BONE MARROW

TRANSPLANTATION

ANEETA TREESA MATHEW

ROLL NO: 9
THIRD YR BSC NSG STUDENT
STCON
INTRODUCTION

• A bone marrow transplant is a procedure that infuses healthy

blood-forming stem cells into your body to replace your
damaged or diseased bone marrow.
• A bone marrow transplant is also called a stem cell transplant.
• Blood and marrow stem cell transplantation are potentially
life saving treatments with application in many malignant and
non malignant disorders.
HISTORY

• In 1955 Dr. E. Donnall Thomas began researching the possibility of using bone
marrow transplantation to cure humans with life-threatening diseases.
• The first successful bone marrow transplant took place in 1960, using bone
marrow from an identical twin.
• The first successful bone marrow transplant using marrow from a sibling who
was NOT an identical twin occurred in 1968.
• The first successful transplant using bone marrow from an unrelated donor
took place in London, England in 1973.
• In 1988, the first successful cord blood transplant was performed.
 BONE MARROW
• Bone Marrow is a soft, spongy tissue
that has many blood vessels and is
found in the center of most bones.
• There are two types of bone marrow:
red and yellow.
• Red bone marrow contains blood
stem cells that can become red blood
cells, white blood cells, or platelets.
• Yellow bone marrow is made mostly
of fat and contains stem cells that
can become cartilage, fat, or bone
cells.
STEM CELLS

• Hematopoietic stem cells are immature cell that

can develop into all types of blood cells, including
white blood cells, red blood cells, and platelets.
• Hematopoietic stem cells are found in the
peripheral blood and the bone marrow.
• Also called blood stem cell.
• Bone marrow stem cells have the ability to
differentiate into another mesodermally derived
tissues, such as skeletal muscle or cardiac muscle.
DEFINITION

• Bone Marrow Transplantation involves taking cells

that are normally found in the bone marrow (stem
cells) , filtering those cells and giving them back
either to the patient they were taken from or to
another person.
 INDICATION
• Aplastic anemia
• Malignant disorders, specifically myelodysplastic
syndromes, leukemia (certain types of acute leukemic,
chronic leukemic, and preleukemic states), lymphoma,
multiple myeloma, neuroblastoma, and selected solid
tumors (breast cancer, ovarian cancer, testicular cancer,
poor-risk germ cell tumors)
• Nonmalignant hematologic disorders, such as Fan coni’s
anemia, thalassemia, and sickle cell anemia
• Immunodeficiency disorders, such as severe com bined
immunodeficiency disease and Wiskott Aldrich syndrome
CONTRA INDICATION

• Uncontrolled infection
• Severe non-correctable cardiac, vascular, or lung disease
• Disabling psychosis
• Significant kidney disease
• Significant liver disease
• Age over 75 yrs
 BONE MARROW HARVESTING
SOURCES OF HARVESTING
The three types of bone marrow donors are ::
1. Allogenic bone marrow
2. Syngeneic bone marrow
3. Autologus bone marrow
 ALLOGENEIC BONE MARROW

• Allogeneic bone marrow is

obtained from a relative or
unrelated donor having a closely
matched HLA type.
• This was the most common type
of bone marrow transplant .
• The rate of allogenic transplants
have dropped with decreased
birth rate and increased use of
autologous and peripheral stem
cell transplant.
ADVANTAGES.
• Patient’s marrow does not
need to be harvestable.
• Lowest rate of relapse
DISADVANTAGES
• Risk for GVHD
• Generally high morbidity
and mortality than other
types of BMT.
 SYNGENEIC BONE MARROW

• Syngeneic bone marrow is donated by an identical

twin.
• Although syngeneic marrow is a perfect HLA match,
which eliminates the risk of marrow rejection.
Advantages::
• Patient’s marrow does not need to be harvested
• Generally low morbidity and mortality than allogenic
BMT.
Disadvantages::
• Higher relapse rate than in allogenic BMT
 AUTOLOGOUS BONE MARROW
• Autologous bone marrow is removed
from the intended recipient during the
remission phase to allow another
course of ablative therapy is given if a
relapse occur.
• Bone marrow is removed from the
patient during an operating harvesting
procedure, frozen and re infused after
the patient has undergone high dose
chemotherapy and possible
radiotherapy.
ADVANTAGES DISADVANTAGES

