The European Blood and Marrow Transplantation Textbook for Nurses: Under the Auspices of EBMT

This Open Access Second Edition textbook, endorsed by the EBMT, provides adult and pediatric nurses with a full and informative guide covering all aspects of transplant nursing including a new chapter dedicated to cellular therapy, nursing implications and care. This book takes the reader from basic principles to advanced concepts on a journey through the history of transplant nursing, including essential and progressive elements to help nurses improve their knowledge and benefit the patient experience, as well as a comprehensive introduction to research and auditing methods. This second edition specifically intended for nurses, complements the EBMT Handbook, a popular educational resource originally developed in 2003 for physicians to accompany an annual training course also serving as an educational reference tool in its own right. This title is designed to develop the knowledge of nurses in transplantation. It is the only one of its kind written by nurse experts, specifically targeted at nurses in this specialist field and acknowledges the valuable contribution that nursing makes to patient care in this area. This new volume presents updated content that is essential for the education of nurses new to transplantation, while also offering a valuable resource for more experienced nurses who wish to refresh their knowledge. This Textbook is open access under a CC BY 4.0 license. Preface Acknowledgements Contents 1: JACIE and Quality Management in HSCT: Implications for Nursing 1.1 Background to JACIE 1.2 Preparing for JACIE Accreditation 1.2.1 Considerations 1.2.2 Implementing a Quality Management System 1.3 The JACIE Accreditation Process 1.3.1 Start Working with the Standards 1.3.2 Application for JACIE Accreditation 1.3.3 Arranging the Inspection Date 1.3.4 The Inspection 1.3.5 The Inspection Report 1.3.6 Corrections and Accreditation Award 1.3.7 Post JACIE Accreditation 1.4 JACIE Standards That Affect Nursing: Clinical and Collection 1.4.1 Staffing and Nursing (Table 1.2) 1.4.2 Training and Competencies (Tables 1.2 and 1.3) 1.4.3 Benefits of Quality Management (Table 1.3) 1.4.4 Audits (Table 1.3) 1.4.5 Reporting Adverse Events (Table 1.3) 1.4.6 Tracking of Collected Products (Table 1.3) 1.4.7 Common Deficiencies That Have Occurred in Previous Editions of the FACT-JACIE Standards 1.5 JACIE: Implications on Nursing—The Nurse’s Perspective 1.6 Results 1.6.1 Does the JACIE Process Have any Implications for Nurses? 1.6.2 Conclusion of the Surveys 1.7 Discussion Points Appendix: Citations Classified in the Role of the Nurse (Survey 2016) References Further Reading 2: HSCT: How Does It Work? 2.1 What Nurses Need to Know 2.1.1 Introduction 2.1.2 Aims of HSCT 2.1.3 Outcomes 2.1.4 Nursing Considerations 2.2 Different Types of HSCT 2.2.1 Autologous Stem Cell Transplantation 2.2.2 Allogeneic Stem Cell Transplantation 2.2.2.1 Allogeneic Transplantation from HLA-Matched Related Donor (MRD) 2.2.2.2 Allogeneic from Unrelated Donor (MUD, MMUD) 2.2.2.3 Cord Blood Transplantation 2.2.2.4 Haploidentical Transplantation 2.2.2.5 Syngeneic Transplantation 2.3 The Stem Cell Sources 2.3.1 Peripheral