Bone Marrow Transplant Carli Turner, Jaclyn Epstein, Morgan Loomis

Bone Marrow Soft, fatty tissue inside the bones Produces blood cells Stem cells: immature cells that give rise to all different blood cells Bone Marrow Transplant: replace damaged or destroyed bone marrow with healthy bone marrow stem cells

Stem Cell Collection Bone Marrow Harvest: Leukapheresis: Under general anesthesia Bone marrow removed from back of hip bones Amount dependent on weight of person Leukapheresis: Donor is given medications to help move stem cells from bone marrow into the blood Blood is removed from donor Stem cells are separated to be given to recipient Red cells are returned to donor

Pre Procedure Chemo/Radiation: Chemotherapy, radiation, or both may be given Ablative: High-dose chemotherapy, radiation, or both are given to kill any cancer cells Kills healthy cells too Reduced intensity treatment: Receive lower doses of chemotherapy and radiation Better for older people who have comorbidities

Types of Transplants Autologous: Allogeneic: Meaning- self. Stem cells are removed before the chemotherapy or radiation treatment. After high-dose chemotherapy or radiation treatments- stems cells are put back in the body to make normal blood cells. Also called: “rescue transplant” Allogeneic: Stem cells are removed from a donor Must partial match HLA Siblings are often good matches Donor registry

Types of Transplants Umbilical cord blood: Type of allogenic Stem cells removed from newborn baby’s umbilical cord right after birth Cells are frozen until needed Less of a need for a perfect match Takes longer to recover

Conditions that require BMT Cancer: leukemia, lymphoma, myelodysplasia, and multiple myeloma Aplastic anemia, congenital neutropenia, severe immunodeficiency syndromes, sickle cell anemia, thalassemia Ablated bone marrow- from chemo or radiation

Prior to Procedure Before procedure Discuss emotional stress Health care provider ask about medical history Physical exam Have 1 or 2 tubes Catheters inserted into a blood vessel in neck and arms Tubes allow for tx. Fluids, and some nutrients Blood draws Discuss emotional stress Meet with counselor Talk to family and children Preparing for procedure Complete Advanced Directive

How are Donor and Recipient Matched? Typing human leukocyte antigen (HLA) tissue Special white blood cells Antigens on WBCs determine genetic makeup of a person’s immune system 100 HLA antigens Few major antigens that determine whether a donor and recipient match Still investigating the role all antigens play in the process of a bone marrow transplant The more antigens that match, the better the engraftment of donated marrow Engraftment: donated stem cells make their way to the marrow and begin producing new blood cells

Donor Recipient Match Cont. Most genes that “code” for the human immune system are on 1 chromosome Two chromosomes  one from each parent A full sibling has a 1 in 4 chance of having gotten the same set of chromosomes and being a “Full Match” for transplant

Evaluation Prior to Transplant Extensive evaluation completed by bone marrow transplant team The decision to undergo a bone marrow transplant is based on many factors Your age, overall health, and medical hx Availability of a donor Your tolerance for specific medications, procedures, or therapies Expectations for the course of the disease Expectations for the course of the transplant Your opinion or preference

Preparation for the Recipient Prior to transplant: extensive evaluation is completed by the bone marrow transplant team All other treatment options are discussed and evaluated for risk versus benefit complete medical history and physical examination are performed Multiple tests to evaluate patient’s blood and organ functions (heart, kidney, liver, and lungs) come into the transplant center up to 10 days prior to transplant for hydration, evaluation, placement of the central venous line, and other preparations Catheter, also called a central venous line, is surgically placed in a vein in the chest area Blood products and medications will be administered through the catheter during treatment

The Procedure High dose of chemotherapy and/or radiation in preparation Intense therapy needed to effectively treat the malignancy and make room in the bone marrow for the new cells to grow (Therapy called ablative  b/c effects bone marrow) Ablative therapy prevents bone marrow production and the marrow becomes empty Empty marrow is needed to make room for the new stem cells to grow and establish a new blood cell production system After Chemo/radiation the marrow transplant is given through central venous catheter Not surgical to place the marrow Similar to receiving a blood transfusion The stem cells find their way into the bone marrow and begin reproducing Supportive care to prevent and treat infections, side effects and complications Frequent blood tests, close vital monitoring, strict fluid input and output, daily weights, clean environment

Considerations for Recipient Pre - Op Post - Op Several weeks in hospital Very susceptible to infection Excessive bleeding Blood transfusions Confined to clean environment Multiple antibiotics and meds Prevent graft-vs.-host disease (allogeneic transplant) Continual lab tests N/V/D, mouth sores, extreme weakness Temporary mental confusion & emotional or psychological distress Pre-treatment screenings Blood tests Infectious disease screening Organ function Blood work Chest x-rays CT scan PET Scans EKG Echo Bone Marrow Biopsy

Risks/Side Effects Infections Low Platelets & low RBCs Likely in patient w/ severe bone marrow suppression Bacterial most common Viral & Fungal  life threatening Any infection can cause an extended hospital stay, prevent or delay engraftment, and/or cause permanent organ damage ABX, antifungals, antiviral meds given Low Platelets & low RBCs Thrombocytopenia (low platelets) and anemia (low red blood cells), as a result of a nonfunctioning bone marrow, can be dangerous and even life- threatening Low platelets can cause dangerous bleeding in the lungs, gastrointestinal (GI) tract, and brain

