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Winthrop P. Rockefeller Cancer Institute: Stem Cell Transplantation and Cellular Therapy Program

Stem Cell Transplant Day

Once the chemotherapy and radiation treatments are completed, you will receive the donor’s stem cells.

They are given through your central venous catheter. They will travel through your bloodstream and into your bone marrow spaces where they begin to grow, making healthy blood cells. The nurse will check your temperature, blood pressure pulse, and oxygen level while you are receiving the stem cells. You will be in the hospital until your new stem cells start to work reasonably well. This takes about four to six weeks from the day of transplant.

Unmodified Stem Cell Transplant

Allogeneic stem cell transplants can be modified or T cell depleted. In unmodified transplants, the stem cells are given without first taking out the T cells. Red cells or plasma may need to be removed before you receive the stem cells if you and your donor are not the same blood type.

The stem cells are given to you through your IV over several hours. This process is like a blood transfusion or unmodified stem cell transplants.

T Cell Depleted Stem Cell Transplant

A T cell depleted stem cell transplant is one in which certain lymphocytes, known as T cells, are removed. Your doctor may not decide that this type of transplant is best for you. If you are to have a T cell depleted stem cell transplant, you will receive it once the process or removing the T cells is complete. This takes 12-24 hours, so you may receive the transplant either late at night or sometimes, the day after your donor has given the stem cells. The doctor will inject them directly into your central venous IV catheter from a large syringe. There are rarely any side effects.

Unrelated Stem Cell Transplant

After the stem cells are obtained from an unrelated donor, they are immediately brought to UAMS Cell Therapy Lab. Here they are processed for an unmodified or a T cell depleted transplant.

Umbilical Cord Blood Transplant

The cord blood cells are stored frozen. On transplant day, they will be thawed in the laboratory and brought to your room in a bag. They will be given through your catheter. Sometimes patients can feel sick to their stomach or get high blood pressure during the cord blood infusion.

Your doctor and nurse will discuss any questions or concerns you may have about the type of transplant you are going to receive.

Possible Complications after Your Transplant

Some complications are possible after your transplant. Infection, bleeding, and anemia are some of the major ones that can occur while you are waiting for your blood counts to return to normal. In most cases there are steps that you and your care team can take to prevent, manage, and treat them.

Infection

You will be at risk for bacterial, fungal, and viral infections for several months after transplant. They are a major risk in the early recovery period until your new marrow grows and makes white blood cells to fight infection. Some infections will still be a risk while your immune system recovers during the first two years after your transplant.

Fever is one important sign of infection. If you develop a fever, a chest x-ray will be obtained and urine and blood cultures will be done. You will be given IV antibiotics to help your body fight the infection. Nearly all patients develop fever during the first two weeks after transplantation. Most infections are treated successfully with antibiotics.

Your doctors and nurses will try to prevent you from getting infections. You will likely be given drugs that are used to treat infections. For the transplant patient, they are also used to prevent them. You will receive antiviral medicines. These help prevent any viral infection you had in the past from coming back after the transplant.

Viral infections can include:

  • Cold sores
  • Recurrence of genital herpes
  • Shingles
  • Cytomegalovirus
  • Other infections affecting the lungs or gut

Bleeding

Your platelet count will be low. Since platelets form blood clots, you will be at risk for bleeding. The mucous membranes of the nose, mouth, skin, and gastrointestinal tract are most commonly infected. You will have platelet transfusions if your count falls below 10,000 or if you have any bleeding.

Anemia

When your red blood cell count is low, you may experience weakness and fatigue. Your nurse will assist you with your daily activities if you need help. You will be given red blood cell transfusion as necessary. These and all other blood products will be irradiated to prevent harmful side effects.

Organ Complication

You may have complications in your kidneys, liver, lungs, or heart. These are not common, but they can be serious. You are at higher risk if you already have a medical condition in any of these organs. This is why we carefully evaluate your organ functions before the transplant.

Kidneys

Your kidneys filter your blood and make urine to send waste products out of the body. The chemotherapy you get before transplant can affect how well your kidneys work. This is temporary, but waste products may remain in your blood until your kidney function improves. It also means that your kidney will have more trouble getting rid of any drugs you are given. Your nurses will keep records of the amount of fluid you get. This includes what you drink and what you are given through your IV line. They will also write down how much urine you make. This will help the doctors know if you are beginning to have problems with your kidneys. You will also have blood tests every day to tell your doctors how your kidneys are working. If necessary, the doctors will adjust the doses of any drugs you are getting to decrease the risk to your kidneys.

