Blood & Marrow Transplantation Program
Frequently Asked Questions
What special preparations will I undergo before transplant?
Will I need any additional medical tests before transplant?
Will I have to stay in the hospital?
Why do I have to stay in the hospital?
Will I be able to have visitors before and after the transplant?
What is a caregiver?
How long will I have to remain in the Tampa area?
What is HLA typing?
How are stem cells collected?
What is a conditioning regimen?
How are stem cells transplanted?
How does the bone marrow recover from transplant?
What are the side effects of stem cell transplant?
What is graft-versus-host disease?
What precautions will I need to take?
What special preparations will I undergo before transplant?
To maintain continuous venous access, you are must have a temporary central venous catheter. This catheter will generally stay in place throughout the transplant process and provides access to the major veins so that you can receive chemotherapy, antibiotics, intravenous nutrition, and medications as needed during the transplant. The catheter can also be used for most blood draws.
The catheter is a hollow silicone (plastic) tube similar to intravenous tubing. It is usually placed in the chest; insertion is done in the outpatient surgery department under local anesthesia and generally takes 30-45 minutes. You may feel some discomfort after your catheter is inserted, but it usually goes away in a day or two.
The catheter is left in place for several weeks to months after the transplant. It will require specialized care to maintain function and to decrease the risk of infection of the catheter site. You and your caregiver will be taught how to care for the catheter at home in specialized line care classes offered by the Transplant Program staff.
The catheter is usually removed when you have recovered from the transplant to the extent that you no longer require intravenous medications, nutrition, or blood product transfusions.
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Will I need any additional medical tests before transplant?
All patients are screened prior to transplant to help the medical team evaluate the your physical condition and determine whether you are in adequate physical health to withstand the procedure. These screening tests include, but are not limited to, assessment of heart, lung, kidney, and liver functions. Heart function is generally assessed using a multiple gated acquisition (MUGA) scan. This scan measures how well the heart can pump blood by using a special dye administered intravenously followed by serial pictures of the heart's pumping activity. Lung function is assessed using pulmonary function tests (PFTs). These tests determine the amount of air taken into the lungs with each breath, the amount exhaled with each breath, the speed at which the air is exhaled, and the amount of oxygen that is able to cross through the lungs into the blood. During the performance of PFTs, blood is removed from the artery to determine the levels of oxygen and carbon dioxide in the blood. Kidney function is measured with blood tests and urine samples collected over a period of 24 hours. Liver function also is measured with blood tests.
Other tests may be done to further assess your health. A dental evaluation is required prior to transplant to exclude infections in the gums or roots of the teeth.Additionally, you will undergo staging studies to assess the extent of your disease. These studies will be specific for your disease and may include radiographic tests such as chest or other x-rays, CT scans, MRI scans, bone scans, and PET scans; you will require bone marrow aspirations and biopsies.
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Will I have to stay in the hospital?
The majority of transplant patients do have to stay in the hospital three to four weeks. Some patients may be able to undergo transplants in the outpatient area, depending on the disease and type of transplant. In this case, the patients are required to stay within 30 minutes of Moffitt Cancer Center.
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Why do I have to stay in the hospital?
During and after the transplant, you will be cared for in a specialized nursing unit where the nurses and other personnel are specially trained to recognize, treat, and prevent the side effects that transplant patients experience during the procedure. All transplant patients stay in private rooms and precautions are used to protect them from infections. The entire transplant floor has special filtration devices called HEPA filters to decrease the risk of airborne infections.
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Will I be able to have visitors during the transplant?
Yes, you will be able to have visitors. Visitors will be required to report to the nursing station and to thoroughly wash their hands. Visitors with a cold or any other infection will not be allowed in the BMT units or the clinics. Children may visit you at the hospital if they have no signs and symptoms of infection and have not recently received childhood vaccinations with any of the live vaccines. The child's pediatrician and the transplant team should be consulted prior to bringing them to the BMT unit.
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What is a caregiver?
One of the requirements for a bone marrow transplant is a primary caregiver. This family member or friend will be caring for you 24 hours a day after your discharge from the transplant unit until you return home. Some patients elect to have two caregivers to share or take turns with caregiver responsibilities.
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How long will I have to remain in the Tampa area?