• Operative procedure
• Marrow must be disesae
• Readily available free, sufficient quantity of
cellular marrow must be
• Usually lower morbidity and aspirable.
mortality than allogenic BMT
• In most cases has higher rate
of relapse than allogenic
BMT.
HLA & TRANSPLANTATION
• The HLA antigens are complex proteins expressed on the surface of
all nucleated cells (A,B,C antigens) or cells of the immune system ( D
antigen).
• Although considerably more complex, determination of HLA type is
similar to that of ABO testing.
• Siblings have a 1 in 4 chance of having identical sets of HLA antigens.
• Because of the complexity of HLA system, unrelated people have less
than a 1 in 5,000 chances of having identical HLA types .
 HARVESTING OF BONE MARROW
EVALUATION OF RECIPIENT
1. Eligibility criteria includes age ( generally younger than 55 for allogenic, 65 for autologous &
syngeneic) and availability of suitable stem cell source .
2. Before undergoing transplantation,an extensive workup ensures that the patient’s disease is
treatable with stem cells and that patient has no limitation that will increase risk of mortality.
3. Specific criteria may vary among transplant centers and treatment protocols ,but generally
include::
• Disease – specific evaluation of severity and extent of current disease manifestations.
• Adequate cardiac function:: genrally left ventricular ejection fraction greater than 45%
• Adequate pulmonary function, genrally forced expiratory capacity & forced vital capacity greaterr i
50%
• Adequate renal function:: generally creatinine less than 2 mg/dl
• Adequate hepatic function:: generally bilirubin less than 2 mg/dl
• No active infections
• No coexisting severe or uncontrolled medical conditions.
 EVALUATION OF DONORS

• Because bone marrow donation for allogenic or syngeneic BMT is

an elective procedure with no benefit to the donor,greater care is
taken to ensure that the potential donor is fit for surgery &
understands the potential risks Autologous bone marrow donors
must generally meet the same criteria. Evaluation include ::
1. Thorough medical history and physical examination
2. Chest X ray
3. ECG
4. Lab evaluation (CBC, chemistry profile, testing for CMV,Hep B,
HIV & syphilis, ABO and Rh determination, coagulation studies)
• Informed consent including potential donor complications
must be obtained.
• Because of the significant loss of blood volume & RBCs during
the harvesting procedure, donors are advised to give one or
two units of autologous blood 1 to 3 weeks before surgery,
which may be reinfused during marrow collection if needed.
• Evaluation of donors for peripheral blood stem cell
transplantation is similar but less stringent.
PRE PROCEDURE CARE

• Prior to transplant an extensive is completed by bone marrow

transplant team .
• All other treatments options are discussed and evaluated for risk and
benefits.
• A central venous catheter is surgically placed into the vein.
• Blood products and medications will be administered through the
central line.
• A suitable donor (tissue typed and matched ) must be available .
Finding a donor can be a challenging & lengthy process.
CYCLE OF COLLECTION

• The cycle of collection during BMT include the following::

1. Collection
2. Processing
3. Cryopreservation
4. Chemotherapy
5. Infusion
COLLECTION

Peripheral blood stem cells

• PBSCs are collected by an apheresis.
• Blood is taken out from one vein and is circulated through the machine
which removes the stem cells and returns the remaining blood & plasma
back to the donor through another needle inserted into the opposite arm.
• Several sessions may be required to collect enough stem cells to assure a
chance of successful engraftment in the recepient.
• Filgrastim is a medication will be given to donor for abot one week prior to
collection.
 BONE MARROW
• It involves collecting stem cells with a needle placed into
the soft centre of the bone ( marrow).
• Most sites used for bone marrow harvest are located in
the hip bones and the sternum. Hip bones are used most
often.
• It is performed under epidural, spinal or general
anesthesia in an operating room.
• An aspiration needle is used to puncture the skin and iliac
crest multiple times & remove marrow 2 to 5 ml aliquots.
• Marrow is drawn up into heparinised syringes and
filtered to remove fibrin clots and other debris.
PROCESSING

• Bone marrow & PBSCs is taken to the processing

laboratory where the stem cells are concentrated and
prepared for freezing process.
CRYOPRESERVATION

• Bone marrow or blood is

preserved for freezing by a
preservative solution
dimethylsulfoxide to keep stem
cells alive until they are infused to
recepient’s blood stream.
CHEMOTHERAPY
• High dise of chemotherapy and / or radiation therapy is given to
the recepient .It is done for ::
• To make room in the bone marrow for the transplanted stem cells
• To suppress the patient’s immune system to lessen the chance of
graft rejection
• To destroy any remaining cancer cells in the patient’s body
This therapy is called ablative or myeloablative because of the effect
on bone marrow.
Ablative therapy prevents this process of cell production and
marrow become empty.
INFUSION

Infusion will be given through central venous catheter,

much like a blood transfusion.
If the stem cells were frozen, they are thawed in warm
water then given right away.
Thawed stem cells are infused into the recipient.
DAYS OF BMT

• The day of transplantation is considered as day 0.

