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What to Expect

Each patient and his/her disease is reviewed by the transplant doctor to decide what type of transplant would hold the most promise of a cure or control of the disease with the least amount of risk. When it is decided that an allogeneic transplant would be the best option, several procedures are done before the start of the transplant. Although the sequence of procedures never changes, the dates may change because of unforeseen events. A calendar will be given to you that will provide dates when these procedures will take place.

1. The First Visit

At your first visit, the transplant doctor will take a complete history of your current disease, previous treatments and other medical history. A physical exam will also be done. The transplant doctor will talk to you about what is involved in a transplant and answer any questions you have.

2. Insurance Approval

At the first visit, you will be asked for information on your insurance company. The transplant team will work closely with you and your insurance company to get approval for the transplant once it is decided to move forward. In the event that your insurance will not cover a transplant, or if you don’t have insurance, other options that might be available will be discussed with you.

Claims Representative

Medical billing can be confusing. Because some of the members of your medical team work "behind the scenes", you may receive bills from persons or organizations with whom you are not familiar. Sorting through the paperwork is important because you want to be sure the bills you are paying are approrpriate for the services you have received.

At the Avera Cancer Institute, a claims representative will help you sort through your bills and assist you in filing your insurance claim forms. There is no charge for an initial visit with the financial counselor. For a small annual charge, our claims representative will completely manage your medical billing file and will contact Medicare and/or your insurance company on your behalf. We strongly encourage all of the patients to visit with the financial counselor.

3. Pre-Transplant Evaluation

If you and your transplant doctor decide to proceed, a pre-transplant evaluation will need to be done. The pre-transplant evaluation includes several tests to:

  • See whether or not your body will be able to tolerate the transplant.
  • Serve as a “baseline” so that they can be compared with the same tests completed after the transplant. This is done to see if any organs were damaged during the transplant (due to high-dose chemotherapy).
  • All tests are done as an outpatient if possible.

Tests:
Each patient’s history and disease determines what tests are ordered, so all tests described below may not be completed for every patient.

Bone marrow biopsy and aspirate: A small amount of marrow is collected from the hip bone to determine how well your bone marrow is working and whether or not disease is present in your marrow. Sedation is used during this procedure. A specially trained registered nurse will give you drugs through your vein that allow you to sleep through the procedure. This makes the test virtually pain free. You may have some discomfort following the test that you can treat with Tylenol® if needed.

Pulmonary Function tests: This study determines how well your lungs are working by measuring the amount of air you breathe in and out and how well the oxygen in your lungs crosses into your blood.

Echocardiogram: This test uses sound waves to make a picture of your heart that tell us how well your heart pumps the blood.

Electrocardiogram(EKG): This test also shows how well your heart is working.

CAT scan: This test is done to see if there is any disease present.

PET scan: This test is done to see if there is any disease present.

Gallium scan: This test is done to see if there is any disease present.

Metastatic bone survey: This test is done to see if there is any disease present.

Blood & Urine tests: These tests are done to see how well your kidneys, liver and bone marrow are working.

Infectious Disease tests: This blood test is done to check for any infections like hepatitis.

The transplant doctor will meet with you to talk to you about the test results. Once it is decided that a transplant will be part of your treatment, the transplant team will meet with you and make plans to begin the transplant process.

4. HLA Typing

When it is decided that an allogeneic transplant would be the best option, a donor needs to be found. To increase the likelihood of a successful transplant and to decrease risks, it is important that the genetic code of the donor matches the patient's as closely as possible.

You and Your donor: Several procedures are done prior to, during, and after the transplant. We want to make sure that both you and your donor have all the information needed and all your questions answered before the transplant. You both must feel comfortable with the transplant team. If at anytime either of you have questions or concerns, always know that the team is here. We are always willing to answer any questions and to support you in any way we can.

The bone marrow is a part of the immune system. It is the immune system that enables the body to recognize “self ” from “non-self” such as foreign substances or tissues. Each of us has a set of proteins or genetic code on the surface of our white blood cells called Human Leukocyte Antigen (HLA). When our immune system identifies that the HLA on a cell does not match ours, the cell is recognized as “non-self”, and our immune system destroys it.

Our genetic code is passed down to us from each of our parents. As a result, our brothers and sisters are more likely to match our HLA type than a parent, grandparent, aunt, uncle or cousin. Each brother and sister has a 25% chance of matching. The more siblings the patient has, the greater the chance of finding a “matched sibling” as a donor.

