Bone Marrow and Stem Cell Transplants: Donor Selection, Surgery, and Recovery

High Angle View Of Person During Bone Marrow Donation
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A bone marrow transplant is a procedure in which special cells (called stem cells) are removed from the bone marrow or peripheral blood, filtered, and given back either to the same person or to another person. Since we now derive most stem cells needed from the blood rather than the bone marrow, a bone marrow transplant is now more commonly referred to as stem cell transplant.

Bone marrow is found in larger bones in the body such as the pelvic bones. This bone marrow is the manufacturing site for stem cells. Stem cells are "pluripotential," meaning that the cells are the precursor cells which can evolve into the different types of blood cells, such as white blood cells, red blood cells, and platelets. If something is wrong with the bone marrow or the production of blood cells is decreased, a person can become very ill or die.

The purpose of a bone marrow transplant is thus to replace cells not being produced or replace unhealthy stem cells with healthy ones. This can be used to treat or even cure certain diseases.

Reasons for a Bone Marrow Transplant

Bone marrow transplants are typically done in patients with blood cancers, such as leukemia or lymphoma, and bone marrow diseases like aplastic anemia.

In conditions such aplastic anemia, the bone marrow stops producing blood cells needed for the body. In diseases such as leukemia, the bone marrow produces abnormal blood cells.

In addition to leukemias, lymphomas, and aplastic anemia, stem cell transplants are being evaluated for many disorders, ranging from solid tumors to other non-malignant disorders of the bone marrow to multiple sclerosis and sickle-cell disease.

Who Is Not a Good Candidate? 

You may be turned down for a bone marrow transplant under the following circumstances:

  • You have an uncontrolled infection.
  • You have severe cardiac, vascular, kidney, liver, or lung disease.
  • You suffer from disabling psychosis.
  • You are over age 75.

23,000 bone marrow or umbilical cord transplants were performed in 2017.

Types of Bone Marrow Transplants

There are two primary types of bone marrow transplants:

Autologous Bone Marrow Transplant

The Greek prefix "auto" means "self." In an autologous transplant, the donor is the person who will also receive the transplant. This procedure, also known as a "rescue transplant" involves removing your stem cells and freezing them. You then receive high dose chemotherapy followed by infusion of the thawed out frozen stem cells. It may be used to treat leukemias, lymphomas, or multiple myeloma.

Allogenic Bone Marrow Transplant

The Greek prefix "allo" means "different" or "other." In an allogeneic bone marrow transplant, the donor is another person who has a genetic tissue type similar to the person needing the transplant. Because tissue types are inherited, similar to hair color or eye color, it is more likely that you will find a suitable donor in a family member, especially a sibling. Unfortunately, this occurs only 25% to 30% of the time.

If a family member does not match the recipient, the National Marrow Donor Program Registry database can be searched for an unrelated individual whose tissue type is a close match. It is more likely that a donor who comes from the same racial or ethnic group as the recipient will have the same tissue traits.

There is a type of allogeneic transplant called a haploidentical transplant. With this, healthy, blood-forming cells from a half-matched donor replace the unhealthy ones. A half-matched donor is one where the donor matches exactly half of your tissue traits. Half-matched donors usually include a person's mother, father, or child. Parents are always a half-match for their children. Siblings have a 50% chance of being a half-match for each other.

In a non-myeloablative bone marrow transplant, or "mini-bone marrow transplant," lower doses of chemotherapy are given that do not completely wipe out or "ablate" the bone marrow as in a typical bone marrow transplant. This approach may be used for someone who is older or otherwise might not tolerate the traditional procedure. In this case, the transplant works differently to treat the disease as well. Instead of replacing the bone marrow, the donated marrow can attack cancerous cells left in the body in a process referred to as "graft versus malignancy."

Your doctor will recommend an autologous or allogenic transplant based on the type of disease you have, as well as the health of your bone marrow, your age, and overall health. For example, if you have cancer or other disease (such as aplastic anemia) in your bone marrow, using your own stem cells is not recommended.

