1. An Introduction to Bone Marrow Transplant
Isabel Duggins
BMT Co-ordinator Clinical Nurse Specialists
King’s College Hospital

2. Session Outcomes Role of the BMT CNS
Indications for transplant- Allo vs Auto
Stem cell mobilisation & harvest
Conditioning & pre transplant workup
Allogenic donor selection
Stem cell infusion & engraftment
Overview of Post transplant care

3. Allogenic Stem cell Transplant
Group of patients that require cells from donor, either related or unrelated. (MUD/VUD)

4. Stem cell –made in the bone marrow

5. Who needs an allo Diseases at the root, the stem cell AML/relapsed
AA (failed ATG/has a sib) and other bone marrow failures
Some Lymphomas
We need to ‘replace’ stem cells/immune system

6. Making the match
We look at the HLA matching system (Human Leukocyte Antigen) not the same as the ABO blood group matching.
HLA system allows our immune system to recognise ‘self’
We look at 10 antigens on the surface of the cells (5 inherited from mum 5 dad) these cells appear on all cell surfaces.
Through a blood test

7. HLA
CELL

8. First we look to siblings
1/4 each time that a sib will be match Can be a 10/10 – Ideal Can be a haplo (5-8/10) Not a match a all (but still a sibling worry don’t worry!) Or no siblings at all

9. In reality only 30% of people find a match with their family

10. We look to the wider population
Anthony Nolan Registry – registered charity
Who has connections with registries all over the world - good for matching different heritages.

11. The charity is named after Anthony Nolan (born 1971–died 1979), who did not suffer from leukaemia but from Wiskott-Aldrich syndrome, a rare inherited blood disorder. It was founded by Anthony's mother Shirley Nolan (1942–2002) in 1974 as the Anthony Nolan Register.

14. So we have a 10/10 match Next we look to ABO match Virology matching
Age and sex of the donor
Health of the donor- family history
Willingness of the donor to donate

15. Collecting the cells
Donor is given hormone sub-cut injections GCSF for ¾ days before the collections
On day -1 or day 0 (location dependent) hooked up to the apheresis machine

17. So we have the donor is the patient ready?
Disease under control/ in remission AML >5% blasts. Through the use of chemo regimes such as FLAG/ FLAG IDA.
Wellness of the patient – counts recovered,no infections etc.
Organ function tests
Access- Hickman line insertion

18. Pre Transplant Work up MOT of all the vital organs
Lung function, ECHO, GFR, chest CT
Dental Checkup
Psychological screening
Fertility

19. All good?
We set a day 0 cell infusion date with the donor either the sib through the apheresis department or through the Anthony Nolan and we work backwards

20. Transplant Regime Mainly for AML we use the FBC or FB4C protocol.
This is the conditioning chemotherapy
Makes room in the patient’s marrow to receive the cells. And may be clears any cancer cells lurking around

23. Admission
Tricky process
Bed availability
Side rooms v bay

24. Hickman Line

25. Giving the chemo All given IV
Kills all rapidly dividing cells leads to
Sore mouth
Diarrhoea
Hair loss
Fluid balance-electrolyte imbalance
Patient has often had chemo before

26. Giving the cells –Day 0 (New Birthday)
Arrive fresh to our stem cell lab. They check the CD34 count. We aim for count 4-7 million.
Then they bring them to the ward.
Nurse pre meds the patient- IV piriton, hydrocortisone and oral paracetamol
Often no reactions and as simple as giving any blood product transfusion

28. And then we wait… Counts are low neutrophils will drop to 0
Will pick up infections.. So this is the most risky time for the patient
Contact isolation, gloves apron
Still allow visitors as good for mental health

29. Engraftment
New cells take hold. Shown in blood tests as neutrophil count comes up >0.5 for 2/3 day with an upward trend.
Battle between new cells and old cells immunosuppression in the form of IV cyclosporin started on day -1 levels are monitored and tapered accordingly (watch renal function)

30. The BATTLE GVHD graft v host disease. Graft – the new cells
Host -the body.
Even though a 10/10 match there are still differences- both ways
Skin, Liver, Gut
But we want graft v disease effect.

31. Risks GVHD – can be life threatening Organ dysfucntion Infection
Long term – disease relapse, secondary cancers.
‘Transplant is a live changing experience’

32. How does the patient feel during inpatient stay

33. Post Transplant First 100 days, Acute phase Post 100 days chronic.
First few months post transplant twice weekly bloods, likely needs blood/electrolyte support.
Once week seen in post transplant clinic
Likely to readmitted during this time
Viral reactivation, infection, GVHD

34. FAQ’s from patients

35. What if no 10/10 donor?
Using a 9/10 V a haplo

36. 9/10 Not as close a match Higher chance of rejection
Higher chance of GVHD
Have to check for donor directed antibodies.

37. Haplo 5-8/10 Can be sibling, mother or father or child.
Wouldn't use un-related in this case (too different)
Different protocol.
Use of Total Body Irradiation.
Often use chemo after day 0…. How does this make sense?!!?!?
Often longer engraftment period.

39. Now lets play a game:

40. Make the match
21 YO female with AA, failed ATG and CYA. Now going to BMT

41. Donor Options 10/10 matched sibling (M) ABO mismatched CMV matched
10/10 Unrelated (M) ABO matched and CMV matched

42. Make the match
49 YO male with AML, in complete cytogenetic remission following 2 courses of chemo

43. Donor Options No matched sib, potentially a haplo.
10/10 ABO minor mismatch, CMV matched
10/10 ABO matched, CMV mismatched.

44. Uh Oh Following recent work up tests we found ejection fraction at 42%
Refer to cardiology

45. Cardiology optimised the patient using bet blockers
Echo repeated
Ejection fraction now

46. 33%.. We made it worse
Patient goes through MDT and we decide

47. Not for BMT
WHY IS SO IMPORTANT THAT WE DO THESE WORK UP TEST?

48. Make the Match
33 YO Nigerian female. AML in remission following several rounds of chemo as chemo refractory.
Now is ready for transplant , has previously relapsed so we have small window to get her to BMT

49. Donor Options 9/10 CMV matched, ABO matched.
Haplo matched brother who lives in Nigeria

50. Depends who you ask ! Brother doesn’t have a passport!
9/10 donor isn’t available until December 2017.

51. A cord search has been initiated
Donor selection can be tricky

52. Autologous Own cells are used Chemo is the key here
Cells act as a rescue

53. Autologous
Patient
Myeloma
Some lymphomas MS

54. Mobilsation can differ
GSCF injections..
Chemotherapy is often used to empty the bone marrow. This tricks the bone marrow to be stimulated to producing more immature cells to re-populate itself and increase the number of healthy cells again.
Mosibil

55. Administration

57. Thanks for listening
Any questions?