Blood Stem Cells 2.3.2 Bone Marrow 2.3.3 Umbilical Cord Blood 2.3.4 HSCT Phases 2.3.4.1 Neutropenic Phase 2.4 Indications for HSC Transplant 2.4.1 Indications for Autologous HSCT 2.4.2 Indications for Allogeneic HSCT 2.5 Indications for Transplant in Non-malignant Diseases (in Children) 2.5.1 Transplant in Inborn Errors of Immunity 2.5.2 Severe Combined Immunodeficiencies 2.5.3 Non-SCID Inborn Errors of Immunity 2.5.3.1 Conditioning 2.5.3.2 Outcome 2.5.4 Newborn Screening 2.5.5 Inherited Bone Marrow Failure 2.5.6 Inherited Diseases: Inborn Errors of Metabolism 2.5.7 Haemoglobinopathies References Indications for Transplant in Non-malignant Diseases in Children 3: Donor Selection 3.1 Introduction 3.2 Human Leukocyte Antigens 3.3 Eligibility for HLA Typing of Potential Related Donors 3.4 Algorithm of Donor Choice and Selection 3.4.1 Donor Selection 3.4.2 HLA Match 3.4.3 Cytomegalovirus (CMV) Status 3.4.4 Blood Group 3.4.5 Gender Match 3.4.6 Parity 3.4.7 Age 3.4.8 Donor Evaluation 3.5 Special Considerations 3.5.1 Screening of Elderly Donors 3.5.2 Screening of Paediatric Donors 3.5.3 Confidentiality 3.5.4 Donor Consent and Clearance 3.5.5 Stem Cell Source 3.6 Conclusion References 4: Transplant Preparation 4.1 The Role of Transplant Coordinator 4.2 Information and Consent 4.3 Information and Consents in the Paediatric Population 4.4 Role of Risk Assessment and Co-Morbidity Scores 4.4.1 ECOG Performance Status 4.5 Fertility Preservation 4.6 Fertility Preservation in the Paediatric Population 4.6.1 Fertility Counselling 4.6.2 When? 4.6.3 Issues 4.6.4 Who? 4.6.5 Recommendations on Fertility Preservation for Girls and Young Women with Childhood Cancer 4.6.5.1 After Treatment 4.6.5.2 Menstruating Girls 4.6.5.3 All Girls Regardless of Maturational Stage 4.6.6 Recommendations on Fertility Preservation for Boys and Young Men with Childhood Cancer 4.6.6.1 Pubertal and Post-pubertal Males 4.6.6.2 Prepubertal Boys 4.6.7 Techniques 4.6.8 Fertility Preservation Options for Children and Young Adults with Distinction Between Established and Experimental Options 4.6.8.1 Addressing Inequalities 4.6.9 Sexuality in Adolescents and Young Adults 4.6.10 Conclusion 4.7 Transplant Workup 4.8 Venous Access Devices: Principles of Placement and Care 4.8.1 Vascular Access Devices 4.8.2 Care and Maintenance 4.8.3 Flushing and Locking 4.8.4 Securement 4.8.5 Occlusion 4.8.6 CVAD Removal 4.8.7 Pre-transplant Disease Assessment 4.9 The Advocacy Role of HSCT Nurses 4.10 Ethical Dilemmas 4.11 Ethical Issues in Minors References 5: Cell Source and Apheresis 5.1 Cell Source 5.2 Cell Collection 5.2.1 Bone Marrow Collection 5.2.2 Cord Blood Collection 5.2.3 Mononeuclear Cell Collections 5.3 Mobilization of Stem Cells and Apheresis 5.3.1 The Role of CD34+ Cells 5.3.2 Cytokines and Mobilisation Regimes 5.4 Leukapheresis Collections 5.5 Complications and Challenges 5.5.1 Adverse Reactions 5.5.2 Vascular Access 5.5.3 Citrate Toxicity 5.5.4 Hypovolemia 5.5.5 Thrombocytopenia 5.6 Apheresis Collection Facility Standards and Quality Management 5.6.1 Training and Competencies 5.6.2 Labelling and Chain of Identity 5.7 Cell Source and Apheresis in the Paediatric Population 5.7.1 Introduction 5.7.2 Cell Sources in the Paediatric