You and your primary caregiver will be required to remain in the Tampa area following transplant until you are sufficiently stable to return home. For patients undergoing autologous transplant, that period of time could range from one to three weeks after discharge from the unit. For patients undergoing allogeneic transplant, the period of time ranges from two to four months. In the case of an outpatient transplant, the patient and the caregiver will remain in Tampa for about 100 days following transplant. Housing arrangements are available through our Psychosocial Oncology team and will be discussed with each patient.
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What is HLA typing?
Human leukocyte antigen (HLA) typing uses laboratory tests to look for specific antigens found on the surface of human white blood cells. These antigens are known as the HLA Class I and Class II antigens. The Class I antigens include the HLA-A, HLA-B, and HLA-C antigens, and the Class II antigens include the HLA-DR, HLA-DQ, and HLA-DP antigens. For each HLA antigen, the body has are two copies known as alleles. Donors and recipients are HLA typed for the Class I and Class II antigens to provide the best possible match. Since HLA-DP antigens are not considered as crucial for the outcome of the transplant, the best match is 10/10. This refers to matching both alleles for the HLA-A, HLA-B, HLA-C, HLA-DR, and HLA-DQ antigens. The minimum required for a recipient and donor to be considered HLA-matched at our center is an 8-of-10 antigen match.
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How are stem cells collected?
Stem cells are most commonly collected for transplant from the peripheral blood. The stem cells need to be mobilized from the marrow into the bloodstream before the collection begins. This is accomplished with the administration of either blood growth factors in the case of normal donors. In the case of autologous transplants, chemotherapy, growth factors or both can be utilized. When stem cells are removed from the circulating blood the procedure is called a peripheral blood stem cell harvest. In this method, the patient (in the case of an autologous transplant) or the donor (in the case of an allogeneic transplant) is connected to an apheresis machine, which uses special filters to remove the white cells from the blood. The remaining blood components (the red blood cells, platelets, and serum) are returned to the patient. The procedure is relatively painless and takes approximately four hours a day and is repeated daily until an adequate number of stem cells are collected within the white cells. For most patients this is usually two days but can be as much as seven days. For most normal donors the procedure takes one full day, but can take as much as three days.
In special cases that are identified by the transplant physician, stem cells are collected from the bone marrow, a procedure called marrow harvest. Marrow harvests are done in the operating room, usually under general anesthesia to ensure that the patient/donor will experience no pain when the marrow is withdrawn. Marrow is drawn from the patient/donor's hipbone using a special syringe and a needle. The harvest itself usually takes about one hour after which the patient/donor is taken to the recovery room. The risks to the patient/donor are minimal; however, the main risk is associated with the use of the general anesthesia. Prior to the harvest, each patient/donor is evaluated by a member of the transplant team and an anesthesiologist to make sure that he/she can tolerate the procedure.
Most patient/donors are released in the evening on the same day of the harvest or the following day. After the harvest, the needle puncture sites may be tender for about one week and some stiffness and difficulty in walking will last for a day or so. In rare cases patient/donors may be tender for up to three weeks. Less than 10 percent of the patient/donor's stem cells are removed and the donor's marrow will grow back quickly. Patients/donors can experience temporary anemia, because approximately 20 percent of the donor's red blood cells are removed during the harvest. To prevent anemia, red blood cells are collected from the donors before undergoing marrow harvest and stored for use following the harvest. Patients will receive regular blood transfusions and do not have red blood cells collected before marrow harvest.
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What is a conditioning regimen?
The conditioning regimen is a treatment plan designed to treat your disease and to prepare your body to receive the transplant. It includes most commonly chemotherapy alone, but at times total body radiation treatments (TBI), or other immunosuppressive medications. It usually takes three to six days to administer the conditioning regimen, depending on the chemotherapies used. Patients undergoing an allogeneic transplant will receive immunosuppressing medications to help their immune system accept the new stem cells. Upon arrival to the transplant unit, you will receive a customized calendar specifying what treatments you will be receiving and the timing of these treatments.
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How are stem cells transplanted?
