In February 2023, the Tandem Transplantation and Cellular Therapy Meetings of ASTCT and CIBMTR brought the latest cutting-edge science and technologies in hematopoietic cell transplantation and cellular therapy to nurses around the globe. Here are some of the highlights I experienced as an advanced practice provider (APP) in blood and marrow stem cell transplantation.
Nirali Shah, MD, MHSc, physician scientist and head of the hematologic malignancies section of the pediatric oncology branch of the National Cancer Institute, discussed hemophagocytic lymphohistiocytosis (HLH)–like complications after receiving chimeric antigen receptor T-cell (CAR T-cell) therapy. I recently saw this in practice, and Shah’s lecture clarified the pathophysiology as well as management of patients with this complication.
HLH post-CAR T occurs because of dysregulation and hyperactivation of the immune system, Shah said. Patients who develop HLH, even post CAR T, will have persistent cytopenias, hyperferritinemia, transaminitis, and coagulopathies. Patients may also experience fevers and hypertriglyceridemia. Patients typically experience the symptoms of HLH after they have had grade 1–2 cytokine release syndrome (CRS). It’s unlikely to see HLH without any CRS. Although we are learning more about HLH-like complications post-CAR T, there is a lot we do not know. Shah reminded healthcare providers to treat the patient. If your patient has recurrent infections, unexplained cytopenias, organ failure, or persistent elevated inflammatory markers post-CAR T, consider HLH and treat per your institution's guidelines.
Sickle Cell Disease
During another lecture I attended, Ellen Olson, RN, MS, CPNP, BMTCN®, CPHON®, blood and marrow transplant (BMT) nurse practitioner at Children's Healthcare of Atlanta Aflac Cancer Center and Blood Disorders, in Atlanta, GA, discussed sickle cell disease (SCD), an autosomal recessive disorder resulting in abnormal hemoglobin. More than 100,000 people in the United States live with SCD, but transplantation is an option for disease management.
Olsen described the delicate balance of introducing transplantation as a treatment option for SCD. Although transplantation treats the disease, it can potentially introduce life-threatening complications, such as infection and graft-versus-host disease (GVHD). As with any treatment, APPs must weigh the risks and benefits and present all options to patients with SCD because post-transplant complications may affect quality of life more than SCD.
Patients who do not have a suitable transplant donor (e.g., a sibling without SCD) may have options for gene therapy, Olsen said. Gene therapy is a process where patients’ stem cells are collected and are then genetically modified by a virus, cryopreserved, and infused back to the patient after they’ve received chemotherapy to empty the bone marrow to allow their new genetically modified stem cells to grow. One of gene therapy’s advantages is that using a patient’s own stem cells eliminates any risk of GVHD. Gene therapy is in the early phases of clinical trial, but early findings are encouraging.
How to Tailor Your Tandem for Advanced Practice
I attended the 2023 Tandem Meetings virtually and found it helped me create my own APP-focused schedule. I searched for discussions particularly geared toward APPs, nursing updates, and pharmacists. Some of the categories specifically name APPs, but I urge all clinicians to look for sessions in other tracks such as pharmacy and abstracts. Although the lecture may not be listed under the APP track, it will disclose the intended audience, such as nurses and administration.