Bone Marrow Donor Procedure

Bone marrow cells can be obtained in three primary ways. These include:

  • Bone marrow harvest: In a bone marrow harvest, stem cells are collected directly from the bone marrow.
  • Apheresis or leukapheresis: In an apheresis, the stem cells are collected from peripheral circulating blood cells (PBSC). An intravenous line is inserted in your arm similar to if you were to donate blood.
  • Umbilical cord blood: Stem cells may also be obtained from cord blood banks, which store blood from the umbilical cord shortly after a baby is born. Since these stem cells are immature, there is less need for a perfect match.

Donating stem cells or bone marrow is fairly easy. In most cases, a donation is made using circulating stem cells (PBSC) collected by apheresis. First, the donor receives injections of a medication for several days that causes stem cells to move out of the bone marrow and into the blood. For the stem cell collection, the donor is connected to a machine by a needle inserted in the vein (like for donating blood). Blood is taken from the vein, filtered by the machine to collect the stem cells, then returned back to the donor through a needle in the other arm. There is almost no need for a recovery time with this procedure.

If stem cells are collected by bone marrow harvest (much less likely), the donor will go to the operating room and while asleep under anesthesia and a needle will be inserted into either the hip or the breastbone to take out some bone marrow. After awakening, there may be some pain where the needle was inserted.

Anyone between the ages of 18 and 60 and in good health can become a donor. There is a form to fill out and a blood sample to give; you can find all the information you need at the National Marrow Donor Program website. You can join a donor drive in your area or go to a local Donor Center to have the blood test done.

Before the Transplant

Once your insurance company has authorized your transplant, you will need to have several before undergoing the actual transplant. These include:

  • Blood tests
  • Urine tests
  • Electrocardiogram (EKG), which measures the heart’s rhythm and function.
  • Echocardiogram, an ultrasound of the heart
  • Chest x-ray
  • Pulmonary function test (PFT) which involves inhaling and exhaling into a machine to measure lung function
  • Computerized Tomography (CT Scan)
  • Magnetic Resonance Imaging (MRI)
  • Positron Emission Tomography (PET scan)
  • A bone marrow biopsy—an outpatient procedure to obtain samples for testing the bone marrow function

You will also meet with a social worker, along with your caregiver(s), to discuss emotional and practical aspects of the transplant (such as how long you will stay in the hospital and who will care for you once you're home).

Finally, you will have a central line implanted. This is a small tube inserted into the large vein in the chest or neck, just above the heart. It makes it easier for your healthcare providers to administer medications, take blood samples, and perform transfusions. It will also reduce the number of needle pokes you’ll need.

Once you have received pre-transplant testing and had your central line inserted, you will have what's called a "preparative" or "conditioning" regimen in order to prepare your body for the transplant itself. You will receive high dose chemotherapy and/or radiation therapy to destroy any cancerous cells throughout the body and make room for the new cells. The regimen may take two to eight days and will destroy your immune system so it can't attack the donated cells after the transplant.

Side effects during this time are the same as with any chemotherapy or radiation treatment, and may include nausea, vomiting, low white-cell count, mouth sores, and hair loss.

During the Transplant

Once a person's original bone marrow is destroyed, the new stem cells are injected intravenously, similar to a blood transfusion. If your cells arrive frozen, the nurse will thaw them in a heated water bath at your bedside and infuse them through your central line into your blood stream. The cells are preserved with a chemical called dimethylsulfoxide (DMSO) that protects the cells during the freezing and thawing process. This preservative will cause your room to have an odor for a day or two.

The stem cells then find their way to the bone and start to grow and produce more cells, a process known as engraftment.

You will be given medications to prevent a possible reaction(s) that may occur due to the preservative in the stem cells or bone marrow. These medications may make you sleepy during the procedure. Your vital signs will be checked often and you will be closely observed by your nurse. You may also have a bad taste in your mouth, or feel a tickle in your throat or experience coughing during the infusion.

Following the transplant, your blood counts will be monitored daily. You will be informed of your results and transfusions of blood and platelets will be given as needed. The nurse will tell you about special precautions to take when your blood counts are low.

