Stem Cell or Bone Marrow Transplant Side Effects

You will need to take your temperature by mouth every day or twice a day for a while. Your transplant team will let you know when to call them with your temperature.

If you get a fever, tests will be done to look for possible causes of the infection (chest x-rays, urine tests, and blood cultures) and antibiotics will be started.

Common types of infection post-transplant

• Bacterial infections are most common during this time.
• Viral infections that were controlled by your immune system can become active again.
• Fungal infections can also pop up.
• You will take medicines to prevent or control these infections for about 6 months or longer after transplant.  

Pneumocystis pneumonia (PCP): This is also called Pneumocystis jirovecii pneumonia. It is a serious fungal infection that can cause fever, cough, and serious breathing problems. The germ doesn’t harm people with normal immune systems, but it can affect people whose immune systems aren’t working correctly yet after transplant.

Cytomegalovirus (CMV): This is a common viral infection that many adults have or had in the past. Adults with healthy immune systems may not have any symptoms, but CMV can cause serious pneumonia in people who’ve had transplants. Pneumonia from CMV mainly happens to people who were already infected with CMV or whose donor had the virus.

Your transplant team checks your blood tests for CMV before transplant and gives you a special medication to keep it under control. If neither you nor your donor had CMV, the transplant team might follow special precautions to prevent this infection while you are in the hospital.

Preventing infection

It can take 6 months to a year after transplant for your immune system to work as well as it should. It can take even longer if you have graft-versus-host disease (GVHD, see below).

You will be watched closely for signs of infection. Your transplant team will give you and your caregivers detailed information about the precautions you need to follow.

Avoid contact with:

• Fresh flowers and plants. These can carry bacteria and fungi. Don’t bring them in your hospital room or living spaces at home.
• Soil, disturbed soil, and mold. Don't touch or be near disturbed soil.
• Feces (human, animal, and bird). Move cat litter boxes away from places you eat or spend time. Don’t clean pet cages or litter boxes. Give this task to a family member or friend.
• Aquariums, reptiles, and exotic pets. Wash your hands after touching pets.

Take extra care with food and meal prep:

• Avoid eating certain fresh fruits and vegetables that can carry bacteria and fungi.
• You might also need to avoid certain other foods for a while.
• All your food must be cooked well and handled very carefully.

 

Bleeding and transfusions

After transplant, you are at risk for bleeding because the conditioning treatment destroys your body’s ability to make platelets. Platelets are the blood cells that help your blood clot.

Your platelet counts will be low for several weeks after transplant. During this time, you might notice easy bruising and bleeding, such as nosebleeds and bleeding gums.  

While you wait for your transplanted stem cells to start working, your transplant team may have you follow special precautions to avoid injury and bleeding.

Platelet or red blood cell transfusions

• If your platelet count drops below a certain level, you may need a platelet transfusion.
• It also takes time for your bone marrow to start making red blood cells. You might need red blood cell transfusions from time to time as you recover.

For more information on the transfusion process, see Blood Transfusion and Donation.

 

Noninfectious lung problems

Pneumonitis is a type of inflammation (swelling) in lung tissue that’s most common in the first 100 days after transplant. But some lung problems can happen much later, even 2 or more years after transplant.

Unlike pneumonia, which is usually caused by germs, pneumonitis may be caused by radiation, graft-versus-host disease, or chemo. It can happen when the areas between the cells of your lungs (called interstitial spaces) get damaged.

If total body irradiation was given with chemo as part of the pre-transplant (conditioning) treatment, the risk of pneumonitis is higher and can be severe.

Watching for signs of lung problems

While you are in the hospital, you’ll get chest x-rays to watch for pneumonitis and pneumonia. Some doctors will do breathing tests every few months if you have graft-versus-host disease (see next section).

Transplant problems that may show up later

You might have problems that show up months, years, or even decades after your stem cell treatment.

Possible long-term risks of stem cell transplant include:

• Organ damage
• Relapse (the cancer comes back)
• Secondary (new) cancers
• Abnormal growth of lymph tissues
• Infertility (the inability to have children)
• Hormone changes, such as changes in the thyroid or pituitary gland
• Cataracts (clouding of the lens of the eye, which causes vision loss)

Why long-term problems happen after stem cell transplant

Several things influence the type of problems that can happen after a transplant. This includes:

• The type of transplant
• The type of pre-transplant chemo (conditioning) or radiation treatment (total body irradiation)
• Your overall health and age when the transplant was done

Other factors include the length and degree of immune system suppression, whether chronic graft-versus-host disease (GVHD) is present, and if so, how bad it is.

Long-term organ problems caused by medications

Long-term problems can also be caused by other medications, such as those that suppress your immune system after transplant. The medications used in transplants can harm your body’s organs, including your heart, lungs, kidneys, liver, bones/joints, and nervous system.

You will need careful follow-up with close monitoring and treatment of potential long-term organ problems. Some of these problems (like infertility) should be discussed before your transplant so you can prepare for them.

Finding and treating long-term problems

You will need routine check-ups for the rest of your life because it’s important to quickly find and manage long-term problems related to your treatment.

Tell your primary care doctor or transplant team right away if you notice any changes or problems. Physical exams by your local cancer care or transplant team might include:

• Blood work
• Imaging tests
• Lung/breathing studies
• Electrocardiogram (EKG)

These tests and others will help look for and keep a check on organ problems.

As transplant methods improve, more people are living longer and doctors are learning more about the long-term results of stem cell transplant.

Some transplant centers have a survivorship clinic to manage long-term problems. Researchers continue to look for better ways to care for survivors and offer the best possible quality of life.

