Intensivmedizin und Notfallmedizin

, Volume 44, Issue 3, pp 129–141 | Cite as

Intensivmedizinische Betreuung von Patienten nach Stammzelltransplantation

  • C. E. Wrede
  • E. Holler


Innerhalb der hämatologischen Therapieverfahren stellen Stammzelltransplantationen (SZT) den umfassendsten Eingriff dar. In verschiedenen Phasen der Transplantation haben diese Patienten erhöhte Risiken für unterschiedliche bakterielle und virale Infektionen sowie Pilzinfektionen. Insbesondere bei allogen transplantierten Patienten ist die Abgrenzung nichtinfektiöser, überwiegend immunologischer Komplikationen, z. B. Graft-versus-Host-Reaktionen oder eine VOD (Veno-occlusive Disease) notwendig, was oft eine diagnostische Herausforderung darstellt. Eine adäquate intensivmedizinische Therapie solcher Patienten kann nur unter Kenntnis der spezifischen Komplikationen nach SZT erfolgen. Diese Zusammenstellung gibt zunächst einen Überblick über die verschiedenen Phasen der SZT mit den entsprechenden infektiösen und nichtinfektiösen Komplikationen, und geht anschließend einzeln auf die organspezifischen pulmonalen, renalen, kardialen, gastrointestinalen, hepatischen und neurologischen Komplikationen nach SZT ein.


Intensivmedizin Stammzelltransplantation allogen autolog Graft versus Host 

Intensive care support of patients after stem cell transplantation


Within the hematologic therapy procedures, stem cell transplantation (SCT) represents the most extensive and invasive intervention. Those patients have certain risks for several bacterial, viral, as well as fungal infections during the different stages of transplantation. Especially in allogenic transplantation, discrimination of non-infectious, mostly immunologic complications like graft-versus-host reactions or VOD (veno-occlusive disease) is crucial, and often represents a therapeutic challenge. An adequate intensive care therapy of these patients can only be achieved with the knowledge of the specific complications of SCT. This review starts with an overview of the SCT stages with their corresponding infectious and noninfectious complications, followed by the discussion of organ specific pulmonary, renal, cardiac, gastrointestinal, hepatic and neurological complications of stem cell transplantation.

