Long Term Follow-Up Post Allogeneic HSCT
Liver & Renal

Updated: October 2010

Liver

A number of factors can cause derangement of liver function including but not limited to medication, CGVHD, viral hepatitis and iron overload. The management of CGVHD is available in the relevant guideline.

Recommendations:

• Monitor liver function tests at least yearly
• Ferritin assessment should be done at 1year post-transplant. Monitoring should continue in patients with ongoing RBC transfusions, Hepatitis C infection or elevated LFTs. Spontaneous reductions in ferritin do occur over several years post transplant. Iron overload should be confirmed with Trasferrin saturation. Iron overload can be managed with venesections. The role of chelation is unclear at present. No formal guidelines are available on level at which venesection should be commenced.
• HBsAg, HBcAg, anti-HBsAb, Hepatitis C PCR should be done at 100 days and 1 year post-transplant. In patients with known Hepatitis B or C monitoring should continue with viral load assays and therapy as recommended by hepatologist should be instituted. Patients with a history of Hepatitis B infection should commence Lamivudine 100mg/day at commencement of chemotherapy and continue for 6 months post or until they are off all immunosuppression.
• Liver biopsy at 8-10 years post SCT should be considered in Hepatitis C positive patients due to the increased risk of cirrhosis.

Renal

Chronic renal dysfunction post transplant is seen quite frequently (27% at 10 years, 3% with severe renal disease i.e., GFR< 30 mls/min/1.73 m²) several years post transplant and can be related to the disease process, nephrotoxins (prior chemotherapy/medication e.g. platinum compounds, carmustine, ifosfamide, anti-infectious agents, immunosuppressive drugs), sepsis, age at transplant, female gender, reduced GFR pre-transplant and hypertension. Management includes discontinuation of the offending nephrotoxic agent, hydration, treatment of sepsis, management of HT and referral to a nephrologist. Nephrotic syndrome can be seen as a manifestation of CGVHD usually responding within 12 weeks to treatment with corticosteroids and cyclosporine (the exception being that seen after NMAs which are quite refractory to therapy). Radiation induced nephritis can be seen up to 6 months post transplant. Substantial hemorrhagic cystitis can subsequently lead to bladder wall scarring and contraction.

Recommendations:

• Regular assessments of renal function should be performed (6-12 monthly BUN, creatinine).
• Yearly 24 hour urine protein estimations should be considered in patients with CGVHD. Yearly GFR estimated in patients with abnormal renal function.

• Renal dysfunction should be appropriately investigated (medications, ultrasound, biopsy) and nephrology consult considered.

The information contained in these guidelines is a statement of consensus of Leukemia/BMT Program of BC professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment. Use of these guidelines and documents is at your own risk and is subject to the Leukemia/BMT Program of BC’s terms of use available at Terms of Use.