Population 5.7.3 Apheresis in Paediatric Population 5.7.4 Key Differences: Paediatric Vs. Adult Apheresis 5.7.4.1 Red Cell Prime 5.7.5 Ethical Considerations 5.7.6 Psychosocial Risks and Benefits References 6: Principles of Conditioning Therapy and Cell Infusion 6.1 Conditioning 6.2 Chemotherapy 6.2.1 Combination Chemotherapy 6.2.2 Cycles and Scheduling 6.2.3 Modes of Administration 6.2.4 Side Effects and Nursing Implications 6.3 Radiotherapy 6.3.1 Total Body Irradiation 6.3.2 Side Effects and Nursing Implications 6.4 Monoclonal Antibodies in Conditioning Therapy 6.5 Paediatric Considerations 6.5.1 Conditioning 6.5.2 Chemotherapy 6.5.3 Total Body Irradiation 6.6 Cell Infusion 6.6.1 Adverse Reactions 6.6.2 Nursing Care: Pre-, During and Post Stem Cell Infusion 6.6.2.1 Pre-infusion Assessment Maintain a Safe Environment Baseline Observations Patient Preparation for Infusion IV Line Care Toileting Psychological Support 6.6.2.2 During Stem Cell Infusion IV Line Care Physiological Monitoring Assess for Potential Side Effects 6.6.2.3 Post Stem Cell Infusion Physiological Monitoring Documentation 6.6.3 JACIE Standards References Further Reading 7: Cell Therapy, Nursing Implications and Care 7.1 What Is Cellular Therapy 7.2 Indications for Use 7.3 The Role of Cellular Therapy in Solid Tumours: TCR/TILS 7.4 The Role of Clinical Trials/Academic Products 7.5 Patient Selection and Referral: 7.6 Apheresis/Manufacturing/Laboratory/Chain of Identity 7.6.1 Apheresis 7.6.2 Manufacturing/Laboratory/Pharmacy/Chain of Identity 7.7 Patient Preparation and Consent 7.8 Bridging Therapy 7.9 Product Receipt 7.10 Lymphodepleting Chemotherapy (LD), Product Thawing and Infusion 7.10.1 Lymphodepleting Chemotherapy (LD) 7.10.2 Product Thawing and Infusion 7.11 Potential Complications and Nursing Implications 7.11.1 Tumour Lysis Syndrome (TLS) 7.11.2 Infection Risk, Neutropenia, Anaemia and Thrombocytopenia 7.11.3 Cytokine Release Syndrome (CRS) 7.11.4 Haemophagocytic Lymphohistiocytosis or Macrophage Activation Syndrome (HLH/MAS) 7.11.5 Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS): 7.12 Discharge 7.13 Follow Up Process 7.13.1 Medium-Term Follow-Up 7.13.2 Infectious Complications 7.13.3 B Cell Aplasia and Hypogammaglobulinemia 7.13.4 Vaccinations 7.14 Psychological Care 7.15 Post 30–100 Days: Relapse/Non-response/Disease Progression/Therapy 7.16 Long-Term Follow-Up (LTFU): 7.17 JACIE 7.18 EBMT/EHA/GoCART-Further Education References 8: BMT Settings, Infection and Infection Control 8.1 Introduction 8.2 Viral Infections 8.2.1 Cytomegalovirus 8.2.1.1 Introduction 8.2.1.2 Presentation 8.2.1.3 Diagnosis 8.2.1.4 Monitoring and Surveillance Prophylaxis 8.2.1.5 Treatment 8.2.2 EBV 8.2.2.1 Introduction 8.2.2.2 Risk, Presentation and Manifestations 8.2.2.3 Diagnosis 8.2.2.4 Treatment 8.2.3 HHV6 8.2.3.1 Introduction 8.2.3.2 Presentation 8.2.3.3 Diagnosis 8.2.3.4 Treatment 8.2.4 Varicella Zoster Virus 8.2.4.1 Introduction 8.2.4.2 Risk Factors 8.2.4.3 Presentation 8.2.4.4 Diagnosis 8.2.4.5 Treatment 8.2.4.6 Vaccination 8.2.5 Hepatitis B 8.2.5.1 Background 8.2.5.2 Clinical Features 8.2.5.3 Treatment 8.2.5.4 Prevention 8.2.6 Hepatitis C 8.2.6.1 Background 8.2.6.2 Clinical Features 8.2.6.3 Treatment 