Hematopoietic Stem Cell Transplantation: a Manual for Nursing Practice

The area of hematopoietic stem cell transplantation (HSCT) has grown immensely since its beginnings. The roots of bone marrow transplantation (BMT) can be traced back to 1949 when Leon Jacobson and his colleagues performed mouse experiments and discovered that mice could recover from lethal irradiation if their spleens were shielded (Appelbaum, 1996). Lorenz, Uphoff, Reid, and Shelton demonstrated in 1951 that radiation protection could be provided with the infusion of syngeneic marrow. In 1955, Main and Prehn showed that mice protected with an allogeneic marrow infusion could permanently accept a skin graft from a marrow donor. By the mid-1950s, several laboratories had shown by cytogenetic markers that the radioprotective effect of BMT was the result of the replacement of the host’s damaged hematopoietic system with healthy cells from a donor (Appelbaum, 1996). In 1959, Dr. E. Donnall Thomas initiated the first attempt to treat leukemia using high-dose chemotherapy followed by syngeneic (identical twin) marrow transplantation (Appelbaum, 1996). In early trials, transplantation using donors other than identical twins proved unsuccessful because of a lack of understanding of human leukocyte antigens (HLAs) and their importance to histocompatibility (Thomas, 1995). By the mid-1960s, it had been discovered, in dogs, that successful allogeneic marrow transplantation could be achieved by matching at the major histocompatibility complex (Appelbaum, 1996). Many of the early transplants were unsuccessful because of only transient engraftment of cells and disease progression. The first successful allogeneic transplant for leukemia occurred in the late 1960s at the University of Minnesota. The donor was a matched sibling, and the recipient was an infant with an immune-deficiency disease (Appelbaum, 1996). The first unrelated allogeneic transplant was performed in 1973. Autologous marrow transplantation was first used successfully in patients with lymphoma in the late 1970s and became more widespread throughout the 1980s (Appelbaum, 1996). Currently, HSCT is used in a wide variety of malignant, nonmalignant, and genetically determined diseases and is the only known cure for many malignant and nonmalignant diseases (see Table 2-1). Transplantation may be referred to by a number of different terms, including BMT, HSCT, peripheral blood stem cell transplant (PBSCT), or umbilical cord transplant. HSCT is the transplantation of hematopoietic progenitor cells, which have the ability to proliferate, repopulate the marrow spaces, and mature. Blood counts and immunity are reestablished and recover when the mature blood cells enter the bloodstream (AABB et al., 2009). Historically, hematopoietic stem cells were collected from the bone marrow. Now physicians can select from three sources: bone marrow, peripheral blood, and umbilical cord blood (UCB) (AABB et al., 2009). The first successful PBSCTs were performed in the 1980s (Duncombe, 1997). This cell source is now used more often than bone marrow in adults undergoing allogeneic transplantation (Harris, 2010). Transplantation of UCB was successfully performed for the first time in 1988 to treat a child with Fanconi anemia. The patient received UCB from a sibling who was a perfect HLA match (Gluckman, 2001). Since then, much has been learned about UCB and the role it can play in transplantation. Multiple UCB banks have been established in the United States and Europe. With these and other advances, UBC transplant is a viable option for adult and pediatric HSCT (Ballen, 2005; Laughlin, 2001, 2005). The use of HSCT has increased for several reasons. First, it allows for the administration of dose-intensive systemic chemotherapy and radiation that would be lethal without transplantation. In addition, HSCT from an allogeneic donor has an additional antitumor effect (AABB et al., 2009). Several characteristics of hematopoietic stem cells make transplantation possible. The first is their ability to regenerate in the marrow. Each hematopoietic stem cell is pluripotent and able to self-replicate, proliferate, and develop into myeloid (red blood cells, platelets, neutrophils, and mac-