Haematopoietic Stem Cell Mobilisation and Apheresis: - EBMT

Haematopoietic Stem Cell 

Mobilisation and Apheresis: 

A Practical Guide for 

Nurses and Other Allied 

Health Care Professionals 

I

The European Group for Blood and Marrow Transplantation 

gratefully acknowledges the following individuals for their 

critical review and contributions to this guide: 

Erik Aerts (RN) Switzerland 

Aleksandra Babic (RN) Italy 

Hollie Devine (RN) USA 

Francoise Kerache (RN) Germany 

Arno Mank (RN) Netherlands 

Harry Schouten (MD) Netherlands 

Nina Worel (MD) Austria

Haematopoietic Stem Cell 

Mobilisation and Apheresis: 

A Practical Guide for Nurses and Other 

Allied Health Care Professionals 

Table of Contents 

Chapter 1: Overview of Autologous Haematopoietic Stem Cell Transplantation. . . . . . . . . . . . . . 1 

Chapter 2: Mobilisation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 

Chapter 3: Stem Cell Collection (Apheresis), Storage, and Reinfusion.. . . . . . . . . . . . . . . . . . . . 13 

Chapter 4: How to Discuss Noted Topics With Patients.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 

Glossary .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 

References.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 

Additional Resources .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 

Notes.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 

Table of Contents

Chapter 1: 

Overview of Autologous Haematopoietic Stem Cell Transplantation 

Widely accepted cancer treatment strategies include chemotherapy and radiotherapy. The rationale for 

administration of high-dose chemotherapy and/or radiation to patients with therapy-sensitive tumours is to 

reduce tumour burden. Delivery of these therapies with respect to higher drug doses and intensified schedule 

are often limited by organ toxicities (eg, bone marrow, heart, and lung) and pancytopenia. To overcome 

these dose limitations, autologous haematopoietic stem cell transplantation (AHSCT), high-dose 

therapy supported by the infusion of haematopoietic stem cells, has evolved as a medical procedure to allow for 

administration of intense drug doses with tolerable organ and haematopoietic toxicity. Infusion of autologous 

stem cells following dose-intensive treatment “rescues” the bone marrow by re-establishing normal 

haematopoiesis. Upon regeneration of bone marrow function, patients may be cured from their disease or 

receive additional cancer treatment. 1,2 

Chapter 1: Overview 

Autologous haematopoietic stem cell transplantation is a complex medical procedure that has been used to 

treat and cure patients with various malignant and non-malignant disorders. Although the first documentation of 

AHSCT use to treat cancer was reported in the 1890s, 3 achievement of a cure in patients with a malignancy was 

only documented in 1978 following a clinical trial conducted at the National Cancer Institute (United States). 4 

Subsequent to this report, numerous advances have been made in the art of AHSCT and thousands of patients 

around the world have had their diseases successfully managed through the use of AHSCT. 

The term “autologous haematopoietic stem cell transplantation” is frequently used interchangeably with the 

terms autologous bone marrow transplantation (aBMT), autologous peripheral blood stem cell transplantation 

(aPBSCT), and autologous haematopoietic cell transplantation (AHCT). 5 “Autologous” means that the donor cells 

used for the procedure are from the patient himself, as opposed to “allogeneic,” which refers to a cell donor 

other than the patient. In certain allogeneic circumstances, the term “syngeneic” is used when the cell donor 

is a patient’s identical twin. The source of stem cells for collection is identified by the terms “bone marrow” and 

“peripheral blood.” Cells for the patient may be collected either from the donor’s bone marrow reserves, such 

as those stored in the iliac crest of the pelvic bones, or from the donor’s peripheral blood. Additionally, umbilical 

cord blood (UCB), found in the umbilical cord and placenta following childbirth, is another source of progenitor 

stem cells used in clinical practice in the setting of allogeneic transplants. 6 When 2 autologous stem cell 

transplantations occur in a scheduled, sequential fashion, this process is referred to as “tandem autologous 

stem cell transplantation.” 6,7 

In the more than 3 decades following the first successful use of AHSCT, the utility of this treatment for malignant 

and non-malignant conditions has been well established (Table 1). 8 In the setting of relapsed malignant 

conditions, standard chemotherapy regimens may produce unacceptable rates of bone marrow suppression 

(myelosuppression), resulting in a low white cell count, low platelet count, and anaemia. This increases the 

risk of potentially fatal infections and bleeds. Following chemotherapy, the patient is therefore given a transplant 

of stem cells to regenerate damaged bone marrow. Thus, the reinfusion of autologous stem cells has become a 

therapeutic modality for reducing prolonged myelosuppression. 9-11 Data demonstrate that high-dose therapy with 

stem cell rescue has a positive impact on disease response rates; however, for some patients it fails to improve 

overall survival when compared to conventional chemotherapy treatments. Thus, the definitive role of AHSCT in 

certain situations, such as the treatment of refractory or relapsed Hodgkin’s lymphoma or chronic lymphocytic 

leukaemia, remains inconclusive 12-15 and indications for AHSCT continue to evolve. 

Chapter 1: Overview of Autologous Haematopoietic Stem Cell Transplantation 

1

Table 1. Indications for Autologous Haematopoietic Stem Cell Transplantation in Adults 8 

Disease 

Acute lymphoid 

leukaemia 

Acute myeloid 

leukaemia 

Chronic lymphoid 

leukaemia 

Chronic myeloid leukaemia 

Myelofibrosis 

Myelodysplastic 

syndrome 

Diffuse large 

B-cell NHL 

Mantle cell 

lymphoma 

Lymphoblastic 

lymphoma and 

Burkitt’s lymphoma 

Follicular B-cell NHL 

Standard of Care 

CR1 (intermediate risk) 

M3 (molecular CR2) 

Chemosensitive relapse; 

≥ CR2 

CR1 


≥ CR2 


≥ CR2 

Optional Based on 

Risks and Benefits 

CR1 (low or high risk) 

CR2 

Poor risk disease 

RAEBt 

sAML in CR1 or CR2 

CR1 (intermediate or high 

IPI at diagnosis) 

CR1 


≥ CR2 

CR1 (intermediate or high 

IPI at diagnosis) 

Investigational or 

Additional Trials 

Needed 

CR1 (standard, 

intermediate or high risk) 

First (CP), failing imatinib 

Accelerated phase or > 

first CP 

Generally Not 

Recommended 

CR2 (incipient relapse) 

Relapsed or refractory disease 

CR3 (incipient relapse) 

M3 (molecular persistence) 

Relapsed or refractory disease 

Blast crisis 

Primary or secondary with an 

intermediate or high Lille score 

RA 

RAEB 

More advanced stages 

Refractory disease 




T-cell NHL CR1 Chemosensitive relapse; 


≥ CR2 

Hodgkin’s lymphoma Chemosensitive relapse; Refractory disease 

CR1 

≥ CR2 

Lymphocyte predominant 


CR1 

nodular Hodgkin’s 

lymphoma 

≥ CR2 


Multiple myeloma 

 

Amyloidosis 

 

Severe aplastic anaemia 

 

Paroxysmal nocturnal 

 

haemoglobinuria 

Breast cancer* 

Adjuvant high risk disease 

Metastatic responding 

Metastatic 

responding 

Germ cell tumours Third-line refractory Sensitive relapses 

Ovarian cancer CR/PR Platinum-sensitive relapse 

Medulloblastoma* Post-surgery Post-surgery 

Small cell lung cancer 

Limited disease 

Renal cell carcinoma 

Metastatic, cytokine-refractory 

Soft cell sarcoma 

Metastatic, responding 

Immune cytopenias 

 

Systemic sclerosis 

 

Rheumatoid arthritis 

 

Multiple sclerosis 

 

Systemic lupus 

 

erythematosus 

Crohn’s disease 

 

Chronic inflammatory 

 

demyelinating 

polyradiculoneuropathy 

CP, chronic phase; CR1, 2, 3, first, second, or third complete remission; CR/PR, complete response/partial response; IPI, International 

Prognostic Index; NHL, non-Hodgkin’s lymphoma; RA, refractory anaemia; RAEB, refractory anaemia with excess blasts; RAEBt, 

refractory anaemia with excess blasts in transformation; sAML, secondary acute myelogenous leukaemia; indicates use of autologous 

haematopoietic stem cell transplantation regardless of stage. 

* For patients with metastatic responding breast cancer or medulloblastoma, autologous haematopoietic stem cell transplantation can be 

considered when the benefits outweigh the risks, although additional studies are warranted. 