The stem cell transplant itself is an intravenous infusion of the stem cells. In the case of an autologous stem cell infusion, the stem cells are thawed at the patient's bedside after removal from the freezer and infused immediately. In the case of an allogeneic stem cell infusion, the stem cells are transferred from the collection site, where they have been harvested from the donor, to the stem cell processing laboratory, where they are processed to count the stem cells, and remove the plasma or red cells, if indicated. The stem cells may undergo additional selection processes depending on the transplant protocol. Finally, the stem cells are delivered to the bedside where they are immediately infused. The stem cell transplant usually takes less than one hour in most cases. During the stem cell transplant, the patient is monitored for any signs of an allergic or other reaction so that appropriate treatment can be administered, similar to procedures performed during routine blood transfusions.
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How does the bone marrow recover from transplant?
When engraftment occurs, you will see rising counts of white blood cells (specifically neutrophils), platelets, and red blood cells. Typically, the first cells to engraft are the leukocytes or white blood cells. Neutrophils are the white cells that fight many of the infections. When there are adequate numbers of neutrophils present, the risk of infection decreases. Platelets and red blood cells take longer to engraft. Discharge from the hospital is based on your recovery from the side effects of the chemotherapy (and irradiation) but not necessarily recovery of the blood counts. Generally, patients are discharged to the outpatient clinic, if there are no active infections and if they start to eat and drink. Complications can occur before or after engraftment, or in the case of allogeneic transplants even beyond 100 days after the transplant.
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What are the side effects of stem cell transplant?
The side effects may include, but are not limited to, the following
- Suppression of the bone marrow: white blood cell, red blood cell, and platelet counts will drop very low There is a risk of infection and the need to use antibiotics.
- Need for transfusion of red blood cells
- Risk of bleeding and need for transfusion of platelets
- Sores in the mouth (mucositis)
- Diarrhea and irritation of the intestinal tract
- Nausea and vomiting
- Difficulty eating, and need intravenous nutrition
- Electrolyte abnormalities
- Swelling
- Weakness, fatigue, malaise (feeling bad)
- Rashes and other skin changes
- Hair loss
- Possible damage to the heart, lungs, liver, kidney, bladder or other organs
- Rejection: failure of the stem cells to grow
- Graft-versus-host disease: reaction of the donor immune system against the recipient's organs
- Infertility, temporary or permanent
- Numbness and tingling of the extremities
- Hearing loss
- Eye discomfort and changes in vision sometimes requiring changes in eyewear prescriptions
- Disability
- Death
Additionally, there may be other unanticipated side effects. You will be monitored closely during the entire transplant period. You will receive special therapies prior to, during, and after the transplant to treat and minimize side effects. The risk of dying from a transplant varies and depends on each patient's characteristics, diagnosis, and the type of transplant being performed.
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What is graft-versus-host disease?
One of the unique complications following allogeneic transplant is graft-versus-host disease (GVHD). Acute GVHD occurs soon after transplant, when the growing donor stem cells begin to recognize the recipient as foreign, and the donor cells attack the patient's own cells. This reaction usually involves a rash, diarrhea and/or hepatitis (inflammation of the liver), although other organs are often affected. The risk depends on the degree of matching between you and the donor, your age and sex, the age and sex of the donor, your disease and the conditioning regimen. Allogeneic transplant patients receive immunosuppressive medications and other interventions to prevent GVHD, but it may still happen.
Low-level GVHD is to some extent beneficial because of the graft-versus-tumor effect. For serious GVHD, additional immunosuppressive medications are given to treat and control this complication. In some cases, however, serious GVHD does not respond to these treatments. These additional immunosuppressive medications increase the risk of infections. Chronic GVHD usually occurs more than 90 days after the transplant and can affect the skin, intestinal tract and mucus membranes, liver, lungs and other organs. The treatment is additional immunosuppressive medications. If limited, GVHD may confer an improved chance of disease cure.
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What precautions will I need to take?
Following the transplant, you are required to follow some special precautions to decrease the risk of infections and other complications. These include:
- A special diet
- Avoid crowds
- The use of face masks is of limited value and is not a substitute for staying away from the sick
- Avoid plants, exotic animals and sick pets
- Avoid returning to work until permitted by your transplant physician
- Avoid sun exposure, if you had an allogeneic transplant and always use sunscreen
- Certain limitations will be placed on sexual activity.
You will receive specific instructions concerning these issues at the time of your discharge from the Transplant Unit.