Key words

intensive care stem cell transplantation allogen autolog graft versus host 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients (2000) MMWR Recomm Rep 49:1–7Google Scholar
  2. 2.
    Afessa B, Peters SG (2006) Major complications following hematopoietic stem cell transplantation. Semin Respir Crit Care Med 27:297–309PubMedCrossRefGoogle Scholar
  3. 3.
    Afessa B, Tefferi A, Dunn WF, Litzow MR, Peters SG (2003) Intensive care unit support and acute physiology and chronic health evaluation III performance in hematopoietic stem cell transplant recipients. Crit Care Med 31:1715–1721PubMedCrossRefGoogle Scholar
  4. 4.
    Afessa B, Tefferi A, Litzow MR, Peters SG (2002) Outcome of diffuse alveolar hemorrhage in hematopoietic stem cell transplant recipients. Am J Respir Crit Care Med 166:1364–1368PubMedCrossRefGoogle Scholar
  5. 5.
    Alessandrino P, Bernasconi P, Caldera D, Colombo A, Bonfichi M, Malcovati L, Klersy C, Martinelli G, Maiocchi M, Pagnucco G, Varettoni M, Perotti C, Bernasconi C (1999) Adverse events occurring during bone marrow or peripheral blood progenitor cell infusion: analysis of 126 cases. Bone Marrow Transplant 23:533–537PubMedCrossRefGoogle Scholar
  6. 6.
    Almyroudis NG, Fuller A, Jakubowski A, Sepkowitz K, Jaffe D, Small TN, Kiehn TE, Pamer E, Papanicolaou GA (2005) Pre- and post-engraftment bloodstream infection rates and associated mortality in allogeneic hematopoietic stem cell transplant recipients. Transpl Infect Dis 7:11–17PubMedCrossRefGoogle Scholar
  7. 7.
    Almyroudis NG, Fuller A, Jakubowski A, Sepkowitz K, Jaffe D, Small TN, Kiehn TE, Pamer E, Papanicolaou GA (2005) Pre- and post-engraftment bloodstream infection rates and associated mortality in allogeneic hematopoietic stem cell transplant recipients. Transpl Infect Dis 7:11–17PubMedCrossRefGoogle Scholar
  8. 8.
    Ayala E, Greene J, Sandin R, Perkins J, Field T, Tate C, Fields KK, Goldstein S (2006) Valganciclovir is safe and effective as pre-emptive therapy for CMV infection in allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 37:851–856PubMedCrossRefGoogle Scholar
  9. 9.
    Bonon SH, Menoni SM, Rossi CL, De Souza CA, Vigorito AC, Costa DB, Costa SC (2005) Surveillance of cytomegalovirus infection in haematopoietic stem cell transplantation patients. J Infect 50:130–137PubMedCrossRefGoogle Scholar
  10. 10.
    Chien JW, Martin PJ, Gooley TA, Flowers ME, Heckbert SR, Nichols WG, Clark JG (2003) Airflow obstruction after myeloablative allogeneic hematopoietic stem cell transplantation. Am J Respir Crit Care Med 168:208–214PubMedCrossRefGoogle Scholar
  11. 11.
    Cooke KR, Hill GR, Gerbitz A, Kobzik L, Martin TR, Crawford JM, Brewer JP, Ferrara JL (2000) Tumor necrosis factor-alpha neutralization reduces lung injury after experimental allogeneic bone marrow transplantation. Transplantation 70:272–279PubMedCrossRefGoogle Scholar
  12. 12.
    Davila ML (2006) Neutropenic enterocolitis. Curr Treat Options Gastroenterol 9:249–255PubMedGoogle Scholar
  13. 13.
    DeLeve LD, Shulman HM, McDonald GB (2002) Toxic injury to hepatic sinusoids: sinusoidal obstruction syndrome (veno-occlusive disease). Semin Liver Dis 22:27–42PubMedCrossRefGoogle Scholar
  14. 14.
    Goker H, Haznedaroglu IC, Chao NJ (2001) Acute graft-vs-host disease: pathobiology and management. Exp Hematol 29:259–277PubMedCrossRefGoogle Scholar
  15. 15.
    Goodrich JM, Mori M, Gleaves CA, Du MC, Cays M, Ebeling DF, Buhles WC, DeArmond B, Meyers JD (1991) Early treatment with ganciclovir to prevent cytomegalovirus disease after allogeneic bone marrow transplantation. N Engl J Med 325:1601–1607PubMedCrossRefGoogle Scholar
  16. 16.
    Gratwohl A, Baldomero H, Frauendorfer K, Urbano-Ispizua A (2006) EBMT activity survey 2004 and changes in disease indication over the past 15 years. Bone Marrow Transplant 37:1069–1085PubMedCrossRefGoogle Scholar
  17. 17.
    Grothaus-Pinke B, Gunzelmann S, Fauser AA, Kiehl MG (2001) Factor XIII replacement in stem cell transplant (SCT) recipients with severe graft-versus-host disease of the bowel: report of an initial experience. Transplantation 72:1456–1458PubMedCrossRefGoogle Scholar
  18. 18.
