Consultation before transplant (pre-BMT)
Your child will meet with your primary transplant doctor to discuss the disease and how appropriate a blood or marrow transplant is for treating it. You will discuss potential risks and benefits of transplant versus no transplant, your transplant preparative regimen (the high-dose chemotherapy or total body irradiation given prior to your transplant) and possible donors for your transplant.
If you and your BMT physician decide to proceed to transplant, you will have a thin, flexible IV tube, called a central venous catheter (also called a central line or Broviac) surgically inserted into a large vein in your chest near the heart. The central line is placed for the administration of your preparative regimen chemotherapies, the stem cell infusion and any fluids and medications you may need during and after your transplant.
Several days prior to your transplant, you will receive high-dose chemotherapy and/or total body irradiation. This is called the preparative or conditioning regimen. The preparative regimen is designed to kill your diseased cells and/or make room in your bone marrow for healthy blood stem cells.
The preparative regimen will take place in the hospital or in an outpatient clinic over several days. The chemotherapy drugs are given through your central venous catheter. During this time, you may have side effects from the preparative regimen including nausea, vomiting, diarrhea and/or mucositis (inflammation of your mucous membranes, such as your mouth and GI tract). Your BMT team will review the common side effects of your preparative regimen with you before your preparative regimen begins, since each regimen has its own possible side effects.
To counteract the side effects, your BMT team will give you anti-nausea and pain medicines. If vomiting and/or diarrhea are severe, they may give you supplemental nutrition via a nasogastric tube (a small spaghetti-sized tube that goes to your stomach to provide liquid nutrition), IV fluids or total parenteral nutrition (TPN, which provides IV fluid and nutrition). After starting the preparative regimen, white blood cells slowly die off, but may not be completely gone by the day of transplantation.
Stem cell infusion ("day 0")
Stem cells from a donor (allogeneic) or from the patient themselves (autologous) will be infused into the patient using their central venous catheter in their hospital room. The bag of cells to be infused often looks like a regular blood or platelet transfusion. Before the infusion, patients are given acetaminophen (Tylenol), diphenhydramine (Benadryl) and hydrocortisone to prevent any immediate reactions to the infusion.
If the cells are from donated marrow, they will be filtered in the laboratory and concentrated before being infused into the patient. If the cells were previously frozen, such as an autologous cell collection or cells from an umbilical cord, the cells will be thawed shortly before they are infused. These cells are frozen using a special preservative called dimethyl sulfoxide (DMSO) that prevents the cells from breaking during the freezing process. DMSO creates a distinct smell during and after infusion and may cause some short-term side effects such as high blood pressure.
If the patient is receiving cells from another person (allogeneic) or an umbilical cord, they will require immunosuppressive medications to prevent rejection of the new stem cells and to prevent the new cells from attacking the patient, called graft-versus-host disease (GVHD). Usually, the immunosuppressive medicines are started shortly before the transplant and are continued for several months after transplantation.
During the time the patient is on immunosuppressive medicines, they will need to be very conscious of staying away from sick people. They are also at increased risk of developing viral infections, such as EBV, CMV, Adenovirus and HHV6, so weekly blood draws are necessary – even if the patient does not have symptoms. If, after several months, the patient does not have any signs of GVHD, we will slowly taper the immunosuppressive medications, giving the body time to adapt.