ACS :: Problems After Transplant

During the first 6 weeks after transplant, until the new bone marrow starts making white blood cells (engraftment), you can easily get infections. During this time of having low white blood cell counts you are said to be neutropenic. (See "White blood cells (leukocytes)" in the "What Is a Bone Marrow or Stem Cell Transplant?" section for more information.) Bacterial infections are the most common during this time. And even common infections, like colds, can be quite dangerous for you. As discussed in "Recovery" in the "The Transplant Process" section, you may get prophylactic antibiotics until your blood counts reach a certain level. This is done to try to keep you from getting an infection.

After engraftment, the risk of infection is lower, but it still can happen. It takes 6 months to a year after a transplant for the immune system of most patients to work as well as it should. It can take even longer for patients with GVHD.

Because of the increased risk, you will be watched closely for signs of infection, such as a fever, and extra precautions will be taken. Anyone who enters your hospital room must wash their hands thoroughly. They probably will also wear gowns, shoe coverings, gloves, and masks. Since flowers and plants can carry bacteria and fungi, they are not allowed in your room. For the same reason, you cannot eat fresh fruits and vegetables. All food must be well cooked. You might need other dietary restrictions as well. Your transplant team will tell you and your family about the precautions you need to follow during this time.

Despite all these precautions, patients often develop fevers, one of the first signs of infection. If this happens, tests will be done to look for the cause of the infection (chest x-rays, urine tests, and blood cultures) and IV antibiotics will be started right away.

After a transplant, you are at risk for bleeding because the conditioning treatment destroys most of your body's platelets. Platelets are the blood cells that help blood to clot. Your transplant team may have you follow special precautions until your platelet counts are staying at safe levels. Your low platelet count usually lasts at least 3 weeks after transplant. In the meantime, you might notice easy bruising and bleeding, such as nosebleeds and bleeding gums. If your platelet count drops below 20,000/mm³ (thrombocytopenia), a platelet transfusion may be needed. (See "Platelets (thrombocytes)" in the "What Is a Bone Marrow or Stem Cell Transplant?" section for more information.)

It also takes time for the bone marrow to begin making red blood cells, and you might need transfusions from time to time as you recover.

This type of pneumonia is most common in the first 100 days after a stem cell transplant. It may be caused by a virus or by radiation or chemo. It is a non-bacterial, non-fungal form of pneumonia that is caused by damage to the areas between the cells of the lungs (called interstitial spaces). It can be severe, especially if TBI (total body irradiation) was given with chemo as part of the conditioning treatment. You should report any shortness of breath or changes in your breathing to your doctor right away. Chest x-rays will be taken in the hospital to watch for signs of pneumonia.

Graft-versus-host disease (GVHD) can happen in allogeneic transplants when the donor immune cells view the recipient's body as foreign. (The recipient's immune system has mostly been destroyed by conditioning treatment and cannot fight back.) The donor immune cells may attack certain organs, most often the skin, gastrointestinal (GI) tract, and liver. This can change the way the organs work and increase the chances of infection. GVHD reactions are very common and can vary from barely noticeable to life-threatening. Acute GVHD may happen 10 to 70 days after a transplant, though the average time is around 25 days.

About one third to one half of allogeneic transplant recipients develops acute GVHD. It is less common in younger patients and in those with closer HLA matches between donor and recipient. The first signs are usually a rash, burning, and redness of the skin on the palms and soles. This can spread over the entire body. Other symptoms include nausea, vomiting, stomach cramps, diarrhea, loss of appetite, yellowing of the skin and eyes (jaundice), and belly pain. Most cases are mild, and those who develop it usually have no long-term effects. In some cases, though, it can be serious or even life threatening. How well a person does depends on how severe the GVHD is. Some cases of GVHD can lead to death.

Doctors try to prevent acute GVHD by giving drugs to lessen the immune response, such as steroids, monoclonal antibodies, methotrexate, cyclosporine, and tacrolimus. Although these help prevent serious GVHD, mild GVHD will almost always happen.

Chronic (ongoing) GVHD can occur anywhere from about 70 to 400 days after the stem cell transplant. A rash on the palms of the hands or the soles of the feet is often the earliest sign. The rash can spread and is usually itchy and dry. In severe cases, the skin may blister and peel, like after a bad sunburn. A fever may also develop. Other symptoms of chronic GVHD can include:

Chronic GVHD is treated with medicines that suppress the immune system, much like those used for acute GVHD. The risk of GVHD can be decreased by removing some immune cells (known as T-cells) from the donor stem cells before the transplant. But this can also increase the risk of graft failure (see next section). Researchers are looking at newer techniques to remove only certain cells, called alloactivated T-cells, from donor grafts. This would reduce the severity of GVHD and allow the donor T-cells to destroy any cancer cells that may have been left.

Graft failure happens when the body does not accept the new stem cells (the graft). Graft failure is more common in patients whose donor marrow is not well matched and in patients who get bone marrow that has had T-cells removed. It very rarely happens.

