7. TYPES OF STEM CELL TRANSPLANTATION
Autologous
Allogeneic
Matched related donors
Matched unrelated donors
Mismatched related donors
Haploidentical donors
Umbilical cord blood donors
Syngeneic –identical twins
8. SOURCES OF STEM CELLS
The stem cells may be obtained from sources such as:
• Bone marrow
• Peripheral blood stem cell transplant
• Umbilical cord blood
• Adipose tissue
• Amniotic fluid
12. TRANSPLANTATION PROCESS
The transplantation process has been divided
into the following phases:
• 1. Pre-treatment workup.
• 2. Preparation
• 3. Conditioning.
• 4. Transplantation of Marrow
• 5. Engraftment.
13. 1. PRE- TREATMENT WORKUP
• Donor selection.
• Financial arrangements.
• Extensive medical evaluation, to establish the client’s physical and
psychosocial status.
• Orientation to centre and transplant process
• Preparation of the family caregiver and
• Establishing central venous access.
• Infection prophylaxis
14. 2. PREPARATION
The preparation may include formal training in symptom management,
medication administration.
Completion of informed consent is obtained.
Harvesting of stem cells:
1. Peripheral blood stem cell.
2. Harvest of stem cell from bone marrow.
15. This method is divided into stages:
• 1. Mobilization: To stimulate the production of PBSCs. Two techniques, using hematopoietic
growth factor (G-CSF) alone or in combination with chemotherapy.
• 2. Apheresis: PBSCs are collected by apheresis, using cell separators. The remaining blood
components are returned to the patients. Apheresis is performed for 3 – 10 days. Each session is
3-4 hours long, a flow of 50/70ml/minute is considered optimal
• 3. Collection: After each collection the stem cells are then placed in a blood bag and
cryopreserved. The cells are kept frozen at -196degreeC.
• Dimethyl sulfoxide (DMSO) is the current gold standard for cell cryopreservation and is the
most commonly used cryoprotectant for HSCs.
Collection of peripheral blood stem cells
19. Bone marrow:
• Adults have approximately about 2.6kgs of bone marrow.
• Red bone marrow is found mainly in flat bones such as Hip bones, skull, ribs,
vertebrae and shoulder blades and in the proximal ends of long bones (femur
and humerus)
Harvest of stem cells from bone marrow
21. • For the autologous transplant: patient must be in remission period.
• For allogenic donor:
a throughout physical examination is required before the harvest is scheduled.
Donor selection and stem cell sources
The following studies are routinely performed on hematopoietic stem cell donors:
History and physical examination
Serum creatinine, electrolyte, and liver function studies
Serologic studies for cytomegalovirus (CMV), herpes viruses, HIV RNA, anti-HIV antibodies,
hepatitis B and C viruses, human T-cell lymphotropic virus-1/2 (HTLV-I/II), and syphilis (VDRL); in
autologous donations, CMV and VDRL testing are not required
ABO blood typing
Human leukocyte antigen (HLA) typing
Chest radiography
Electrocardiography (ECG)
22. • Bone marrow Aspiration is a surgical procedure requiring general or spinal anaesthesia.
• Multiple aspiration is performed in one setting.
• The volume of the marrow is determined by the size of the donor, as well as the type of
transplant.
• Usually 10-15ml/kg of body weight will yield: 500- 700ml of needed stem cells. Therefore
a 50kg patient would contribute approximately 500 to 750ml of bone marrow and of
obtaining 5ml per aspiration, approximately 100 to 150 aspirations are required.
• Ideally this amount of marrow should contain 1 to 4x108
nucleated cells.
• Once collected the marrow is mixed with heparinized solution, filtered to remove bone
fragments and fat and placed in a blood bag.
• At this point purging is done using monoclonal antibodies or chemotherapeutic agents.
• T-cell depletion. RBC can also be removed (To prevent GVHD)
25. 3. CONDITIONING
It is a process of preparing the patient to receive bone marrow.
It accomplishes vital functions:
1. Destroy the malignant disease.
2. Destroy the patient’s pre-existing immunologic state.
3. Create space in the marrow cavity for proliferation of transplanted stem cells.
26. Preparative or conditioning regimens involve delivery of maximally tolerated doses of
multiple chemotherapeutic agents with nonoverlapping toxicities and may be classified
as follows:
• Myeloablative regimens
• Nonmyeloablative regimens- mini-transplant or mention reduced-intensity conditioning (RIC).
graft-versus-cancer effect
27. Conditioning regimen
• The drugs, given in high doses that ablate marrow function, enable the
greatest possibility of tumor kill.
• Agents that are currently being used include: cyclophosphamide,
demethylbusulfan, cytrabine, cisplatin, bleomycin.
• Radiation dose is given one time for 6 – 7 days. Higher total dose to be
delivered with less side effects.
• Common side effects: nausea, vomiting, myelosuppression, neurotoxicity,
haemorrhage, alopecia, erythema.
28. 4. TRANSPLANTATION
For autologous:
The frozen marrow is thawed in a
normal saline bath, given by a
rapid IV push via central line.