Liver

Your liver removes harmful substances from your body fluids, absorb nutrients, and produces bile. Bile helps you digest your food. Side effects on your liver include problems with digestion. A more serious problem is that the liver may no longer remove breakdown products of your body and you will become jaundiced. In some patients small blood vessels in the liver are injured. This is called Veno-occlusive disease or VOD. These vessels can then become blocked so that blood cannot flow. This can cause the liver to become enlarged and may damage liver cells. Fluid may fill the abdomen. Liver problems of this sort usually begin within the first three weeks after transplant. With rare exception, all patients receive a drug that helps to prevent clot formation in the liver. This drug is called heparin, and it is given through your venous catheter. If you have side effects in your liver, your doctor will discuss the treatment options with you in more detail.

Lungs

Your lungs control breathing. Infections that affect the lungs may cause problems with breathing. Two problems that can occur during transplant are:

  • An infection causing pneumonia and
  • Damage of your lungs from chemo and radiation

This most commonly occurs in the first few weeks after transplant and can be serious. You will have regular chest x-rays while you are in the hospital. Your doctors and nurses will watch you closely for any signs of pneumonia. Tell them if you notice any change in your breathing. Do not ignore a cough or shortness of breath. Treatment depends on what causes the pneumonia.

Exercise your lungs. This may help to keep them clear. Your nurse will show you how to do deep breathing. You may also use an incentive spirometer. For this, you inhale deeply through a small tube to force a tiny ball to rise. You will receive different kinds of medicines to prevent or treat lung infections. Your nurse will review your routine with you.

Heart

Your heart pumps blood throughout your body. Certain chemotherapy drugs may have side effects that damage the heart. Your doctors will watch your heart function carefully while you are in the hospital.

Graft versus Host Disease

T cells are white blood cells whose function is to attack foreign cells. They are responsible for starting GVHD.

GVHD is an immune response of the T cells in the donor transplant (graft) against the patients hosts (body).

There is a chance that GVHD will develop when the new stem cells begin to ‘engraft’ or grow. A close match of

HLA or tissue type between you and your donor helps lower the risk, but does not eliminate it. Other factors in GVHD are your age and the gender of your donor. Anyone whose donor is not and identical twin receives some type of prevention for GVHD. This prevention would include either removal of the T cells from the transplant that causes GVHD, or drugs to prevent those T cells from causing GVHD. There are pros and cons to each method, and there are reasons that you would receive one or the other. Your doctor will discuss these with your before admission.

There are two kinds of GVHD, acute (early) and chronic (late and longer lasting). Acute and chronic GVHD were defined in the past in large part by their timing relative to the transplant. Now acute GVHD no longer occurs only within the first three months. That is because we have many treatments for transplants and many sources for donors. IT can develop later than that, but usually within the first year. Chronic GVHD usually occurs within the first year, but rarely before the first three months after transplant. It may not occur at all. The symptoms of either may be mild to severe. You may develop acute, but not chronic GVHD. You may develop chronic GVHD without having acute. Your may develop both. You may or may not be free of symptoms between acute and chronic. Most patients develop neither or at least milder forms that do not require ongoing treatment beyond two years.

Symptoms of acute GVHD can affect the skin, gastrointestinal tract, liver, or all of these organs. A skin rash may appear on parts or all of your body. You may have a yellow skin color (jaundice) and an enlarged liver. You may also have nausea, vomiting and mild to severe diarrhea.

Chronic GVHD often develops after the first 100 days, and usually within the first year after transplant. Symptoms may include skin rash or dry or thickened skin, loss of appetite and weight, diarrhea, dry mouth and sores in the mouth, dry eyes, hair loss, inflammation of the liver, loss of energy, or increased risk for infections.

GVHD can be mild or severe. It may slow the growth of the bone marrow. This means it will take longer for your immune system to function. It may affect one or more parts of the body. If you have it, your doctor will discuss the treatment plan with you. Mild cases of GVHD may be helpful for patients with active leukemia and lymphoma going into transplant. Return of this disease is lower in transplant survivors who had mild GVHD. That is because the donor T cells may attack any remaining cancer cells. Doctors are doing more research to learn how to maximize this anti-cancer effect. If your disease was in complete remission before transplant, you do not need the beneficial effect of GVHD.

Graft Failure or Rejection

The transplanted cells sometimes do not grow up successfully inside your body. Graft rejection means your immune system rejects the new stem cells. The treatment you get before the transplant are aimed at preventing the graft rejection. The risk of rejection lasts about two to four weeks after the transplant. Occasionally, graft failure can be at a later time after your transplant if it occurs, one option may be to get more stem cells from your donor if they are available. This is called a ‘boost’. Your doctor will discuss various treatment options with you if this occurs.

Relapse

A risk for many patients is that their disease can comeback. This can happen if the treatments you had before the transplant did not kill all of your cancer cells. Your risk is higher if you have your transplant when you are in an advanced stage of disease or are already in relapse.

Infection Precautions at a Glance

Personal Hygiene

Keeping yourself clean is very important. You will follow a shower routine that includes washing your skin daily. Start with your neck and move down your body. Wash your upper body, middle section, legs finally your feet. Pay extra attention to washing under your arms, groin, and perineum since these areas are moist and harbor germs. The perineum is the area between a woman’s vagina and rectum and a man’s penis and rectum. Shampoo your scalp with ordinary shampoo or soap once a day. Tell your nurse if you need help.