8.2.6.4 Prevention 8.2.7 Hepatitis E 8.2.7.1 Background 8.2.7.2 Clinical Features and Developing Countries 8.2.7.3 Treatment 8.2.7.4 Prevention 8.3 Adenovirus 8.3.1 Introduction 8.3.2 Risk Factors 8.3.3 Presentation 8.3.4 Diagnosis 8.3.5 Treatment 8.4 Coronavirus 8.4.1 SARS-Cov-2 Virus 8.4.1.1 Introduction 8.4.1.2 Risk Factors 8.4.1.3 Presentation 8.4.1.4 Diagnosis 8.4.1.5 Treatment 8.4.1.6 Nurse Implication 8.5 Respiratory Complications 8.5.1 Typical Onset of Pulmonary Complications Following Stem Cell Transplantation 8.5.2 Diagnostics 8.6 Bacterial Infections 8.6.1 Gram-Positive and Gram-Negative Bacteria 8.7 Infection Control Management 8.7.1 Isolation 8.7.2 Equipment and Cleaning 8.7.3 Hand Hygiene 8.7.4 Personal Protective Equipment (PPE) 8.7.5 Waste and Linen 8.7.6 Movement of Patients 8.8 Faecal Microbiota Transplant 8.9 Fungal Infections 8.9.1 Diagnosis 8.10 Mycobacteria 8.10.1 Diagnosis 8.11 Pneumocystis jirovecii 8.11.1 Introduction 8.11.2 Risk Factors 8.11.3 Presentation 8.11.4 Diagnosis 8.11.5 Treatment 8.12 BMT Setting, Infection and Infection Control 8.12.1 Introduction 8.12.2 Reverse Barrier Nursing and Protective Isolation 8.12.2.1 Protective Isolation and Cleaning 8.12.2.2 Handwashing 8.12.2.3 Environmental Cleaning 8.12.2.4 Management of Linen 8.12.2.5 Access to Low Environmental Loading Department 8.12.2.6 Personal Hygiene 8.12.2.7 Oral and Gastrointestinal Mucositis 8.12.2.8 Central Venous Devices 8.12.2.9 Low Bacterial Diet 8.13 Psychological Support 8.14 Health Education at Discharge 8.15 Nursing Implications 8.16 BMT Settings, Infections and Infection Control for Paediatric Patients Be Aware 8.16.1 Inborn Errors of Immunity Patients 8.16.2 BCGitis References 9: Transplantation Through the Generations 9.1 Transplanting the Child 9.1.1 The Role of EBMT in Paediatric HSCT 9.1.2 Child Growth and Development 9.1.3 The Child and the Experience of Disease 9.1.3.1 Hospitalisation 9.1.4 The HSCT Experience 9.1.4.1 The Paediatric Patient Experience of HSCT 9.1.4.2 The Parent Experience of HSCT 9.1.4.3 Sibling Donor Experience in HSCT 9.1.5 Centred Nursing Care of Patients and Caregiver’s Undergoing HSCT 9.1.5.1 The Relationship Between Nurse, Caregiver and Child 9.1.5.2 Nursing Involvements in Care of Children Undergoing HSCT 9.1.5.3 Decision-Making 9.2 Transplantation Through the Ages: Adolescents and Young Adults 9.2.1 Introduction 9.2.2 Special Indications for HSCT in AYA 9.2.3 Considerations for Care 9.2.3.1 Risk-Taking Behaviour and Non-compliance 9.2.3.2 Fertility 9.2.3.3 Impact of Treatment on the Family Unit 9.2.3.4 Body Image 9.2.3.5 Impact on Life 9.2.4 Teenager as a Child vs. Adult 9.2.4.1 Consenting for Treatment 9.2.4.2 Communication 9.2.4.3 Confidentiality 9.2.5 TYA Cancer Care in Europe: A General Review 9.2.6 Development of TYA Cancer Units: The UK Experience 9.2.7 AYA Care: An MDT Approach 9.2.8 Summary 9.3 Transplanting the Adult and the Older Adult: Nursing Considerations 9.3.1 Differences Between Older and Younger Patients 9.3.2 Geriatric Assessment 9.3.2.1 Functional Status 9.3.2.2 Vision and Hearing Impairments 9.3.2.3 Comorbidity and Polypharmacy 9.3.2.4 Cognitive Functioning 9.3.2.5 Geriatric Syndromes 9.3.2.6 Medication Adherence 9.3.2.7 