A bone marrow transplant is a procedure to replace damaged or destroyed bone marrow with healthy bone marrow stem cells. Bone marrow is the soft, fatty tissue inside your bones. The bone marrow produces blood cells. Stem cells are immature cells in the bone marrow that give rise to all of your different blood cells. Before the transplant, chemotherapy, radiation, or both may be given.
This may be done in two ways:
- Ablative (myeloablative) treatment — High-dose chemotherapy, radiation, or both are given to kill any cancer cells. This also kills all healthy bone marrow that remains and allows new stem cells to grow in the bone marrow.
- Reduced intensity treatment, also called a mini transplant — Lower doses of chemotherapy and radiation are given before a transplant. This allows older people, and those with other health problems to have a transplant.
There are three kinds of bone marrow transplants:
- Autologous bone marrow transplant — The term auto means self. Stem cells are removed from you before you receive high-dose chemotherapy or radiation treatment. The stem cells are stored in a freezer. After high-dose chemotherapy or radiation treatments, your stems cells are put back in your body to make normal blood cells. This is called a rescue transplant.
- Allogeneic bone marrow transplant — The term allo means other. Stem cells are removed from another person, called a donor. Most times, the donor’s genes must at least partly match your genes. Special tests are done to see if a donor is a good match for you. A brother or sister is most likely to be a good match. Sometimes parents, children, and other relatives are good matches. Donors who are not related to you, yet still match, may be found through national bone marrow registries.
- Umbilical cord blood transplant — This is a type of allogeneic transplant. Stem cells are removed from a newborn baby’s umbilical cord right after birth. The stem cells are frozen and stored until they are needed for a transplant. Umbilical cord blood cells are very immature so there is less of a need for perfect matching. Due to the smaller number of stem cells, blood counts take much longer to recover.
A stem cell transplant is usually done after chemotherapy and radiation is complete. The stem cells are delivered into your bloodstream, usually through a tube called a central venous catheter. The process is similar to getting a blood transfusion. The stem cells travel through the blood into the bone marrow. Most times, no surgery is needed.
Donor stem cells can be collected in two ways:
- Bone marrow harvest — This minor surgery is done under general anesthesia. This means the donor will be asleep and pain-free during the procedure. The bone marrow is removed from the back of both hip bones. The amount of marrow removed depends on the weight of the person who is receiving it.
- Leukapheresis — First, the donor is given several days of shots to help stem cells move from the bone marrow into the blood. During leukapheresis, blood is removed from the donor through an IV line. The part of white blood cells that contains stem cells is then separated in a machine and removed to be later given to the recipient. The red blood cells are returned to the donor.
A bone marrow transplant may be used to:
- Safely allow treatment of your condition with high doses of chemotherapy or radiation by replacing or rescuing the bone marrow damaged by treatment
- Replace diseased or damaged marrow with new stem cells
- Provide new stem cells, which can help kill cancer cells directly
Bone marrow transplants can benefit people with a variety of both cancerous (malignant) and noncancerous (benign) diseases, including:
- Acute leukemia
- Aplastic anemia
- Bone marrow failure syndromes
- Chronic leukemia
- Hodgkin’s lymphoma
- Immune deficiencies
- Inborn errors of metabolism
- Multiple myeloma
- Myelodysplastic syndromes
- Non-Hodgkin’s lymphoma
- Plasma cell disorders
- POEMS syndrome
- Primary amyloidosis
Bone Marrow Transplant Process Include:-
- Stem cell infusion
- Neutropenic phase
- Engraftment phase
- Post- engraftment phase
The conditioning period last for 7-10 days
The purpose are ( by delivery of chemo and / or radiation therpy).
- To eliminate Maligancy
- To provide immune suppression to prevent rejection of new stem cell
- Create space for new cells
Stem cell processing and infusion
- Infusion – 20 minutes to an hour , varies depending on the volume infused
- The stem cell may be processed before infusion , if indicated
- Depletion of T-cells can be performed to decrease GVHD
- Infused through a CVL , much like blood transfusion
Anaphylaxis , volume overload , and a (rare) transient GVHD are the major potential complication involved.
Stem cell product that have been cryopreserved contain dimethyl sulfoxide as a preservative and potentially can cause renal failure, in addition to the unpleasant smell and taste.