    Hale GA, Rochester RJ, Heslop HE, Krance RA, Gingrich JR, Benaim E, Horwitz EM, Cunningham JM, Tong X, Srivastava DK, Leung WH, Woodard P, Bowman LC, Handgretinger R (2003) Hemorrhagic cystitis after allogeneic bone marrow transplantation in children: clinical characteristics and outcome. Biol Blood Marrow Transplant 9:698–705PubMedCrossRefGoogle Scholar
  19. 19.
    Heath JA, Mishra S, Mitchell S, Waters KD, Tiedemann K (2006) Estrogen as treatment of hemorrhagic cystitis in children and adolescents undergoing bone marrow transplantation. Bone Marrow Transplant 37:523–526PubMedCrossRefGoogle Scholar
  20. 20.
    Herbrecht R, Denning DW, Patterson TF, Bennett JE, Greene RE, Oestmann JW, Kern WV, Marr KA, Ribaud P, Lortholary O, Sylvester R, Rubin RH, Wingard JR, Stark P, Durand C, Caillot D, Thiel E, Chandrasekar PH, Hodges MR, Schlamm HT, Troke PF, de PB (2002) Voriconazole versus amphotericin B for primary therapy of invasive aspergillosis. N Engl J Med 347:408–415PubMedCrossRefGoogle Scholar
  21. 21.
    Holler E (2002) Cytokines, viruses, and graft-versus-host disease. Curr Opin Hematol 9:479–484PubMedCrossRefGoogle Scholar
  22. 22.
    Jones RJ, Lee KS, Beschorner WE, Vogel VG, Grochow LB, Braine HG, Vogelsang GB, Sensenbrenner LL, Santos GW, Saral R (1987) Venoocclusive disease of the liver following bone marrow transplantation. Transplantation 44:778–783PubMedCrossRefGoogle Scholar
  23. 23.
    Kache S, Weiss IK, Moore TB (2006) Changing outcomes for children requiring intensive care following hematopoietic stem cell transplantation. Pediatr Transplant 10:299–303PubMedCrossRefGoogle Scholar
  24. 24.
    Kessinger A, Schmit-Pokorny K, Smith D, Armitage J (1990) Cryopreservation and infusion of autologous peripheral blood stem cells. Bone Marrow Transplant 5(Suppl 1):25–27PubMedGoogle Scholar
  25. 25.
    Kumar S, DeLeve LD, Kamath PS, Tefferi A (2003) Hepatic veno-occlusive disease (sinusoidal obstruction syndrome) after hematopoietic stem cell transplantation. Mayo Clin Proc 78:589–598PubMedCrossRefGoogle Scholar
  26. 26.
    Kuruvilla J, Forrest DL, Lavoie JC, Nantel SH, Shepherd JD, Song KW, Sutherland HJ, Toze CL, Hogge DE, Nevill TJ (2004) Characteristics and outcome of patients developing endocarditis following hematopoietic stem cell transplantation. Bone Marrow Transplant 34:969–973PubMedCrossRefGoogle Scholar
  27. 27.
    Lehmann S, Isberg B, Ljungman P, Paul C (2000) Cardiac systolic function before and after hematopoietic stem cell transplantation. Bone Marrow Transplant 26:187–192PubMedCrossRefGoogle Scholar
  28. 28.
    Ljungman P (2004) Treatment of adenovirus infections in the immunocompromised host. Eur J Clin Microbiol Infect Dis 23:583–588PubMedCrossRefGoogle Scholar
  29. 29.
    Marr KA, Seidel K, Slavin MA, Bowden RA, Schoch HG, Flowers ME, Corey L, Boeckh M (2000) Prolonged fluconazole prophylaxis is associated with persistent protection against candidiasis-related death in allogeneic marrow transplant recipients: long-term follow-up of a randomized, placebo-controlled trial. Blood 96:2055–2061PubMedGoogle Scholar
  30. 30.
    McDonald GB (2006) Advances in prevention and treatment of hepatic disorders following hematopoietic cell transplantation. Best Pract Res Clin Haematol 19:341–352PubMedCrossRefGoogle Scholar
  31. 31.
    McSweeney PA, Niederwieser D, Shizuru JA, Sandmaier BM, Molina AJ, Maloney DG, Chauncey TR, Gooley TA, Hegenbart U, Nash RA, Radich J, Wagner JL, Minor S, Appelbaum FR, Bensinger WI, Bryant E, Flowers ME, Georges GE, Grumet FC, Kiem HP, Torok-Storb B, Yu C, Blume KG, Storb RF (2001) Hematopoietic cell transplantation in older patients with hematologic malignancies: replacing high-dose cytotoxic therapy with graft-versus-tumor effects. Blood 97:3390–3400PubMedCrossRefGoogle Scholar
  32. 32.
    Nichols WG (2003) Management of infectious complications in the hematopoietic stem cell transplant recipient. J Intensive Care Med 18:295–312PubMedCrossRefGoogle Scholar
  33. 33.
    Nichols WG (2003) Management of infectious complications in the hematopoietic stem cell transplant recipient. J Intensive Care Med 18:295–312PubMedCrossRefGoogle Scholar
  34. 34.
    Parikh CR, Coca SG (2006) Acute renal failure in hematopoietic cell transplantation. Kidney Int 69:430–435PubMedCrossRefGoogle Scholar
  35. 35.
    Parikh CR, Coca SG (2006) Acute renal failure in hematopoietic cell transplantation. Kidney Int 69:430–435PubMedCrossRefGoogle Scholar