2 

Haematopoietic Stem Cell Mobilisation and Apheresis: 

A Practical Guide for Nurses and Other Allied Health Care Professionals

An AHSCT is a complex process involving a multidisciplinary approach and resource utilisation. Historically, 

this treatment was offered only at large academic medical centres. However, due to medical progress and our 

knowledge of the AHSCT procedure, patients are receiving this therapy in community settings. The stem cell 

transplant process can be summarised in 8 distinct phases (Figure 1): (1) administration of mobilisation 

agents, (2) mobilisation, (3) collection, (4) preparation of product for storage, (5) cryopreservation, (6) 

administration of preparative regimen, (7) stem cell transplantation, and 8) engraftment and recovery. 1,2,6,16 

For a more detailed explanation of each phase, please see Chapter 3. 

Figure 1. The Stem Cell Transplant Process 1,2,6,16 

1 

Injections 

Mobilisation 

2 3 

Collection 

Injections of mobilisation agents 

Stem cells are stimulated to move into the 

bloodstream from the bone marrow space 

Collection of mobilised stem cells from the blood 

using the apheresis machine 

4 

Preparation for Storage 

5 

Cryopreservation 

6 

Chemotherapy 

and/or Radiation 

Stem cells collected are stored in infusion bags 

Freezing of stem cells for use after completion of 

preparative regimen 

Administration of preparative regimen intended to 

kill any remaining cancer cells and make a space for 

new cells to live 

7 

Stem Cell Transplant 

8 

Engraftment and Recovery 

Previously collected stem cells are thawed and infused 

back into the bloodstream 

One aim of autologous stem cell transplant is for infused stem cells to mature into functional blood components such as neutrophils 

and platelets. The first signs of engraftment and recovery include increasing absolute neutrophil and platelet counts 

Chapter 1: Overview of Autologous Haematopoietic Stem Cell Transplantation 

3

Once patients are identified as being candidates for AHSCT, they undergo detailed evaluations to ensure that they 

will be able to tolerate the procedure. Patients are administered exogenous agents to stimulate the migration 

of progenitor cells from the bone marrow into the peripheral blood. Procurement of these cells is achieved by 

apheresis. At the conclusion of apheresis, cells are processed and cryopreserved for future use. Product 

storage time is typically a few weeks to months, although some investigators have reported storing product 

for up to 14 years without loss of product viability. 17-19 Following apheresis, patients may receive additional 

chemotherapy to treat their underlying disease or proceed directly to receiving a transplant preparative regimen 

(ie, high dose chemotherapy ± radiotherapy) followed by infusion of previously collected stem cells. The first 

signs of engraftment, indicated by an increase in white blood cell (WBC) counts, usually occur within 2 to 4 

weeks following the infusion of autologous stem cells. 1,2 

4 



Chapter 2: Mobilisation 

Haematopoiesis refers to the production of cellular components of blood. This process occurs continually to 

maintain normal immune system function and haemostasis. In adults, haematopoiesis primarily occurs in the 

bone marrow that is contained within the pelvis, sternum, vertebral column, and skull. 20,21 Production of mature 

blood cells specifically occurs in the bone marrow microenvironment (Figure 2). 20-22 

Figure 2. Bone Marrow Microenvironment 20-22 


All blood cells are derived from progenitor stem cells, also referred to as pluripotent stem cells. These cells 

have the capacity for unlimited self-renewal and the ability to differentiate into all types of mature blood cells. 

The pluripotent stem cell can differentiate into 1 of 2 types of common progenitor cells—the common myeloid 

progenitor and the common lymphoid progenitor. These common progenitor cells can further differentiate 

into committed cellular components through an intricate cascade of events (Figure 3). The end result is the 

production of cells in the myeloid lineage and the lymphoid lineage. Cells in the myeloid lineage, such as red 

blood cells, platelets, macrophages, and neutrophils are responsible for tissue nourishment, oxygenation, blood 

viscosity, coagulation, and immune function such as innate and adaptive immunity. The lymphoid lineage 

components, namely T cells and B cells, provide the foundation for the adaptive immune system. 2,20 

Cytokines play an integral role in haematopoiesis. When progenitor cells are exposed to cytokines, the 

maturation cascade to produce committed mature blood cell components can occur. Examples of important 

cytokines are listed in Figure 3. These cytokines are found endogenously, although during the stem cell collection 

process, some are often exogenously administered to patients in an effort to enhance the yield of stem 

cells within a short time period. 21-25 Examples of these exogenous cytokines include filgrastim (glycosylated 

granulocyte colony-stimulating factor [G-CSF]) and lenograstim (non-glycosylated G-CSF). 


5

Figure 3. Stem Cell Maturation Cascade 2,20 

Epo, erythropoietin; G-CSF, granulocyte colony-stimulating factor; GM-CSF, granulocyte-macrophage colony-stimulating factor; 

IL, interleukin; M-CSF, macrophage colony-stimulating factor; SCF, stem cell factor; Tpo, thrombopoietin. 

Chemokines are a subset of cytokines associated with a single receptor and assist in cell movement. 

Stromal cells are layers of cells that support the bone marrow microenvironment. These cells produce the 

chemokine stem cell derived factor-1 alpha (SDF-1α). This chemokine is an important signalling molecule involved 

in the proliferation, homing, and engraftment of stem cells. For a given time in their development, stem cells 

express the chemokine receptor CXCR4. CXCR4 is responsible for anchoring stem cells to the bone marrow 

microenvironment. When CXCR4 and SDF-1α bind, interactions between integrins and cell adhesion molecules 

also occur. The anchoring of stem cells within the bone marrow microenvironment occurs by continuous 

production of SDF-1α by stromal cells. It is the loss of attachment to the stromal cells, along with the loss of 

SDF-1α activity, that favours the release of stem cells into peripheral circulation. Blockade of this receptor with 

a chemokine antagonist (such as plerixafor) has elevated circulating haematopoietic stem cells (HSCs) and aided 

stem cell collections in patients with multiple myeloma and lymphoma. 26-31 

6 



Pluripotent stem cells express the cell surface marker antigen CD34. This marker is the indicator most frequently 

used in clinical practice to determine the extent and efficiency of peripheral blood stem cell collections. 25 

Although not a complete measure of the quantity and quality of collected cells, blood samples from collections 

are assayed to determine the number of CD34+ cells present. Once specific cell targets are achieved, cell 

collections are completed and stored for future use. Standard target levels can vary among treatment centres 

and a patient’s specific goal is related to the underlying disease, the source of stem cells, and the type of 

transplantation to be performed. In general, a target level of 2 × 10 6 CD34+ cells/kg body weight is considered 

the minimum for autologous transplantation, with optimal levels being ≥ 5 × 10 6 CD34+ cells/kg for a single 

transplant and ≥ 6 × 10 6 CD34+ cells/kg for a tandem transplant. 23,25,32-36 

Historically, autologous stem cell collections involved 

the removal of bone marrow cells from a patient’s 

bilateral posterior iliac crest region (Figure 4) under 

general anaesthesia in a hospital operating room. 

However, due to advances in medical technology, most 

collections today are performed by apheresis (Figure 

5). Peripheral blood stem cell collection is considered 

the preferred method for mobilisation prior to AHSCT 

due to patient convenience, decreased morbidity, and 

faster engraftment of WBCs and platelets. Additional 

comparisons between harvest of bone marrow and 

peripheral blood for autologous transplantation are 

summarised in Table 2. 1,2,37-40 

Figure 4. Bone Marrow Harvest 

Table 2. Advantages and Disadvantages of Haematopoietic Stem Cell Collection Methods 1,2,37-40 

Collection 

Method 

Advantages 

Disadvantages 

Bone marrow • Single collection 

• No need for special catheter placement 

• Use of cytokines not necessary 

Peripheral 

blood 

• Does not require general anaesthesia and 

can be performed in an outpatient setting 

• Faster neutrophil and platelet 

engraftment 

• Associated with lower rates of morbidity 

and mortality 

• Potentially less tumour cell contamination 

of product 

• Performed in an acute care setting since it 

requires general anaesthesia 

• Slower neutrophil and platelet engraftment 

• Higher rates of morbidity and mortality 

• Potentially more tumour cell contamination of 

product 

• Collection may take several days 

• Sometimes requires placement of large-bore, 

double-lumen catheter for collection 

• Haemorrhage, embolism, and infection are 

possible complications related to insertion of 

central venous catheter 


7

Figure 5. Apheresis Collection 

The concentrations of HSCs are 10- 

100 times greater in the bone marrow 

compared to the peripheral circulation. 1 

Therefore, methods to increase the 

circulating concentrations of HSCs 

are necessary to ensure adequate 

and successful collections. Agents 

used to mobilise HSCs include the 

administration of cytokines with or 

without chemotherapy prior to scheduled 

collection periods. 

