Stem cell transplant
The decision to undertake a haematopoietic stem cell transplant is always a very considered decision. It will be an option, if you’ve certain blood cancers, such as leukaemias, lymphomas and multiple myeloma; if you’ve bone marrow failure or dysfunction and can’t produce sufficient levels of blood cells; or if you’ve certain immunodeficiency states and auto-immune conditions.
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Pre-stem cell transplant
If you’re being transplanted for cancerous conditions, you would have at this point been through many rounds of chemotherapy and/or radiation therapy, depending on the nature of your cancer and hopefully be in remission prior to transplant or have a very low burden of residual cancer cells present.
If you’re undergoing an autologous stem cell transplant (using your own blood stem cells), you would have had your blood stem cells collected by this time. This process is called apheresis and takes a few hours; your blood flows from a large IV line or central venous catheter and is processed in an apheresis machine which removes blood stem cells. The rest of the cells flow back into you through a different IV line or through a different port of the central line. By the time transplant dates have been set, your clinical case has been discussed at a transplant meeting and signed off by more than one doctor in the medical team. It has been approved by the medical aid and so begins the countdown to day 0, which is the day of the infusion of blood or bone marrow stem cells.
Generally, the transplant process can be divided into the following phases:
- Pre-hospital preparation
- Hospital admission
- Conditioning therapy
- Day 0 – stem cell infusion
- Day 1 – 28 post-stem cell infusion
- Post-hospital recovery (1 – 12 months)
- Long-term transplant follow-up (12 months +)
This generally begins about two to three weeks prior to the planned admission for transplant. You undergo blood tests and depending on your underlying diagnosis, concomitant medical conditions and the type of transplant planned, you may also be sent for X-rays, a heart sonar, dental assessment, lung functions, psychologist review, etc. This is to make sure that you’re fit enough to undergo the transplant process as well as to pre-empt and plan for potential complications.
A port, J-line or central venous catheter may be inserted to facilitate chemotherapy and other infusions, procedures like plasma exchanges, and the stem cell infusion. It’s also an opportunity for you to engage with the medical and support team and discuss any concerns. A meeting will take place between one of the treating doctors (a nurse or social worker is often present as well) and you and your family/next of kin to discuss the results of these tests, the details of the upcoming transplant as well as potential risks and complications. You’ll sign a consent form agreeing to the transplant.
Finally, the day arrives to be hospitalised. You’re admitted into an isolation room where you have a private bathroom. There are no rules when preparing for what lies ahead psychologically or physically.
Be prepared for a long-stay which at best would last two to three weeks and at worse may stretch into months if serious complications arise. Psychosocial support is important; being in a room alone for most of the day eventually affects even the most positive people. You should ask to speak to a counsellor or the practice psychologist, should overwhelming emotions arise.
What to pack
When packing, remember to pack things to stave off boredom and reduce anxiety like reading materials, a laptop/tablet, crafts or hobbies (painting supplies, etc). Bringing momentos or photographs from home helps as well. Chemotherapy and/or radiation therapy and/or immunotherapy are given during this time over a handful of days. Depending on what the underlying disease indication for the transplant, this may be to eradicate any cancerous cells that may still be lingering, to prepare the bone marrow to receive the upcoming stem cells and to manipulate the immune system to prevent rejection of stem cells.
The day of the stem cell infusion is typically the most uneventful day. The stem cells, whether your own or donor stem cells (allogeneic transplant), are infused intravenously much like a regular blood transfusion. Intravenous pre-medication, including an antihistamine and a dose of steroids will be given prior. The stem cells will very quickly leave the blood and make their way to the bone marrow to start repopulating the marrow with healthy cells.
Once your blood counts are at safe levels (stem cell engraftment),if there are no serious infective or other complications, you’ll be discharged. In the case of allogeneic transplants, you’re seen at least once a week for the first 12 weeks post-transplant. With autologous transplants, the likelihood of complications post-discharge is less, and you’re seen two to four weekly.
Long-term transplant follow-up
This is important to look for late complications and to monitor for relapse of the underlying disease for which you were transplanted. If you underwent an allogeneic transplant, you’ll also get re-vaccinated (re-vaccination schedule is followed over many months). Undergoing a haematopoietic stem cell transplant is a daunting, detailed, expensive and medically complicated process but for many, it’s their only option.
Dr Lucille Sarah Singh is a physician and clinical haematologist in private practice at Alberts Cellular Therapy based at Netcare Pretoria East Hospital. She is an active member of SASH and SASCeTS and serves regularly on the clinical review panel of SAOC.
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