Hematopoietic Stem Cell Transplant
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| Human cell surface markers (HLA) | Used by immune system to recognize foreign cells
Class I & II antigens: determined by several genes
Many alleles for each gene
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| Inheritance (HLA) | 1 set of antigens from each parent (total of 10 typed)
Biological parent 5/10 match
Full siblings 1 in 4 chance of being 6/6 or 10/10 match
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| Tissue typing for Autologous Donor | Donor is patient itself so no problems and all maker molecules match
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| Tissue type for Synegeic donor | Identical twin all maker molecules match
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| Allogenic donor | a related donor or unrelated donor, only some marker molecules match
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| What is the purpose of autologous HSCT? | is to rescue after high dose therapy to eliminate malignancy
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| What is the purpose of Allogeneic HSCT? | purpose is to replace diseased marrow and provide Graft v. Tumor effect
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| How is HSCT done in older adults ? | don’t aggressively remove bone marrow but will still will replace
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| What is the process pre-transplant HSCT? | Oncologist refers patient to BMT service
Lengthy complex consent form
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| What happens in day -10 to day 0 HSCT? | Admission (relocation of family to BMT unit; orientation to unit protocol; CVL placed (if not already done) and conditioning
Conditioning: High-dose chemotherapy and/or TBI; biologic response modifiers; antiemetics
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| What happens on day 0 HSCT? | Transplant day: autologous, purged, unpurged, peripheral stem cells; allogeneic, T-depleted, related, unrelated; syngeneic.
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| What happens day Day +1 - +14 HSCT? | Aplasia to engraftment
Aplasia: toxicity due to conditioning regimen; analgesics; infection prophylaxis and treatment; blood products; TPN; GVHD prophylaxis; VOD
Engraftment: viral prophylaxis continues; GVHD prophylaxis and treatment; toxicities begin
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| What happens Day +30 HSCT? | varies, can be as early as 15 for auto
Discharge: social and ADL restrictions to prevent infection; interstitial pneumonia; viral prophylaxis continues; GVHD meds
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| What happens Day +31- +100 HSCT? | Postdischarge: long-term follow up; integration
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| What happens Day +100 to 1 year HSCT? | Allos continue care by BMT service
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| What are the HSCT conditioning regimen? | Eradication/Myeloablation
Kills tumor cells
In process destroys bone marrow
Empties bone marrow space
Provides room for growth of healthy cells
Immunosuppression
Prevents rejection of graft
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| What happens before patient receives myeloblative alleogenic transplant? | allogeneic transplants--the most common type--patients with blood cancers must undergo a conditioning regimen of high-dose chemotherapy or radiation to kill any resident cancer cells, suppress the patient's immune system &leave a disease-free environment
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| What is a mini-transplant? | Nonmyeloablative (Mini); AKA Reduced Intensity Conditioning. Sufficient immunosuppression to allow donor cell engraftment but less aggressive
Injury to organs less, fewer infections, fewer transfusions
Higher relapse rates
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| What are the possible side effects of infusion of stem cells? | Nausea, possible fever spike from DMSO , or allergic reaction
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| Fresh stem cells have to be infused within what time? | within 24 hours of collection, slow central venous catheter
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| Time to engraftment depends on | Stem cell source (cord blood takes longer)
Cell dose
GCSF/GMCSF may be given to promote
Average 10-14 days for peripheral stem cells,
14-21 days marrow and cord blood
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| Evidence of engraftment | ANC >500
Platelets ≥ 20,000 without transfusion
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| What are immediate complications of transplant within first week? | Nausea/vomiting
Diarrhea
Hemorrhagic cystitis
Stomatitis – worse withTBI
Mucositis
Pancytopenia
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| What are the delayed complication of transplant between 7-60 days? | Anorexia
Bone marrow suppression
Infections – viral, bacterial, fungal
Capillary leak syndrome
Pulmonary hemorrhage/ pneumonitis
Veno-occlusive disease (VOD)
Hemorrhagic cystitis/acute renal failure
Graft failure
Acute GVHD
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| What are the late complications of transplant after 60 days | Late – after 60 days
Immunosuppression
Chronic GVHD
Cataracts
Endocrine dysfunction
Pulmonary restrictive diseases
Infection
Bacteria/fungal/PCP/CMV/varicella
Second malignancies
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| 1 in 2 have symptoms of : | GVHD – shows up within first 6 months, sometimes up to 2 years later
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| What is the discharge criteria for HSCT? | ANC ≥ 500 for 2 days
Afebrile
Off IV antibiotics for 48 hours
Able to eat and take oral medications
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| What family education should be provided for HSCT? | When and who to call list
Follow up in clinic
Caring for central line(s)
Medications
Permitted activities
Nutrition
Signs & Symptoms of problems
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| All of the following are standing orders for a first fever spike following stem cell transplant. Which one should the nurse act on first? | Blood cultures times two(central and peripheral)
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| A stem cell transplant survivor comes to the clinic for a follow up visit on day +150. She describes skin rashes and mouth pain, as well as dry eyes and blurred vision. The nurse should further inquire about which of these related symptoms? | Vaginal dryness and sexual discomfort
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| Mrs. L., a 42-year-old female with non-Hodgkin’s lymphoma (NHL), is considering a stem cell transplant. She asks the nurse what the difference is between a stem cell transplant and a bone marrow transplant (BMT). What is the nurse’s best response? | “A BMT is one type of stem cell transplant. The only difference is the source of the stem cells.”
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| Mrs L. has decided to undergo a bone marrow transplant (BMT). The nurse explains that as part of her preparation for a BMT, she will complete a conditioning process that involves: | High-dose chemotherapy and total body irradiation to destroy the bone marrow
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| On day +21, the BMT nurse notes that Mrs L.’s WBC, RBC, and platelet counts are increasing. The nurse would be correct in interpreting this finding as evidence that: | The transplant has engrafted
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