaluate chronic graft-versus-host disease (GVHD) signs and symptoms with clinical manifestations and photos by area of the body.
Review GVHD screening guidelines

Download the app for post-HCT considerations at the point of care

A hand holding a smart phone with the NMDP Transplant Guidelines app home screen displayed.

The HCT Guidelines app puts evidence-based guidelines at your fingertips. What's included:

Long-term screening guidelines organized by organ system with recommendations for tests or procedures and their frequency
Vaccination schedule for patients starting as early as 6 months after HCT
Chronic GVHD screening tools with a photo atlas

Get the iOS app

Get the Android app

Download the app on your mobile device or save a PDF version.

Patient-friendly guidelines are also available for you to order, download or print in English or Spanish. Access the free patient guidelines.

Complications to watch for during the first year after HCT

Transplant recipients are immunocompromised after HCT and may also experience treatment-related organ and tissue damage. If your patient returns to your care within the first year after transplant, they’ll require careful monitoring to ensure any complications are recognized early when therapeutic options can be more effective. If your patient experiences a complication, collaborate quickly with the transplant center to develop a treatment plan.

These are some of the most common complications that you may see from transplant infusion to one-year post-transplant. Chronic GVHD screening is discussed separately as it is a complex disease with many manifestations.

Oral mucositis is inflammation of oral mucosa that typically manifests as erythema or ulcerations. It can result from the cytotoxic effects of chemotherapy- and radiation-based pre-transplant conditioning regimens. [8,9]

Mouth sores associated with acute GVHD may also develop 2-4 weeks post-transplant. The severity and the patient's hematologic status govern appropriate oral management. Meticulous oral hygiene and palliation of symptoms are essential.
Acute GVHD is a common complication of allogeneic transplantation in which activated donor T cells attack the tissues of the transplant recipient after recognizing host tissues as antigenically foreign. The resulting inflammatory cytokines can cause tissue damage. The commonly involved organs include the liver, skin, mucosa and gastrointestinal tract.

By classical definition, GVHD appearing before day 100 post-transplant is acute GVHD; GVHD appearing after day 100 is chronic GVHD. However, acute GVHD may still occur later than 100 days post-transplant (e.g., during tapering of immunosuppressive drugs or following a donor lymphocyte infusion). Some patients may also develop an overlap syndrome, where features of both acute and chronic GVHD are present. [10,11]
Graft failure is a rare, but life-threatening, complication following allogeneic HCT. The most common cause of graft failure is an immunological rejection of the graft mediated by recipient T cells, natural killer cells and/or antibodies. Other causes are infection, recurrent disease or an insufficient number of stem cells in the donated graft. Graft failure occurs in approximately 5% of allogeneic transplants. [12]

The rate of failure can vary by graft source. Patients allo-sensitized through prior blood transfusions or pregnancy and those receiving reduced-intensity conditioning are also at a higher risk of experiencing graft failure.

If graft failure occurs, treatment is a second HCT using cells from the same donor or from a different donor. Patients experiencing graft failure after a cord blood transplant cannot get backup cells from the same cord blood unit. However, it may be possible to use a different cord blood unit or a backup adult donor instead.
All transplant recipients are susceptible to infections and require careful monitoring, which allows for timely administration of antibacterial, antiviral and/or antifungal agents. [3]

Average times of full immune recovery are:
- Neutrophils and phagocytes: 1 month
- T cells: 6-12 months
- B cells: 12-24 months
Common infections in early and late post-transplant time periods are shown below.

>0-3 months:
- Most bacteria
- Candida, Aspergillus, other fungi
- Herpes simplex
- Pneumocystis carinii
- Cytomegalovirus (CMV)
>3 months:
- P. carinii
- Varicella-Zoster viruses
- CMV
- Encapsulated bacteria
Organ injury and toxicity following transplant can include hepatic veno-occlusive disease (VOD) also known as sinusoidal obstruction syndrome, renal failure, pulmonary toxicity, thrombotic microangiopathy (TMA) and cardiovascular complications.

