Long term screening

Recognizing complications early when there are more effective treatment options is critical to the well-being of transplant recipients.

Complications from hematopoietic cell transplantation (HCT) can develop long after a patient leaves a transplant center and returns to a primary physician. Use these guidelines to deliver the specialized care transplant patients need to prevent late complications and to reduce morbidity.

These long-term screening guidelines are based on International Recommendations for Screening and Preventative Practices for Long-Term Survivors of Transplantation and Cellular Therapy: A 2023 Update, developed by experts across 29 international transplant institutions. [1]

The guidelines are organized by organ system to assist in patient care planning. Use the following charts to:

Become aware of the specialized care transplant recipients need
Plan for tests and treatments
Trigger discussions with patients on proper self-care

Screening guidelines

Click on any link to jump directly to that section:

Cardiac & vascular complications
Dermatologic
Endocrine complications
Gastrointestinal complications
Hematologic
Immunity & infections
Muscular
Neurologic & cognitive
Ocular
Oral & dental
Psychosocial
Renal & urinary complications
Respiratory
Sexual health, fertility & pregnancy
Skeletal
Subsequent malignant neoplasm

Cardiac & vascular complications

Recommendation	Frequency	Notes
Tests/procedures
Lipid panel	Low risk: At 6 months and then annually High risk: Every 36 months	Less frequent testing reasonable for children Multimodal weight loss program for obese adults
Hemoglobin A1c	Low risk: At 36 months and then annually High risk: Every 6 months	Less frequent testing reasonable for children
Echocardiogram (Adults)	Within 1 year if anthracyclines ≥250 mg/m2, or with lower exposure and additional cardiomyopathy risk factors As needed if without anthracycline exposure	Additional surveillance based on risk factors Referral to cardiology if abnormal imaging and/or concerning symptoms If available, consider referring to cardio-oncology program for those at very high risk
Echocardiogram (Children)	Screening according to Children’s Oncology Group guidelines	Additional surveillance based on risk factors Referral to cardiology if abnormal imaging and/or concerning symptoms If available, consider referring to cardio-oncology program for those at very high risk
Recommendations
Management of dyslipidemia	According to American Heart Association/American College of Cardiology recommendations or local guidance	N/A
Management of hypertension	According to population guidance	Measurement of blood pressure, weight, and body mass index (BMI) at each survivorship visit
Other considerations
Hurler syndrome	Close monitoring for cardiopulmonary dysfunction after HCT	N/A
Amyloidosis	v	N/A

Dermatologic

Recommendation	Frequency	Notes
Tests/procedures
Dermatologic exam	Risk factor dependent	Frequency/extent of examination tailored to individual risk factors: prior or present graft- versus-host disease (GVHD), sun exposure and radiation history, voriconazole exposure, family history, and history of skin cancer Regular skin self-examination; refer to a dermatologist for further evaluation of suspicious lesions Regular skin exam involves exposure of all body areas and includes manual palpation to detect sclerosis
Recommendations
Discuss risk of dermatologic complications	At comprehensive survivorship visits	Particularly related to chronic graft-versus-host disease (cGVHD), medications, and radiation Advise to seek medical attention for non-healing skin lesions, skin tightening or other changes
Discuss sun exposure	At comprehensive survivorship visits	Advise to avoid direct sun exposure without appropriate protection: proper clothing, hats, applying UVA/UVB sunscreen to exposed areas Particularly important for patients on immunosuppression, voriconazole, with a history of total body irradiation (TBI) or skin chronic GVHD

