Bone marrow transplant

HSCT definition

Hematopoietic Stem Cell Transplantation: stem cells collected, processed, and IV infused to restore/replace bone marrow function

HSCT use: malignant diseases

Leukemia, lymphoma, multiple myeloma

HSCT use: nonmalignant diseases

Aplastic anemia, immune deficiencies (e.g., SCID)

HSCT use: solid tumors

Occasionally used for neuroblastoma and germ cell tumors

HSCT stem cell source: bone marrow

Bone marrow harvest (historical method of collection)

HSCT stem cell source: peripheral blood

Peripheral blood stem cells collected via apheresis; now the most common method

HSCT stem cell source: umbilical cord

Umbilical cord blood stored from newborns as a stem cell source

Peripheral collection method

Uses GCSF to stimulate stem cells into peripheral blood for easier collection

Peripheral collection advantages

Less invasive, faster engraftment, higher stem cell yield

Peripheral collection disadvantages

Higher risk of chronic graft-versus-host disease compared to bone marrow harvest

HSCT type: Allogeneic (AlloHSCT)

Stem cells from a donor; includes matched or unmatched sibling/unrelated donor

HSCT type: Autologous (AutoHSCT)

Stem cells from the patient; collected before chemotherapy

HSCT type: Syngeneic

Stem cells from an identical twin; genetically identical donor

HSCT conditioning: myeloablative

High-dose chemotherapy ± total-body irradiation to destroy bone marrow

HSCT conditioning: nonmyeloablative

Lower-dose chemotherapy to allow engraftment without full marrow destruction

HSCT conditioning: mini-transplant

Another term for nonmyeloablative regimen; gentler approach for older or frail patients

Myeloablative AlloHSCT definition

Involves high-dose chemotherapy and sometimes total-body irradiation (TBI)

Myeloablative AlloHSCT purpose: marrow ablation

Completely eradicates the patient’s bone marrow; used for leukemias and myelodysplastic syndromes (MDS)

Myeloablative AlloHSCT purpose: malignancy

Destroys malignant cells to reduce relapse risk

Myeloablative AlloHSCT purpose: engraftment

Prevents rejection of donor stem cells

Nonmyeloablative AlloHSCT definition

Uses lower doses of chemotherapy to prepare for stem cell transplant

Nonmyeloablative AlloHSCT goal

Destroys malignant cells without fully eradicating bone marrow

Nonmyeloablative AlloHSCT immune effect

Suppresses immune system to allow donor stem cell engraftment

Nonmyeloablative AlloHSCT benefits

Less organ toxicity and fewer infections compared to myeloablative regimens

Nonmyeloablative AlloHSCT suitability

Ideal for older patients or those with organ dysfunction

Nonmyeloablative AlloHSCT indication

Used for non-malignant hematologic diseases like aplastic anemia

HLA function

Determines donor/recipient DNA compatibility

HLA role

Distinguishes between self and non-self cells

HLA match benefit

Full match reduces risk of graft rejection and graft-versus-host disease (GVHD)

HLA mismatch consequence

Mismatched HLA requires more immunosuppression

HLA perfect match

A perfect match (10/10) means all 5 HLA pairs match on both chromosome copies

HLA analogy

HLA is like security badges; perfect match = welcome, mismatch = immune system alarm

Engraftment definition

Process where transplanted stem cells migrate to bone marrow, grow, divide, and produce new blood cells

Chimerism definition

Measures proportion of donor cells vs recipient cells in the body

Engraftment: neutrophils

Defined as ANC >500/μL for 3 consecutive days; average timeline: Day +10 to +20

Engraftment: platelets

Platelet count >20,000–50,000/μL without transfusion; average timeline: Day +15 to +30

Engraftment: RBCs

Gradual recovery over weeks to months

Engraftment factor: stem cell source

Faster with peripheral blood; slower with bone marrow or umbilical cord blood (UCB)

Engraftment factor: transplant type

Faster with autologous transplant; slower with allogeneic transplant

Engraftment factor: conditioning regimen

Faster with myeloablative; slower with reduced-intensity conditioning

Engraftment factor: HLA match

Faster with fully matched donor; slower with mismatched donor

Engraftment syndrome definition

Non-infectious inflammatory condition occurring after HSCT during early neutrophil recovery

Engraftment syndrome feature: fever

Noninfectious fever

Engraftment syndrome feature: skin

Skin rash

Engraftment syndrome feature: GI

Diarrhea

Engraftment syndrome feature: lungs

Pulmonary infiltrates

Engraftment syndrome treatment

Improves with steroid therapy rather than antibiotics

Autologous transplantation definition

Also called ‘Rescue Transplant’; uses patient’s own stem cells

Autologous transplant indication: solid tumors

Used for diseases not involving bone marrow (e.g., neuroblastoma) requiring high-dose chemotherapy

