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Problems that may come up shortly after
transplant
Infection
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.
Bleeding and transfusions
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.
Interstitial pneumonia
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
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.
GVHD is rare in syngeneic or autologous transplant patients.
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:
- decreased appetite
- diarrhea
- abdominal (belly) cramps
- weight loss
- jaundice (yellow color of the skin and eyes)
- enlarged liver
- bloated abdomen (belly)
- pain in the upper right part of the abdomen
- increased levels of liver enzymes in the blood
- the skin feels tight
- dry, burning eyes
- dryness or sores in the mouth
- burning sensations when eating acidic foods
- bacterial infections
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
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.
Long-term problems after transplant
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:
- infertility (the inability to produce children)
(This is discussed below in "Stem cell
transplant and
having children.")
- hormone changes, such as changes in the thyroid or
pituitary gland
- damage to the liver, kidneys, lungs, heart and/or
bones and joints
- cataracts (clouding of the lens of the eye, which
causes loss of vision)
- secondary (new) cancers
- abnormal growth of lymph tissues (see below in "Post-transplant
lymphoproliferative disorders")
Organ problems
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.
Secondary (new) cancers
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.
Risk factors for developing a second cancer are being studied
and may include:
- radiation (such as TBI) as part of the conditioning
treatment
- previous radiation treatment that was not part of
the transplant process
- immune system problems (such as GVHD,
HLA-mismatched allogeneic transplant, and immunosuppressant therapy)
- having a female donor
- being over age 40 at the time of transplant
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
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.
Stem
cell transplant and having children
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.
For more information see Fertility and Cancer: What Are
My
Options?.
Last Medical Review: 05/27/2009
Last Revised: 05/27/2009
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