Day 0 to engraftment
Engraftment is when transplanted stem cells enter the bloodstream, make their way to the bone marrow and start making new blood cells. Engraftment occurs 10 days to 4 weeks after a stem cell transplant.
The time between when the conditioning therapy is given and engraftment takes place is very important. During this time, recipients can feel tired and generally unwell. Until their bone marrow starts to recover, recipients are at risk of fever, infection, bleeding, anemia, damage to the vital organs (such as the heart, lungs, liver and kidneys) and nutritional problems. Most of these problems are worse when the blood count is at its lowest, usually 2–3 weeks after the transplant. The healthcare team will monitor the recipient very closely during this time.
The recipient may be kept in isolation to reduce the chance of infection. The healthcare team will do daily blood tests and regular temperature checks. They will also monitor the recipient for bleeding, nausea, vomiting, diarrhea and any other problems.
When necessary, the recipient will receive blood transfusions and medicines for infection. Nutritional supplements may be given, or in more severe situations, special nutritional fluid is given through the central venous catheter (total parenteral nutrition, or TPN).
Until engraftment takes place, colony-stimulating factors, such as filgrastim (Neupogen), may be given to:
- speed up engraftment
- reduce the length of time that blood cells are their lowest, which lowers the risk of infection
- allow the recipient to be discharged from the hospital earlier
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Engraftment to discharge
Engraftment can be confirmed with blood tests and a bone marrow sample. Gradually, the blood cell counts begin to rise as new blood cells are made. When this happens, and if there are no complications, recipients may be allowed to go home or move into accommodation close to the transplant centre. They must remain nearby in case they have a problem and need to go back to the hospital.
Before recipients can leave the hospital, they must:
- be able to eat and drink enough fluids
- not have a fever, vomiting or diarrhea
- have safe levels of blood cell counts
An allogeneic transplant uses stem cells from a donor. It is a more intensive procedure than an autologous transplant, which uses the recipient’s own stem cells. It may take longer for the bone marrow to recover after allogeneic transplant, so the recipient is at risk for problems, such as infection, for a longer period of time. The recipient may be in the hospital for 4–6 weeks (an average of about 5 weeks for an allogeneic transplant). People who have an autologous transplant may need to spend less time in the hospital.
Recovery time varies from person to person. Some people may need to stay in the hospital longer if problems develop. Recipients may still tire easily and feel weak for months because it can take 6–12 months, or longer, for the immune system to recover.
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Follow-up after discharge
The recipient will have frequent checkups after discharge. Daily assessment and treatment may be needed until:
- the new marrow is functioning properly
- there are no serious problems
- it looks like the cancer is under control
Follow-up schedules may vary from person to person, but they usually follow the same general schedule.
First 3 months
For the first 3 months after leaving the hospital, recipients are usually assessed at least once a week.
- Frequent blood tests are done to check blood cell counts.
- Recipients take antibiotics and antiviral drugs to reduce the risk of infection.
- If donated stem cells were used, recipients may have to take drugs to suppress the immune system and reduce the risk of graft-versus-host disease (GVHD).
- Blood or platelet transfusions may be needed.
- Recipients may need to go back to the hospital if they feel unwell. They should always carry a 24-hour hospital contact number and get in touch with the hospital right away if they develop:
- a fever over 38°C
- infection of the skin or teeth
- skin rashes
- severe diarrhea
- shortness of breath or trouble breathing
Until blood cell counts return to normal, recipients are encouraged to:
- Eat a healthy diet and avoid possible risks of infection from foods. Drinking alcohol during this time can increase the risk of bleeding or interfere with medicines.
- Avoid crowded places, such as shopping malls.
- Avoid contact with children who have recently been exposed to infectious diseases (such as chicken pox) or immunized with live viruses (such as a certain polio vaccine).
- Follow the doctor’s instructions to reduce the risk of infection.
- Carry or wear a medical alert card, bracelet or necklace.
Any infections will usually need to be treated. Recipients continue to take drugs to lower the risk of infection and graft-versus-host disease.
After 3 months
After 3 months, the doctor will decide how often follow-up needs to be done. If there are no serious problems, follow-up may be done less frequently, such as every 3–6 months.
Follow-up is done to assess:
- the person’s health
- any problems or concerns
- whether any adjustments need to be made to medicines or activities
- how well the bone marrow is working
- whether the cancer has come back (recurred)
- The risk of recurrence (relapse) depends on the status of the cancer at the time of transplant.
- If a relapse does occur, it usually happens within the first 2 years after the transplant. Recurrence can also occur several years later.
If there are no problems or complications, follow-up visits will happen once a year with the family doctor or hematologist (a doctor who specializes in treating blood disorders). Sometimes a return visit to the transplant centre may be needed.
Checkups can include:
- physical examination
- blood tests
- bone marrow aspiration and biopsy
- imaging tests, such as CT scan
- PET scan or gallium scan may be done in people with lymphoma.
One hundred days after the transplant (Day 100) is an important milestone for people who have had a stem cell transplant. They may undergo restaging tests to determine the status of the disease and its response to treatment.
Recovery depends on the person’s physical condition before the transplant and the side effects they experienced. Many people will not have any major problems after leaving the hospital, but recovery occurs gradually. Talk to the doctor about when to return to school or work and to resume exercise and sexual activity.
By the end of the first year, the immune system usually returns to normal and the bone marrow produces blood cells normally again. It may take longer for some people, especially if they are on immune-suppressing drugs. About 1–2 years after stem cell transplant, most people need to be immunized with vaccines that are commonly given in childhood (such as polio and measles vaccines). Talk to the doctor about which vaccines should be given to help restore the immune system
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