Advances in the treatment of cancer and improvements in supportive care over the past 10 years have improved the results and tolerability of blood and marrow transplants (BMT). However, BMT remains a major procedure. For allogeneic transplantation, the patient receives bone marrow or blood stem cells from a tissue-matched (HLA-matched) donor who may or may not be a relative. Identical twin allogeneic transplants are called syngeneic transplants.
You will be admitted to the hospital on the day your high-dose preparative therapy begins. Your admission date may be changed based on your health status or bed availability. The length of your admission will be about four to six weeks.
High Dose Chemotherapy
Chemotherapy begins soon after you are admitted to the hospital. Your doctor will discuss all the drugs you will receive and their side effects. Your nurse practitioner, inpatient nurse and pharmacist also will be available to answer questions. In addition, you may receive written information on these drugs in a consent form.
Precautions are taken to minimize side effects from these drugs. For example, when receiving some types of chemotherapy, patients must shower thoroughly twice a day to remove the drug that is excreted through the skin – this is done to help prevent or minimize chemotherapy burns. The inpatient nurse will go over any other special precautions that you may need to take.
Total Body Irradiation
Some patients receive total body irradiation (TBI) in addition to chemotherapy. This radiation therapy is intended to destroy remaining cancer cells and further suppress the immune system.
TBI treatments are given in the radiotherapy department, usually over a period of three to four days. The treatment itself is painless, but there may be uncomfortable side effects after treatment, such as mouth and throat sores, nausea, stomach and intestinal irritations, and skin redness. Antinausea medication is usually given before each treatment to reduce nausea.
The Transplant Procedure
The transplant of blood stem cells or bone marrow will be infused one to three days after the last chemotherapy or radiation dose. The day of transplantation is referred to as Day 0. The days before the transplant are counted as minus days and the days after the transplant are plus days.
The transplant procedure is similar to a simple blood transfusion and will be done in your hospital room. You may have a family member in the room with you if you wish. The actual procedure will take approximately one hour, depending on the volume of stem cells. The blood stem cells will be infused through your central venous catheter just like a regular blood transfusion. Your nurse will check your blood pressure, temperature, breathing and pulse, and will watch for any side effects.
Usually there are no side effects, but occasionally patients may experience chills, flushing of the face, nausea and vomiting, headache, and changes in blood pressure and breathing. Your urine also may be tinged red for the first 24 hours after transplantation. If your urine remains red after this time or becomes red later, tell your nurse.
Waiting for Engraftment
The new bone marrow does not recover immediately after it has been transplanted. The stem cells of the transplanted marrow will travel to the bones, reseed the marrow space, and go through a growth process before the mature cells are released from the bone marrow into the blood stream. It takes approximately two to three weeks for your marrow to start producing white blood cells, red blood cells and platelets.
Engraftment is the term used to describe when your new marrow begins to function and produce blood cells. While awaiting engraftment, no mature cells leave the marrow and enter the blood stream. Your blood counts will show very low values and you will require careful monitoring by the health care team. The goal is to support you with red blood cell and platelet transfusion until you are producing cells again. You will also need antibiotics to prevent infections from bacteria, fungi and viruses.
Delayed Side Effects
The body feels the effects of the chemotherapy or radiation about a week after a BMT. When the blood counts are low, you feel like you have the flu and may not want to do much. This will last for about two weeks and will decrease as your blood counts improve. You may notice a number of other symptoms as well, including:
- Loss of appetite
- Nausea and vomiting
- Changes in vision
- Mouth and throat soreness
- Difficulty sleeping and fatigue
- Hair loss
- Skin reactions
- Graft-versus-host disease
Preparing to Leave the Hospital
When your neutrophil count is rising, your team will start talking to you about discharge. You will need to be sure that arrangements have been made for someone to stay with you after you are discharged, to assist you with daily needs and to be available for clinic visit transportation. You and a family member will learn how to care for your catheter and all about your medications.
To be discharged, you will need to be:
- Eating at least 1,000 calories daily
- Drinking at least one quart of fluid daily
- Free of active medical problems
- Without a fever
- Off most intravenous medications and taking your pills without problems
- Show that you can care for your intravenous catheter
A case manager will assist with arrangements for home care. The nurse practitioner will go over your discharge and outpatient instructions and the pharmacist will review your medications with you.
Routine Outpatient Visits
Your BMT doctor and nurse practitioner will follow you closely after your transplant. You will have blood work done and, if necessary, will be given intravenous medications or fluids. Expect to be in the Hematology/BMT Clinic twice a week for at least two to three months.
Your risk of infection will remain higher than normal for at least six to 12 months after allogeneic BMT even though your body is again producing white blood cells. You will be instructed on how to help prevent infection, including washing your hands, avoiding large crowds and refraining from smoking cigarettes or marijuana.
The Caregiver's Role
All patients undergoing an allogeneic bone marrow or stem cell transplant are required to have an identified person who can assist them after they are discharged from the hospital. We call this person the "caregiver." In order to be approved for an allogeneic BMT each patient must identify a person or persons who can fulfill the responsibilities of the caregiver, which include:
- Providing emotional support
- Providing physical support
- Gathering and reporting information
- Caring for a central venous catheter
- Managing and understanding medications
UCSF Health medical specialists have reviewed this information. It is for educational purposes only and is not intended to replace the advice of your doctor or other health care provider. We encourage you to discuss any questions or concerns you may have with your provider.
Charalambos (Babis) Andreadis
Kristen M. Hege
Lawrence D. Kaplan
Thomas G. Martin
Rebecca L. Olin
Catherine C. Smith
Jeffrey L. Wolf