Nutritional Status 9.3.2.8 Socio-economic 9.3.2.9 Decision-Making References Transplanting the Child Transplantation Through the Ages: Teenage and Young Adults (TYA) Transplanting the Adult and the Older Adult: Nursing Considerations 10: Early and Acute Complications and the Principles of HSCT Nursing Care 10.1 Oral Care in Transplantation 10.1.1 Introduction 10.1.2 Oral Mucositis (OM) 10.1.3 Key Principles of Treatment 10.1.4 Care of the Oral Cavity 10.1.5 Prevention of Oral Damage 10.1.6 Anti-infective Prophylaxis 10.1.7 Treatment of Oral Complications 10.1.7.1 Mild/Moderate Mucositis 10.1.7.2 Severe Mucositis 10.1.8 Treatment of Specific Oral Complications 10.1.8.1 Bleeding from OM 10.1.8.2 Xerostomia (Dry Mouth) 10.1.8.3 Aphthous Lesions 10.1.8.4 Trismus (Spasm of the Jaw Muscles) 10.1.8.5 Graft-Versus-Host Disease (GvHD) 10.1.9 Post-treatment Care and Follow-Up 10.1.10 Conclusion 10.2 Sepsis and Principles of Care 10.2.1 Introduction 10.2.2 Definition of Sepsis 10.2.3 Clinical Criteria for Sepsis 10.2.4 Risk Factors 10.2.4.1 Neutropenia 10.2.4.2 Barrier Breakdown 10.2.4.3 Immunocompromised and Supressed T- and B-Cell Function 10.2.4.4 Presence of Acute Graft-Versus-Host Disease (aGvHD) 10.2.4.5 Poor General Status 10.2.5 Strategies for Infection and Sepsis Prevention 10.2.6 Diagnosis and Management 10.2.7 Nursing Considerations and Care 10.3 Haemorrhagic Cystitis 10.3.1 Introduction 10.3.2 Definition 10.3.3 Incidence 10.3.4 Pathogenesis 10.3.4.1 Drug-Related HC 10.3.4.2 Non-drug-Related HC 10.3.5 Diagnosis 10.3.6 Prognosis 10.3.7 Prevention of Chemotherapy (Cyclophosphamide/Ifosfamide)-Induced HC 10.3.8 Treatment 10.3.9 Nursing Aspects 10.4 Sinusoidal Obstruction Syndrome/Veno-Occlusive Disease 10.4.1 Introduction 10.4.2 Definition and Pathogenesis 10.4.3 Incidence and Prognosis 10.4.4 Risk Factors 10.4.5 Diagnosis 10.4.6 Prevention 10.4.7 Treatment 10.4.8 Nursing Aspects 10.5 Other Early Complications of Endothelial Origin 10.5.1 Introduction 10.5.2 Pathogenesis 10.6 Engraftment Syndrome (ES) 10.6.1 Definition 10.6.2 Incidence and Prognosis 10.6.3 Risk Factors 10.6.4 Diagnosis 10.6.5 Prevention 10.6.6 Treatment 10.6.7 Nursing Aspects 10.7 Idiopathic Pneumonia Syndrome 10.7.1 Definition 10.7.2 Incidence and Prognosis 10.7.3 Risk Factors 10.7.4 Diagnosis 10.7.5 Prevention 10.7.6 Treatment 10.7.7 Nursing Aspects 10.8 Diffuse Alveolar Haemorrhage 10.8.1 Definition 10.8.2 Incidence and Prognosis 10.8.3 Risk Factors 10.8.4 Diagnosis 10.8.5 Prevention 10.8.6 Treatment 10.8.7 Nursing Aspects 10.9 Transplant-Associated Thrombotic Microangiopathy (TA-TMA) 10.9.1 Definition 10.9.2 Incidence 10.9.3 Prognosis 10.9.4 Risk Factors 10.9.5 Diagnosis 10.9.6 Prevention 10.9.7 Treatment 10.9.8 Nursing Aspects References 11: Supportive Care 11.1 Nursing Assessment 11.2 Pain Assessment 11.3 The Role of Early Warning Scores 11.3.1 Early Warning Scores in the Adult Setting 11.3.2 HSCT and Intensive Care 11.3.3 Early Warning Scores in the Pediatric Setting 11.4 Nutritional Assessment 11.5 The Role of Allied Health Professionals 11.6 Principles of Nutritional Support 11.6.1 Nutritional Problems in Intensive Chemotherapy Treatment 11.6.1.1 Reduced Resistance to Infection 11.6.1.2 Food