Germs are often carried on your hands or on objects that your touch. Wash your hands thoroughly with soap after you urinate or move your bowels. Also wash your hands before eating.

Keep the skin clean around your central venous IV catheter. The dressing that covers and protects it will be changed once a week unless it gets wet or dirty. To reduce the chance of infection, do not let the IV tubing touch the floor.

Oral Hygiene

Take good care of your mouth throughout your hospitalization. Good mouth care can help prevent infections and other complication in your mouth. The nurse will work with you to plan your mouth care routine. Below are some of the guidelines to follow:

  • You will be given a mouthwash was to rinse your mouth before and after meals and at bedtime. Use only the mouth wash your nurse gives you. Do not use a commercial mouthwash or toothpaste because these products irritate and dry the mucous membranes of the mouth and throat.
  • When your platelet count is low, you may bleed easily. Use extra caution when brushing your teeth, and always use an ultra-soft tooth brush.
  • Do not use dental floss
  • Avoid licking your lips. This increase drying and chapping.
  • To keep our lips moist, apply a lubricant after mouth care and every two to four hours as needed.
  • If your mouth becomes sensitive, avoid hot, spicy, acidic, or coarse foods. You may prefer soft or liquid food served chilled or at room temperature.
  • Tell your nurse if you have any tenderness, discomfort or pain in your mouth. If your mouth becomes painful, your doctors will prescribe medicine to decrease the pain.

Protective Isolation

You will be on reverse isolation precautions to protect you from outside germs. Once they are started, you will be on them until you are discharged.

Bleeding Precautions

Since platelets work to prevent and control bleeding, you will have a higher chance of bleeding when your platelet count is low. The nurse will check your stool and urine routinely for blood. You should also:

  • Use an electric razor when shaving.
  • Follow safety measures to prevent falls or accidents.
  • To protect yourself while walking, wear slippers with rubber soles.
  • Do not use nail clippers or scissors
  • Tell the health care team if you have any signs of bleeding, such as a nosebleed from your gums, increased bruising, bright red or black stools, or blood- tinged vomit.

Transfusions

Your blood count will be checked every day; the counts will be below normal until the stem cells start to grow. You may need red blood cell and platelet transfusions.

*Red blood cell transfusions are usually given when the hemoglobin falls below 7.

*You will have platelet infusions when your platelet count falls below 10,000.

Basic Guidelines for Blood Donors

If your friends and family would like to support your cause by donating blood or platelets they may call the

Arkansas Red Cross at: 501-614-4400

The blood donation center is located at 401 S. Monroe Little Rock AR, 72205

Donating red blood cells takes about one hour and involves using one arm. An individual can donate blood again 56 days after his or her donation. Blood can be stored for 30 days.

It takes about 2 ½ hours to donate platelets. It usually involves only one arm. A donor can give platelets as often as twice a week it can be done 72 hours before or after a blood donation. Platelets can be stored for five days.

To schedule an appointment to donate blood or platelets, donors should call the Arkansas Red Cross at (501) 614-4400.

Blood product or donors must:

  • Be 17-75 years of age.
  • Weigh over 110 pounds or (50 kilograms).
  • Not have signs of a cold or active allergy at the time of donation.
  • Not have a history or any illness such as hepatitis, jaundice, cancer, etc.
  • Call the donor room if they are taking any medication and wish to donate.
  • Not take aspirin, or any product that contains aspirin-like drugs (ibuprofen, Motrin, Naprosyn, Anaprox, Advil, and Aleve) within three days before donating. Acetaminophen (Tylenol, Anacin 3) is acceptable
  • Not drink alcohol eight hours before donating.
  • Have a lighter meal before donating.
  • Avoid fatty foods before donating.

It may take up to 18 months for your immune system to recover. With some patients, it takes even longer while some recover in six months. We will do blood tests to see how your immune recovery is progressing. These begin about two to three months after your transplant. The tests will tell us how many T cells you have and how well they are working. You will take medicine to prevent infection until we know your immune system can fight off infections. When that happens, you will most likely be given vaccinations to re-immunize you against some diseases. These vaccinations are similar to some of the vaccines you received as a child.

Stress and Anxiety

We know that it can be frightening to have new treatments or to stay in your room for such a long time. Some transplant patients have told us that they feel bored in the room because “there’s nothing to do.” Others have said, they are “tired of feeling sick” and “can’t wait to go home,” or they “are anxious and depressed.” It is natural to feel like this, and sometimes it helps just to talk about things. Please talk with your nurse, social worker, or doctor about your feelings. Psychiatrists are also available to talk to you and your family. They can advise the transplant team about medications for your emotions. It is important that we all work together.