Endocrine complications

Recommendation	Frequency	Notes
Tests/procedures
Thyroid function test	At 1-year post-transplant or sooner if symptomatic, and annually thereafter	Thyroid stimulating hormone (TSH) and free T4 recommended Central nervous system (CNS) radiation therapy is a risk factor for central hypothyroidism
Recommendations
Assessment of suspected growth abnormality	Routine monitoring	Should be evaluated and treated by an endocrinologist, weighing clinical risks vs. benefits of hormonal therapy Routine assessment of growth velocity including height, weight, and BMI should be performed for children
Assessment of gonadal dysfunction	Annually	Assessment of menarche/ menstrual history and menopausal symptoms Routine assessment of onset/ progression of puberty with tanner staging for children; increasing frequency when approaching puberty or with concerns Gonadal assessment at 1year post-HCT in adults; subsequent frequency according to clinical needs Involvement of appropriate subspecialties for potential HRT
Assessment for adrenal insufficiency	Monitoring as needed	Adrenocorticotropic hormone (ACTH) stimulation test for patients on long-term corticosteroids when weaning corticosteroids

Gastrointestinal complications

Recommendation	Frequency	Notes
Tests/procedures
Liver function testing (transaminases, total bilirubin, alkaline phosphatase)	Without risk factors: Every 12 months for the first year and then annually With chronic hepatitis, chronic graft versus host disease (cGVHD) tapering immune suppression therapy (IST) beyond first year: More frequent monitoring	N/A
Other considerations
Hepatitis B virus (HBV) infection	Chronic HBV: Lifelong monitoring of HBV DNA at least every 2 months; HBV DNA and alanine aminotransferase (ALT) every month after withdrawing antivirals; prophylactic anti-HBV therapy should be considered regardless of HBV DNA levels to prevent reactivation; continue at least 1 year after IST withdrawal Resolved HBV: HBV DNA monitoring at least every 2 months for at least 3 years after stopping IST; prophylactic anti-HBV therapy if unable to monitor HBV DNA, continue at least 3 years after IST withdrawal	N/A
Hepatitis C virus (HCV) infection	Chronic HCV: Routine HCV RNA testing at baseline and if getting HCV antiviral therapy or has unexplained ALT elevation; antiviral therapy if available and check liver function tests (LFT) and complete blood count (CBC) every 6-12 months	Recommendations for testing, managing, and treating hepatitis C
Cirrhosis	Monitor for varices, hepatocellular carcinoma (HCC), and other sequalae	Referral to hepatologist for monitoring
Dyskeratosis congenita	Frequent LFTs	Hepatologist referral if abnormalities noted

Hematologic

Recommendation	Frequency	Notes
Tests/procedures
Complete blood count	At each visit for at least 10 years post-HCT	If abnormal, repeat as needed
Ferritin	Regular monitoring until normalized	Nonspecific, initial screening test for iron overload
MRI (iron quantification)	To assess liver and cardiac iron levels when concern; follow-up as needed to follow progress after treatment	Risk based on transfusion history and HCT indication
Post-HCT phlebotomy	With confirmed iron overload; duration dependent on response	Consider iron chelation if ineligible for phlebotomy Resumption of menses in females may reduce iron
Recommendations
Venous thromboembolism (VTE) prophylaxis in patients with multiple myeloma	When receiving immunomodulatory imide drugs and chemotherapy and/or dexamethasone after HCT	N/A
Bleeding risk assessment	Prior to initiating anticoagulation	N/A
Other considerations
Hemoglobinopathy	Perform chimerism at least every 3 months in year 1 post-HCT and every 6 months thereafter Further chimerism based on previous results	N/A
Hurler syndrome	Neurologic screening for spinal canal narrowing and carpal tunnel syndrome	N/A
Inherited bone marrow failure syndromes	Require specialized follow-up with a multidisciplinary specialist team	N/A

Immunity & infections

Recommendation	Frequency	Notes
Tests/procedures
Vaccination	Consider beginning inactivated vaccines at 3-6 months post-HCT	According to published guidelines, considering patient age and country recommendations Includes patients with GVHD and/or on IST given higher risk of infection
Other considerations
Asplenia/functional asplenia	Vaccinate for S. pneumoniae and N. meningitidis (MCV4, group B) Educate on sepsis/fever management Consider antimicrobial prophylaxis	N/A
Hypogammaglobulinemia	Supplemental intravenous immunoglobulin (IVIg) may be considered for selected HCT recipients with IgG < 400 mg/dL (4 g/L): patients with recurrent sino-pulmonary infections; patients with very low levels (<200 mg/dL); or receiving anti-B cell or CAR T-cell therapy	N/A
Multiple myeloma	Specific antimyeloma medications warrant specific antimicrobial prophylaxis	N/A
Inborn errors of immunity	Pay careful attention to immune reconstitution and mixed chimerism Assess lymphocyte subsets, mitogen proliferation, immunoglobulin levels and antibody responses every 3-6 months until normalized and as needed	N/A

