Introduction

Patients with a haematological malignancy such as leukaemia, lymphoma and myeloma may undergo a haemopoietic stem cell transplant as part of their cancer treatment. This is a highly specialised procedure and is undertaken in a specialised transplant unit. If you have been allocated to a specialist transplant unit, you will have the opportunity to observe and experience high-intensity transplants and learn to care for acutely sick patients. If you have not been allocated to this area, you may be able to arrange an insight visit. Whether you get the opportunity to visit a haemopoietic transplant unit or not, you may meet individuals who are either preparing for the procedure or who have undergone the treatment. Increasingly, low-risk haemopoietic stem cell transplants are being performed in more general areas such as the community setting (Dix & Geller 2000). This requires community-based healthcare professionals to be knowledgeable and skilled in caring for these patients. Although the transplant phase is very intensive and patients can become critically unwell, patients require long-term support so you may meet these patients during the post-transplant phase.

Haemopoietic stem cell transplant is the use of high-dose cytotoxic therapy (with or without radiotherapy) and a transfusion of haemopoietic stem cells to ‘rescue’ the patient’s haematological status. Previously, bone marrow was used in transplants, extracted from the iliac crest under local anaesthetic. This was painful and intrusive. To avoid this, stem cells are now used. Stem cells are the cells that develop into, or differentiate into, all types of blood cells – red and white cells and platelets – and can easily be accessed peripherally.

There are three types of haemopoietic transplant, depending on where the stems cells come from:

Whatever the type of haemopoietic transplant, the principles of treatment are similar. Before the stems cells can be collected, the number of peripheral stem cells must be increased – this is called priming. This can be achieved in two ways. First, subcutaneous (SC) injections of colony-stimulating factors (discussed in Ch. 12), such as granulocyte colony-stimulating factor (GCS-F) can be used. This growth factor stimulates the body’s stem cells to divide and develop into more neutrophils. Second, cytotoxic therapy can be used. As the immune system recovers from being suppressed by the cytotoxic drugs, the number of stems cells in the peripheral blood increases. Eight to ten days after the cytotoxic drugs have been given, the stem cells can be harvested by a procedure called apheresis. This uses a machine called a cell separator which is attached to the patient via an intravenous cannula and only removes white blood cells. This process may take a few hours and may be performed several times until enough cells have been collected. The cells are then cryopreserved with a chemical and can be stored until required.

Once priming is complete, patients undergo pretransplant conditioning; this involves giving high-dose cytotoxic drugs. Sometimes total body irradiation (TBI) is also given. This serves two purposes: to reduce the number of cancer cells and to suppress the patient’s immune system to prevent the rejection of the donor cells or graft. This will destroy bone marrow production and peripheral white blood cells, which would lead to death, so in order to rescue the immune system, the stored stem cells are transfused. Before the cells are infused, the patient receives IV fluids to hydrate them. The frozen cells are then defrosted gently and give intravenously. Patients may have an allergic reaction to the preserving chemical.

Side effects

Patients undergoing haemopoietic stem cell transplant experience similar side effects to patients receiving cytotoxics, however the toxicities are much more severe and last much longer. While the newly acquired stem cells establish themselves and replace the white blood cells, patients will have severe and prolonged neutropenia, making them highly susceptible to infection and sepsis. It is very common for patients to experience anaemia (low red blood cells) and thrombocytopenia (low platelets) (if all blood cells are reduced, this is called pancytopenia); veno-occlusive disease (small blood vessels in the liver become blocked); severe mucositis; nausea and vomiting; and diarrhoea.

Due to the severity of the risk of infection and other acute toxicities, patients are usually cared for in a single side room on a specialist transplant unit. Most patients become critically ill in the first few weeks and need very careful intensive nursing care.

The procedure is often associated with significant mortality and the physical and psychosocial status of patients is commonly disrupted and their recovery slow, affecting quality of life (Liptrott 2007).

Patients require frequent and regular haemodynamic monitoring (blood pressure; pulse; respirations; oxygen saturations; temperature; central venous pressure). They will need meticulous fluid balance monitoring and maintenance to ensure they are well hydrated and have good renal function; nutritional support (usually total parental nutrition (TPN) is given intravenously); oral care; personal hygiene; assessment and management of gastrointestinal disturbance (diarrhoea and nausea/vomiting); pain assessment; daily blood counts; and psychosocial assessment and support.

It usually takes a few weeks before it is known whether the transplant has been successful. If donor cells are used, there is a chance that the patient may reject the new stems cells. This is known as graft versus host disease (GVHD) and can cause debilitating side effects such as skin blistering, reduced liver function and gastrointestinal tract disturbance. There may be many severe long-term side effects of GVHD such as infertility, cataracts, reduced hormone production, pulmonary complications and relapse (Brown 2010). To minimise GVHD, immunosuppressive therapy is used, such as ciclosporin (given orally), which may be continued for months or years if the patient experiences chronic GVDH (Grundy 2006).

Having undergone a haemopoietic stem cell transplant, patients often experience long-term side effects that may be multidimensional, affecting the individual psychologically (loss of control; fear of relapse; facing own mortality; change of body image) as well the physically (loss of fertility; diminished physical strength and fatigue; secondary cancers).

Caring for patients

There has been a shift in how and where patients are cared for. More patients are receiving treatment at home following an autologous haemopoietic stem cell transplant. This means the patient receives their cytotoxic treatment as an inpatient and is then discharged home immediately to receive post-transplant care. Alternatively, they may receive their cytotoxic treatment and stem cell transplant at home under the care of a community-based haematology team. District nurses play an integral role in caring for these patients and will be involved in the care of central lines and the administration of antibiotics, as well as all aspects of care. This brings its own challenges as well as opportunities and improvements to the patient experience and outcome.