Congress Abstracts 2006

99

COMPARISON OF THE AMOUNT OF RENAL INSUFFICIENCY AND MUCOSITIS BETWEEN A NEW IMMUNE SUPPRESSION REGIMEN TO PREVENT GRAFT VERSUS HOST DISEASE AND PROMOTE ENGRAFTMENT DURING ALLOGENEIC HEMATOPOIETIC STEM CELL TRANSPLANTATION AS COMPARED TO THE STANDARD OF CARE. Sallie Brovitz-Palmer, RN, BSN, OCN^®, and Tracy Douglas, RN, MSN, OCN^®, Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD; and Michele Phelps, RN, BSN, and Leo Luznik, MD, Johns Hopkins University, Baltimore, MD.

Allogenic bone marrow transplantation is a curative therapeutic option for many patients with severe hematologic malignancies. However, it is associated with many side effects that require expert nursing management. Using the standard approach of cyclosporine and low dose methotrexate to prevent graft-versus-host disease (GVHD), grade four hemorrhagic mucositis and renal insufficiency is common. Cyclosporine is nephrotoxic and is associated with renal tubular acidosis leading to renal insufficiency. It has been shown that up to 75% of allogeneic transplants develop a doubling of their creatinine. A new regimen to prevent GVHD and promote engraftment uses high dose cyclophosphamide on day three and four post stem cell infusion to provide immune suppression and kill activated donor lymphocyte cells which are associated with GVHD.

It is proposed that high dose cyclophosphamide given after an allogeneic stem cell transplant will cause less renal insufficiency and less mucositis than the standard approach to GVHD prophylaxis.

During the last two years, 18 related allogeneic patients and 9 matched unrelated donor patients were transplanted using the post transplant high dose cyclophosphamide regimen. Patients had their mucositis graded by the nursing staff. The maximum creatinine was recorded for all twenty- seven patients. The percent that doubled their initial creatinine and the percent that had grade three and four mucositis were compared to published measures of patients on cyclosporine and methotrexate.

22% of patients had grade three and no patient had grade four mucositis. 26% of patients had renal insufficiency using the post transplant cyclophosphamide regimen, which is much less than the standard allogeneic regimens using cyclosporine and low dose methotrexate.

Even a subtle decrease in renal function can herald a more complicated clinical course involving renal failure, fluid and electrolyte balance, and multi-organ failure. Renal insufficiency makes it difficult to dose immune suppression, antibiotics and other medications. Mucositis is related to infection, longer length of stays, pain, and decreased nutrition. Using an allogenic regimen that reduces these two common morbidities will improve the overall mortality of allogenic bone marrow transplantation. Nurses managing allogenic patients need to understand how different regimens can affect common morbidities related to transplant.