Aversion, Taste and Smell Changes, and Bad Taste in the Mouth 11.6.1.3 Nausea and Vomiting 11.6.1.4 Reduced Appetite and Early Satiety (Full Feeling) 11.6.1.5 Mucositis (See Oral Complications Section for Further Information) 11.7 Transfusion 11.7.1 Introduction 11.7.2 Blood Products and Indication 11.7.3 Blood Groups and Pre-transfusion Investigations 11.7.4 Processed Blood Products 11.7.5 Transfusion Reactions 11.7.6 Hemovigilance 11.7.7 Conclusion 11.8 Physiotherapy and Exercise 11.9 Psychological/Spiritual Care 11.9.1 Introduction 11.9.2 Basic Information of Psychological Care for the HSCT Recipient 11.9.3 Role of the Consultative Psychiatric Nurse for the HSCT Patient 11.10 Therapeutic Interventions, e.g., Complementary Therapies, Music, Touch, and Massage 11.10.1 Activity Therapies 11.10.1.1 Creative Activities 11.10.1.2 Social Activities 11.10.1.3 Rental Service (in Some Hospitals/Organizations) 11.10.2 Art Therapies 11.10.3 Music Therapies 11.10.4 Complementary Therapies/Care 11.10.4.1 Aromatherapy 11.10.4.2 Therapeutic Touch 11.10.4.3 Living Color Lamp 11.11 Skin Care (See Also Chap. 11 GvHD About Skin Care) 11.11.1 Introduction 11.11.2 Skin and Chemotherapy 11.11.3 Skin Responding at the Treatment 11.11.4 Skin and Rash 11.11.5 Skin and Acne 11.11.6 Advice on Itching 11.11.7 Skin and Risks of Bleeding and Infections 11.11.8 Skin and the Sun 11.12 Discharge from Inpatient Care 11.12.1 School, Study, and Work 11.12.2 Domestic Work 11.12.3 Social 11.12.4 Driving 11.12.5 Sports Activities 11.13 Readmissions to Hospital 11.13.1 Urgent Complaints 11.13.2 Complaints 11.14 Pediatric Considerations References 12: Graft-Versus-Host Disease (GvHD) 12.1 What Is Graft Versus Host Disease (aGvHD)? 12.1.1 Definitions 12.2 Background to GvHD 12.3 Acute GvHD 12.4 Pathophysiology of GvHD 12.4.1 Risk Factors 12.4.2 Signs and Symptoms of aGvHD 12.4.2.1 Skin 12.4.2.2 Gastrointestinal 12.4.2.3 Liver 12.4.3 Classification of Acute GvHD: Grades I–IV 12.4.4 Prevention of GvHD 12.4.5 GvHD Prophylaxis Medications 12.4.5.1 Initial Treatment of Acute GvHD 12.4.6 Second-Line Therapies for aGvHD 12.4.7 Nursing Care Considerations for aGvHD 12.4.8 Cutaneous 12.4.9 Gastrointestinal 12.5 Chronic Graft-Versus-Host Disease 12.6 Chronic GvHD Grading 12.6.1 Diagnosis of cGvHD 12.6.2 Chronic GvHD of the Skin 12.6.3 Chronic GvHD of the Oral Cavity 12.6.4 Chronic GvHD of the Eyes 12.6.5 Chronic GvHD of the Genitalia 12.6.6 Chronic GvHD of the Gastrointestinal (GI) Tract 12.6.7 Chronic GvHD of the Liver 12.6.8 Chronic GvHD Pulmonary System 12.6.9 Chronic GvHD of the Musculoskeletal System 12.6.10 Scoring of Chronic GvHD 12.7 Assessment of Response 12.8 Treatment of Chronic GvHD 12.8.1 Second-Line, Third-Line and Other Therapies for Chronic GvHD 12.8.2 Topical Treatments for cGvHD of the Eyes 12.8.3 Topical Treatments for Oral cGvHD 12.8.4 Ancillary and Supportive Care for cGvHD of the Skin 12.8.5 Connective Tissue Involvement in cGvHD 12.8.6 Quality of Life 12.9 The Future 12.10 GvHD in Children 12.10.1 Incidence and Risk Factors 12.10.2 Treatment Appendix 1: Classification of Patients with Acute GVHD Hyperlink to MAGIC Paper and Acute GvHD Assessment Appendix 2: Scoring of Chronic GvHD References 13: Graft Versus