Muscular

Recommendation	Frequency	Notes
Assess range of motion	At each clinic visit for patients with chronic GVHD	Ideally with medical photos for subsequent comparison Encourage patients to also perform self-assessment
Other considerations
Glucocorticoids	Routinely evaluate patients on glucocorticoid treatment for glucocorticoid-induced myopathies; observe patient rising from a squatting position Patients with/at risk for steroid myopathy should engage in physical activity and physical therapy; physiatry referral may be beneficial, low resistance exercise to prevent/slow loss of muscle mass	N/A
Myalgia/weakness	Chronic GVHD-associated polymyositis, statin toxicity, or myasthenia gravis should be included in differential diagnosis of myalgia/weakness if persistent or progressive CPK, aldolase, anti-acetylcholine antibodies are a reasonable next step; if negative, muscle MRI, EMG or muscle biopsy may be considered.	N/A

Neurologic & cognitive

Recommendation	Frequency	Notes
Tests/procedures
Clinical assessment for peripheral nervous system (PNS) and central nervous system (CNS) dysfunction	At 6 and 12 months post-HCT, ≥yearly thereafter	Earlier and more frequent evaluation to be considered in high-risk patients Careful history/examination/review of systems/medication history and assessment of time of onset of neurological signs and symptoms during survivorship visits
Audiologic evaluation	Within first year post-HCT	Patients with exposures to head and neck irradiation, platinum chemotherapy, aminoglycosides, or an inherited condition associated with hearing disability Follow-up evaluations as clinically warranted
Neurocognitive testing	Pediatrics: Within first year post-HCT Adults: As needed	Strongly consider before returning to work/school, major changes in school (i.e., moving from elementary to middle school), or changes in school performance
Recommendations
Council on hearing loss prevention	At initial survivorship visit	Council patients about hearing loss prevention and to seek assessment for new symptoms Hearing loss may be present in adenosine deaminase (ADA) deficiency prior to HCT and require developmental support, regular otolaryngology, and audiological assessment post-HCT
Pediatrics: Discuss/monitor development/cognition	Annually	Can be performed by pediatrician Educational/vocational progress assessment recommended
Adult: Screen for cognitive changes	At comprehensive survivorship visit	Query for cognitive function changes (may be subtle) Inquire about difficulties multitasking, attention, remembering things or whether thinking feels slow Exclude reversible causes of cognitive decline: depression, fatigue, insomnia, medication Neurocognitive testing and imaging should be considered if functional impairment
Geriatric: Comprehensive geriatric assessment	At 6 and 12 months post-HCT	To identify patients more likely to benefit from enhanced toxicity risk prediction and aid treatment decision-making
Other considerations
Sickle cell disease (SCD)	All patients undergoing HCT for sickle cell disease should be offered neurocognitive testing posttherapy, if available	N/A

Ocular

Recommendation	Frequency	Notes
Tests/procedures
Ocular exam	At onset of any chronic GVHD, dry eye symptoms, changes in vision or other eye symptoms	NIH Consensus Development Project recommends consultation with an eye specialist every 3 months during the first year post-HCT and then at longer intervals thereafter Monitoring of intraocular pressure (IOP) important in patients receiving any form of glucocorticoids
Recommendations
Question about eye concerns	At comprehensive survivorship visits	Advise to report dryness, light sensitivity, excessive tearing, foreign body sensation, pain, redness, swelling, mucoid aggregates, vision changes Inform about risk of premature cataracts for TBI recipients
Other considerations
Hurler syndrome	Ongoing ophthalmologic assessment for glaucoma, cataracts, progression of corneal clouding	N/A