During the period(2-4 weeks) , the patient essentially has no effective immune system Healing is poor and the patient is very susceptible to infection Supportive care and empiric antibiotic therapy are the mainstays of successful passage through this phase.
During this period(several weeks), the healing process begins with resolution of mucosities and lesions required in addition fever begin to subside and infection often begin to clear. The greatest challenges at this time are management of GVHD and prevention of viral infections(Especially CMV)
Post –engraftment phase
This period last for months to year hallmark of this phase includes the gradual development of tolerance weaning off of immunosuppression management of chronic GVHD and documentation of immune reconstition.
Graft-versus-host disease: A potential risk when stem cells come from donors
If you receive a transplant that uses stem cells from a donor (allogeneic transplant), you may be at risk of developing graft-versus-host disease (GVHD). This condition occurs when the donor stem cells that make up your new immune system see your body’s tissues and organs as something foreign and attack them.
GVHD may happen at any time after your transplant. Many people who have an allogeneic transplant get GVHD at some point. The risk of GVHD is a bit greater if the stem cells come from an unrelated donor, but it can happen to anyone who gets a bone marrow transplant from a donor.
There are two kinds of GVHD: acute and chronic. Acute GVHD usually happens earlier, during the first months after your transplant. It typically affects your skin, digestive tract or liver. Chronic GVHD typically develops later and can affect many organs.
Chronic GVHD signs and symptoms include:
- Joint or muscle pain
- Shortness of breath
- Persistent cough
- Vision changes, such as dry eyes
- Skin changes, including scarring under the skin or skin stiffness
- Yellow tint to your skin or the whites of your eyes (jaundice)
- Dry mouth
- Mouth sores
Before the Procedure
Your provider will ask about your medical history and do a physical exam. You will have many tests before treatment begins.
Before transplant, you will have 1 or 2 tubes, called central venous catheters, inserted into a blood vessel in your neck or arms. This tube allows you to receive treatments, fluids, and sometimes nutrition. It is also used to draw blood. Your provider will likely discuss the emotional stress of having a bone marrow transplant. You may want to meet with a counselor. It is important to talk to your family and children to help them understand what to expect.
You will need to make plans to help you prepare for the procedure and handle tasks after your transplant:
- Complete an advance care directive
- Arrange medical leave from work
- Take care of bank or financial statements
- Arrange care of pets
- Arrange for someone to help with household chores
- Confirm health insurance coverage
- Pay bills
- Arrange for care of your children
- Find housing for yourself or your family near the hospital, if needed
After the Procedure
A bone marrow transplant is usually done in a hospital or medical center that specializes in such treatment. Most of the time, you stay in a special bone marrow transplant unit in the center. This is to limit your chance of getting an infection.
Depending on the treatment and where it is done, all or part of an autologous or allogeneic transplant may be done as an outpatient. This means you do not have to stay in the hospital overnight.
How long you stay in the hospital depends on:
- Whether you developed any complications related to the transplant
- The type of transplant
- Your medical center’s procedures
While you are in the hospital:
- The health care team at (Bone Marrow Transplant Hospital) will closely monitor your blood count and vital signs.
- You will receive medicines to prevent GVHD and prevent or treat infections, including antibiotics, antifungals, and antiviral medicine.
- You will likely need many blood transfusions.
- You will be fed through a vein (IV) until you can eat by mouth, and stomach side effects and mouth sores have gone away.
After you leave the hospital, be sure to follow instructions on how to care for yourself at home.
Pretransplant tests and procedures
You’ll undergo a series of tests and procedures to assess your general health and the status of your condition, and to ensure that you’re physically prepared for the transplant. The evaluation may take several days or more.
In addition, a surgeon or radiologist will implant a long thin tube (intravenous catheter) into a large vein in your chest or neck. The catheter, often called a central line, usually remains in place for the duration of your treatment. Your transplant team will use the central line to infuse the transplanted stem cells, medications and blood products into your body.
Collecting stem cells for autologous transplant
If a transplant using your own stem cells (autologous transplant) is planned, you’ll undergo a procedure called apheresis (af-uh-REE-sis) to collect blood stem cells.
Before apheresis, you’ll receive daily injections of growth factor to increase stem cell production and move stem cells into your circulating blood so that they can be collected.
