BONE MARROW

TRANSPLANTATION

Dr. Binu Babu Mrs. Jincy Ealias

Asso. Professor Assi. Professor
 Bone Marrow
• Bone Marrow is the soft spongy tissue that
fills the cores of larger bones.
• It serves an active function in the body by
producing all three types of blood cells, as
well as lymphocytes, which support the
immune system.
• Bone marrow is found in the center of most
bones and has many blood vessels. There
are two types of bone marrow: red and
yellow.
– Red marrow contains blood stem cells that can
become red blood cells, white blood cells, or
platelets.
– Yellow marrow is made mostly of fat
 Stem cells
• Stem cells are cells with the potential to
develop into many different types of cells in
the body. They serve as a repair system for
the body.
• There are two main types of stem cells:
embryonic stem cells and adult stem cells
 Characteristics of stem cell
• They can divide and renew themselves over
a long time
• They are unspecialized, so they cannot do
specific functions in the body
• They have the potential to become
specialized cells, such as muscle cells, blood
cells, and brain cells
 Bone Marrow Transplant
• Bone Marrow transplant is a procedure used to
treat patients with life-threatening blood,
immune or genetic disorders.
• This includes leukaemia and bone marrow
cancers.
• A bone Marrow transplant replaces the unhealthy
blood-forming cells with healthy ones.
• Healthy bone marrow stem cells are harvested
from matching bone marrow donors.
 Indications for bone
marrow transplantation
 Bone marrow transplant is done to treat a number of cancerous
and non cancerous conditions such as:
 Cancerous conditions:
• Leukemia
• Lymphoma
• Multiple myeloma
• Myelodysplasia.
 Non cancerous conditions:
• Aplastic anemia
• Hemoglobinopathies
• Immunodeficiency disorders and conditions affecting blood
present from birth
 Types of Transplant
• Autologous (own cells)
• Allogeneic
– cells from another person
• Sibling
• Unrelated Donor
• Parent or relative
– or source: Umbilical cord
Autologous bone marrow transplant

Peripheral blood stem cells (PBSCs).

• Stem cells are taken by apheresis process.
• Apheresis is a process of collecting stem cells that
float in the blood (peripheral blood stem cells).
Bone marrow harvest.
• Stem cells are collected by using a needle placed
into the soft center of the bone.
• Most sites used for bone marrow harvesting are in
the hip bones because they have a larger number of
stem cells.
 Allogeneic bone marrow transplant

• The donor is another person who shares the

same or similar genetic type as the patient.
• This is often a brother or sister. Finding a
matching donor can be a lengthy process. In
some cases, a parent may be a donor. Or the
donor may be a matched unrelated donor
(MUD) found on a bone marrow registry.
• Stem cells are taken from the donor either
by apheresis or bone marrow harvest.
Allogeneic Blood/Bone Marrow Donor is
a brother or sister
 Only 25% of patients are that lucky!
 There is a 1 in 4 chance that any child will match
another child of the same parents
 The formula for knowing whether there is a donor
(1-(3/4)n)
 In 1% of cases, a parent may be a donor because
of shared HLA types
 Major obstacle in the treatment of patients
who would benefit from an allogeneic
transplant.
 Umbilical cord blood transplant
• Stem cells are taken from an umbilical cord
right after a baby’s birth.
• These stem cells grow into mature blood
cells quicker and more effectively than stem
cells from the bone marrow of another child
or adult.
• The stem cells are tested, typed, counted,
and frozen until they are needed for a
transplant.
 Pre-Bone Marrow Transplantation
Procedures
 Bone marrow transplantation regimens
vary from one patient to another, and
depend upon the type of cancer
 the treatment program used by the medical
center.
 the clinical trial protocol (if the patient is
enrolled in a clinical trial), as well as other
factors.
 Transplant Process (5 steps)
1. Conditioning,
2. Stem cell infusion,
3. Neutropenic phase,
4. Engraftment phase
5. Post-engraftment period.
 Conditioning Phase
• The conditioning period typically lasts 7-10 days.
• The purposes are (by delivery of chemotherapy
and/or radiation)
• to eliminate malignancy
• to provide immune suppression to prevent
rejection of new stem cells
• create space for the new cells
• Radiation and chemotherapy agents differ in
their abilities to achieve these goals.
 Stem cell processing and infusion
• Infused through a CVL, much like a blood
transfusion.
• Anaphylaxis, volume overload, and a
(rare) transient GVHD are the major
potential complications involved.
• Stem cell products that have been
cryopreserved contain dimethyl sulfoxide
(DMSO) as a preservative and potentially
can cause renal failure, in addition to the
unpleasant smell and taste.
 Stem cell processing and infusion
• Infusion - 20 minutes to an hour, varies
depending on the volume infused. The stem
cells may be processed before infusion, if
indicated. Depletion of T cells can be
performed to decrease GVHD.
• Premedication with acetaminophen and
diphenhydramine to prevent reaction.
 Neutropenic Phase
• During this period (2-4 wk), the patient
essentially has no effective immune system.
• Healing is poor, and the patient is very
susceptible to infection.
• Supportive care and empiric antibiotic
therapy are the mainstays of successful
passage through this phase.
 Engraftment Phase
• During this period (several weeks), the
healing process begins with resolution of
mucositis and other lesions acquired. In
addition, fever begins to subside, and
infections often begin to clear. The greatest
challenges at this time are management of
GVHD and prevention of viral infections
(especially CMV).
 Post-engraftment Phase
• This period lasts for months to years.
Hallmarks of this phase include the gradual
development of tolerance, weaning off of
immuno suppression, management of
chronic GVHD, and documentation of
immune reconstitution.
 Adverse Effects
• Gastrointestinal tract :
• Ulcers & dysfunction of GIT occur frequently.
• Skin:
• Rashes may develop.
• Hair follicles:
• Hair loss occurs temporary
• Lungs:
• Pneumonia
• Blood vessels:
• Inflammation-damaged blood vessels
• Liver :
• Jaundice
 Graft Verses Host Disease (GVHD)
• GVHD sometimes occurs with allogeneic transplantation.