Oral & dental

Recommendation	Frequency	Notes
Tests/procedures
Evaluation by a dentist or oral medicine specialist	At 6 and 12 months post-HCT, ≥yearly thereafter	Earlier and more frequent evaluation to be considered in high-risk patients (e.g., Fanconi anemia, radiation to the head or neck, or refractory chronic GVHD)
Recommendations
Screen for chronic GVHD, high-risk habits	At comprehensive survivorship visit	Avoid smoking, vaping and chewing tobacco Decrease regular intake of sugar containing beverages Avoid intraoral piercing
Perform a thorough head, neck and oral exam	At comprehensive survivorship visit	N/A
HPV vaccination	According to published guidelines, considering patient age and country recommendations	N/A
Other considerations
Children	Perform oral and radiologic assessment for tooth development	N/A
Xerostomia	Should receive meticulous oral hygiene, undertake preventive measures for dental/ periodontal disease, and receive aggressive treatment of oral infections Avoid trauma to oral mucosa	N/A

Psychosocial

Recommendation	Frequency	Notes
Tests/procedures
Mental health screening with standardized questionnaire	At comprehensive survivorship visits	Example: NCCN distress thermometer No gold standard for screening mental health after HCT; take care to not overburden patients with patient reported outcome (PRO) tools To guide clinical investigations or behavioral or psychological support, particularly if multiple somatic complaints, new GVHD, major life events or treatment changes
Recommendations
Review psychosocial and mental health	Day +100, +180, +365, then annually	Review current symptom patterns, distress, medications, comorbidities, and physical activity Regularly inquire to level of spousal/caregiver psychological adjustment, family functioning, educational, vocational activities, and financial toxicity Appropriate referral if necessary Offer peer support and return to work/school programs
Discuss medication adherence	Ongoing	Set incremental goals for healthy diet (i.e., vegetables, fruits, whole grains, low in excess sugars, dried foods, red/processed meat, and dietary supplements), activity, weight management Encourage adequate sleep and age-appropriate preventative measures
Discuss healthy lifestyle	Comprehensive survivorship visits	Set incremental goals for healthy diet (i.e., vegetables, fruits, whole grains, low in excess sugars, dried foods, red/processed meat, and dietary supplements), activity, weight management Encourage adequate sleep and age-appropriate preventative measures
Other considerations
Adolescents and young adults	Provide transition of care education and plans	N/A
Persons with disabilities	Assess those with significant physical, visual, or auditory disabilities for appropriate support services and medical equipment needs	N/A

Renal & urinary complications

Recommendation	Frequency	Notes
Tests/procedures
Renal function testing	At 6 months, 1 year, and at least annually thereafter	Includes complete urinalysis, urine albumin to creatinine ratio, BUN/creatinine More frequent monitoring for multiple myeloma and amyloidosis Possible renal anomalies predisposing to chronic kidney disease (CKD) among patients with bone marrow failure syndromes, inborn errors of metabolism (IEM), or Artemis deficiency
Recommendations
Management of hypertension		Measurement of blood pressure, weight, and BMI at each survivorship visit

Respiratory

Recommendation	Frequency	Notes
Tests/procedures
Pulmonary function tests (PFT) screening	Every 3 months for the first year after HCT, every 6 months for the second year, and then annually for 5 years after HCT (or until final adult height in children, whichever occurs later)	Spirometry and hemoglobin corrected diffusing capacity of the lungs for carbon monoxide (DLCO) age Age <6 years: if unable to perform, can consider alternative screening with pulse oximetry, multiple breath washout testing, parametric mapping by CT
CT chest Imaging	At onset of pulmonary symptoms or abnormal PFTs	N/A
Recommendations
Pulmonary consultation	At onset of pulmonary symptoms or abnormal PFT	Especially in setting of irreversible air flow obstruction
Vaccination against respiratory pathogens	Consider beginning inactivated vaccines at 3-6 months post-HCT	According to published guidelines, considering patient age and country recommendations
Counsel on avoidance of tobacco, smoking, vaping	At comprehensive survivorship visit	N/A
Other considerations
Dyskeratosis congenita	Perform PFTs at regular intervals post-HCT Refer to pulmonologist with any abnormalities	N/A
Chronic GVHD	PFTs at initial diagnosis then at least spirometry every 3-6 months until discontinuation of all systemic immunosuppressive therapy	N/A