A simple blood test can reveal your HLA typing. A small amount of blood is taken from the patient and the brothers and sisters. The blood is sent to a special laboratory where the HLA antigens are identified. There are six antigens that are identified. The results are then reviewed by the transplant doctor who compares the results to see if there is a match. If there is a match, that person will need to be seen by the transplant doctor and have a few tests completed to make sure that he/she is well enough to be the donor. If there is not a match, a decision will need to be made whether or not to look for an unrelated donor in the National Marrow Donor Program database. The success of an allogeneic transplant depends largely on how well the HLA of the donor matches the patient. The higher the number of antigens that match, the greater the success that the donor’s stem cells will do well in the patient’s body.

When the donor’s stem cells repopulate the patient’s bone marrow, the patient takes on the immune system of the donor. The donor’s stem cells will see the patient’s body as not its own and can start a war with the tissues of the patient’s body. This war can cause liver damage, skin changes and stomach and bowel problems. This is called, graft versus host disease (GVHD). The graft (the donor’s stem cells) versus the host (the patient). When all six antigens of the donor’s HLA type match the patient’s antigens, there will be less chance for graft verses host disease.

5. Donor Evalutation

Donor Information:
The donor for a patient undergoing a stem cell transplant, is very special. The gift that is given is one that no one else can give.

Prior to the donation of stem cells, the donor will undergo a “donor evaluation”. This evaluation is done to make sure that the donor is well enough to undergo the procedures that are required of a donor as well as to protect the patient from diseases or infections that could be passed on by the donation. The procedures that are done include:

  • Blood Work: Blood is drawn to check the function of the bone marrow, kidney, and liver. Blood will also be taken to check for any past or present diseases such as hepatitis that could be passed on to the patient through the donation of stem cells. A pregnancy test will be done on females.
  • Chest X-ray: This is to make sure that the lungs are healthy.
  • Electrocardiogram or EKG: This is a test that is able to trace the electrical conduction of the heart. This is done to make sure that there are not any problems with the heart.
  • Physical Examination: The transplant doctor will take a medical history and complete a physical exam. This is done to make sure that the donor is well enough to undergo the donation.

6. Consent Meeting

A consent meeting will be scheduled after the pre-transplant tests have been completed, and you and your physician have decided to go forward with the transplant. Family members and/or close friends are welcome to come with you. The transplant process will be reviewed including the stem cell collection, the chemotherapy drugs that will be given during the transplant, common side effects and dates for the transplant. This is done so that you have all the information you need and get all your questions answered before the transplant. Consent forms for the transplant will be given to you to read at home. We will have you sign them prior to starting the transplant process.

7. Donor: Stem Cell Mobilization

Once the transplant doctor has completed the evaluation and decides that you are healthy enough to be the donor, arrangements are made to start getting you ready for the stem cell donation. The team will give information on each of the procedures that are done prior to the stem cell donation. The donation of stem cells is timed with the day that the patient needs to receive them or the transplant day. Each of the procedures are described as follows:

Mobilization
Stem cells are found in the bone marrow and the peripheral blood. Stem cells are needed in order to “rescue” the bone marrow that has been wiped out from the high dose chemotherapy and/or radiation given during the transplant and to give the patient a new immune system. It is the donor’s stem cells that will restore the function of the patient’s bone marrow and immune system. Stem cells are collected from one of two sources, either the bone marrow or the peripheral blood. Generally the peripheral stem cell collection procedure is done; however, bone marrow collections can be performed if needed.

Since stem cells are found in our blood but in low numbers, we need to “mobilize” the stem cells out from the bone marrow into the blood stream. Mobilization is most often done as an outpatient at Avera Hematology and Transplant. You will receive daily growth factor injections for five days. On the fifth day, the stem cells will be collected.

Common side effects of the growth factor include bone or muscle aches, headaches, difficulty sleeping, and tiredness. Other less common side effects are nausea, vomiting, and irritability. The safety and health of the donor and patient is very important. Studies on donors one to many years after donation have not shown any adverse effects on their health.

8. Donor: Catheter Placement

Early in the morning on the fifth day of mobilization, arrangements will be made to have a catheter placed by a surgeon. This catheter is a tube with two “lumens” or separate lines that is inserted into a large vein in the chest under the collarbone or in the neck area. This procedure is usually performed as an out-patient in surgery. The insertion may cause some discomfort; however, pain medication will be given to help control the pain. The catheter will only be in until enough stem cells have been collected. Usually enough stem cells are collected on the first day; therefore, the catheter is removed the same day as it is placed. The removal of the catheter does not require another surgical procedure. Removal of the catheter is not painful.