Tumour Effect 13.1 Introduction 13.2 Mechanism of GvM/GvL Effect 13.3 Minimal Residual Disease (MRD) 13.4 Chimerism 13.5 Management of Relapsed Disease 13.6 Treatment Approaches for Post-Allogeneic HSCT Relapse 13.7 Management of Relapsed Disease 13.7.1 Immunotherapy 13.8 Withdrawal of Immunosuppression 13.8.1 DLI 13.8.2 Chemotherapy 13.9 Molecular or Targeted Therapies 13.10 Second HSCT 13.11 Conclusion References 14: Engraftment, Graft Failure, and Rejection 14.1 Engraftment 14.2 Engraftment Definition 14.3 Engraftment Syndrome 14.4 Management of ES 14.5 Nursing Considerations 14.6 Graft Failure 14.7 Graft Rejection 14.8 Incidence of Graft Failure 14.9 Risk Factors Associated with Graft Failure 14.10 Treatment Options for GF 14.10.1 Changes to Immune Suppression 14.10.2 Donor Lymphocyte Infusion 14.10.3 CD34+ Boost 14.10.4 Autologous Backup 14.10.5 Growth Factors 14.10.6 Regrafting 14.11 Pediatric Considerations 14.12 Nursing Considerations References 15: Late Effects and Long-Term Follow-Up 15.1 Principles of Care 15.2 Survivorship and Quality of Life 15.2.1 Quality of Life Assessment 15.2.2 Common Post-HSCT Concerns 15.2.2.1 Physical Well-Being 15.2.2.2 Psychological Distress 15.2.2.3 Return to Work (RTW) 15.2.2.4 Sexuality 15.3 Addressing Sexuality 15.3.1 Providing Support and Information 15.3.2 Addressing Fertility Concerns 15.4 Summary 15.4.1 Wider Impact of Survivorship Care 15.4.2 Models of Long-Term Follow-Up 15.4.3 Opportunities for Nurses 15.5 Post-transplant Complications and Surveillance 15.5.1 Second Malignancies 15.5.2 Systematic Post-transplant Screening and Investigations 15.5.3 Ocular Screening 15.5.4 Oral Examination 15.5.5 Pulmonary Screening 15.5.6 Cardiovascular Tests 15.5.7 Hepatic Complications 15.5.8 Renal Surveillance 15.5.9 Musculoskeletal Assessment 15.5.10 Neurological Assessment 15.5.11 Endocrine Surveillance 15.5.12 Second Malignancy Screening 15.5.13 Psychological Screening 15.5.14 Fertility Concerns 15.5.15 Summary 15.6 Metabolic Syndrome 15.7 Adherence in the Long-Term Follow-up Setting 15.8 Immunisations Following Stem Cell Transplantation 15.8.1 CAR-T Considerations 15.8.2 COVID-19 15.9 End-of-Life Care in the Haematopoietic Stem Cell Transplant (HSCT) Setting 15.9.1 Background 15.9.2 End-of-Life Care 15.9.3 Care for those Who Are Dying 15.9.4 Managing Symptoms 15.9.5 Support 15.9.6 Conclusion 15.10 Late Effects and Long-Term Follow-Up in Paediatric Patients 15.10.1 Specific Late Effects After HSCT in Childhood 15.10.1.1 Growth Impairment 15.10.1.2 Neurocognitive Impairment 15.10.2 Return to School References Further Reading 16: Nursing Research and Audit in the Transplant Setting 16.1 Introduction/Background 16.2 Service Evaluation: Audit or Research? 16.3 Performing/Undertaking Research 16.4 Interpreting Nursing Research 16.5 Nursing Research 16.5.1 The Research Question 16.5.2 Designs for Nursing Research 16.5.3 Literature Reviews 16.5.4 Quantitative, Qualitative, and Mixed Method Research 16.5.5 Classifications of Research by Time 16.5.6 Cross-Sectional Study Design 16.5.7 Longitudinal Study Design 16.5.8 Prospective Study Design 16.5.9 Retrospective Study Design 16.6 Ethical Issues in Nursing Research 16.7 Conclusion References