LDS Hospital

(801) 408-1100Map8th Avenue & C StreetSalt Lake City, UT 84143
Bone Marrow Treatment Process Image

The bone marrow transplant experience can be very overwhelming and sometimes seem like an endless journey. Many questions may arise when the patient and their family decide to proceed with a bone marrow transplant. This guide is intended to give them a general overview of what they can expect during their transplant experience.

Before your transplant:

The planning phase begins when the patient and their family first consider transplant as a treatment option. The patient will meet with many team members during the preparation phase to help facilitate and make decisions. The goal of this phase is to make the decision to accept transplantation, to gain access to treatment and understand and make preparations to initiate treatment, including:

Selecting a caregiver - Because it is possible to receive much of the transplant regimen and follow up care outside the hospital setting, a caregiver is necessary to assist with daily activities, as well as to help the transplant team monitor for symptoms that should be reported and treated immediately. Additional responsibilities and training for the caregiver would include dispensing oral medications and administering of intravenous fluids, antibiotics, etc via an infusion pump and caring for the patient's central line.

Childcare - Spouses of patients with small children often find it hard to juggle both parenting and caregiver. It is recommended that a parent designate someone to help share the load and trade off caring for the children and caring for the patient. This is a time to rely on family and friends without guilt.

Planning your stay - There will be a great number of details to work out with your transplant team, your family, and your place of employment. Every situation is unique, so the specifics of your particular course of treatment may vary. How rapid your transplant process moves will also depend on your individual case. At the Intermountain Bone Marrow Transplant Program a clinical coordinator will be assigned to you. This coordinator will meet you early on in the process and will continue to follow you until your return to your referring physician. The bone marrow transplant social worker and coordinator will work with you throughout the transplant process. They will help provide assistance with housing, school arrangements, and letters for airlines or employers. The patient will be required to stay in the Salt Lake area for a long length of time. We know this can add stress to an already vulnerable situation. But we have many resources to help ease the transition.

Advanced directives - Advance directives include such documents as 'Durable Power of Attorney for Healthcare" and living wills. Completing these documents enables a patient and family to specify someone who shall be legally responsible for making decisions about the medical treatment should the patient become incapable of making them. The bone marrow transplant social worker will discuss advance directives prior to beginning the transplant process. There is a legal notary within the hospital.

Other special preparations:

Dental preparations - One of the most common sources of infections is the mouth. Routine dental care is required prior to beginning therapy. The patient should have a thorough dental examination to detect cavities or other problems. Ideally, any problems should be treated and healed before the patient arrives for treatment. Contact the clinical coordinator for specific guidelines prior to a dental visit.

  • Immunizations - Family members are encouraged to receive the flu shots prior to arrival.
  • Fertility -  The expectation is that patients will be sterile following bone marrow transplant. Storage of sperm for men should be considered if there is a strong desire to birth children in the future. Unfortunately, it is very difficult for a woman to store ova and is usually not feasible financially.
  • Donor - If the decision is made to have an allogeneic transplant, then a donor needs to be identified. Kits can be mailed by the clinical coordinator to siblings for blood to be shipped to our lab and tested. If a related donor is not identified, then a search will be initiated through the National Marrow Donor Program (NMDP).

    The NMDP is a national registry that contacts volunteer donors throughout the world. This process to identify and schedule collection for an unrelated donor can take several weeks. For more information on how to become a volunteer donor visit the NMDP site.

    If a sibling is identified, there will be an information session and health screening evaluation done prior to the patient beginning the transplant. Once the donor has been deemed acceptable, they will be asked to sign a volunteer consent after the risks have been discussed.

There are two ways that stem cells can be collected:

  1. Bone marrow harvest: A bone marrow harvest is a surgical procedure requiring general or spinal anesthesia. Multiple aspirations from the crests of the pelvic bone will be performed. If the marrow is to be used for an autologous transplant, it will be cryopreserved (frozen) and stored. If the marrow is to be used for an allogeneic transplant, it will be infused within 48 hours of harvest.
  2. Stem cell collection: The process of collecting peripheral blood stem cells (PBSC) is divided into three stages: mobilization, collection and infusion. Mobilization is stimulation of the stem cells to move from the bone marrow into the peripheral blood using the administration of a medication. These cells are then collected into an apheresis machine. Once apheresed, autologous stem cells are cryopreserved, while allogeneic stem cells are infused immediately.