20 to 30 minutes procedure.
S.E: nausea, vomiting, shortness
of breath.
For allogenic transplantation:
Marrow is infused on the same day
as it is collected.
Unfiltered tubing must be used for
IV infusion
1-5 hours procedure.
S.E: nausea, vomiting.
After completion of the conditioning regimen, the stem cells must be infused.
29. 5. ENGRAFTMENT
• The time immediately after the transplantation.
• This usually takes 2 to 3 weeks and is evidenced by increasing blood
counts.
• During this period patient experience severe pancytopenia and
immunosuppression.
• The patient’s care during this period focused on prevention of bleeding and
infection.
• Patients typically receive antibiotics and blood components during this
time.
36. COMPLICATIONS
1. Graft failure:
• Rare occurrence 5 to 15%
• Failure of marrow recovery to return.
• Seen in:
HLA mismatched marrow extensive marrow fibrosis before transplantation,
who have only received cyclophosphamide for conditioning.
2. Infection:
• 10-15%
• First 6 weeks.
• Usually the causative agents are from patient’s own micro flora.
• Common agents are gram positive, gram negative bacteria
37. 3. Pneumonitis:
• It is the most common cause of death in the first 100 days after BMT.
• Commonly caused by CMV
• Carries a 60% mortality rate
• Risk factors: total body irradiation, presence of GVD, advanced age (more
than 45 years), prior lung injury.
4. Recurrence of the disease.
• Disease recurrence remains the most significant problem after
transplantation.
• Major factor for patient mortality after 3 months.
• Relapse is more common in autologous because of hidden malignant cells.
38. 5. Graft versus host disease: After allogenic transplantation
Acute GVD: occurring before 100 days
• Risk factors: HLA mismatched, advanced patient age (greater than 45 years)
Chronic GVHD: after 100 days. Up to 1 year.
• It can be a continuation of acute GVHD or can occur without any preceding
GVHD
• It is a multiorgan syndrome
• General findings: maculopapular rash over the skin surface, bilirubin increase,
G.I symptoms (nausea, vomiting, diarrhea, severe abdominal pain)
40. 5. Veno-occlusive disease:
10- 20% of the patients, occurs in First 3 weeks.
Mortality rate counts to 50%
Occlusion of central veins of the liver resulting in venous congestion and
statis, results in damage of hepatic cells.
Diagnosed by its classical symptoms:
Weight gain greater than 5% over baseline,
hepatomegaly, right upper quadrant pain, total serum bilirubin level above
2mg/dl and ascites.
Risk factors: history of hepatitis.
42. 6. Transplant problems that may show up later
• Organ damage
• Relapse (the cancer comes back)
• Secondary (new) cancers
• Abnormal growth of lymph tissues
44. LATE EFFECTS:
• Cataracts: complication after total body irradiation.
• Gonadal dysfunction: after TBI, 90% females experience ovarian failure
and require hormonal replacement , in males absent or abnorma.
spermatogenesis.
• Growth failure: common in children, 40-50% of children have decreased
growth hormone, causing a retardation of spinal growth.
• Hypothyroidism: associated with TBI, affects as many as 60% of the
patients receiving single dose Radiation therapy
45. HOW LONG CAN YOU LIVE AFTER A STEM CELL TRANSPLANT?
• A stem cell transplant may help to live longer. In some cases, it can even
cure blood cancers.
• About 50,000 transplantations are performed yearly, with the number
increasing 10% to 20% each year.
• More than 20,000 people have now lived five years or longer after having
a stem cell transplant
47. Diagnosis: pain related to side effects of treatment regimen.
Interventions:
• Assess patient’s pain location, onset, frequency, intensity.
• Identify effective pain control measures.
• Administer pain killers as ordered.
• Assess for effectiveness of pain control measures.
• Instruct patient in relaxation techniques.
Outcomes:
• Patient will be able to identify the activities that increase or decrease pain
• Relief of the pain.
48. Diagnosis: body image disturbance/ risk for, related to treatment process
Interventions:
• Encourage the patient to verbalize feelings about appearance and perceptions of life
style changes.
• Validate perceptions and assure that responses are appropriate.
• Promote acceptance of positive, realistic body image.
• Explore the ways that patient can cope with the body image changes within their
cultural expression
• Outcomes:
• Patient will be able to verbalize and demonstrate acceptance of appearance.
• Demonstrate willingness and ability to resume self care roles and responsibilities.
49. Diagnosis: fluid volume deficit or excess evidenced by altered electrolytes.
Interventions:
• Monitor patient’s Intake output, Weight, Abdominal girth, Edema, Serum electrolytes,
Blood Urea Nitrogen, Hemoglobin and haematocrit.
• Assess patietnt for signs of fluid overload or dehydration.
• Assess the sign of GVD
Outcomes:
• Patient will be able to maintain normal fluid volume and electrolyte balance as
evidenced by:
• Normal blood and urinary laboratory values
• Maintaining baseline weight
• Normal skin turgor
• Moist mucous membrane
50. Diagnosis: nutrition altered, less than body requirements, related to effects or
treatment process.