Cancer that comes back after stem cell transplant

The goal of a stem cell transplant in cancer is to prolong life and even cure the cancer in many cases. But sometimes the cancer comes back. This is called relapse or recurrence, depending on how long after a transplant it happens.

• Relapse or recurrence can happen a few months to a few years after transplant.
• It’s rare for it to happen 5 or more years after transplant.

Treatment options if cancer comes back

If cancer comes back, treatment options are often quite limited. A lot depends on your overall health at that point and whether the type of cancer you have responds well to medication treatment.

Treatment for people who are otherwise healthy and strong may include chemotherapy or targeted therapy.

Some people who’ve had allo transplants may be helped by getting white blood cells from the same donor to boost the graft-versus-cancer effect. This is called donor lymphocyte infusion. Sometimes a second transplant is possible.

Understanding the risks and benefits of treatment

Most of these treatments pose serious risks even to healthier people, so people who are frail, older, or have chronic health problems are often unable to have them. Other options may include palliative (comfort) care or a clinical trial.  

It’s important to understand the expected outcome of any further treatment. Talk with your cancer care team about the purpose of the treatment and be sure you understand the benefits and risks before you decide.

Second cancers (new cancers caused by treatment)

There is also a chance of getting a second cancer after transplant. Studies show that people who have allo transplants are at higher risk of getting a second cancer than people who have a different type of stem cell transplant.

Second cancers that can happen after stem cell transplant include:

• Solid tumor cancers in different organs
• Leukemia, after auto transplant
• Myelodysplastic syndromes (MDS), after auto transplant

If they happen, these cancers tend to develop a few years or longer after the transplant.

What increases the risk of a second cancer after stem cell transplant?

Risk factors for getting a second cancer after stem cell transplant are being studied. These may include:

• Radiation (such as total body irradiation) and high-dose chemo as part of the conditioning treatment
• Previous chemo or radiation treatment that wasn’t part of the transplant process (the younger a person is when radiation is given, the greater their risk for certain types of cancer)
• Immune system problems such as graft-versus-host disease, HLA-mismatched allo transplant, and immunosuppressant therapy
• Infection with viruses such as Epstein-Barr (EBV), cytomegalovirus (CMV), hepatitis B (HBV), or hepatitis C (HCV)

Successfully treating a first cancer gives a second cancer time (and the chance) to develop. This is true no matter what type of cancer you were treated for. Even without the high doses used for transplant, treatments like radiation and chemo can lead to a second cancer in the future.

Post-transplant lymphoproliferative disorder

Post-transplant lymphoproliferative disease (PTLD) is a cancer that can develop after an allo stem cell transplant. It is a type of lymphoma — an out-of-control growth of lymph cells.

PTLD after allo stem cell transplant is fairly rare.

• If it happens, it is usually within the first year after transplant.
• It most often develops within 1 to 6 months after transplant, when the immune system is still very weak.

How PTLD develops

PTLD is linked to B cells (a type of white blood cell that is part of the immune system) and the presence of Epstein-Barr virus (EBV).

T-cells normally help rid the body of cells that contain viruses. When the T-cells aren’t working well, EBV-infected B-lymphocytes (a type of white blood cell) can grow and multiply.

Most people are infected with EBV at some time during their lives, but the infection is controlled by a healthy immune system. Pre-transplant treatment weakens the immune system, allowing the EBV infection to get out of control. This can lead to PTLD.

Treating PTLD

PTLD is life-threatening. It may show up as lymph node swelling, fever, and chills.

Rituximab is considered 1st line treatment for PTLD.  It’s often treated by cutting back on immunosuppressant drugs to let a person’s immune system fight back. Other treatments include chemo, radiation, immunotherapy, and CAR-T.

Even though PTLD doesn’t often happen after transplant, it’s more likely to occur with less well-matched donors and when strong suppression of the immune system is needed. Studies are being done to identify risk factors for PTLD and look for ways to prevent it in people who have had a transplant and are at risk.

Stem cell transplants and fertility

Most people who have stem cell transplants become infertile (unable to have children).

This is not caused by the transplant itself, but by the high doses of chemo and/or radiation therapy. These treatments affect both normal and abnormal cells and often damage reproductive organs.

Your cancer care or transplant team may be able to tell you if your treatment is likely to cause infertility.

If having children is important to you, or if you think it might be important in the future, talk to your cancer care or transplant team. They can refer you to a fertility specialist and discuss ways to protect your fertility before treatment.

For more information on having children after cancer treatment, see Fertility Problems.

Women

After chemo or radiation, some women may find their menstrual periods become irregular or stop completely.

Even if your periods stop, you may still be able to get pregnant. The medications used in transplants can harm an unborn child, so it’s important to use birth control before and after a transplant.

Men

The medications used during transplant can also damage sperm. To avoid starting a pregnancy, men should use birth control during the transplant process. Your transplant team can tell you how long you need to be careful.

Transplants may cause temporary or permanent infertility for men as well. Fertility returns in some men, but the timing is unpredictable. Men might consider storing their sperm before having a transplant.

Your transplant team will tell you how long after transplant you need to avoid starting a pregnancy.

Managing the emotions of a transplant

You might go through feelings of distress, anxiety, depression, joy, or anger. Adjusting emotionally after a stem cell transplant can be hard because of the length of time you feel ill and isolated from others.

You might 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 after transplant.

Reach out to support groups, social workers, or counselors for help.

Learn more

• Getting a Stem Cell or Bone Marrow Transplant
• Managing Distress, Anxiety, and Depression During Cancer Treatment