Sexual health, fertility & pregnancy

Recommendation	Frequency	Notes
Tests/procedures
Fertility assessment	As age appropriate and for those contemplating future parenthood	Semen analysis or assessment of ovarian function Discussion about risk of premature menopause Fertility specialist consult for those desiring pregnancy to understand fertility potential and options (i.e. IVF, donor gamete) Contraception advised for those wishing to avoid parenthood
Recommendations
Sexual activity	As appropriate	Counseling regarding safe sex practices and contraceptive options
Sexual function	Discuss at 36 months post-HCT and then continue annually	Prompt referral for medical or psychosocial needs for patient and partner as necessary Assessment of hypogonadism and/or urogenital GVHD with appropriate gynecology or genitourinary team referral
Pregnancy	As appropriate	Patients should be followed throughout pregnancy by expert in high-risk obstetrics and may require review by an anesthetist prior to delivery
Other considerations
Pregnant women with systolic dysfunction/ cardiac risk factors	Cardiology follow-up during pregnancy	N/A
Those with underlying genetic disorder/ cancer predisposition syndrome	Genetic counseling prior to pregnancy	N/A
Women exposed to uterine radiation and desiring pregnancy	Counsel on risk of uterine factor infertility	N/A

Skeletal

Recommendation	Frequency	Notes
Tests/procedures
DEXA	Standard risk: At 1-year post-HCT High risk: At 3 months post-HCT	If abnormal, repeat Q1-2 years, sooner if ongoing risks or response assessment <5 years old, lumbar spine bone mineral density (BMD) may be measured; DEXA hip measurements less reliable for age <13. FRAX and vertebral fracture assessment (VFA) may help evaluation/management
Recommendations
Optimize calcium and vitamin D intake	At comprehensive survivorship visits	Vitamin D may be measured regularly in those at deficiency risk
Recommend weight-bearing exercise	At comprehensive survivorship visits	N/A
Discuss hormone replacement therapy	As needed	Patients with hypogonadism if age appropriate, and not otherwise contraindicated
Other considerations
Bisphosphonates	Consider bisphosphonates in high-risk patients, significant abnormalities on DEXA or FRAX assessments, or fragility fractures Bisphosphonate choice made with consideration of the patient’s presentation, renal function, and respective adverse events For patients with multiple myeloma (MM), supportive management with use of bisphosphonates for at least 2 years	N/A
Avascular necrosis (AVN)	Maintain a high index of suspicion for AVN risks include prior AVN, radiation exposure or prolonged glucocorticoids Routine imaging screening for asymptomatic AVN not indicated Symptomatic patients: non-contrast MRI is the most sensitive way to confirm and stage AVN; once diagnosis of AVN prompt referral to orthopedic specialist recommended	N/A
Hurler syndrome	Neurologic screening for spinal canal narrowing and carpal tunnel syndrome	N/A