Risk/Side Effects Cont. Pain mouth sores and gastrointestinal (GI) irritation is common High does of chemo and radiation  mucositis (inflammation of the mouth and GI tract) Fluid Overload can lead to pneumonia, liver damage, and high blood pressure the kidneys cannot keep up with the large amount of fluid being given in the form of intravenous (IV) medications, nutrition, and blood products Can be damaged from disease, infection, chemo/radiation or antibiotics

Risks/Side Effects Cont. Respiratory Distress Infection, inflammation of the airway, fluid overload, graft-versus-host disease, and bleeding are all potential life-threatening complications that may occur in the lungs and pulmonary system Organ Damage liver and heart are important organs that may be damaged during the transplantation process Permanent damage caused by infection, graft – vs. – host disease, high doses of chemo/radiation, or fluid overload

Risk/ Side Effects Cont. Graft Failure Transplant not holding Result due to infection, recurrent disease, or if the stem cell count of the donated marrow was insufficient to cause engraftment Graft – Vs. – Host Disease serious and life-threatening complication of a bone marrow transplant occurs when the donor's immune system reacts against the recipient's tissue in GVHD the new or transplanted immune system can attack the entire patient and all of his or her organs Because new cells do not recognize the tissues and organs of the recipient's body as self Most common sites for GVHD are GI tract, liver, skin and lungs

Nursing Implications Monitor labs such as Hct, Hmgb, RB, INR, Wbc, and platelets. Asses vitals, air way, and for pain. Monitor organ functioning Isolation Medications to prevent infection and GVHD Assess vision, muscle weakness, and fatigue. Monitor fluid status TPN until mouth sores and GI side effects go away. Ex. Labs: Internal bleeding, clotting, infection, and rejection of transplant. Pain; site of insertion, abdominal pain, mouth sores. Urine output, Liver: AST LST, Kidney: BUN& cret and GFR, Cardiac: Potassium mag, Blood pressure Isolation due to high risk of infection Antibiotics GVHD – Prednisone, immunosupressants Fluid status may be altered due to GI upset

Prognosis A bone marrow transplant may completely or partially cure your illness. Varies greatly from person to person Usually it takes up to 1 year to recover fully, depending on what complications occur. Complications or failure of the bone marrow transplant can lead to death. Depends on certain factors such as the complications you experience and the odds against you (age, match of donor, overall health). Effectiveness “The number of transplants being done for an increasing number of diseases, as well as ongoing medical developments, have greatly improved the outcome for bone marrow transplant in children and adults”(Hopkins Medicine). Continuous follow-up care is essential and is key for the patient following a bone marrow transplant. This can greatly effect the overall outcome.

How to Donate Step 1: Get ready to donate Join Be The Match Registry. Sent a swab to swab the inside of your mouth to compare specific protein markers, known as human leukocyte antigens (HLA) with HLA markers of patients who need a bone marrow transplant. If you are a match to a pt, you will be contacted to confirm your willingness to donate. Update Health information and undergo additional testing to see the degree of a match you are to that patient. If you are a match you will be given detailed information about the donation procedure and recovery process, including risks and side effects. Have a physical exam and give blood samples to make sure that donation is safe for both you and the patient.

Donating process cont. Step 2: Donation of PBSC or Bone Marrow. PBSC The patient’s doctor will choose which one is best for the patient. PBSC PBSC donation is a non surgical procedure. For 5 days prior to the donation you will be given injections of Filgrastim, a medication that increases the number of blood forming cells in your blood stream. The donation of blood is removed through a needle on one arm and is passed through a machine that separates the blood forming cells. The blood is then returned through your opposite arm. Bone Marrow A surgical procedure that takes place in the OR where the doctors use needles to withdraw liquid marrow from the posterior site of the pelvic bone. Donors will feel no pain due to being under anesthesia.

Donating process cont.. Step 3: Recovery and follow-up The time it takes for a donor to recover varies. Most donors are able to return to work, school and other activities within 1 to 7 days after donation. Donor will have follow up appointments until able to resume normal activities. To donate go to bethematch.org

Questions 1. What are the benefits of using an autologous transplant vs. allogeneic transplant 2. What is the antigen that must be matched for a bone marrow transplant? 3. What is graft versus host disease?

References Bone Marrow Pre – Transplant Screening: Required Tests. Cleveland Clinic. Retrieved from https://my.clevelandclinic.org/health/treatments_ and_procedures/hic_Bone_Marrow_and_Transpla ntation/hic-bone-marrow-pre-transplant- screening-required-tests

References Bone Marrow Transplant. MedlinePlus. Retrieved from https://www.nlm.nih.gov/medlineplus/ency/articl e/003009.htm Bone Marrow Transplant. John Hopkins. Retrieved from http://www.hopkinsmedicine.org/healthlibrary/cond itions/hematology_and_blood_disorders/bone_marr ow_transplantation_85,P00086/