• Engraftment and recovery following the transplant is counted as plus
days.
• Engraftment is when the blood-forming cells received on transplant
day start to grow and make healthy blood cells.
• Engraftment usually happens within the first 30 days after transplant
but sometimes can take longer. Engraftment means new cells are
working properly and starting to rebuild immune system.
 POST PROCEDURE CARE
• Be alert , very susceptible to infection.
• May experience excessive bleeding.
• Need for blood transfusion
• Be confined to a very clean environment to minimize the
chance of infection.
• Take multiple antibiotics and other medications.
• Give medications to prevent graft versus host disease ( if
the transplant was allogenic ).
• The transplanted new cells tend to attack the host tissue,
even the donor is a relative such as brother, sister or
parent
• Undergo continual laboratory testing
• Client may experience nausea, vomiting, diarrhoea, mouth sores &
extreme weakness.
• Experience temporary emotional or physiological distress
• After BMT drugs referred to recipient are ::
• Anti-emetics: Patients may continue on anti-emetic therapy for
several days following their transplant until appetite stabilizes.
• Immunosuppressives: For patients of the allogeneic stem cell
transplant procedure, cyclosporine is most commonly prescribed.
Patients may be placed on Prednisone if “graft vs. host disease”.
(GVHD) develops.
• Antibiotics: Since patients are at risk for developing a significant
blood-borne infection, most patients are placed on prophylactic
antibiotics. A special diet for neutropenic patients and other
precautions to reduce risk of infection will be followed .
• Follow up care of donor must include
1. Assessment of harvest site
2. Evaluation of comfort
3. Psychological support
 NURSING MANAGEMENT
Assessment
• History and physical examination
• Extent of the disease
• Availability of a donor
• Tolerance for specific medicines, procedures, or therapies
• Allergies
• Patient’s current fears and concern
• Current pain
• Knowledge of disease status
• Knowledge of transplantation
• Usual coping strategies
• Level of fatigue and usual sleep pattern
 PRE OPERATVE NURSING MANAGEMENT
Recipient
• Obtain an informed consent
• Explain patient about the procedure thoroughly
• Encourage patient’s to express their concerns regarding the procedure
• Provide psychological support
• Assist during central line insertion
Donor
• Obtain informed consent
• Explain procedure thoroughly
• Prepare the skin for bone marrow collection
• Provide support for donors also because they also have concerns about their
own health and procedure they will undergo.
POST OPERATIVE NURSING MANAGEMENT
• Monitor laboratory studies:CBC, noting whether WBC count falls or sudden
changes occur in neutrophils
• Place patient in a private room. Limit visitors as indicated.
• Prohibit live plants or flowers. Restrict fresh fruits and make sure they are
properly washed or peeled.
• Avoid using indwelling urinary catheters and giving I.M. injections.
• Limit invasive procedures (venipuncture and injections) as possible
• Change IV tubing according to your facility’s policy. Use strict sterile
technique.
COMPLICATIONS
1. Hematopoietic complications
• Neutropenia
• Anemia
• Nursing Actions
• Assess vital signs and observe for any signs of infection
• Monitor Hb and WBC counts
• Orient patient about the need of reverse isolation
• Advice to follow a neutropenic diet
• Energy energy conservation techniques
• Anticipate the need for blood transfusion
2. GI COMPLICATIONS

• Mucositis
• Nausea
• Vomiting
• Diarrhea
• Nursing action
• Monitor input and output daily
• Advice good oral hygiene including brushing with soft toothbrush and rinsing mouth with
warm water
• Encourage to suck crushed ice or ice rollers
• Administer anti emetics as orders
3. INFECTION

• Marrow recipient are at high risk of bacterial, fungal and viral

infection
• Nursing action
• Encourage to use mask and follow reverse isolation
• Proper hand hygiene
• Avoid plants and flowers in room
• Monitor visitors for infection
• Administer antibiotics prophylactically
 4. GRAFT VERSUS HOST DISEASE
• GVHD occurs when an immuno incompetent patient recevies
immunocompetent cells.
• GVHD response may begin 7 to 30 days after transplantation
Clinical manifestations
Skin: rashes, thickness, or yellow skin and eyes
Gastrointestinal: diarrhoea or nausea
Mouth: dryness or ulcers
Also common: abnormality of taste, dry eyes, frequent infections, or weight
loss
Management
• Immunosuppresive agents ( methotrexate, cyclosporine) has been
most effective as a preventive rather than a treatment measure.
OTHER COMPLICATIONS

1. Renal and genitourinary

Renal faliure, Hemorrhagic cystitis
2. Hepatic complications
Hepatomegaly , Bilirubinemia, weight gain
3. Pulmonary complications
Bacterial pneumonias , RSV infection, Parainfluenza infection
BIBLIOGRAPHY

• Joyce M Black , Medical Surgical Nursing,First south Asia

edition, Elsevier publications, pg no :: 2155-2158
• Lippincott, Mannual Of Nursing Practice, Ninth Edition, Pg
no :: 1013 –1017
• Susan L Groenwald , Comprehensive Cancer Nursing
Review , Second Edition, Pg no :: 154 –158
• www.cancer.org