9. Donor: Stem Cell Donation

Stem cell collection is done using a procedure called aphaeresis (ay-fer-ee-sis). This is an outpatient procedure performed by specially trained registered nurses supervised by the transplant doctor. The catheter you had placed will be used for stem cell collection. Two tubes or lumens of your catheter will be connected to the aphaeresis machine. Through the catheter, a small amount of your blood is removed and returned to you by the aphaeresis machine. As your blood travels through the aphaeresis machine, the stem cells are separated from the other blood cells in your blood and are removed and collected into a separate bag. The rest of the blood is returned to you.

Aphaeresis is painless and causes very few side effects. Common side effects are lightheadedness, chills, numbness around the lips, and cramping in the hands. These side effects are due to a lowering of the calcium in your blood. The aphaeresis nurse will give you calcium during the procedure to prevent these side effects from happening.

The aphaeresis procedure lasts about 4-6 hours. After each collection, we need to determine the number of stem cells that have been collected. The target number of stem cells is at least 2 million cells per kilogram of the patient's weight. Aphaeresis is done daily until the target number of cells is reached. Typically, only one collection is needed from a donor. After the collection, the stem cells are taken to the lab for the cell count to be completed. Once we know how many stem cells were collected, plans are made to remove the catheter or to set up a time for a second collection the next day.

10. Conditioning Therapy

The chemotherapy and/or radiation therapy you will receive during transplant is very strong. Great attention to detail is taken as the transplant team plans for your conditioning therapy. The goal of the conditioning therapy is to destroy any disease that might still be remaining in your body, to suppress the immune system and to make room for the stem cells that will be given.

This high dose chemotherapy is so strong that it will hopefully overwhelm the remaining disease and kill it. Unfortunately the high dose chemotherapy will not only kill any remaining disease but will also “wipe out” your bone marrow. This will prevent it from manufacturing the white and red blood cells and platelets that you need. The stem cells collected from your donor will be able to rescue your bone marrow from the effects of the chemotherapy and allow your bone marrow to recover and produce normal blood counts.

Conditioning therapy begins after admission to Avera McKennan Hospital & University Health Center or Avera Hematology & Transplant Clinic. During the days of chemotherapy, you will receive anti-nausea medications on a schedule to decrease your risk of becoming nauseated. You will receive plenty of intravenous fluids to make sure that you are flushing the chemotherapy out of your body. Most often the chemotherapy remains in the body for only 24 to 48 hours. The days of chemotherapy are numbered in minus numbers, and we count backwards to Day 0. On Day 0, there is no remaining chemotherapy in your body, and the stem cells can be given at that time.

Total Body Irradiation Therapy
If you will be receiving radiation therapy as a part of your preparative therapy, the radiation is given either before or after your chemotherapy, depending on the treatment regimen your transplant physician has chosen for you.

11. Day of Transplant

Stem Cell Infusion (Day 0)
The day the stem cells are infused is called “Day 0”. The infusion of stem cells will take place after the chemotherapy is done and enough time has passed to make sure no chemotherapy remains in your body. Unlike chemotherapy, radiation therapy does not require any time to leave your body. Once the radiation therapy is done, the stem cells can be given immediately without any harmful effect on them. The infusion of stem cells can happen anytime during the day. The transplant team will set up a time based on your last dose of chemotherapy or radiation treatment and the collection of cells from your donor. Your nurse will let you know what time the infusion is scheduled, so family members or friends who want to be there can plan accordingly.

The infusion of stem cells is done in your room. There are very few problems with the infusion of stem cells, but we do monitor you closely, so if problems arise we can take care of them quickly. Before the infusion, your nurse will connect you to several monitors:

  • A clip will be placed on your finger to measure the oxygen level in your blood.
  • Patches are put on your chest which are connected to a machine in order to monitor your heart rhythm.
  • A blood pressure cuff will be placed on your arm to monitor your blood pressure and pulse.
  • A special blood tubing will be connected to your catheter which is used to infuse the stem cells slowly through your catheter similar to transfusions of red blood cells or platelets.

There are few side effects of the infusion of stem cells. The side effects are:

  • Reaction similar to an allergic reaction like hives
  • Shortness of breath, or chest tightness

If these occur, medications will be given to reverse them

After the stem cells enter the bloodstream, it will take them approximately 24 hours or so to travel into the bone marrow. Once in the bone marrow, the stem cells will begin the process of producing new white blood cells, red blood cells, and platelets. It generally takes these stem cells between 12 – 20 days to make enough cells to be measurable in the blood sample. Your blood counts will be checked daily, and when the counts start to increase, we know that the stem cells have “engrafted”. Even though your blood counts have recovered, recovery of your immune function takes much longer.

12. Transplant Timeline

If you would like to see a graphic timeline of the transplant process, download this timeline pdf file. Note, this timeline covers both autologous and allogeneic transplant processes.

Other Information

You can also view patient education about the autologous transplant process.