Filgrastim and lenograstim used as single-agent mobilisers have been well established, with both agents 

having reliably demonstrated increased concentrations of circulating HSCs. 41,42 G-CSF is thought to stimulate 

HSC mobilisation by decreasing SDF-1α gene expression and protein levels while increasing proteases that 

can cleave interactions between HSCs and the bone marrow environment. 43-46 The mechanism of action for 

G-CSF is illustrated in Figure 6. 43-46 The recommended dose of filgrastim and lenograstim is 10 mcg/kg/day as 

a subcutaneous injection for multiple days. 47,48 However, these growth factors are typically given at a total daily 

dosage of 3-24 mcg/kg/day. 25 Data indicate that divided doses of G-SCF (eg, lenograstim 5 mcg/kg twice daily) 

are more efficacious than single-dose administration (eg, lenograstim 10 mcg/kg once daily) by producing a 

higher yield of CD34+ cells and the need for fewer apheresis procedures. 49-51 However, current clinical practice 

does not favour one schedule over the other. 

Figure 6. Mechanism of Action of G-CSF 43-46 

CXCR4, chemokine receptor 4; G-CSF, granulocyte colony-stimulating factor; SDF-1α, stromal cell derived factor-1 alpha. 

8 



Since it is common to see an increase in HSCs following recovery from myelosuppressive chemotherapy, another 

method to mobilise HSCs involves the administration of chemotherapy, usually in conjunction with cytokines. 22,24,25 

This is frequently referred to as “chemomobilisation.” Chemotherapy and cytokines work synergistically 

to mobilise HSCs, although the exact mechanism for chemotherapy mobilisation has not been fully explained. 

Possible mechanisms for mobilisation following chemotherapy include chemotherapy effects on the expression 

of cell adhesion molecules in the bone marrow and chemotherapy-induced damage to stromal cells in the bone 

marrow. Both of these lead to increased circulating concentrations of HSCs due to disruption of the bone marrow 

microenvironment. 28 The kinetics of CD34+ cell and WBC production following chemotherapy and growth factor 

administration are illustrated in Figure 7. 

Figure 7. Generalised Kinetics of Leucocyte and CD34+ Cell Chemotherapeutic agents 

Mobilisation Into the Peripheral Blood Following Chemotherapy most commonly used for 

and Cytokine Administration 

chemomobilisation include highdose 

cyclophosphamide and 

etoposide. 22,25,38 Filgrastim 

(5 mcg/kg/day) can be utilised 

as the cytokine partner in 

chemomobilisation. 47 Because 

no single chemotherapy 

mobilisation regimen has 

demonstrated superiority over 

the others, some clinicians 

may elect to mobilise patients 

during a cycle of a diseasedirected 

chemotherapy regimen. 

G-CSF, granulocyte colony-stimulating factor. 

Examples of regimens utilised 

include cyclophosphamide, 

doxorubicin, vincristine, and prednisone (CHOP) and ifosfamide, carboplatin, and etoposide (ICE). 25 Additionally, 

the use of rituximab (a monoclonal antibody directed at cells that express CD20) prior to mobilisation 

has not demonstrated inferior yields of CD34+ cells; in fact, it may assist with decreasing the amount of 

tumour contamination in the collected product. 52,53 Adverse events associated with commonly employed 

chemotherapeutic agents used in mobilisation regimens are listed in Table 3. 54,55 

Table 3. Complications* Associated With Chemotherapeutic Agents Commonly Used for 

Mobilisation (Like Cyclophosphamide or Etoposide) 54,55 

Short-Term Side Effects 

• General malaise (weakness) 

• Infertility 

• GI symptoms (diarrhoea, nausea, vomiting, appetite loss, stomach discomfort 

or pain) 

• Skin and mucosal effects (rash, texture change in nails, alopecia, mucositis) 

• Myelosuppression (thrombocytopenia, leucopoenia) 

• Infusion-related side effects (such as hypotension, flushing, chest pain, fever, 

diaphoresis, cyanosis, urticaria, angio-oedema, and bronchospasm) 

• Allergic reaction 

• Signs of an infection, such as chills or a fever 

• Blood in the urine (may be a sign of bladder damage) 

• Blood in the stool 

GI, gastrointestinal. 

* Please see prescribing information for complete list of adverse reactions. 

Long-Term Side Effects 

• Decreased urination 

(may be a sign of kidney 

damage) 

• Difficulty breathing or 

water retention (which 

may be signs of congestive 

heart failure) 

• Secondary malignancies 

(may present as unusual 

moles, skin sores that 

do not heal, or unusual 

lumps) 


9

Plerixafor is a novel agent that has recently 

been approved in the European Union for use 

in conjunction with G-CSF in lymphoma and 

multiple myeloma patients whose cells mobilise 

poorly, to mobilise stem cells from the bone 

marrow into the peripheral blood for collection 

and autologous transplantation. 56 Plerixafor 

is a small-molecule CXCR4 antagonist that 

reversibly inhibits the interaction between 

CXCR4 and SDF-1α (see plerixafor mechanism 

of action in Figure 8). 57-61 Use of plerixafor in 

combination with G-CSF has been shown to 

improve CD34+ cell collections in lymphoma 

and multiple myeloma patients compared 

to G-CSF alone. 30,62,63 Very common adverse 

reactions associated with the use of filgrastim, 

lenograstim, and plerixafor are listed in 

Table 4. 47,48,56,64 

Figure 8. Plerixafor Mechanism of Action 57-61 

An unfortunate outcome following HSC 

collections is poor stem cell yield. The 

most important risk factor for inadequate 

mobilisation is the amount of myelosuppressive 

chemotherapy a patient has received prior to 

collection. Agents that are toxic to stem cells, CXCR4, chemokine receptor 4; SDF-1α, stromal cell derived factor-1 alpha. 

such as cyclophosphamide (doses > 7.5 g/m 2 ), 

melphalan, carmustine, procarbazine, fludarabine, nitrogen mustard, chlorambucil, are particularly detrimental to 

stem cell collection yields. Other risk factors associated with low CD34+ cell collections are listed in Table 5. 25,65-73 

Table 4. Very Common (> 10%) Adverse Reactions* Associated With Agents Used in Stem Cell 

Mobilisation 47,48,56,64 

Agent 

Adverse Events 

Filgrastim • Musculoskeletal pain 

Lenograstim • Bone and back pain 

• Leucocytosis and thrombocytopenia 

• Transient increases in liver function tests 

• Elevated LDH 

• Headache and aesthenia 

Plerixafor • Diarrhoea and nausea 

• Injection and infusion site reactions 

LDH, lactate dehydrogenase. 

* Please see summaries of product characteristics for complete lists of adverse reactions. 

10 



Table 5. Risk Factors and Characteristics Associated With Poor Autologous Stem Cell 

Mobilisation 25,65-73 

• Type and amount of chemotherapy administered to patient prior to mobilisation 

• Advanced age (> 60 years) 

• Multiple cycles of previous chemotherapy for treatment of underlying disease 

• Radiation therapy 

• Short time interval between chemotherapy and mobilisation 

• Extensive disease burden 

• Refractory disease 

• Tumour infiltration of the bone marrow 

• Prior use of lenalidomide 

• Evidence of poor marrow function (eg, low platelet and CD34+ cell blood count) at time of mobilisation 

Few options exist for patients who mobilise poorly, and standard management of these patients continues to 

evolve and remains ill-defined. Currently acceptable strategies for remobilisation involve increasing the doses 

of chemotherapy agents and/or cytokines, using a combination of cytokines, and extending the time between 

chemotherapy for disease treatment and apheresis. The option of performing a bone marrow harvest to collect 

cells is an alternative strategy. However, it is falling out of favour to previously mentioned methods due to 

slower engraftment, increased need for resource utilisation (longer hospitalisation and more supportive care 

management), and higher risk of mortality. 25,35,65,66,74-76 More promising is the use of newer and recently approved 

agents (such as plerixafor) as part of established mobilisation techniques to increase stem cell yields during 

collections. A comparison between mobilisation methods is listed in Table 6. 22,24,25,28,37-39 

Table 6. Comparison of Mobilisation Methods 22,24,25,28,37-39,77-81 

Mobilisation Regimen Characteristics 

Filgrastim or lenograstim • Low toxicity 

• Outpatient administration 

• Can be self-administered 

• Reasonable efficacy in most patients 

• Predictable mobilisation, permitting easy apheresis scheduling 

• Shorter time from administration to collection compared to 

growth factor + chemotherapy 

• Bone pain 

• Lower stem cell yield compared to growth factor + chemotherapy 

Filgrastim or lenograstim + 

chemotherapy 

Filgrastim or lenograstim + 

plerixafor 

• Higher stem cell yield compared to growth factor alone 

• Fewer stem cell collections 

• Potential for anticancer activity 

• May impair future mobilisation of stem cells 

• May require hospitalisation 

• Associated with an increased number of side effects 

• Inconsistent results 

• Longer time from administration to collection compared to growth factor 

• Low predictability of time to peak peripheral blood CD34+ cell levels 

• Low toxicity 

• Outpatient administration 

• Low failure rate 

• High probability of collecting optimal number of CD34+ cells 

• Efficacy in poor mobilisers 

• Predictable mobilisation permitting easy apheresis scheduling 

• Shorter time from administration to collection compared to 

growth factor + chemotherapy 

• Gastrointestinal adverse effects 


11

Chapter 3: Stem Cell Collection (Apheresis), Storage, and Reinfusion 

Prior to initiation of the stem cell collection process, patients must be thoroughly evaluated and determined 

to be acceptable transplant candidates and able to tolerate all of the procedures involved. Some of the medical, 

nursing, and psychosocial evaluations can occur prior to a patient’s first visit or referral to a transplant service 

or clinic. The patient’s primary medical haematologist/oncologist frequently serves as a patient’s first contact 

during the transplantation process. All of the testing, evaluation, and education involved throughout a patient’s 

transplant involves a myriad of health care professionals working together to orchestrate this complex 

medical procedure. 

