1. Bone Marrow Transplant
Carli Turner, Jaclyn Epstein, Morgan Loomis

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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.

22. 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.

23. 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

24. 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?

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

26. References
Bone Marrow Transplant. MedlinePlus. Retrieved from e/ htm
Bone Marrow Transplant. John Hopkins. Retrieved from
itions/hematology_and_blood_disorders/bone_marr ow_transplantation_85,P00086/