Autologous transplant indication: hematologic malignancies

Used in recurrent blood cancers (e.g., multiple myeloma) to achieve long-term remission

Autologous transplant indication: donor absence

Occasionally used when no suitable donor is available

Autologous transplant risk

Possible contamination with malignant cells → increased risk of relapse

Autologous transplant complication: infection

Risk of infections due to chemotherapy-induced immunosuppression

Autologous transplant complication: toxicity

Toxicity from aggressive chemotherapy used before stem cell reinfusion

Autologous transplant advantage

Immunosuppressants not needed since the stem cells are from the patient

Allogeneic HSCT definition

Patient receives healthy blood-forming stem cells from a donor to replace their own

Allogeneic HSCT indications

Used for blood cancers and certain blood or immune system disorders

Allogeneic HSCT timing

Best performed when patient is disease free

Allogeneic HSCT requirements

HLA-matched donor, immunosuppressive therapy, and chimerism monitoring

Allogeneic HSCT advantage: graft-versus-tumor

Donor cells attack residual malignant cells, reducing relapse risk

Allogeneic HSCT advantage: clean slate

Receives disease-free stem cells, restoring healthy marrow function

Nursing care: infection control

Strict infection prevention measures due to immunosuppression

Nursing care: psychosocial support

Provide emotional support and patient education throughout transplant process

Nursing care: immunosuppressant monitoring

Monitor drug levels to ensure therapeutic effect and prevent toxicity

Nursing care: complication vigilance

Watch for transplant-related complications such as GVHD and sinusoidal obstruction syndrome (SOS)

Nursing care: toxicity monitoring

Assess for chemotherapy or immunosuppressant side effects

Nursing care: fluid & nutrition

Balance fluid intake/output and ensure adequate nutrition

Nursing care: counts & organ function

Monitor blood counts and organ function regularly during recovery

HSCT infection concern

Infection is the most primary concern in transplant patients

HSCT infection prevention

Strict measures such as positive pressure rooms and HEPA filtration

HSCT infection prophylaxis

Prophylactic treatment against PCP and viral infections

HSCT infection reactivation

Viral reactivation risks include herpes simplex, EBV, CMV, and varicella zoster

Acute GVHD definition

Donor lymphocytes initiate immune response against recipient tissues; major cause of morbidity and mortality

Acute GVHD timing

Occurs within 100 days post-transplant

Acute GVHD target organ: liver

Elevated liver enzymes, jaundice

Acute GVHD target organ: skin

Rash, erythema

Acute GVHD target organ: GI

Abdominal pain, diarrhea (bloody/mucoid), nausea, malabsorption

Acute GVHD prevention

Minimized through immunosuppressive therapy before and after transplant

Acute GVHD treatment

Symptom relief, immunosuppressant adjustment, and steroids

Chronic GVHD definition

Multisystem disorder occurring >100 days post-transplant; resembles autoimmune disease with persistent inflammation and fibrosis

Chronic GVHD timing

Develops after 100 days post-transplant or overlaps with acute GVHD

Chronic GVHD target organ: eyes

Dryness, irritation, vision changes

Chronic GVHD target organ: mouth

Oral ulcers, dryness, pain, difficulty eating

Chronic GVHD target organ: lungs

Restrictive lung disease, fibrosis, breathing difficulties

Chronic GVHD target organ: fascia/joints

Stiffness, contractures, limited mobility

Chronic GVHD target organ: genital tract

Pain, dryness, scarring

Chronic GVHD treatment

Steroids, continued immunosuppressants, photopheresis (induces apoptosis of leukocytes)

HSCT success: engraftment

Engraftment achieved; transplanted stem cells migrate, grow, and produce new blood cells

HSCT success: donor cells

Donor cells established with full donor chimerism; no need for long-term immunosuppressants

HSCT success: complications

No major complications post-transplant

HSCT success: disease status

Patient remains disease free

HSCT success: recovery

Patient achieves recovery and restored health

HSCT definition

Replacement of bone marrow function using healthy stem cells

HSCT type: autologous

Uses patient’s own stem cells

HSCT type: allogeneic

Uses donor stem cells

HSCT requirement

HLA matching is critical to prevent rejection and GVHD

HSCT engraftment

Sign of marrow recovery: neutrophils → platelets → RBCs

HSCT major risks

Infection, GVHD, toxicity

HSCT nursing care

Infection control, monitoring, psychosocial support

HSCT success criteria

Measured by engraftment, donor chimerism, disease control, and patient recovery