The medical pre-evaluation is the first step a patient must complete when undergoing an AHSCT. This involves 

the patient’s primary medical oncologist making a referral to a transplant centre or service. The physician provides 

the transplant team with information that often includes specifics relating to the care of the patient up to this 

time point, such as past medical history, cancer status, summary of cancer treatments and responses, and 

complications experienced during therapy. Accompanying this information are any available radiograph and 

laboratory testing results. 

After review of the patient’s medical information, the transplant team will initiate their own battery of tests and 

evaluations to assess a patient’s eligibility to proceed with stem cell collection and transplantation. This involves 

restaging the patient to verify or establish current disease status, ascertaining the function of various organs 

(eg, kidneys, liver, and lungs), documenting the absence of certain comorbid conditions and infectious diseases 

(eg, congestive heart failure and the presence of human immunodeficiency virus), and evaluating the overall 

performance status and psychosocial condition of the patient. At this time, extensive education will be initiated 

for the patient and their family and/or caregivers. Often a member of the nursing profession (clinic nurse, nurse 

educator, or nurse coordinator) will coordinate the education process for the patient and those involved in their 

care (see Chapter 4). 

Upon determination that a patient is eligible to proceed to transplantation, preparing them for the collection 

process occurs next. The preferred method for venous access is the placement of a peripheral catheter at the 

time of an apheresis session (eg, insertion into the antecubital vein). For those patients in whom peripheral line 

placement is not feasible, appropriate catheter selection and central venous placement (eg, internal jugular 

vein) is scheduled prior to the first stem cell collection. Catheters used for apheresis procedures must be able 

to tolerate large fluctuations in circulating blood volume. Therefore, these catheters are often large-bore, double 

lumen devices that can be used temporarily during cell collections, or placed permanently and used throughout 

the transplantation process. As with most catheters placed in the area of the upper extremities, patients should 

be monitored for signs and symptoms of hypotension, shortness of breath, and decreased breath sounds as 

these can be indicative of venous wall perforation, haemothorax, and/or pneumothorax, all of which are rare 

but serious complications that can occur. In some cases, catheters for apheresis may be placed centrally in 

a femoral vein if patients are at an increased risk of developing complications from a catheter placed in the 

upper extremity or chest wall. For centrally placed catheters, radiographic evaluation is used to verify catheter 

placement prior to clearance for its use. Additionally, instructions on caring for the catheter to prevent infection 

and maintain its integrity should be extensively reviewed with the patient and/or caregivers. 1,2,16,82,83 

Chapter 3: Collection, 

Storage, and Reinfusion 

Preparation for stem cell collections in an apheresis centre or unit follows the pre-transplantation evaluation 

and catheter placement. Patients will be advised and counselled on therapies that they will receive during 

mobilisation with respect to administration schedule and expected adverse effects. As previously detailed in 

Chapter 2, agents used during this stage of AHSCT usually include single-agent cytokines (such as filgrastim) 


13

that are given with or without certain chemotherapy agents, a designated cycle of disease-specific chemotherapy 

regimen, or more recently, filgrastim or lenograstim in combination with plerixafor. Upon initiation of the 

mobilisation regimen, patients can expect to undergo their first apheresis session in as little as 4 to 5 days 

or, in some cases, 2 to 3 weeks later. 1,16,83 The extent of mobilisation is ascertained through evaluation of a 

patient’s WBC count. Serial measurements of the patient’s WBC count will assist the clinician in determining the 

appropriate time to commence collection procedures. Additionally, centres may use peripheral blood CD34+ 

cell levels as a surrogate for mobilisation status. Established thresholds for apheresis initiation may vary across 

centres, but typically range from 5 to 20 CD34+ cells/microlitre. Although useful in estimating mobilisation 

efficacy, peripheral blood CD34+ counts can be variable within and across centres. 35,84,85 

Figure 9. Example of an Apheresis Machine Once mobilisation has reached an optimal level, 

a patient can be scheduled for sessions in the 

apheresis centre. An apheresis technician highly 

trained in stem cell collections is responsible 

for the equipment utilised in the collection 

process (Figure 9). Clinical nurses working in the 

apheresis unit are responsible for educating the 

patient about the stem cell collection process and 

monitoring patients for any adverse reactions. 

Patients are connected to the apheresis machine 

by their catheter. One lumen is used to draw blood 

out of the patient and into the machine. Here the 

blood is spun at high speeds in a centrifugation 

chamber housed within the cell separator 

machine. The desired stem cells are collected 

during the entire procedure, either in cycles or 

continuously, and the remaining blood components 

are returned to the patient through the second 

lumen of their catheter. This second lumen 

additionally can be used to administer intravenous 

fluids, electrolyte supplements, and medications 

to the patient. Each apheresis session lasts 

approximately 2-5 hours during which upwards 

to 30 litres of blood, or 6 times the average total human blood volume, is processed. Collections can occur on a 

daily basis until the target CD34+ levels are achieved. The apheresis process can last for up to 4 days depending 

on patient characteristics and the mobilisation regimen utilised. 2,16,17,82,86-88 

Apheresis procedures are relatively safe. Although the mortality rate is quite low at an estimated 3 deaths 

per 10,000 procedures, 89 apheresis is associated with some morbidity. Citrate is an anticoagulant used during 

the apheresis process to prevent blood clotting. Thus, one of the most common adverse effects seen during 

this procedure is citrate toxicity manifested as hypocalcaemia. This occurs due to binding of ionised serum 

calcium, which leads to hypocalcaemia. Signs and symptoms of citrate toxicity as well as its management are 

further described in Table 7. Monitoring serum calcium level prior to and throughout apheresis may decrease 

the likelihood of hypocalcaemia. 16,82,90 Additional adverse effects of citrate toxicity include hypomagnesaemia, 

hypokalaemia, and metabolic alkalosis. Magnesium, like calcium, is a divalent ion that is bound by citrate. 

Declines in serum magnesium levels often are more pronounced and take longer to normalise compared to 

aberrations in calcium levels. Signs and symptoms of hypomagnesaemia, hypokalaemia, and metabolic alkalosis 

as well as their management are further described in Table 7. 16,82,90 

14 



Table 7. Common Apheresis Complications 16,82,90 

Adverse Effect Cause Signs and Symptoms Corrective Action 

Citrate toxicity 

Anticoagulant (citrate) 

given during apheresis 

Hypocalcaemia 

Common: dizziness, tingling in area 

around the mouth, hands, and feet 

Uncommon: chills, tremors, muscle 

twitching and cramps, abdominal 

cramps, tetany, seizure, cardiac 

arrhythmia 

Slow the rate of apheresis; 

increase the blood:citrate ratio; 

calcium replacement therapy 

Hypomagnesaemia 

Common: muscle spasm or weakness 

Uncommon: decrease in vascular tone; 

cardiac arrhythmia 

Hypokalaemia 

Common: weakness 

Uncommon: hypotonia and cardiac 

arrhythmia 

Metabolic alkalosis 

Common: worsening of hypocalcaemia 


increase the blood:citrate 

ratio; magnesium replacement 

therapy 


increase the blood:citrate ratio; 

potassium replacement therapy 


increase the blood:citrate ratio 

Thrombocytopenia 

Platelets adhere to 

internal surface of the 

apheresis machine 

Uncommon: decrease in respiration 

rate 

Low platelet count, bruising, bleeding 

Prime apheresis machine with 

blood products in place of normal 

saline; platelet transfusion 

Hypovolaemia 

Patient intolerant of 

large shift in extracorporeal 

blood and plasma 

volumes 

Dizziness, fatigue, light-headedness, 

tachycardia, hypotension, diaphoresis, 

cardiac arrhythmia 

Slow the rate of apheresis 

session or temporarily stop it; 

