There are several steps in the transplant process. The steps are much the same, no matter what type of transplant you are going to have.

Patient evaluation and preparation

You will first be evaluated to find out if you are eligible for a transplant. A transplant is very hard on your body. It can be hard emotionally, too. Many different medical tests may be done to try to find out how well you can handle the transplant process. These might include:

• HLA tissue typing
• a complete history and physical exam
• evaluation of your psychological and emotional strengths
• identifying who will be your primary caregiver throughout the transplant process
• bone marrow biopsy
• CT (computed tomography) scan or MRI (magnetic resonance imaging)
• heart tests, such as an electrocardiogram (EKG) or echocardiogram
• lung studies, such as a chest x-ray and pulmonary function tests (PFTs)
• consults with other members of the transplant team, such as a dentist, dietitian, or social worker
• blood tests, such as a complete blood count, blood chemistries, and screening for viruses like hepatitis B, CMV, and HIV

You will also talk about your health insurance coverage and related costs that you might have to pay.

You may have a central venous catheter put into a large vein in your chest. This is most often done as outpatient surgery, and usually only local anesthesia is needed (the area where the catheter is to be put in is made numb). Nurses will use the catheter to draw blood and give you medicines. If you are getting an autologous transplant, it can also be used for apheresis to harvest your stem cells. The catheter will stay in place during your treatment and for some time afterward, usually until your transplanted stem cells have engrafted and your blood counts are steadily returning to normal.

Eligibility

Younger people, those who are in the early stages of disease, or those who have not already had a lot of treatment, are often better able to tolerate transplant. Some transplant centers set age limits. For instance, they may not allow allogeneic transplants for people over 50 or autologous transplants for people over 60 or 65. Some people also may not be eligible for transplant if they have other major health problems, such as serious heart, lung, liver, or kidney disease. A "mini-transplant," described under "Allogeneic stem cell transplant" in the section "Types of Stem Cell Transplants" may be an option for some of these patients.

Hospital admission

The hospital's transplant team will decide if you need to be in the hospital to have your transplant, or if it will be done in an outpatient center. If you have to be in the hospital, you will likely go in the day before the transplant is scheduled. During this time, the transplant team makes sure you and your family understand the process and want to go forward with it.

The transplant experience can be overwhelming. Your transplant team will be there to help you physically and emotionally prepare for the process and discuss your needs. Every effort will be made to answer questions so you and your family fully understand what will be happening to you as you go through transplant. This is important because once the transplant process begins, there is no going back--serious problems can result if treatment is stopped at any time during transplant.

To reduce the chance of infection during treatment, patients who are in the hospital are put in private rooms that have special air filters. The room may also have a protective barrier to separate it from the outside and/or a positive air pressure system to make sure outside air does not enter the room.

Conditioning treatment

Conditioning, also known as bone marrow preparation or myeloablation, is treatment with high-dose chemo and/or radiation therapy. It is done for one or more of the following reasons:

• to make room in the bone marrow for transplanted stem cells
• to suppress the patient's immune system to lessen the chance of graft rejection
• to destroy all of the cancer cells anywhere in the patient's body

No one conditioning treatment is used for every transplant. Your treatment will be planned just for you based on the type of disease you have, the type of transplant, and any chemo or radiation therapy you have had in the past.

If chemo is part of your treatment plan, it will be given through an intravenous (IV) catheter or as pills. If radiation therapy is planned, it is given to the entire body (called total body irradiation or TBI). The TBI may be given all at once in a single treatment session or in divided doses over a few days.

This phase of the transplant can be very uncomfortable since high doses are used. Chemo and radiation side effects can make you sick, and it may take months to fully recover. A very common problem is mouth sores that will need to be treated with strong pain medicines. You may also have nausea, vomiting, be unable to eat, lose your hair, and have lung or breathing problems. Conditioning may also cause premature menopause in women and will likely make both men and women unable to have children. (See "Stem cell transplant and having children" in the section "Problems After Transplant.") Before having a transplant, you need to discuss the transplant process and all the consequences with your doctors. It also helps to talk to others who have already had transplants.

Infusion of cells

After the conditioning treatment, you are given a couple of days rest before getting the new, healthy stem cells. They will be given through your IV catheter, much like a fast blood transfusion. If the stem cells were frozen, you may get some medicines before the stem cells are given. This is done to keep you from reacting to the preserving drugs that are used when freezing the cells.

If the stem cells were frozen, they are thawed in warm water then given right away. For allogeneic or syngeneic transplants, the donor cells may be harvested in an operating room, then processed in the lab. Once they are ready, the cells are brought to the recipient's room and infused. The length of time it takes to get all the stem cells depends on the volume of fluid that the stem cells are in.

You will be awake for this process and it doesn't hurt. This is an important step and often has great meaning for recipients and their families. Many people consider this their rebirth or chance at a second life. They may celebrate this day as they would their actual birthday.