During apheresis, blood is drawn from a vein and circulated through a machine. The machine separates your blood into different parts, including stem cells. These stem cells are collected and frozen for future use in the transplant. The remaining blood is returned to your body.
Collecting stem cells for allogeneic transplant
If you’re having a transplant using stem cells from a donor (allogeneic transplant), you will need a donor. Once a donor is found, stem cells are gathered from that person for the transplant.
Stem cells can come from your donor’s blood or bone marrow. Your transplant team decides which is better for you based on your situation.
Another type of allogeneic transplant uses stem cells from the blood of umbilical cords (cord blood transplant). Mothers can choose to donate umbilical cords after their babies’ births. The blood from these cords is frozen and stored in a cord blood bank until needed for a bone marrow transplant.
What you can expect
During your bone marrow transplant:- Your bone marrow transplant occurs after you complete the conditioning process. On the day of your transplant, stem cells are infused into your body through your central line. The transplant infusion is painless. You’ll be awake during the procedure. After your bone marrow transplant when the new stem cells enter your body, they travel through your blood to your bone marrow. In time, they multiply and begin to make new, healthy blood cells. This is called engraftment. It usually takes several weeks before the number of blood cells in your body starts to return to normal. In some people, it may take longer.
In the days and weeks after your bone marrow transplant, you’ll have blood tests and other tests to monitor your condition. You may need medicine to manage complications, such as nausea and diarrhea.
After your bone marrow transplant, you’ll remain under close medical care. If you’re experiencing infections or other complications, you may need to stay in the hospital for several days or sometimes longer. Depending on the type of transplant and the risk of complications, you’ll need to remain near the hospital for several weeks to months to allow close monitoring.
You may also need periodic transfusions of red blood cells and platelets until your bone marrow begins producing enough of those cells on its own.
You may be at greater risk of infections or other complications for months to years after your transplant. You’ll have periodic lifelong follow-up appointments with your doctor to monitor for late complications.
Medications After Bone Marrow Transplant
If your bone marrow transplant is using stem cells from a donor (allogeneic transplant), your doctors may prescribe medications to help prevent graft-versus-host disease and reduce your immune system’s reaction (immunosuppressive medications).
After your transplant, it takes time for your immune system to recover. During this time, you may be given medications to prevent infections.
Diet and other lifestyle factors
After your bone marrow transplant, you may need to adjust your diet to stay healthy and to prevent excessive weight gain. Your nutrition specialist (dietitian) and other members of your transplant team will work with you to create a healthy-eating plan that meets your needs and complements your lifestyle. Your dietitian can also give you food suggestions to control side effects of chemotherapy and radiation, such as nausea.
Some of your dietitian’s recommendations may include:
- Following food safety guidelines to prevent foodborne infections
- Eating a wide variety of healthy foods, including vegetables; fruits; whole grains; lean meats, poultry and fish; legumes; and healthy fats, such as olive oil
- Limiting salt intake
- Restricting alcohol
- Avoiding grapefruit and grapefruit juice due to their effect on a group of immunosuppressive medications (calcineurin inhibitors)
After your bone marrow transplant, regular physical activity helps you control your weight, strengthen your bones, increase your endurance, strengthen your muscles and keep your heart healthy. As you recover, you can slowly increase your physical activity.
Taking steps to prevent cancer is even more important after your transplant. Don’t smoke. Wear sunscreen when you’re outside, and be sure to get the cancer screenings your doctor recommends.
A bone marrow transplant can cure some diseases and put others into remission. Goals of a bone marrow transplant depend on your individual situation, but usually include controlling or curing your disease, extending your life, and improving your quality of life.
Some people complete bone marrow transplantation with few side effects and complications. Others experience numerous challenging problems, both short and long term. The severity of side effects and the success of the transplant vary from person to person and sometimes can be difficult to predict before the transplant.
It can be discouraging if significant challenges arise during the transplant process. However, it is sometimes helpful to remember that there are many survivors who also experienced some very difficult days during the transplant process but ultimately had successful transplants and have returned to normal activities with a good quality of life.
Types of Bone Marrow Transplant:
There are two major types of bone marrow transplants. The choice of transplant will depend upon the type of disease a patient is suffering from –