PRE-TRANSPLANT PROCESS and

BASIC HLA DISCUSSIONDana Broadway RN, BSN, CHTC

BMT Nurse CoordinatorVCUHS Bone Marrow Transplant Program

Staff Nurse 1989-1995Coordinator 1995 - Present

Introduction to Bone Marrow Transplantation

OBJECTIVES

• Describe the process and time line from the New Patient Consult to BMT Admission

• Describe the process and time line from Related Donor

Identification to actual PBSC/BM donation

• Describe the importance of HLA typing and identify important unrelated donor identification characteristics

Patient Process

NP Consult

Induction/Salvage Chemotherapy

Restaging/Pre-testing

Second Consult

BMT Admission

Stem Cell Collection

New Patient Consult

• PA/NP• History and Physical• MD• Review disease process• Treatment options• Coordinator• Immediate specific needs identified - ?Social

Work, ?Financial Coordinator• Initial Plan• Patient is discussed in weekly Clinical Conference

Induction/Salvage Chemotherapy

• Insurance• Donor Identification (tissue typing)• Unrelated donor search if necessary• Referring MD communication• Patient education • Housing/Environmental Issues• Caregiver Identification• Review of diagnostic slides• 2 – 4 months depending on disease being treated

Restaging/Pre-testing

• CT/PET/MRI• BMBX• Labwork to evaluation disease• Organ Function (PFTs, MUGA/Echo, LFTs, KFTs,

etc)• Infection evaluation (gyn, dental, cultures, CT

scans) • Menses suppression• Some insurance companies require mammogram,

PSA screening, colonoscopy• This phase can take up to 1 – 2 weeks

Formal Second Consult

• MD review test results

• MD consent (standard of care and/or clinical trial if eligible, Advanced Medical Directive, NMDP consents)

• Meet with the rest of the BMT Team - Radiaton Oncology, Psych, Social Work, Financial Coordinator)

• Obtain preauthorization from insurance company

• Meet with Coordinator to put a tentative plan on the calendar

• This phase can take up to 1 – 2 weeks

Stem Cell Collection

• Mobilization method

• Veinous access: line placement for majority of patients

• Apheresis or Bone Marrow Harvest

• Home Health for injections and/or line care

• Communication with apheresis/OR/BM Lab/Clinic

• This phase takes 1 – 3 weeks

BMT Admission

• Insurance pre-certification

• High dose chemotherapy regimen identified and communicated to Pharmacy

• Final education session with patient

• Final planning session with patient

• Complete chart to Inpatient BMT Unit

Related Donor Process

HLA Typing

Donor Evaluation

Stem Cell/Bone Marrow Collection

HLA Typing

Donor Evaluation• History & Physical

• Labwork (organ function, IDMs)

• CXR, EKG

• Risk Factor Assessment

• Social Work Evaluation

• Arm evaluation

• Education

• Consent

• This is all done in 1 day

Related Donor Collection

• Generally starts about a week after evaluation day

• Communication with apheresis/OR/BM Lab/Clinic

• PBSC (Peripheral Blood Stem Cell) Collection– Neupogen given x 3 days

– Start apheresis (stem cell collection) on the 4th

– Usually collect in 1-3 days

• Bone Marrow Harvest– Outpatient

HLA Basics

H = Human

L = Leukocyte • White Cells

• Component of the immune system

• Recognizes self from non-self

A = Antigen – a substance that when introduced into the body

stimulates the production of an antibody. (ref: dictionary.com)

HLA Basics

• HLA plays an important role in identifying self from non-self – VERY IMPORTANT IN TRANSPLANTATION

• Proteins on the outer surfaces on most cells of the body

• Inherited from our parents

• Located on chromosome 6

6 Different HLA Groups

Class

I

A B C

Class

II

DR DQ DP

• A, B, DR important in related donors

• A, B, C, DR important in unrelated donors

• Role of DQ, DP still under investigation

How you inherit DNA

MOM

B b

DAD

b b

Bb Bb bbbb

How you inherit DNA

MOMA01, B44, DR07 A02, B57,

DR13

DADA04, B08, DR03 A05, B10,

DR16

A01, B44, DR07 A01, B44, DR07 A02, B57, DR13 A02, B57, DR13

A04, B08, DR03 A05, B10, DR16 A04, B08, DR03 A05, B10, DR16

DNA Based HLA Typing• Serologic: A01, B02, DR15

• Low Resolution: A01XX, B02XX, DR15XX

• Intermediate Resolution: Results are narrowed to 2 or more alleles

A 01AB (0101, 0102)

B 02AC (0201, 0203)

DR 15MN (1503, 1505)

• High Resolution: Identifies the specific allele

A 0102

B 0103

DR 1503

What is a Match?• Related Allogeneic BMTs:

– 6/6 A, B, DR high resolution match preferred

– 5/6 mismatch acceptable

• Unrelated Allogeneic BMTs: – 8/8 A, B, C , DR high resolution match preferred

– 7/8 mismatch acceptable

– Current practice prefers A mismatch, over B, over C, over DR mismatches

• Cord Blood Transplants:– 4/6 match or better

What Other Factors are Involved in Unrelated Donor

Identification?• Weight of donor/cell count of cord

• Age

• Gender

• CMV status

• Parity

• Number of previous donations

• Race

• ABO Group

QUESTIONS?

•dbroadway@mcvh-vcu.edu

•804-828-3554