During your transplant:

The preparation phase begins when the patient arrives at the transplant center and starts the process of the medical evaluation, informed consent, treatment plan, education classes, and other preliminary activities. Family members will also be educated to assume their roles.

Medical evaluation - An outpatient medical evaluation or "work-up" is performed and results evaluated prior to beginning any therapy. Some tests may be performed through the patient's primary care physician if arranged by the clinical coordinator. Medical evaluation is needed to assess current medical status of the patient, and also to create baseline evaluations for post transplant follow up. This evaluation can include, but is not limited to: scans, blood tests, a detailed medical history, pulmonary function testing (lung evaluation), heart function testing (echocardiogram and electrocardiogram) as well as disease specific testing (bone marrow aspiration and biopsy, 24 hour urine evaluation, and lumbar puncture).

Informed consent - After the medical evaluation has been completed, a conference will be held to discuss the findings. In the conference, the individualized treatment plan will be discussed. Informed consent will be obtained. This is a shared decision making process between the patient, family and health care providers. Included in the conference will be the risks associated with each specific patient based on the prior medical evaluation.

Central venous catheter - Prior to the start of the actual transplant process, a central venous catheter will be placed. The stem cells, chemotherapy, hydration fluids, nutritional supplements, antibiotics, antifungals, antivirals, and blood products will be administered through this catheter. Patients who currently have a central venous catheter will have the catheter assessed by the transplant team and a decision will be make to either use the existing catheter or replace it.

Preparative regimen - The preparative regimen or conditioning phase begins the actual transplant process. During this phase, the patient is admitted to the LDS hospital inpatient bone marrow transplant unit. The inpatient unit is HEPA filtered and isolated from other exposures within the hospital. Family and friends can visit at any time and should be screened for any obvious illness or infections. Hand washing is required when entering and leaving any bone marrow transplant patient's room.

The conditioning consists of the high dose chemotherapy and/or radiation. The goal of this therapy is to destroy any residual cancer and in the allogeneic setting to obliterate the patient's bone marrow function to allow donor cells to engraft. Depending on the type of transplant, some conditioning therapy can be administered in the outpatient setting.

Transplant to engraftment - The transplant phase is the infusion of stem cells or bone marrow. The actual infusion is a relatively simple process using the patient s central venous catheter. This is a milestone in every patient's treatment. CELEBRATE!

This phase includes close monitoring, supportive treatment and management of complications while waiting for signs of engraftment (new cell growth). The patient continues to require close monitoring for infections and possible complications due to the preparative regimen.

Patients will be monitored very closely, encouraging patient involvement in their own care to help facilitate a rapid recovery. There are times that patient's may have to go to the intensive care unit due to severe infections and/or complications. This waiting period can be very difficult and test even your most effective coping skills.

Approximately 10-28 days after the transplant, signs that the new bone marrow or stem cells are engrafting will begin to show. This is the phase when the patient is recovering their immune and marrow function and will require less supportive care. As the new immune system continues to improve, the patient will begin to feel better both physically and mentally.

Visitation policy - At the Intermountain Bone Marrow Transplant Program, visiting hours in the inpatient units are completely open. Both children and adults who do not have an infectious disease or illness may visit the patient at any time. 

After your transplant:

As the patient recovers and no longer needs intensive medical monitoring and supportive care, preparation for discharge will begin. Surrounding this transition there are often feelings of anxiety, eagerness and fear. Caregivers and support systems will be established to help alleviate these feelings.

Full recovery is an ongoing process. The patient will be followed closely in the outpatient setting to help encourage slowly increasing their activity, regaining strength along with monitoring of symptoms and gradual tapering of supportive therapies. Families will be taught what to watch for and when to call for evaluation.

Graft versus host disease - Graft versus host disease is a complication that occurs only with allogeneic transplants. While as many as 30-50% of allogeneic stem cell recipients develop graft versus host disease, most cases are mild. Graft versus host disease usually occurs when the stem cells begin to engraft and the donor cells (graft) recognize the patient's cells (host) as foreign and begin to attack it.