  36. 36.
    Parikh CR, McSweeney P, Schrier RW (2005) Acute renal failure independently predicts mortality after myeloablative allogeneic hematopoietic cell transplant. Kidney Int 67:1999–2005PubMedCrossRefGoogle Scholar
  37. 37.
    Pene F, Aubron C, Azoulay E, Blot F, Thiery G, Raynard B, Schlemmer B, Nitenberg G, Buzyn A, Arnaud P, Socie G, Mira JP (2006) Outcome of critically ill allogeneic hematopoietic stem-cell transplantation recipients: a reappraisal of indications for organ failure supports. J Clin Oncol 24:643–649PubMedCrossRefGoogle Scholar
  38. 38.
    Pihusch M, Bacigalupo A, Szer J, von Depka PM, Gaspar-Blaudschun B, Hyveled L, Brenner B (2005) Recombinant activated factor VII in treatment of bleeding complications following hematopoietic stem cell transplantation. J Thromb Haemost 3:1935–1944PubMedCrossRefGoogle Scholar
  39. 39.
    Pihusch M, Wegner H, Goehring P, Salat C, Pihusch V, Hiller E, Andreesen R, Kolb HJ, Holler E, Pihusch R (2005) Diagnosis of hepatic venoocclusive disease by plasminogen activator inhibitor-1 plasma antigen levels: a prospective analysis in 350 allogeneic hematopoietic stem cell recipients. Transplantation 80:1376–1382PubMedCrossRefGoogle Scholar
  40. 40.
    Richardson PG, Murakami C, Jin Z, Warren D, Momtaz P, Hoppensteadt D, Elias AD, Antin JH, Soiffer R, Spitzer T, Avigan D, Bearman SI, Martin PL, Kurtzberg J, Vredenburgh J, Chen AR, Arai S, Vogelsang G, McDonald GB, Guinan EC (2002) Multi-institutional use of defibrotide in 88 patients after stem cell transplantation with severe veno-occlusive disease and multisystem organ failure: response without significant toxicity in a high-risk population and factors predictive of outcome. Blood 100:4337–4343PubMedCrossRefGoogle Scholar
  41. 41.
    Runde V, Ross S, Trenschel R, Lagemann E, Basu O, Renzing-Kohler K, Schaefer UW, Roggendorf M, Holler E (2001) Adenoviral infection after allogeneic stem cell transplantation (SCT): report on 130 patients from a single SCT unit involved in a prospective multi center surveillance study. Bone Marrow Transplant 28:51–57PubMedCrossRefGoogle Scholar
  42. 42.
    Saiz A, Graus F (2004) Neurological complications of hematopoietic cell transplantation. Semin Neurol 24:427–434PubMedCrossRefGoogle Scholar
  43. 43.
    Santo Tomas LH, Loberiza FR Jr, Klein JP, Layde PM, Lipchik RJ, Rizzo JD, Bredeson CN, Horowitz MM (2005) Risk factors for bronchiolitis obliterans in allogeneic hematopoietic stem-cell transplantation for leukemia. Chest 128:153–161PubMedCrossRefGoogle Scholar
  44. 44.
    Schmitz N, Bacigalupo A, Hasenclever D, Nagler A, Gluckman E, Clark P, Bourquelot P, Greinix H, Frickhofen N, Ringden O, Zander A, Apperley JF, Gorin C, Borkett K, Schwab G, Goebel M, Russell NH, Gratwohl A (1998) Allogeneic bone marrow transplantation vs filgrastim-mobilised peripheral blood progenitor cell transplantation in patients with early leukaemia: first results of a randomised multicentre trial of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 21:995–1003PubMedCrossRefGoogle Scholar
  45. 45.
    Schulenburg A, Turetschek K, Wrba F, Vogelsang H, Greinix HT, Keil F, Mitterbauer M, Kalhs P (2004) Early and late gastrointestinal complications after myeloablative and nonmyeloablative allogeneic stem cell transplantation. Ann Hematol 83:101–106PubMedCrossRefGoogle Scholar
  46. 46.
    Soubani AO (2006) Critical care considerations of hematopoietic stem cell transplantation. Crit Care Med 34:S251–S267PubMedCrossRefGoogle Scholar
  47. 47.
    Soubani AO, Kseibi E, Bander JJ, Klein JL, Khanchandani G, Ahmed HP, Guzman JA (2004) Outcome and prognostic factors of hematopoietic stem cell transplantation recipients admitted to a medical ICU. Chest 126:1604–1611PubMedCrossRefGoogle Scholar
  48. 48.
    Zager RA (1994) Acute renal failure in the setting of bone marrow transplantation. Kidney Int 46:1443–1458PubMedGoogle Scholar

Copyright information

© Steinkopff-Verlag 2007

Authors and Affiliations

  • C. E. Wrede
    • 1
  • E. Holler
    • 2
  1. 1.Klinik und Poliklinik für Innere Medizin IKlinikum der Universität RegensburgRegensburgGermany
  2. 2.Abteilung für Hämatologie und internistische OnkologieKlinikum der Universität RegensburgRegensburgGermany

Personalised recommendations