Pulmonary complications

In the early post-transplant neutropenic period, there is an increased risk of various bacterial, fungal and viral infections of the lung, and pneumonia develops in 40% to 60% of transplant recipients. [13] The pneumonias that can occur include herpes simplex pneumonitis, cytomegalovirus pneumonitis and Pneumocystis carinii pneumonia.

Bronchiolitis obliterans syndrome and bronchiolitis obliterans organizing pneumonia can appear later (post day 100) in the transplant recovery period. Bronchiolitis obliterans is closely associated with chronic GVHD and may result from alloimmunologic injury to host bronchiolar epithelial cells. [13,14]

Renal complications

Chronic kidney disease (CKD) is associated with the use of TBI in the transplant conditioning regimen, although many cases are idiopathic. Total body irradiation (TBI)-associated CKD has a typical latency of 3-6 months from irradiation to injury. CKD after transplantation may not be recognized early due to competing clinical priorities such as the treatment of GVHD and monitoring for infections and disease recurrence. [15]

Liver complications

Sinusoidal obstructive syndrome (SOS) also known as VOD of the liver (SOS/VOD) is the result of damage to the hepatic sinusoids, resulting in biliary obstruction. Risk factors include the use of busulfan, TBI, infection, acute GVHD and pre-existing liver dysfunction due to iron overload or hepatitis. [16]

Thrombotic microangiopathy

Transplant-associated TMA is a rare complication after allogeneic transplantation and can occur after autologous transplantation. Risk factors for TMA include pre-transplant conditioning with busulfan, fludarabine, platinum-based chemotherapy and TBI. TMA is also associated with the use of the calcineurin inhibitors, tacrolimus and cyclosporine. Transplant-associated TMA syndromes present as hemolytic uremic syndrome (HUS) or thrombotic thrombocytopenic purpura (TTP). [17]

Cardiovascular complications

Cardiovascular complications may manifest as subclinical abnormalities or present as overt congestive heart failure or angina. The cardiac complications include any cardiac dysfunction due to cardiomyopathy, valvular anomaly or conduction anomaly. [18]

Free resources for your patients after transplant

NMDP Patient Support Center
One-on-one support for patients and caregivers, with staff fluent in English and Spanish and interpreters available.
Explore support
Patient education materials
Educational materials to support patients after HCT that you can order, download or print—with resources available in multiple languages.
Browse materials
Counseling and support
Emotional support and counseling program for patients and caregivers with support in English and Spanish from licensed NMDP social workers.
Get the details (Opens in a new tab)