intravenous fluid boluses 

Catheter 

malfunction 

Blood clot forms or 

catheter is not well 

positioned to allow for 

adequate blood flow 

Inability to flush catheter, fluid collection 

under skin around catheter site; 

pain and erythema at catheter site; arm 

swelling, decrease in blood flow 

Reposition the catheter; gently 

flush catheter; treat blood clot 

Infection 

Microbial pathogens 

enter bloodstream 

through catheter or 

catheter site 

Fever, chills, fatigue, red and 

erythematous skin around catheter; 

hypotension, positive blood cultures 

Administer antibiotics; possibly 

remove catheter 

Due to large fluctuations in blood volume during apheresis, patients may experience hypovolaemia. Signs 

and symptoms of hypovolaemia as well as its management are further described in Table 7. 16,82,90 Prior to 

starting apheresis, baseline pulse and blood pressure are measured and continuously assessed at regular 

intervals. Additionally, it is recommended that haemoglobin and haematocrit also be monitored. Patients at 

risk of developing hypovolaemia include those with anaemia, those with a previous history of cardiovascular 

compromise, and children or adults with a small frame. Preventative measures are aimed at minimising the 

extracorporeal volume shift by priming the apheresis machine with red blood cells and fresh frozen plasma in 

place of normal saline. Hypovolaemia may also be managed by providing intravenous fluid boluses and slowing 

the rate of flow on the apheresis machine. Another potential problem stemming from hypovolaemia is the 

development of a life-threatening cardiac dysrhythmia. If this occurs, apheresis should be interrupted and 

symptoms should subside before proceeding with collections. 16,82,90 

Thrombocytopenia, infection, and catheter malfunction are other complications that may be encountered during 

stem cell collections. When the patient’s blood is in the cell separator machine, platelets can adhere to the 

centrifuge device. Decreases in platelet concentrations can be precipitous and obtaining platelet counts prior 

to each collection is essential. If thrombocytopenia is present pre-apheresis, patients may receive platelet 


15

transfusions. Additional management of thrombocytopenia during apheresis is the return of platelet-rich 

plasma collected during apheresis to the patient at the conclusion of the apheresis session. 2,16,82,90 As with any 

catheter, frequent manipulation in the absence of proper catheter care and maintenance may predispose the 

patient to infections and/or cause the catheter to malfunction. Proper sterile technique should be utilised at all 

times to decrease the risk of contamination with microbial pathogens that can lead to bloodstream infections. 

Furthermore, routine catheter care should include administration of flushes to prevent blood clot formation. 

Commonly observed complications during apheresis are summarised in Table 7. 1,2,16,82,83,90 

At the conclusion of apheresis, stem cells are isolated from red blood cells and WBCs and then placed in infusion 

bags in preparation for cryopreservation and storage. Many centres have cryopreservation laboratories that 

maintain collected stem cell products in liquid nitrogen until the time of the patient’s transplantation. A common 

cryopreservative used is dimethylsulfoxide (DMSO). DMSO maintains cell viability by preventing ice crystal 

formation within the cells during storage. 2,82,91 Additionally, the collected product may be manipulated by a 

pharmacological, immunological, or physical method to reduce contamination with tumour cells. Quality testing is 

performed on collections to ascertain contamination with microbes as well as to determine the number of viable 

cells available for transplantation. Once a patient reaches their CD34+ collection goal, apheresis sessions are 

complete. Reaching minimum thresholds for CD34+ cell amounts is important as cell dose appears to positively 

correlate with engraftment and outcome. 17,22,25,32-36,92 

The next stage of the AHSCT process is preparing the patient for the actual transplant. Nurses play an 

important role in educating patients and caregivers about the transplant processes and procedures as well 

as the critical time leading up to engraftment and recovery. Whereas some patients can expect to proceed to 

transplant within days following mobilisation, others may undergo the transplantation procedure within a few 

weeks following stem cell collection. During the interim, additional chemotherapy may be given to the patient 

to help maintain their disease status. Once the transplant date is scheduled, approximately 1 week prior to the 

transplant date, patients begin their preparative regimen in the ambulatory or inpatient unit of the hospital. The 

preparative regimens may consist of chemotherapy alone or chemotherapy in combination with radiation therapy. 

Chemotherapy agents selected for use during this time can be different than those used during previous cancer 

treatments and during mobilisation. Often, if similar agents are chosen, the doses during this phase are higher 

than previously administered. The patient often benefits from cytoreduction in their tumour following this 

phase of treatment. As a consequence of the intensity of treatment, patients experience ablation of their marrow 

stores, hence the need for infusion of their previously collected cells as “rescue” therapy. 1,2,16,82 Other expected 

sequelae from high-dose chemotherapy used in conjunction with AHSCT are summarised in Table 8. 1,2,16,82 

Table 8. Effects Following High-Dose Chemotherapy Used in AHSCT 1,2,16,82 

Organ Effects Interventions 

Gastrointestinal tract Nausea, vomiting, diarrhoea, anorexia, 

mucositis 

Antiemetics, mouth care regimens, pain 

medications, nutritional supplementation 

Blood components Pancytopenia Antibiotics, blood transfusions 

Kidneys Haemorrhagic cystitis Mesna, intravenous fluids, pain medications, 

bladder irrigation 

Liver 

Sinusoidal obstructive syndrome 

(veno-occlusive disease) 

Diuretics, fluid restriction, intensive supportive care 

Brain and nervous system Headache, tremors, seizures Pain medications, intensive supportive care 

Heart Oedema, hypertension Fluid restriction, diuretics, antihypertensive 

medications 

Lungs Atelectasis Pulmonary toilet 

Skin Rash, discoloration Topical emollients, skin care and bathing regimen 

AHSCT, autologous haematopoietic stem cell transplantation. 

16 



Before high-dose chemotherapy is administered Figure 10. Storage of Collected Stem Cells 

to the patient, the integrity of stored stem cells 

is verified. On the day of stem cell infusion, the 

previously collected product is removed from liquid 

nitrogen storage (Figure 10), thawed, and prepared 

for patient administration. 17 The infusion itself can 

occur in an ambulatory or hospital setting. Prior 

to infusion, the product is rigorously inspected 

and tested for quality control measures such as 

CD34+ cell counts and the presence of microbes. 

Several members of the health care team will also 

ensure that the product is the patient’s collected 

cells. The patient is prepared for the infusion by 

receiving premedications (eg, an antihistamine, an 

antipyretic), having their intravenous line equipped 

to receive the cells, and being placed on medical 

equipment to monitor their vital signs throughout 

the procedure. The actual time for infusion can 

vary based on the patient and the number of bags collected during apheresis, but typically ranges from 30 to 

120 minutes. Patients should be frequently monitored for adverse events during the infusion that may require 

adjustment of the infusion rate for the product. Resuscitative equipment should be readily available should a 

medical emergency occur. 1,2,16,82 Frequently encountered reactions during autologous stem cell infusions are 

listed in Table 9. 1,2,16,82 

Table 9. Complications Associated With Autologous Stem Cell Infusion 1,2,16,82 

Adverse Effect Signs and Symptoms Corrective Action 

Reactions to DMSO Common: nausea, vomiting, abdominal cramping, headache, 

garlic aftertaste 

Treatment of symptoms 

Rare: Hypotension, rapid heart rate, shortness of breath, 

fever, neurologic complications 

Oedema Fluid retention, puffiness, weight gain, hypertension Diuretics, fluid restriction 

Contamination of 

stem cell product 

DMSO, dimethylsulfoxide. 

Hypotension, rapid heart rate, shortness of breath, fever, 

chills, rigors, positive blood culture for microbial pathogen 

Antibiotics, intensive supportive 

care 

The last component of AHSCT is engraftment and recovery. During this critical time, the infused stem cells find 

their way back to the bone marrow microenvironment and repopulate depleted marrow stores. Post-transplant, 

cytokines are administered to enhance stem cell maturation and to re-establish blood cell components. The 

first sign of engraftment is the return of circulating WBCs to a sufficient level defined as an absolute neutrophil 

count (ANC) of > 500/mm 3 for 3 consecutive days, which typically occurs 7-14 days after the stem cells have 

been infused into the patient. 1,2 Increased platelet levels (absent of transfusion support) is another indicator 

of recovery, and occurs at a later time point, averaging 2-3 weeks following the transplant. 1,2 Until engraftment 

occurs, patients are at an increased risk of infections, so precautions must be taken to avoid exposure to 

microbial pathogens. Patients often require supportive care strategies and therapies, including administration of 

antiemetics, pain medications, antibiotics, and nutrition support to ameliorate consequences following the highdose 

chemotherapy preparative regimen and the subsequent prolonged period of pancytopenia. 1,2,16,82 


17

1 

4 

Chapter 4: How to Discuss Noted Topics With Patients 

Stage Heading 

Some of the most important nursing 

contributions throughout the AHSCT process 

are patient education and psychosocial 

support to patients and their families. 