Interventions:
• Assess nutritional intake and monitor calorie counts.
• Assess for causes of decreased nutritional intake: nausea, vomiting, xerostomia, taste
changes.
• Provide small, frequent meals.
• Determine cultural preferences and meaning of foods.
• Initiate referral to dietician for assessment of food preferences and appropriateness of
diet.
Outcomes:
• Patient will be able to report/maintain adequate nutritional status during periods of
decreased oral intake.
• Experience minimal or no nausea.
51. Diagnosis: knowledge deficit related to transplantation procedure
Interventions:
• Evaluate patient and family readiness to learn.
• Identify barriers to learning such as language such as language, physical
deficiencies, psychosocial deficiencies, intellectual development.
• Determine patient and family’s knowledge of transplant procedure.
• Review information patient and family have already been given.
• Provide written, audio-visual education material and review with patient and family
• Allow adequate time for verbalization of fears and anxiety.
• Reinforce and clarify information as needed.
Outcomes:
• Patient/family will be able to explain the knowledge regarding Transplant.
• Describe medical and nursing intervention available according to their
understanding levels.
52. Diagnosis: skin integrity, impaired, risk for related to treatment process and to
GVHD.
Interventions:
• Assess impaired area every shift for colour, scaling, bleeding, drainage, tenderness.
• Avoid use of harsh soaps, hot water, perfumes, deodorants.
• Maintain meticulous hygiene with antibacterial soap.
• Instruct patient to avoid exposure to sun and to use sunscreen when out in sun.
Outcomes:
• Patient will be able to have an intact skin free of infection.
53. Diagnosis: coping ineffective, related to transplantation process and potential
lifestyle changes.
Interventions:
• Assess patient’s level of distress and anxiety.
• Listen attentively and provide support.
• Encourage verbalization of fears.
• Provide reassurance that anxiety or distress are common feelings among
transplantation.
• Initiate referrals to social work, psychology, or common feelings among transplant
patients.
Outcomes:
• Patient will be able to identify coping patterns.
• Identify personal strengths and accept support.
54. Diagnosis: infection related to myelosuppression and immunosuppression.
Interventions:
• Assess for sign and symptoms of infection. (fever, cough, erythema)
• Institute measures to prevent exposure to potential source of infection (hand washing,
hygiene maintenance, good oral hygiene)
• Monitor WBC and differential.
• Monitor vital signs and head to toe system assessments frequently.
• Obtain cultures for blood, urine, stool, sputum,
• Administer antibiotics, antifungals, antivirals as prescribed.
• Instruct patient and family in prevention of infection.
• Implement protective isolative precautions.
• Minimize invasive procedures.
Outcomes:
• Patient will be free of infections, vitals: stable, no signs of infections.
55. Diagnosis: growth and development affected related to late effects of treatment.
Interventions:
• Monitor patient’s growth according to standard growth chart.
• Assess for accomplishments of normal growth and developmental tasks.
• Provide referrals to educational and emotional support as needed.
• Administer growth hormone as ordered and assess for response.
Outcomes:
• Patient will be able to demonstrate an increase in behaviours in personal, social,
language, and cognition and motor activities appropriate for age.
56. PROGNOSIS
• The type and stage of the disease, patient’s age, performance status and donor
availability determine the type of transplant that can be done and the chances of
survival.
• ALL is the most common leukaemia among children, for those patients who do not
have suitable donor, Autologous BMT is done but these patients have relapse rate
of 70% to 75%
• Survival rates of AML patients with allogenic BMT are 35% to 60%
• Allogenic BMT provides a 30% to 50% chances of survival and the only hope of
cure.
• For non malignant diseases like aplastic anaemia, Allogenic BMT is responsible for
approximately an 80% overall survival rate.
57. CONCLUSION
Stem cell transplantation, regardless of the source of stem cells, offers a cure and new
hope for the future to many patients with life threatening diseases. Bone marrow
transplantation is a strenuous medical treatment that in and of itself can be life threatening.
As with any major medical treatment and life threatening situations faced by patients and
family, the general stresses that affect them must be addressed. Everyday life of these
patients will be disrupted by transplantation. There will be changes in their roles and the
financial burden can be devastating to the families. Therefore caring for patients undergoing
HSCT requires comprehensive and consistent nursing management. Patient/ family
teaching is the key to providing assistance to patients throughout the transplant process.
Editor's Notes
#2:A stem cell is a cell with the unique ability to develop into specialized cell types in the body. In the future they may be used to replace cells and tissues that have been damaged or lost due to disease.
They are vital to the development, growth, maintenance, and repair of our brains, bones, muscles, nerves, blood, skin, and other organs .
#4:the ability to go through numerous cycles of cell division i.e. mitotic division while maintaining the undifferentiated state (make copies of themselves)
to differentiating into a diverse range of specialized cell types.
Stem cell from one tissue may be able to give rise to cell types of completely different tissue e.g. Blood cells becoming neuron, liver cells producing insulin and hematopoietic stem cells, developing into heart muscle.
It refers to the varying ability of stem cells to differentiate into specialized cell types.