There are two types of graft versus host disease; acute and chronic:

  1. Usually the acute occurs in the first 100 days after the transplant and can be much more severe. Common manifestations include attack of the skin, gastrointestinal tract and the liver. The onset is fast, requiring quick and aggressive treatment to decrease mortality. Graft versus host disease is treated with immunosuppressive drugs, which will increase the chance of a patient acquiring infections.
  2. Chronic graft versus host disease occurs later and the onset is more gradual. It can affect almost any organ or tissue to any degree. The type of transplant you receive will play a major role in the chance of getting graft versus host disease and the severity of the complication.

Medications are given during the transplant to prevent this graft versus host disease from becoming severe. There is data to support that this graft versus host disease also seems to cause a graft versus cancer effect as well, minimizing the chance of the cancer returning after the transplant.

Long term recovery - The long-term recovery phase involves leaving the Salt Lake City area, dealing with any ongoing clinical issues and re-establishing life patterns. As the patient prepares to return to their home, another medical evaluation and conference will be performed to discuss any ongoing clinical issues. A plan will be made regarding follow up visits, precautions, medications, etc. Allogeneic transplant recipients will be requested to return every 2-4 weeks to monitor for signs and symptoms of graft versus host disease until they are 3 months off immunosuppression. Most patients will have decreased stamina and may not be able to return to work for many months post transplant.

Long term effects - There are a number of potential long-term effects and complications following transplant. Some patients develop hormone failure due to the high dose chemotherapy and their hormone function should be monitored on a regular basis. Long-term complications can also include secondary cancers and any sign or symptom should be evaluated early. The use of sunscreen and annual pap smears, mammograms, etc. should be established. Most patients are at risk for six months to one year following transplant and even longer if you have received an allogeneic transplant and are on immunosuppression medications. Precautions should be taken to avoid these infections, including; avoiding large crowds, obvious fungus in basements, dirt, etc. and wearing a mask when going out in public is recommended.

Guidelines after your transplant - The following is a guideline to help determine what you can do and when you can do it after your transplant.

<><><>

 

 

 

Activity

Autologous Transplant
patients >3 months
without central line

Allogeneic Transplant
receiving immuno-suppression
with central line

 

Allogeneic Transplant
receiving immuno-suppression
with central line

Hot Tub/swimming                   

Yes

No

Yes

Gardening

Yes

No

Yes

Mowing lawn/Raking leaves

Yes

No

Yes

Woodworking (sawdust)

Yes

No

Yes

Household cleaning

Yes

Yes

Yes

Animals (not handling,
cleaning cages, feces)

Yes

Yes

Yes

New pets

Yes

No

Yes

Reptiles

Yes

No

Yes

Working with Livestock/horses

Yes

No

Yes

Golfing (sun protection,
no venous catheter)

Yes

Yes

Yes

Spectator events (church,
movies, games- no hand shaking)

Yes

Yes
(with MD approval)

Yes

Airline travel

Yes

Yes
(with MD approval)

Yes

Eat raw fish

Yes

No 

Yes

Return to work
(part time)

Yes

Yes
(with MD approval)

Yes

 

Sun exposure: 

  • Always use SPF > 30%!
  • Wear a hat, long sleeve shirt and pants if able.

Child vaccinations:

  • Avoid vaccinations with live viruses (MMR, oral polio) until approved by transplant center to receive.
  • Avoid contact with a child receiving the oral polio vaccine for 7 days.
  • Avoid contact with a child receiving the MMR vaccination for 72-96 hours.

Every element in the process is important and should be outlined in detail with your transplant coordinator. As you begin the process, other questions and issues may arise; we're here to help you through the process and be a resource.

To request information, ask questions, or learn more about the program, please contact us:

Intermountain Bone Marrow Transplant

8th Avenue C Street
Salt Lake City, UT 84143
Phone: (801) 408-3729
Fax: (801) 408-8453

Outpatient Nurses

8 a.m. to 4:30 p.m.
Monday thru Friday
Phone: (801) 408-1262

Copyright © , Intermountain Healthcare, All rights reserved.