4.4 Hematopoietic Stem Cell Transplant Flashcards
Hematopoietic Stem Cell Transplantation (HSCT)
- Standard of care to treat hematologic malignancies
- Done through apheresis where cells are collected, processed, and reinfused into the patient
Treatments
Allogenic - From a donor other than the patient
Autologous - From the patient
Syngeneic - From an identical twin
Myeloablative - High dose chemotherapy and occasional total-body irradiation
Non-Myeloablative - Mini transplants. Does not completely destroy bone marrow cells
AlloHSCT
- Used for bone marrow disease
- Requires human leukocyte antigen-matched donor (very limiting)
- Transplanted cells cause a Graft-Versus-Tumor Effect to eliminate the cancer
PROCESS
- Engraftment - Collected HSCs are infused IV into the patients bone marrow which takes 2-4 weeks. Once done, the new bone marrow begins to produce RBCs, WBCs, and Platelets
- BEFORE ENGRAFTMENT PATIENTS ARE AT HIGH RISK FOR INFECTION, SEPSIS, BLEEDING
Myeloablative/Nonmyeloablative Chemotherapy
Nonmyeloablative Chemotherapy is less toxic and often used for older patients or patients with underlying organ dysfunction
Acute Side Effects
- Alopecia (autoimmune disorder with hair loss)
- Hemorrhagic Cystitis (Bladder bleeding)
- Encephalopathy
- Pulmonary Edema
- AKI
- Fluid/Electrolyte Imbalances
- Severe Mucositis
Chronic Side Effects
- Sterility
- Pulmonary/Cardiac/Neurologic/Hepatic Dysfunction
- Osteoporosis
- Avascular Bone Necrosis
- Diabetes
- Secondary Malignancies
Hepatic Sinusoidal Obstructive Syndrome (HSOS)
- Chemotherapy induced inflammation of sinusoidal epithelium
- Inflammation causes embolization of RBCs resulting in destruction, fibrosis and occlusion of sinusoids.
S/S
- Weight gain
- Hepatomegaly
- Ascites
- Increased Bilirubin
Graft-Versus-Host (GVHD)
- Major cause of morbidity and mortality in allogenic transplants
- Donor lymphocytes attack recipient tissue during engraftment
- Prevented with cyclosporine (immunosuppression)
Acute - Within first 100 days
Chronic - After first 100 days
Autologous HSCT
- Used for patients who do not have a suitable donor
- Can also be used for patients who have healthy bone marrow but require bone marrow-ablative chemotherapy to cure aggressive malignancies
- Most commonly used to treat lymphoma and multiple myeloma
PROCESS
- Stem cells are collected from patient and preserved for reinfusion
- They are treated to kill malignant cells called “purging”
- HIGH RISK OF INFECTION, SEPSIS AND BLEEDING BEFORE ENGRAFTMENT
- HSOS IS ALSO STILL A RISK
- Does not require immunosuppression
Disadvantages
- Tumor cells may still remain despite treatment
Synergistic Transplants
- Less GVHD risk however also less Graft-Versus-Tumor effect
- There is a risk of transmitting genetic defects so even if an identical twin is an available donor, other donors may be more suitable
Hyperthermia
- Used to destroy cancer tumors
- Effective when combined with radiation, chemotherapy, biological therapy
Nursing Management of HSCT
Pretransplant
- Nutritional assessment, physical exam, organ function test, psychological evaluation.
- Blood work for past infectious antigen exposures
- Assess support systems, finances, insurance
- Informed consent and patient education
During Treatment
- Close monitoring of toxicities (diarrhea, nausea, hemorrhagic cystitis)
- Monitor VS, O2 sat, adverse effects (fever, chills, SOB, chest pain, n/v, hypo/hypertension, taste changes, tachycardia)
- Adverse effects may happen with CRYOPROTECTANT DIMETHYLSULFOXIDE (used to preserve harvested stem cells) which causes n/v, chills, dyspnea, cardiac dysrhythmias, hypotension, and progress to cardiac/respiratory arrest.
Post Transplant Care
Engraftment Syndrome
- Occurs during neutrophil recovery phase. May cause fever, skin rash, weight gain, pulmonary infiltrates and improves after corticosteroid therapy (not antibiotic therapy).
Infections
- Most at risk of developing infections within the first 30 days.
- Pulmonary toxicities can open opportunity for fungal infections (aspergillus)
Renal Complications
- Acute Tubular Necrosis from nephrotoxic chemotherapy
Dietary Implications
- Neutropenic diet to decrease exposure to foodborne toxins.
- No fresh fruit, vegetables or anything washed. Also everything must be cooked
Tumor Lysis Syndrome
HSOS
- Causes fluid retention, jaundice, abdominal pain, tender/enlarged liver, encephalopathy
Pulmonary Complications
- Pulmonary edema, interstitial pneumonia
Donor Care
- Donors may experience mood alterations, decreased self-esteem, guilt from transplant failures.
- Promote reducing anxiety