Infusion side effects are rare and usually mild. The preserving agent that is used when freezing the cells (called dimethylsulfoxide or DMSO) causes many of the side effects. It can cause you to have a strong taste of garlic or creamed corn in your mouth. Sucking on candy or sipping flavored drinks after the infusion can help with this. Your body will also smell like this. The smell may bother those around you, but you may not even notice it. The smell, along with the taste, may last for a few days, but slowly fades away. Often having cut oranges in the room will offset the odor and make the experience more pleasant. Patients who have transplants from cells that were not frozen do not have this problem because the cells were not mixed with the preserving agent.

Other short-term side effects of the stem cell infusion may include:

• fever or chills
• shortness of breath
• hives
• tightness in the chest
• low blood pressure
• coughing
• chest pain
• less urine output
• feeling weak

Again, side effects are rare and usually mild. If they do happen, they are treated as needed and the stem cell infusion is always completed.

Recovery

The recovery stage begins after the stem cell infusion. During this time, you and your family wait for the cells to engraft, or "take," after which they begin to multiply and make new blood cells. The time it takes to start seeing a steady return to normal blood counts varies depending on the patient and the transplant type, but is usually about 2 to 6 weeks.

During the first couple of weeks you will have low numbers of red and white blood cells and platelets. Right after transplant, when your counts are the lowest, you may be given antibiotics to keep you from getting infections (called prophylactic antibiotics). You may get anti-bacterial, anti-fungal, and anti-viral drugs. These antibiotics are usually given until your white blood cell count reaches a certain level. Still, complications such as infection due to low white blood cell counts (neutropenia), or bleeding problems due to low platelet levels (thrombocytopenia), may develop. Many patients have high fevers and need IV antibiotics to treat serious infections. Transfusions of red blood cells and platelets are given until the bone marrow is working again and blood cells are being made.

Except for graft-versus-host disease, which only happens with allogeneic transplants, the side effects from autologous, allogeneic, and syngeneic stem cell transplants are much the same. Problems may include gastrointestinal (GI) or stomach problems, and heart, lung, liver or kidney problems. (We will talk more about these later, in the section "Problems After Transplant.") You might also go through times of distress, anxiety, depression, joy, or anger. Adjusting emotionally after the stem cells can be hard because of the length of time you feel ill and isolated from others.

Having a transplant is a big decision. Your life and family relationships will be disrupted. Your future becomes uncertain, the process makes you feel bad, and financially it can be overwhelming. You may feel like you are on an emotional roller coaster during this time. Support and encouragement from family, friends, and the transplant team are very important to get you through the challenges of transplant.

Discharge

The discharge process actually begins weeks before your transplant. It starts with teaching done by the transplant team that will include:

• the precautions you will need to take
• how to prepare your home
• how to care for your central venous catheter
• how to take good care of your mouth and teeth
• what type of diet you should follow
• activities you can and can't do
• when to call the transplant team or other health care professionals
• who will take the role of primary caregiver and what the job will involve

For the most part, transplant centers don't discharge patients until they meet the following criteria (See "What are stem cells?" in the section "What Is a Bone Marrow or Stem Cell Transplant?" for more information about neutrophils, platelets, and hematocrit.):

• they have no fever for 48 hours
• they are able to take and keep down oral medicines for 48 hours
• their nausea, vomiting, and diarrhea are controlled with medicine
• their neutrophil count (absolute neutrophil count or ANC) is at least 500 to 1,000/mm³
• they have a hematocrit of at least 25% to 30%
• they have a platelet count of at least 15,000 to 20,000/mm³
• they have someone to help them at home and a safe and supportive home environment

If patients do not meet discharge criteria, but do not need the intensive care of the transplant unit, they may stay in another hospital unit.

Rehabilitation

The roller coaster ride may continue after you go home. Plus, you will be feeling pretty tired after going through the transplant process. After discharge, in the rehabilitation period, some people have physical or psychological problems. These ongoing needs must now be managed at home. Transplant patients are still followed closely during the rehab period. You may need daily or weekly exams along with things like blood tests, chest x-rays, bone marrow tests, or spinal taps (lumbar punctures). During the early rehab stage, you also may need blood and platelet transfusions, or treatment with antibiotics and/or blood-stimulating growth factors. These visits are frequent at first, but will decrease if things are going well. It can take 6 to 12 months, or even longer, for blood counts to get close to normal and the immune system to work well.

Some problems may show up even a year or more after the stem cells are infused. Physical problems are usually from the chemo and/or radiation treatment, but other issues may pop up too. Problems can include:

• GVHD (in allogeneic transplants)
• infections
• lung problems, such as pneumonia
• kidney, liver, or heart problems
• cataracts
• low thyroid function
• slowed growth and development in children
• reproductive or sexual problems (like infertility and early menopause)
• secondary cancers
• overwhelming tiredness (fatigue)
• memory loss, trouble concentrating
• emotional distress, depression, body image changes, anxiety
• job and insurance discrimination
• changes in relationships
• changes in how you view the meaning of life
• feeling indebted to others

Your transplant team is still available to help you. It is important that you talk to them about any problems you are having--they can be sure you get the support you need to manage the changes that you are going through.

Last Medical Review: 05/27/2009
Last Revised: 05/27/2009