Opportunities for teaching are many, from 

describing research protocols to explaining 

medical procedures and therapies; nurses 

in a variety of positions have the expertise 

to guide patients throughout the process. 

Education about AHSCT should begin prior 

to the initial referral for transplantation and 

continue throughout the indicated followup 

period after transplantation. Imparting 

knowledge to patients and caregivers not 

only eases fears and concerns (Table 10), 

but it makes individuals feel empowered in 

making the best decisions for themselves 

or their loved ones. The education given 

to patients can occur through a variety of 

methods, including explanations and demonstrations, and it is frequently repeated to ensure understanding. 

Media to assist patient and caregiver comprehension includes written materials, videos, and group teaching 

exercises. Table 11 lists key teaching points nurses often provide patients and their caregivers during the AHSCT 

This is where a description would go as needed 

Stage Heading 

process. 1,2,16,82,93 

Table 10. Sources for Concern Experienced by Patients and Caregivers During AHSCT 

LOREM IPSUM 

• Ability of the patient to tolerate the procedures surrounding AHSCT 

STEM CELL 

• Ability of the patient to collect sufficient stem cells to proceed with transplant 

COLLECTION 

• Likelihood of disease relapse after AHSCT 

• Response to additional treatment in the setting of disease relapse or poor mobilisation 

• Life expectancy of the patient 

• Maintaining regularly scheduled appointments for clinic visits and diagnostic procedures 

• Secondary complications as a result of AHSCT and their treatment 

• Required lifestyle changes and their impacts 

• Ability to pay for procedures, treatments, and ancillary expenses (eg, temporary housing, transportation between 

home and treating facility, child care) 

• Ability to maintain employment during treatment and/or resume employment after therapy 

• Ability to maintain social, physical, and/or emotional relationships with others 

This • is Psychological where well-being a description of oneself and loved would ones go as needed 

Chapter 4: Patient Topics 



19

Table 11. Key Teaching Points for Nurses Involved in Caring for AHSCT Patients 1,2,16,82,93 

Stage of AHSCT 

Prior and up to the 

time of referral for 

transplantation 

Pre-transplantation 

evaluation 

Educational Opportunities 

• General overview of the entire transplantation procedure 

• Caregiver roles and responsibilities during the procedure 

• Introduction to members of the transplant team and explanation of each of their roles 

in patient care 

• Overview of the transplant clinic, including hours of operation 

• Explanation of all laboratory tests, scans, and procedures needed for work-up 

• Detailed explanation of transplant procedure, including common complications 

• Resources available to patients and caregivers to assist with psychosocial support and 

coping mechanisms 

• Catheter placement and care during transplantation and apheresis 

Mobilisation and 

apheresis 

• How and when to administer agents used in the mobilisation process 

• Schedule of chemotherapy used in the mobilisation process 

• What medications a patient should and should not take during mobilisation 

• Expected adverse effects and their management for all agents used in mobilisation 

• Review of care of catheter used for apheresis 

• Explanation of apheresis procedure 

• Expected adverse effects from apheresis procedure 

• Importance of laboratory monitoring and how to manage electrolyte imbalances 

• Stem cell collection target level 

• Options for patients who mobilise poorly or fail to mobilise 

Preparative regimen • Treatment plan and schedule of conditioning chemotherapy, including expected adverse 

effects and how to manage them 

• Review of supportive care medications that may be used during this time 

• Preventative measures for development of infections 

Stem cell infusion • Process for thawing and infusing stem cells 

• Potential complications following infusion of cells and how these effects are managed 

• How patient will be monitored during the infusion and thereafter 

Engraftment and recovery • Monitoring parameters and laboratory testing used to assess patient status 

• Reinforcement of neutropenic precautions 

• Signs and symptoms of infection and treatments available to manage patients 

• Significance of blood counts and how engraftment and recovery are determined 

• Other expected complications following transplantation and their management 

• Discharge planning process 

• Discharge medication education with respect to how to take medications at home and 

expected adverse effects 

• Any necessary lifestyle changes 

Monitoring and follow-up • Clinic appointment schedule 

• How to monitor progress at home and when it is necessary to contact a health care 

professional 

• Long-term sequelae following transplantation and secondary complications 

• Risk and management of relapsed disease 


20 



Initial teaching about AHSCT ideally begins at the time of the initial diagnosis of cancer or other disease. 

Although some patients may not proceed to AHSCT, possession of basic knowledge of state-of-the-art treatment 

throughout their continuum of care will empower the patient to make difficult decisions. The nurses in the 

medical haematology/oncology clinic or unit should assist patients in understanding what role, if any, an AHSCT 

has in their care. This is the time to introduce basic concepts of the mobilisation procedures, the stem cell 

transplant, and the period following transplantation. 

Once a patient is evaluated in a transplant centre, they will meet nurses who have different roles within 

the transplant programme. For example, a nurse coordinator is responsible for directing the pre-transplant 

preparation through the coordination of medical testing and evaluation. The nurse coordinator collaborates 

with clinic nurses to educate patients and their families, giving them an overview of the clinic operations and 

detailed explanations of the procedures surrounding the transplantation process. After a patient is approved 

for the transplantation, nurses in the clinic will assist with coordinating care with the apheresis centre, 

including scheduling appropriate catheter placement and providing any associated teaching. The nurses also 

assist with any psychosocial needs and make referrals to other members of the team as necessary (eg, social 

workers). Nurses should also encourage patients and their caregivers to achieve their own educational goals by 

encouraging them to ask the medical team any questions they may have prior to initiating any procedures. 

During mobilisation and apheresis, nurses will remain in close contact with patients and their families, 

communicating information regarding follow-up for apheresis procedures, total CD34+ counts post-apheresis, 

and the next phase of the plan of care. Prior to starting apheresis, adverse effects of this procedure are 

explained as well as the management of their central venous catheters. It is important for nurses to recognise 

patients at greatest risk of poor mobilisation. In such instances, nurses should possess basic knowledge about 

remobilisation strategies and how to proceed with treatment and, moreover, whether AHSCT will be a treatment 

option. If the nurse can confidently discuss potential options, the patient and their family members may have 

greater confidence that the nurse is their advocate, thus reducing any additional fears and stressors. 

The provision of care surrounding the actual stem cell transplant, including administration of the preparative 

regimen, the stem cell infusion, and supporting the patient through engraftment and recovery create 

opportunities for nurses to provide patients some of the most intensive and extensive education during the 

multiple processes involved in AHSCT. Numerous medications are utilised during this time period, most of 

which have the potential for serious adverse effects and/or drug interactions. It is not unusual for patients 

to experience times of extreme debilitation and emotional exhaustion. Nurses can expect to assist with the 

management of adverse effects through supportive care mechanisms and be attentive to the concerns and 

anxiety expressed by patients and caregivers. Following recovery from transplantation, nurses continue to 

support patients through the discharge process, preparing them for the transition of care into the home setting. 

Even after the patient has recovered from the transplant, the educational role of the nurse continues. Patients 

continue to need counselling and guidance about lifestyle changes and when resumption of pre-transplant 

activities can be expected. An understanding of routine follow-up visits and medical surveillance are essential for 

positive patient outcomes. Long-term sequelae from chemotherapy and other treatment modalities should be a 

part of the educational process during the post-transplant period. It is also prudent to discuss the possibility of 

disease relapse with patients and how management of their disease will be handled should this occur. Overall, 

nursing education administered to the transplant recipient is a complex and dynamic process that should be 

personalised to the patient’s disease, treatment plan, cognitive level, and psychosocial needs. 


21

Glossary 

Allogeneic: refers to 2 different persons who do not share the same genetic composition 

Adaptive immunity: function of the immune system that is highly specific and is acquired through exposure to 

specific antigens 

Apheresis: the process of removing blood from an individual, separating cellular components, and then 

returning remaining portions back to the donor 

Autologous: refers to when one is both the donor and the recipient 

Autologous haematopoietic stem cell transplantation: medical procedure involving the collection and 

storage of a person’s blood stem cells followed by administration of high dose chemotherapy and/or radiation 

therapy with subsequent reinfusion of stem cells to restore normal blood cell production 

Chemokines: a subset of cytokines that serve as chemoattractants responsible for guiding the migration of 

cells 

Chemomobilisation: the process of mobilising stem cells from the bone marrow into the peripheral blood 

through the use of chemotherapy in conjunction with one or more cytokines such as filgrastim 

Cryopreservation: the process of storing cells, tissues, or organs by a cooling mechanism that maintains the 

viability of the product for later use 

Cryopreservative: also known as cryoprotectant; a substance added to collected cells prior to storage to 

prevent dehydration or the formation of ice crystals that can decrease the viability of the product upon thawing. 

