Department of Haematology
Patient Leucocyte Infusion Schedule
Patient Name: / DOB: / NHI no:Patient Number: / (Number allocated by registry - for MUD transplants only. Delete if not required)
Referring Dr/Centre: / GP:
Consultant:
Height: / Weight: / BSA:
Diagnosis: / BMT date:
Date of DLI: / 1. / 2. / 3.
Date of admission: / Date of discharge:
Discharge: / Hb g/L / WCC x 109/L / Neuts x 109/L / Platelets 109/L / Wt kg
PRE-TRANSPLANT ASSESSMENT:
Previous chemo-radio therapy (significant total doses):
Previous complications:
Allergies/adverse reactions:
Significant other illness:
Disease status at DLI:
Performance Status at transplant (ECOG):
Outstanding investigations:
Venous access:
ABO/Rh group:
RBC/HLA antibodies:
HLA type:
Respiratory function:
Ejection fraction:
GFR baseline:
Respiratory viral screen:
Swabs for staph aureus:
Serology / Positive for:
Negative for:
Date of dental assessment:
Date Consent Signed:
Allogeneic Donor Details
Donor name or number: / DOB: / NHI no:
Donor Consultant: / GP:
Weight:
Date of donor assessment:
ABO/Rh group:
RBC/HLA antibodies:
HLA type:
Serology - / Positive for:
Negative for:
Consent signed:
Check List for Patient v Donor
PATIENT / DONOR
HLA type:
ABO/Rh group:
? Blood group incompatibility: / ABO major Yes / NA / ABO minor Yes / NA
ABO mixed Yes / NA / Rh incompatibility Yes/ NA
CMV status:
Red cell Xmatch:
Date of donor admission:
Transplant Protocol – Conditioning and Peritransplant Supportive Care
BLOOD PRODUCT SUPPORT:
All blood products to be irradiated from 6 weeks prior to transplant and for at least 12 months following, longer if significant chronic GVHD. CMV negative blood products are not required.
Insert relevant instruction for any mismatches from Transplant red book (in notes/blood products)
GvHD PROPHYLAXIS
Continue clinical monitoring for signs of GvHD
CDC+D weekly
Transplant protocol – Infection prophylaxis
Continue with post transplant prophylaxis as prescribed. If GVHD or neutropenia develop, commence prophylaxis as for allograft transplant.
DETAILED DAILY SCHEDULE:
DAY / DATE / BMT DAY / TIME / PLAN
Appointment with consultant, sign consent
0830 / Admit to Haematology Dayward/BMTU
0 / 0900 / 1L D4S + 30mmol NaHCO3 and 30mmol KCl over 4 hrs
1300 / Premed Frusemide 40mg IV, Ondansetron 8mg PO/IV, hydrocortisone 100mg IV, promethazine 6.25mg IV.
1330 / Reinfusion of CD3+ cells [add dose]
1345 / 1L D4S + 30mmol NaHCO3 and 30mmol KCl over 4 hrs
+1
+2 / 0830 / Registrar visit,
Return to ?home if appropriate
See weekly for GVHD assessment, CBC +D, LFTs, CMV PCR, until day +90 after DLI
+28 / Engraftment assessment, check chimerism. Peripheral blood 30mL in EDTA tubes. Ensure labs have been notified.
Margaret McDonald, FISH (ph 81568).
Vickie Hanrahan , DNA (ph 89785).
William Titulaer, Cell Sorting (ph 80579).
+56 / For chimerism study, ensure labs have been notified.
disease reassessment.
Ongoing disease monitoring as per protocol.
PROTOCOL AUTHORISED BY:
NAME: / ______/ SIGN: / ______ / DATE: / ______
NAME: / ______/ SIGN: / ______ / DATE: / ______
CONSULTANTS / (Original signed only)
Schedule Issued: 2/06/2016 12:48 PM / Updated: 2nd June 2016
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