References

Rotz SJ, Bhatt NS, Hamilton BK, et al. International recommendations for screening and preventative practices for long-term survivors of transplantation and cellular therapy: A 2023 update. Transplantation and Cellular Therapy. 2024;30(4):349-385. doi: 10.1016/j.jtct.2023.12.001. Access
Carpenter P, Boeckh M, Deeg J, et al. Long-term follow-up after hematopoietic stem cell transplant general guidelines for referring physicians. Fred Hutchinson Cancer Center. Published 2023. https://www.fredhutch.org/content/dam/www/research/patient-treatment-and-support/ltfu/LTFU_HSCT_guidelines_physicians.pdf. Access
Tomblyn M, Chiller T, Einsele H, et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: A global perspective. Biol Blood Marrow Transplant. 2009;15(10):1143-1238. doi: 10.1016/j.bbmt.2009.06.019. Access
Ljungman P, Cordonnier C, Einsele H, et al. Vaccination of hematopoietic cell transplant recipients. Bone Marrow Transplant. 2009;44(8):521-526. doi: 10.1038/bmt.2009.263. Access
Jagasia MH, Greinix HT, Arora M, et al. National Institutes of Health Consensus Development Project on Criteria for Clinical Trials in Chronic Graft-versus-Host Disease: I. The 2014 Response Criteria Working Group Report. Biol Blood Marrow Transplant. 2015;21(3):389-401. doi: 10.1016/j.bbmt.2014.12.001. Access
Lee SJ, Wolff D, Kitko C, 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. The 2014 Response Criteria Working Group Report. Biol Blood Marrow Transplant. 2015;21(6):984-999. doi: 10.1016/j.bbmt.2015.02.025. Access
These guidelines have been developed by NMDP in consultation with Sandra A. Mitchell, CRNP, MScN, AOCN; National Institutes of Health Clinical Center; and Steven Z. Pavletic, MD; National Cancer Institute, National Institutes of Health, Bethesda, Md. The information in this document does not represent the official position of the NIH or the U.S. Government.
Oral Complications of Chemotherapy and Head/Neck Radiation: Oral Mucositis. National Cancer Institute (PDQ database). Access
Keefe DM, Schubert MM, Elting LS, et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer. 2007;109(5):820-831. doi: 10.1002/cncr.22484. Access
Martin PJ, Rizzo JD, Wingard JR, et al. First- and second-line systemic treatment of acute graft-versus-host disease: Recommendations of the American Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant. 2012;18(8):1150-1163. doi: 10.1016/j.bbmt.2012.04.005. Access
Flowers MED, Inamoto Y, Carpenter PA, et al. Comparative analysis of risk factors for acute graft-versus-host disease and for chronic graft-versus-host disease according to National Institutes of Health consensus criteria. Blood. 2011;117(11):3214-3219. doi: 10.1182/blood-2010-08-302109. Access
Olsson R, Remberger M, Schaffer M, et al. Graft failure in the modern era of allogeneic hematopoietic SCT. Bone Marrow Transplant. 2013;48(4):537-543. doi: 10.1038/bmt.2012.239. Access
Yen KT, Lee AS, Krowka MJ, Burger CD. Pulmonary complications in bone marrow transplantation: a practical approach to diagnosis and treatment. Clin Chest Med. 2004;25(1):189-201. doi: 10.1016/S0272-5231(03)00121-7. Access
Yoshihara S, Yanik G, Cooke KR, Mineishi S. Bronchiolitis obliterans syndrome (BOS), bronchiolitis obliterans organizing pneumonia (BOOP), and other late-onset noninfectious pulmonary complications following allogeneic hematopoietic stem cell transplantation. Biol Blood Marrow Transplant. 2007;13(7):749-759. doi: 10.1016/j.bbmt.2007.05.001. Access
Cohen EP, Pais P, Moulder JE. Chronic kidney disease after hematopoietic stem cell transplantation. Semin Nephrol. 2010;30(6):627-634. doi: 10.1016/j.semnephrol.2010.09.010. Access
Laskin BL, Goebel J, Davies SM, Jodele S. Small vessels, big trouble in the kidneys and beyond: hematopoietic stem cell transplantation-associated thrombotic microangiopathy. Blood. 2011;118(6):1452-1462. doi: 10.1182/blood-2011-02-321315. Access
Ho VY, 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. 2005;11(8):571-575. doi: 10.1016/j.bbmt.2005.06.001. Access
Tichelli A, Bucher C, Rovó A, et al. Premature cardiovascular disease after allogeneic hematopoietic stem-cell transplantation. Blood. 2007;110(9):3463-3471. doi: 10.1182/blood-2006-10-054080. Access

Post-transplant care and early HCT complications

Guidance to support hematology/oncology practices providing long-term care for patients after transplant

Access web-based post-transplant care guidelines

Long-term screening

Vaccinations

GVHD screening

Download the app for post-HCT considerations at the point of care

Complications to watch for during the first year after HCT

Free resources for your patients after transplant

NMDP Patient Support Center

Patient education materials

Counseling and support

References

About NMDP

Explore

Connect with us

Post-transplant care and early HCT complications

Guidance to support hematology/oncology practices providing long-term care for patients after transplant

Access web-based post-transplant care guidelines

Long-term screening

Vaccinations

GVHD screening

Download the app for post-HCT considerations at the point of care

Complications to watch for during the first year after HCT

Oral mucositis

Acute graft-versus-host disease

Stem cell graft failure

Early infections

Organ injury/toxicity

Free resources for your patients after transplant

NMDP Patient Support Center

Patient education materials

Counseling and support

References