Bone Marrow (Stem Cell) Transplant

What is a bone marrow transplant?

A bone marrow transplant is also known as a stem cell transplant or hematopoietic stem cell transplant. It is a medical procedure to replace bone marrow that has been damaged by disease, infection or chemotherapy.

Bone marrow is the spongy, fatty tissue inside your bones. It holds hematopoietic stem cells that are able to make new blood cells. In broad terms, our bodies have 3 types of blood cells:

• Red blood cells (haemoglobin), which carry oxygen and nutrients around your body
• White blood cells, which fight infections
• Platelets, which prevent excessive bleeding through clotting

During the transplant, healthy stem cells are introduced into your bloodstream so that they can travel to your bone marrow, produce new blood cells and promote the growth of new marrow.

Types of bone marrow transplants

Depending on the source of healthy stem cells, there are 2 types of transplants:

1. Allogeneic transplant, where the source of the healthy stem cells is another person.
2. Autologous transplant, where the source of the healthy stem cells is yourself (before you start chemotherapy or radiation treatment)

Why do you need a bone marrow transplant?

Bone marrow transplants are used to treat medical conditions that damage the bone marrow, such as:

• Anaemia, caused by bone marrow failure
• Leukemia, a type of cancer affecting white blood cells
• Lymphoma, a different type of cancer affecting white blood cells
• Myeloma, a type of cancer affecting plasma cells (a specific type of white blood cells that produce antibodies)
• Certain blood, immune system and metabolic disorders

Bone marrow transplants can also repair bone marrow that was damaged due to intensive cancer treatment.

Your doctor will only recommend a bone marrow transplant if other treatments have not been effective, and you are in relatively good health despite your condition.

Who should not undergo a bone marrow transplant?

In general, age does not affect your eligibility for a bone marrow transplant. However, you may be ineligible if you have other major health problems such as serious heart, lung, liver, or kidney disease.

What are the risks and complications of a bone marrow transplant?

Bone marrow transplants are complex procedures with significant risks. Your doctor will discuss the risks and possible benefits to help you decide whether to proceed.

Complications that may occur with bone marrow transplants include:

• Graft versus host disease (GvHD). This occurs in allogeneic transplants when the transplanted cells start attacking other cells.
• Infections. As bone marrow transplants weaken your immunity, you may face a higher risk of infection while your body recovers.
• Low platelets and low red blood cells, which may result from non-functioning bone marrow. Low platelets can cause dangerous internal bleeding.
• Pain. High doses of chemotherapy and radiation can cause inflammation of the mouth and gastrointestinal (GI) tract, leading to painful mouth sores and GI irritation.
• Fluid overload, where the kidney cannot cope with the large amount of fluid being given in the form of intravenous (IV) medicine, nutrition and blood products.
• Respiratory distress, which may occur if there is infection or inflammation of the airway.
• Organ damage. The liver and heart are important organs that may be damaged during the transplantation process.

How do you prepare for a bone marrow transplant?

Bone marrow transplants may require extensive preparations, such as:

• Appointing a primary caregiver to look after you and update your medical team when necessary.
• Making necessary work and personal arrangements for your hospital stay.
• Preparing your home to facilitate your recovery after your hospital discharge. This means:
  • Cleaning your home, especially the rooms that you will be resting in. This is important as your immune system will be weakened after the bone marrow transplant, which makes you more likely to be infected by bacteria.
  • Targeting areas that may have dust, mould, mildew and other tiny particles which may be harmful during your recovery.
• Going through medical tests, such as:
  • Blood tests
  • Physical exams
  • Evaluations of your psychological and emotional states
  • A bone marrow biopsy
  • A CT scan or MRI scan
• Visiting a dentist to get any dental work done in advance. Once you start your bone marrow transplant, you will be at a higher risk of infection.
• Taking care of your diet and fitness. A healthy lifestyle is key to preparing for your transplant. Start with small steps, such as:
  • Eating little and often.
  • Adding protein and calorie-rich ingredients into your meals.
  • Doing gentle exercises such as walking, cycling and yoga.

What can you expect in a bone marrow transplant?

A bone marrow transplant does not involve surgery. Instead, it involves the insertion of a needle into your vein.

Estimated duration

A bone marrow transplant may require a hospital stay of up to 2 – 4 weeks.

Before the procedure

If you are undergoing an:

• Allogeneic stem cell transplant, the team will collect stem cells from your donor's blood or bone marrow.
• Autologous stem cell transplant, the team will extract and later return stem cells into your body.

Depending on your condition, your doctor may recommend proceeding with conditioning treatment or multiple myeloma treatment:

Conditioning treatment

Conditioning treatment usually involves chemotherapy and sometimes radiation therapy. The goal is to:

• Destroy existing cancer cells
• Destroy existing bone marrow cells to make room for healthy stem cells
• Stop your immune system from working to reduce the risk of the transplant being rejected

As conditioning treatment involves a lot of medication, your doctor will insert a central line tube into a large vein near your heart. This allows your doctor to administer medication without the need for multiple injections.

The conditioning process usually lasts up to a week. You will remain in the hospital throughout this duration. After you have completed the conditioning treatment, your doctor will let you rest for 1 – 2 days before proceeding with the transplant.

Multiple myeloma treatment

Multiple myeloma is cancer that affects a specific type of white blood cell, called plasma cells. It causes cancerous plasma cells to gather in the bone marrow and push out healthy blood cells.

If you have multiple myeloma, you may need to undergo induction chemotherapy for a few months to reduce the number of plasma cells in your bone marrow. This should be followed by conditioning treatment.

During the procedure

The stem cells will be infused into your body through the central line. This process takes a few hours and you will remain awake throughout.

During the infusion, you may experience pain, chills, fever, hives and chest pain.

After the procedure

After undergoing a bone marrow transplant, you will be kept under close medical care to check your body's response to the procedure. You will remain in the hospital for at least a few weeks to settle in your bone marrow and produce new blood cells.

During this period, you may:

• Feel lethargic
• Experience vomiting, diarrhoea and loss of appetite
• Receive fluids by mouth or through a tube to prevent malnutrition
• Have periodic transfusions of red blood cells and platelets until your bone marrow produces enough of them on its own
• Stay in a disinfected room to lower your risks of getting infections

Many patients can return home within 1 – 3 months after the transplant. However, if you develop complications such as an infection, you may need to remain in the hospital for longer.

Care and recovery after a bone marrow transplant

Your recovery process may take several months or longer. During this period you may not be able to return to work or resume your previous lifestyle.

You will be at risk of infections for the next 1 – 2 years as it takes a while for your immune system to return to full strength.

During the recovery period, you will have to attend follow-up appointments with your doctor to check on your health and progress.