• Lymphocytes from the donor graft attack the cells of the host

• GVHD can usually be treated with steroids or other immunosuppressive

agents.
• Acute GVHD occurs before day 100 post-transplant

• Chronic GVHD occurs beyond day 100

• Recent advances have reduced the incidence and severity of this post-
transplant complication, but GVHD, directly or indirectly, still accounts for
approximately 15% of deaths in stem cell transplant patients
• Chronic GVHD can develop months or even years post-transplant
 GVHD symptoms
Skin/Hair
• Rash, scleroderma, lichenoid skin changes, dyspigmentation,
alopecia
Eyes
• Dryness, abnormal Schirmer's Test, cornealerosions,
conjunctivitis , Mouth Atrophic changes, lichenoid changes,
mucositis, ulcers, xerostomia, dental caries
Lungs
• Bronchiolitis obliterans
GI tract
• Esophageal involvement, chronic nausea/vomiting, chronic
diarrhea, malabsorption, fibrosis, abdominal pain/cramps
Liver
• Abnormal LFTs, biopsy abnormalities
Genitourinary
• Vaginitis, strictures, stenosis, cystitis
Musculoskeletal
• Arthritis, contractures, myositis, myasthenia,
fascities
Hematologic
• Thrombocytopenia, eosinophilia, autoantibodies
 Post-bone marrow transplantation
care
 A two- to four-week waiting period follows the marrow transplant
before its success can begin to be judged.
 The marrow recipient is kept in isolation during this time to minimize
potential infections.
 The recipient also receives intravenous antibiotic, antiviral, and
antifungal medications, as well as blood and platelet transfusions to
help fight off infection and prevent excessive bleeding.
 Blood tests are performed
 daily to monitor the patient's kidney and liver function, as well as
nutritional status.
 Other tests are performed as necessary.
 Further side effects, such as nausea and vomiting, can be treated with
other medications.
 References
• Seeley, R. R., Tate, P., & Stephens, T. D. (2008). Anatomy
& physiology. Mcgraw-Hill.
• Snell, R. S. (2004). Clinical anatomy for medical
students. Lippincott Williams & Wilkins.
• Rizzo, J. D. (2005). Clinical bone marrow and blood
stem cell transplantation. Bone Marrow
Transplantation, 35(3), 319–319. https://
doi.org/10.1038/sj.bmt.1704735
• Connie Henke Yarbro, Wujcik, D., & Barbara Holmes
Gobel. (2018). Cancer nursing : principles and practice.
Jones & Bartlett Learning.