Before the transplant, the patient has tests to make sure it is likely that high-doses of chemotherapy and radiation therapy will be tolerated. Testing of the patient includes lung function tests (blowing into a machine), heart function tests (looking at the heart with sound waves and at the electrical signals that make the heart beat), kidney function tests (urine collection), and liver function tests (blood tests). The state of the patient's disease is checked prior to transplant. This testing may include a bone marrow exam, spinal tap, and CT scans (special X-rays). The patient also has testing to find hidden infection before transplant. This testing may include CT scans of the sinuses and lungs. If the patient does not have a central venous catheter (rubber-like tube that can stay in a large blood vessel for a long time), one will be put in prior to transplant. Before the transplant, a stem cell donor is chosen and tested to make sure that he or she can give stem cells safely.
After admission to the hospital, your child will be given three to nine days of chemotherapy and possibly radiation therapy. This is called the conditioning regimen. The purpose of radiation therapy and chemotherapy is to kill problem cells in the person receiving the transplant. These cells include cancer cells in patients having a transplant for cancer, and abnormal bone marrow or immune system cells for patients having transplants for non-cancerous conditions. Another purpose is to prevent the patient's immune system from attacking or rejecting the donor's stem cells. The patient's bone marrow and immune system is partially or totally destroyed by the chemotherapy and radiation therapy.
Different radiation therapy and chemotherapy treatments are used depending on the reason for the transplant. A member of the Blood and Marrow Transplant team will provide a schedule of your child's therapy. Radiation therapy is given as total body irradiation. It is usually given in six equal doses over three days. Radiation therapy is given two times per day, once early in the morning and then again in the afternoon. Chemotherapy drugs are given one to four times per day. The number of days of chemotherapy varies between three to nine days depending on the reason for transplant and whether or not radiation therapy is used. Chemotherapy drugs are given through a central venous catheter. Patients receive medications to prevent nausea and vomiting related to the chemotherapy and radiation therapy. After the chemotherapy and radiation therapy are done, the donor's stem cells are collected. The stem cells are given to the patient through the central venous catheter in the same way a blood transfusion is given.
During the three to four weeks that it takes the donor stem cells to start making enough blood cells, the patient's white blood cell count will be very low. White blood cells help prevent infections. The patient usually has a fever after transplant and gets drugs to treat infections. The patient usually needs transfusions of red blood cells and platelets. It is common for patients having a stem cell transplant to develop mouth sores and diarrhea for one to two weeks after transplant. The patient is given pain medications when needed in order to be comfortable.
After a transplant from another person, the patient may get graft-versus-host disease (GVHD). GVHD happens when the donor's immune system cells (collected with the stem cells) recognize the patient's body as foreign and attack it. GVHD usually starts three to four weeks after transplant. GVHD is discussed in more detail below.
When the patient is able to eat and drink, has no serious medical problems, has a white blood cell count high enough to fight some infections, and is getting platelet transfusions less than daily, the patient is discharged from the hospital. Patients return to the Blood and Marrow Transplant clinic for follow-up. Patients having transplants from a donor usually need to be seen in clinic one to three times per week up until 100 days after transplant. Patients receiving their own stem cells are seen less often. After 100 days, visits will be as needed, but usually at least once a month. Some patients may need to be seen every one to two weeks. Patients with leukemia will usually have a bone marrow test at 28 days and 100 days after transplant.
Patients usually have clinic visits with the Blood and Marrow Transplant team at one year after transplant and then yearly thereafter. These clinic visits usually include drawing blood for blood counts and for tests of kidney and liver function. These visits may also include lung function tests and heart function tests.