Subsequent malignant neoplasm

Recommendation	Frequency	Notes
Tests/procedures
CBC/therapy-related myeloid neoplasms (tMN) screening	High risk: Annual for ≥10 years	High risk: Consider more frequent screening (i.e., chemotherapy, age; autologous HCT) Attention to unexplained cytopenias, macrocytosis, or cellular atypia
Epstein-Barr virus (EBV) DNA screening	Variable	For prevention of PTLD in high-risk patients (e.g., ATG, alemtuzumab, ex-vivo T-cell depletion)
Cervical cancer screening/pap smear	Most: Variable Fanconi anemia (FA): Annual	For most, screening interval based on attained age and risk factors FA: Starting in adolescence
Oral exam	Most: Annually High risk: Every 6 months	High risk: Oral chronic GVHD, tobacco use, FA Advise reporting non-healing lesions, leukoplakia, localized pain, changes in mucosal color/texture
Esophagogastroduodenoscopy (EGD)	Variable	Endoscopic screening for esophageal cancer may be considered in high-risk patients (chronic GVHD receiving prolonged immunosuppression, symptoms of gastroesophageal reflux, dysphagia)
Colonoscopy/colorectal cancer screening (CRC)	Variable	Pediatric survivors <age 45 years and radiation therapy (RT) exposed: CRC screening colonoscopy or multitarget stool DNA screening at 5 years post-RT exposure or age 30 years, whichever occurs later Adult survivors: As part of shared decision making, consider exposed to abdominal/pelvic RT or TBI who underwent HCT at ≥25 years of age, colonoscopy beginning 5 years post-RT exposure and no later than age 45 years Screen patients without RT exposure according to general population guidelines, individual risk factors/family history Screen patients with colon Cancer Predisposition Syndrome (CPS) [e.g., hereditary nonpolyposis colorectal cancer (HNPCC), familial adenomatous polyposis (FAP), diamond blackfan anemia (DBA)] based on underlying CPS Risk in those exposed to TBI likely dose dependent; lower doses may not increase the risk to level that risk/benefit of early colonoscopy warranted
Breast cancer/mammography/breast MRI	Variable	Female recipients of TBI or chest RT should begin breast cancer screening with mammogram and breast MRI (if available) at age 25-, or 8-years post-RT, whichever occurs later, but no later than age 40 Survivors without additional risk factors should participate in regular annual mammograms/ clinical breast exam according to general population guidelines for geographical region and individual risk factors including family history
Thyroid exam	Annually	Patients should have an annual thyroid exam and review of potential symptoms of thyroid cancer As part of shared decision making, consider ultrasound screening in patients who received thyroid RT; Routine use of thyroid ultrasound may not provide additional benefit; some groups recommended Screen patients with inherited thyroid CPS (e.g., multiple endocrine neoplasia, FAP) based on underlying condition
Brain MRI	Variable	As part of shared decision making, consider meningioma screening in patients who received CNS RT
Recommendations
General counseling	At comprehensive survivorship visits	Based on treatment exposures, time from exposure, chronic GVHD history, and other modifying factors Encourage to avoid high-risk behaviors, unhealthy diet (e.g., tobacco and vaping, passive tobacco exposure, alcohol abuse; high fat/low fiber diet)
Breast cancer risk counseling	At comprehensive survivorship visits	In high-risk individuals, discussion with appropriate experts on risk reduction strategies (i.e., prophylactic mastectomy, prophylactic medical therapies, lifestyle) Counsel on additional breast cancer risk factors (i.e., BRCA1/2, family history)
Other considerations
Epstein-Barr virus (EBV) viremia	Recommend pre-emptive treatment with Rituximab Note: PTLD evaluation includes LN palpation, review of B-symptoms (fever, drenching night sweats, ≥10% weight loss over 6 months)	N/A
Human papillomavirus (HPV)	HPV vaccination according to country-specific general population recommendations, unless otherwise contraindicated Note: HPV role in mucocutaneous/ genital cancers post-HCT unclear	N/A
Fanconi anemia	Survivors with mutations in BRCA2 (FANCD1) or PALB2 (FANCN) require screening for specific solid cancers	N/A

Multiple formats to meet your needs

Other ways you can access these long-term screening guidelines:

Download the PDF guidelines
Download the guidelines for iOS or Android
Access HCT Guidelines app

We also offer the guidelines using patient-friendly language:

6 months after transplant care guide (English)
6 months after transplant care guide (Spanish)
12+ months after transplant care guide

References

Rotz SJ, Bhatt NS, Hamilton BK, et al. (2024). International recommendations for screening and preventative practices for long-term survivors of transplantation and cellular therapy: A 2023 update. Transplantation and Cellular Therapy, 30(4) 349-385. DOI: 10.1016/j.jtct.2023.12.001.