An example is dimethylsulfoxide (DMSO) 

Cytokines: small proteins released by cells that facilitate cellular behaviour as well as communication and 

interaction between cells 

Cytoreduction: the reduction in the number of cancer cells 

Engraftment: when infused stem cells begin to proliferate and make new blood cellular components. Often this 

is defined in relation to minimum levels for neutrophil and platelet counts 

Haematopoiesis: the process of producing new blood cell components 

Haemostasis: regulation of the blood system to maintain stable, constant conditions relating to bleeding and 

clotting 

Innate immunity: function of the immune system that is nonspecific, naturally present, and does not rely on 

prior exposure to an antigen 

Mobilisation: the process of increasing the number of stem cells from the bone marrow into the peripheral 

circulation prior to collection 

Monoclonal antibody: a type of antibody produced from a single clone of immune cells 

Myelosuppression: the inhibition of bone marrow activity often resulting in decreased production of blood 

components 

Pancytopenia: a decrease in all types of blood cells, including white blood cells, red blood cells, and platelets 

Pluripotent: describes cells that have the ability to self-replicate and the potential to differentiate into specific 

cell types 

Progenitor: a precursor or original cell that may or may not be capable of self-renewal 

Remobilisation: the process of mobilisation after failure from a previous attempt 

Rituximab: a chimeric monoclonal antibody that binds to CD20 protein on the surface of cells 

Stromal: refers to the stroma; the stroma is the supportive framework of tissue that usually comprises 

connective tissue 

Syngeneic: refers to 2 different persons with the exact genetic composition (ie, identical twins) 

Tandem autologous stem cell transplantation: process in which a person receives 2 scheduled, 

sequential transplants with their own stem cells collected prior to the first transplant 

Glossary 

23 

Glossary, References, 

and Additional Resources

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24 



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36. Giralt S, Stadtmauer EA, Harousseau JL, et al. International myeloma working group (IMWG) consensus statement and 

guidelines regarding the current status of stem cell collection and high-dose therapy for multiple myeloma and the role of 

plerixafor (AMD 3100) Leukemia. 2009;Jun 25 [epub ahead of print]. 

37. Jansen J, Thompson JM, Dugan MJ, et al. Peripheral blood progenitor cell transplantation. Ther Apher. 2002;6(1):5-14. 

38. Jansen J, Hanks S, Thompson JM, Dugan MJ, Akard LP. Transplantation of hematopoietic stem cells from the peripheral blood. 

J Cell Mol Med. 2005;9(1):37-50. 

39. Switzer GE, Goycoolea JM, Dew MA, Graeff EC, Hegland J. Donating stimulated peripheral blood stem cells vs bone marrow: do 

donors experience the procedures differently? Bone Marrow Transplant. 2001;27(9):917-923. 

40. Damiani D, Fanin R, Silvestri F, et al. Randomized trial of autologous filgrastim-primed bone marrow transplantation versus 

filgrastim-mobilized peripheral blood stem cell transplantation in lymphoma patients. Blood. 1997;90(1):36-42. 

41. Bishop MR, Anderson JR, Jackson JD, et al. High-dose therapy and peripheral blood progenitor cell transplantation: effects of 

recombinant human granulocyte-macrophage colony-stimulating factor on the autograft. Blood. 1994;83(2):610-616. 

42. Kopf B, De Giorgi U, Vertogen B, et al. A randomized study comparing filgrastim versus lenograstim versus molgramostim plus 

chemotherapy for peripheral blood progenitor cell mobilization. Bone Marrow Transplant. 2006;38(6):407-412. 

43. Petit I, Szyper-Kravitz M, Nagler A, et al. G-CSF induces stem cell mobilization by decreasing bone marrow SDF-1 and upregulating 

CXCR4. Nat Immunol. 2002;3(7):687-694. 

44. Levesque JP, Hendy J, Takamatsu Y, Williams B, Winkler IG, Simmons PJ. Mobilization by either cyclophosphamide or granulocyte 

colony-stimulating factor transforms the bone marrow into a highly proteolytic environment. Exp Hematol. 2002;30(5):440-449. 

45. Heissig B, Hattori K, Dias S, et al. Recruitment of stem and progenitor cells from the bone marrow niche requires MMP-9 

mediated release of kit-ligand. Cell. 2002;109(5):625-637. 

46. Levesque JP, Takamatsu Y, Nilsson SK, Haylock DN, Simmons PJ. Vascular cell adhesion molecule-1 (CD106) is cleaved by 

neutrophil proteases in the bone marrow following hematopoietic progenitor cell mobilization by granulocyte colony-stimulating 

factor. Blood. 2001;98(5):1289-1297. 

47. Neupogen ® (filgrastim) [summary of product characteristics]. Cambridge, United Kingdom: Amgen Ltd; 2009. Please refer to the 

applicable national summary of product characteristics. 

48. Granocyte ® (lenograstim) [summary of product characteristics]. London, United Kingdom: Chugai Pharma UK Ltd; 2009. Please 

refer to the applicable national summary of product characteristics. 

49. Kroger N, Renges H, Kruger W, et al. A randomized comparison of once versus twice daily recombinant human granulocyte 

colony-stimulating factor (filgrastim) for stem cell mobilization in healthy donors for allogeneic transplantation. Br J Haematol. 

2000;111(3):761-765. 

50. Kim S, Kim HJ, Park JS, et al. Prospective randomized comparative observation of single- vs split-dose lenograstim to mobilize 

peripheral blood progenitor cells following chemotherapy in patients with multiple myeloma or non-Hodgkin’s lymphoma. Ann 

Hematol. 2005;84(11):742-747. 

51. Komeno Y, Kanda Y, Hamaki T, et al. A randomized controlled trial to compare once- versus twice-daily filgrastim for mobilization 

of peripheral blood stem cells from healthy donors. Biol Blood Marrow Transplant. 2006;12(4):408-413. 

52. Flinn IW, O’Donnell PV, Goodrich A, et al. Immunotherapy with rituximab during peripheral blood stem cell transplantation for 

non-Hodgkin’s lymphoma. Biol Blood Marrow Transplant. 2000;6(6):628-632. 

53. Naparstek E. The role of the anti-CD20 antibody rituximab in hematopoietic stem cell transplantation for non-Hodgkin’s 

lymphoma. Curr Hematol Rep. 2005;4(4):276-283. 

54. Cytoxan ® (cyclophosphamide injection) [prescribing information]. Princeton, NJ: Bristol-Myers Squibb Company; 2005. 

55. Etoposide injection [prescribing information]. Bedford, OH: Bedford Laboratories; 2008. 

56. Mozobil ® (plerixafor) [summary of product characteristics]. Naarden, The Netherlands: Genzyme Europe B.V.; 2009. Please refer 

to the applicable national summary of product characteristics. 

57. Martin C, Bridger GJ, Rankin SM. Structural analogues of AMD3100 mobilise haematopoietic progenitor cells from bone marrow 

in vivo according to their ability to inhibit CXCL12 binding to CXCR4 in vitro. Br J Haematol. 2006;134(3):326-329. 

58. Hatse S, Princen K, Bridger G, De Clercq E, Schols D. Chemokine receptor inhibition by AMD3100 is strictly confined to CXCR4. 

FEBS Lett. 2002;527(1-3):255-262. 

59. Fricker SP, Anastassov V, Cox J, et al. Characterization of the molecular pharmacology of AMD3100: a specific antagonist of the 

G-protein coupled chemokine receptor, CXCR4. Biochem Pharmacol. 2006;72(5):588-596. 

60. Gerlach LO, Skerlj RT, Bridger GJ, Schwartz TW. Molecular interactions of cyclam and bicyclam non-peptide antagonists with the 

CXCR4 chemokine receptor. J Biol Chem. 2001;276(17):14153-14160. 

61. Broxmeyer HE, Orschell CM, Clapp DW, et al. Rapid mobilization of murine and human hematopoietic stem and progenitor cells 

with AMD3100, a CXCR4 antagonist. J Exp Med. 2005;201(8):1307-1318. 

62. Devine SM, Flomenberg N, Vesole DH, et al. Rapid mobilization of CD34+ cells following administration of the CXCR4 antagonist 

AMD3100 to patients with multiple myeloma and non-Hodgkin’s lymphoma. J Clin Oncol. 2004;22(6):1095-1102. 

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25

63. Calandra G, McCarty J, McGuirk J, et al. AMD3100 plus G-CSF can successfully mobilize CD34+ cells from non-Hodgkin’s 

lymphoma, Hodgkin’s disease and multiple myeloma patients previously failing mobilization with chemotherapy and/or cytokine 

treatment: compassionate use data. Bone Marrow Transplant. 2008;41(4):331-338. 