The time for your bone marrow to engraft and start to work and make new white cells, red cells, and platelets differs depending on the type of transplant you receive.

Complications

The most critical time is usually when the bone marrow is destroyed so that few blood cells remain. Destruction of the bone marrow results in greatly reduced numbers of all of the types of blood cells (pancytopenia). Without white blood cells, there is a serious risk of infection, and infection precautions are used in the hospital (isolation). Low levels of red blood cells (anemia) often require blood transfusions while waiting for the new stem cells to begin growing. Low levels of platelets (thrombocytopenia) in the blood can lead to internal bleeding.

A common complication affecting 40% to 80% of patients receiving donor bone marrow or cells is graft versus host disease. This occurs when white blood cells (T cells) in the donated cells attack tissues in the recipient; this can be life-threatening. To prevent this, you will be given immunosuppressive drugs for an indefinite period of time.

There is a possibility that high dose chemotherapy as well as a number of other medications required during transplant can cause a decrease in the ability of your lungs, heart, kidney or liver to function. These organ toxicities are usually mild as well as temporary and reversible. Sterility is a potential complication of high dose chemotherapy Although most patients who undergo a transplant will be infertile afterwards, those who do not wish to become pregnant should not assume they cannot. The normal options of avoiding unwanted pregnancies need to be practiced.

After the Transplant

It usually takes two to three weeks for your white blood cell count to be high enough to be discharged from the hospital; when cord stem cells are used, it can take four weeks. You are at high risk for infection at this time, so you will need to take precautions such as:

  • Taking antibiotics, antiviral and antifungal medications, as well as granulocyte colony stimulating factors (G-CSF) as prescribed by your doctor.
  • Avoiding interaction with other people.
  • Practicing proper hygiene.
  • Avoiding plants and flowers, which can harbor bacteria.
  • Avoiding certain foods.

Your white blood cell count may be in the normal range when you are discharged from the hospital, but your immune system may not function normally for as long as one year. Here are some guidelines to help you stay free from infections:

  • Make sure hands are washed after touching an animal, before and after meals, before preparing food, after using the toilet, and before taking medications. (If you must change a baby's diaper, wear disposable gloves and wash your hands immediately afterward.)
  • Avoid large crowds and people with infections or colds for at least one month.
  • Take your temperature at the same time once or twice a day.
  • Avoid swimming in oceans, lakes, public pools, rivers, or hot tubs for three months.
  • Talk to your doctor before receiving any immunizations.

Call your doctor immediately if you experience any of the following symptoms:

  • A temperature greater than 100.5 degrees
  • A persistent cough
  • Chills with or without fever, or chills that occur after your central line is flushed
  • Nausea and vomiting
  • Persistent pain
  • Diarrhea, constipation, or pain with bowel movements
  • Shortness of breath
  • Redness, swelling, drainage, or tenderness at your catheter site
  • Pain, burning, or increased frequency of urination
  • Sores in the mouth or throat
  • Any sore or wound that does not heal
  • Any unusual vaginal discharge or itching
  • Exposure to chicken pox
  • Sudden bruises or hives
  • Headache that persists or any severe headache
  • Blurry vision
  • Persistent dizziness

Prognosis

The goal of stem cell transplants is to cure disease. A cure may be possible for some cancers, such as some types of leukemia and lymphoma, but for others, remission is the best result. Remission refers to a period in which there are no signs or symptoms of cancer. After a transplant, you'll need to see your doctor and have tests to watch for any signs of cancer or complications from the transplant. Some patients will experience a relapse of their disease even after a transplant.

There is no overall survival rate for bone marrow and stem cell transplants, as survival depends on numerous factors, including your age, your specific disease, how close of a match the healthy stem cells were, and your overall health prior to the transplant.

The National Marrow Donor Program has a directory of transplant centers with data on each one's one-year survival rate.

Support and Coping

A bone marrow transplant can be a very physically and emotionally demanding experience. Most hospitals and transplant centers will offer support services for you as well as your loved ones as you go through the process. The National Marrow Donor Registry/Be the Match Support Center offers individual, peer, and group support programs, as well as referrals to other support resources.

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