The type of problems that can happen after transplant depend on many factors, such as the type of transplant done, the conditioning treatment used, the patient's overall health, the patient's age at the time of transplant, the length and degree of immune system suppression, whether chronic GVHD is present and how severe it is. The problems can be caused by the conditioning treatment (the pre-transplant chemotherapy and radiation therapy), especially TBI (total body irradiation), or by other drugs used during transplant (such as the drugs that may be needed to suppress the immune system after transplant). Potential long-term risks of transplant include:

You may need careful follow-up with close monitoring and treatment of the long-term organ problems that the transplant process can cause. Some of these, like infertility, will be discussed early in the transplant process, so you can be prepared for them.

It is important that any long-term problems are found and treated quickly. Physical exams by your doctor, blood work, imaging studies, and telling your doctor about any changes or problems you've noticed will help with this. As transplant methods have improved, more people are living longer and doctors are learning more about the long-term results of stem cell transplant. Researchers continue to look for better ways to care for these survivors to ensure the best possible quality of life.

Along with the possibility of the original cancer coming back after it was treated with a stem cell transplant, there is also a chance of having a second cancer after transplant. This is especially true for those who have had an allogeneic transplant. Studies have shown that people who have had allogeneic transplants have a higher risk than other people of getting a second cancer. The most common secondary cancers are solid tumors, often of the skin, mouth, and lung.

Second cancers can take many years for to develop, so they have been studied best in those who have lived a long time after treatment. Successfully treating a first cancer gives a second cancer time (and the chance) to develop. No matter what type of cancer is treated, and even without the high doses used for transplant, treatments like radiation and chemotherapy can lead to a second cancer in the future. For more information on this, please see our information on Second Cancers Caused by Cancer Treatment.

Post-transplant lymphoproliferative disorders (PTLD) is an out-of-control growth of lymph cells that can be seen after an allogeneic stem cell transplant. It is linked to a malfunction of T cells (a type of immune cell) and the presence of Epstein-Barr virus (EBV). T cells normally help rid the body of cells that are infected with a virus. When the T cells aren't working well, EBV-infected B-lymphocytes can grow and multiply. Most people are infected with EBV at some time during their lives. In the United States, as many as 95% of adults between 35 and 40 years of age have been infected, but the infection is controlled by a healthy immune system. The conditioning treatment given before transplant weakens the immune system, allowing the EBV infection to get out of control -- which can lead to a PTLD.

Still, PTLD after allogeneic stem cell transplant is rare. It most often happens in recipients of T-cell-depleted stem cells, or recipients of non-T-cell depleted stem cells that came from a mismatched or unrelated donor. It also happens in people who need anti-thymocyte globulin (ATG) or anti-CD3 monoclonal antibody for treatment of acute graft-versus-host disease (GVHD). Recipients who got stem cells from older donors and recipients who had severe immune problems before transplant may also have a higher risk of developing a PTLD.

PTLDs after allogeneic stem cell transplant most often happen within 1 to 6 months after transplant, when the immune system is still very weak. They are often linked to the effects of Epstein-Barr virus (EBV) on donor B lymphocytes. PTLD is life-threatening. It may show up as lymph node swelling, fever, and chills. There is no one standard treatment, but it is often treated by cutting back on immunosuppressant drugs to let the patient's immune system fight back. Other treatments include white blood cell (lymphocyte) transfusions to boost the immune response, using drugs like rituximab to kill the B cells, and giving anti-viral drugs to treat the EBV.

Even though PTLD doesn't happen a lot after transplant, it is likely to happen more as the use of less-matched donors and the need for greater immunosuppression goes up. Studies are being done to identify risk factors for PTLD and look for ways to watch out for it in transplant patients who are at risk.

Despite these possible long-term problems, stem cell transplant has been used to cure thousands of people with otherwise deadly cancers. Research today is being done to not only to cure a patient's cancer, but also improve transplant methods and reduce the chance of problems after stem cell transplant.

Most people who have transplants become infertile or unable to have children. This is not caused by the transplant itself, but rather by the high doses of chemo and/or radiation therapy used. These treatments affect both normal and abnormal cells, and often damage reproductive organs. But not all stem cell transplant recipients become infertile. If having children is important to you, or if you think it might be important in the future, talk to your doctor before treatment about ways to save your fertility. Your doctor may be able to tell you if a particular treatment will be likely to cause infertility.

After chemo or radiation, women may find their menstrual periods become irregular or stop altogether. This doesn't always mean they cannot get pregnant, so birth control is recommended before and after a transplant.

Men might consider storing their sperm before having a transplant. Sperm samples are collected, then frozen and stored in a sperm bank. This process can take several days. The stored sperm can later be thawed and used to fertilize a partner's egg using artificial insemination.

Other kinds of reproductive techniques, including cryogenic preservation (freezing) of embryos, sperm, and eggs are available for future donation. Adoption is another of the many possibilities for couples who want to have families after transplant.

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