64. Neupogen ® (filgrastim) [package insert]. Thousand Oaks, CA: Amgen Inc; 2007. 

65. Stiff PJ. Management strategies for the hard-to-mobilize patient. Bone Marrow Transplant. 1999;23 Suppl 2:S29-33. 

66. Micallef IN, Apostolidis J, Rohatiner AZ, et al. Factors which predict unsuccessful mobilisation of peripheral blood progenitor cells 

following G-CSF alone in patients with non-Hodgkin’s lymphoma. Hematol J. 2000;1(6):367-373. 

67. Bensinger W, Appelbaum F, Rowley S, et al. Factors that influence collection and engraftment of autologous peripheral-blood stem 

cells. J Clin Oncol. 1995;13(10):2547-2555. 

68. Hosing C, Saliba R, Ahlawat S, et al. Poor hematopoietic stem cell mobilizers: a single institution study of incidence and risk 

factors in patients with recurrent or relapsed lymphoma. Am J Hematol. 2009;84(6):335-337. 

69. Demirer T, Buckner CD, Gooley T, et al. Factors influencing collection of peripheral blood stem cells in patients with multiple 

myeloma. Bone Marrow Transplant. 1996;17(6):937-941. 

70. Paripati H, Stewart AK, Cabou S, et al. Compromised stem cell mobilization following induction therapy with lenalidomide in 

myeloma. Leukemia. 2008;22(6):1282-1284. 

71. Popat U, Saliba R, Thandi R, et al. Impairment of filgrastim-induced stem cell mobilization after prior lenalidomide in patients with 

multiple myeloma. Biol Blood Marrow Transplant. 2009;15(6):718-723. 

72. Fruehauf S, Haas R, Conradt C, et al. Peripheral blood progenitor cell (PBPC) counts during steady-state hematopoiesis allow to 

estimate the yield of mobilized PBPC after filgrastim (R-metHuG-CSF)-supported cytotoxic chemotherapy. Blood. 1995;85(9):2619- 

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73. Fruehauf S, Schmitt K, Veldwijk MR, et al. Peripheral blood progenitor cell (PBPC) counts during steady-state haemopoiesis 

enable the estimation of the yield of mobilized PBPC after granulocyte colony-stimulating factor supported cytotoxic 

chemotherapy: an update on 100 patients. Br J Haematol. 1999;105(3):786-794. 

74. Goterris R, Hernandez-Boluda JC, Teruel A, et al. Impact of different strategies of second-line stem cell harvest on the outcome 

of autologous transplantation in poor peripheral blood stem cell mobilizers. Bone Marrow Transplant. 2005;36(10):847-853. 

75. Jantunen E, Kuittinen T. Blood stem cell mobilization and collection in patients with lymphoproliferative diseases: practical issues. 

Eur J Haematol. 2008;80(4):287-295. 

76. Seshadri T, Al-Farsi K, Stakiw J, et al. G-CSF-stimulated BM progenitor cells supplement suboptimal peripheral blood 

hematopoietic progenitor cell collections for auto transplantation. Bone Marrow Transplant. 2008;42(11):733-737. 

77. Hicks ML, Lonial S, Langston A, et al. Optimizing the timing of chemotherapy for mobilizing autologous blood hematopoietic 

progenitor cells. Transfusion. 2007;47(4):629-635. 

78. Bargetzi MJ, Passweg J, Baertschi E, et al. Mobilization of peripheral blood progenitor cells with vinorelbine and granulocyte 

colony-stimulating factor in multiple myeloma patients is reliable and cost effective. Bone Marrow Transplant. 2003;31(2):99-103. 

79. Seggewiss R, Buss EC, Herrmann D, Goldschmidt H, Ho AD, Fruehauf S. Kinetics of peripheral blood stem cell mobilization 

following G-CSF-supported chemotherapy. Stem Cells. 2003;21(5):568-574. 

80. DiPersio JF, Micallef I, Stiff PJ, et al. Phase III prospective randomized double-blind placebo-controlled trial of plerixafor plus 

granulocyte colony-stimulating factor compared with placebo plus granulocyte colony-stimulating factor for autologous stem cell 

mobilization and transplantation in patients with non-Hodgkin’s lymphoma. J Clin Oncol. 2009;Aug 31 [epub ahead of print]. 

81. Dipersio JF, Stadtmauer EA, Nademanee A, et al. Plerixafor and G-CSF versus placebo and G-CSF to mobilize hematopoietic stem 

cells for autologous stem cell transplantation in patients with multiple myeloma. Blood. 2009;113(23):5720-5726. 

82. Buchsel PC, Leum E, Randolph SR. Nursing care of the blood cell transplant recipient. Semin Oncol Nurs. 1997;13(3):172-183. 

83. Reddy RL. Mobilization and collection of peripheral blood progenitor cells for transplantation. Transfus Apher Sci. 2005;32(1):63-72. 

84. Perez-Simon JA, Caballero MD, Corral M, et al. Minimal number of circulating CD34+ cells to ensure successful leukapheresis 

and engraftment in autologous peripheral blood progenitor cell transplantation. Transfusion. 1998;38(4):385-391. 

85. Basquiera AL, Abichain P, Damonte JC, et al. The number of CD34(+) cells in peripheral blood as a predictor of the CD34(+) yield 

in patients going to autologous stem cell transplantation. J Clin Apher. 2006;21(2):92-95. 

86. Cassens U, Barth IM, Baumann C, et al. Factors affecting the efficacy of peripheral blood progenitor cells collections by largevolume 

leukaphereses with standardized processing volumes. Transfusion. 2004;44(11):1593-1602. 

87. Gasova Z, Marinov I, Vodvarkova S, Bohmova M, Bhuyian-Ludvikova Z. PBPC collection techniques: standard versus large volume 

leukapheresis (LVL) in donors and in patients. Transfus Apher Sci. 2005;32(2):167-176. 

88. Arslan O, Moog R. Mobilization of peripheral blood stem cells. Transfus Apher Sci. 2007;37(2):179-185. 

89. Smith DM, Ness MJ, Landmark JD, Haire WW, Kessinger A. Recurrent neurologic symptoms during peripheral stem cell apheresis 

in two patients with intracranial metastases. J Clin Apher. 1990;5(2):70-73. 

90. Winters JL. Complications of donor apheresis. J Clin Apher. 2006;21(2):132-141. 

91. Gorlin J. Stem cell cryopreservation. J Infus Chemother. 1996;6(1):23-27. 

92. Feugier P, Bensoussan D, Girard F, et al. Hematologic recovery after autologous PBPC transplantation: importance of the number 

of postthaw CD34+ cells. Transfusion. 2003;43(7):878-884. 

93. Ford RC, Wickline MM. Nursing role in hematopoietic cell transplantation. In: Appelbaum F, Forman SJ, Negrin RS, Blume KG, eds. 

Thomas’ Hematopoietic Cell Transplantation. Hoboken, NJ: Wiley-Blackwell; 2009:461-477. 

26 



Additional Resources 

• American Cancer Society: http://www.cancer.org 

• American Society for Blood and Marrow Transplantation (ASMBT): http://www.asbmt.org 

• American Society for Apheresis (ASFA): http://www.apheresis.org 

• Blood and Marrow Transplant Information Network (BMT InfoNet): http://www.bmtinfonet.org 

• Cancerworld: http://www.cancerworld.org 

• Center for International Blood and Marrow Transplant Research (CIBMTR): http://www.cibmtr.org 

• The European Group for Blood & Marrow Transplantation (EBMT): http://www.ebmt.org 

• International Myeloma Foundation: http://myeloma.org 

• LeukemiaNet: http://www.leukemia-net.org 

• Leukemia and Lymphoma Society: http://www.leukemia-lymphoma.org 

• Leukemia Research Foundation: http://www.leukemia-research.org 

• Lymphomainfo.net: http://www.lymphomainfo.net 

• Lymphoma Coalition: http://www.lymphomacoalition.org 

• Lymphoma Forum and Lymphoma Association: http://www.lymphoma.org.uk 

• Lymphoma Research Foundation: http://www.lymphoma.org 

• Myeloma Euronet: http://www.myeloma-euronet.org 

• Multiple Myeloma Research Foundation: http://www.multiplemyeloma.org 

• National Bone Marrow Transplant Link (NBMT Link): http://www.nbmtlink.org 

• National Cancer Institute: http://www.cancer.gov 

• National Marrow Donor Program: http://www.marrow.org 

Additional Resources 

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This brochure was made possible by a 

financial contribution from 

Genzyme Europe B.V.

Haematopoietic Stem Cell Mobilisation and Apheresis: - EBMT

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