Transplant Process
Bone Marrow Transplantation

Inpatient Bone Marrow Transplant
An inpatient Bone Marrow Transplant is a procedure that is undertaken by using a donor’s bone marrow. This type of transplant is called an allogeneic transplant, and the source of bone marrow may be a sibling, a matched unrelated donor, or an umbilical cord transplant.

A patient who undergoes an inpatient Bone Marrow Transplant is admitted to the Bone Marrow Transplant Unit for high-dose chemotherapy or a combination of high-dose chemotherapy and radiation therapy. This part of the treatment lasts approximately seven days. Then, the donor marrow is collected in surgery either from a sibling donor or collected from an unrelated donor at a National Marrow Donor site. The marrow is then infused directly to the patient through their central venous catheter placed in the chest. The procedure is similar to a blood transfusion. There is no pain, and the procedure takes 30 minutes to several hours. In fact, in most cases, the patient does not experience any discomfort. The patient remains in the hospital for three to four weeks, in order to receive supportive care consisting of antibiotics, immunosuppressive drugs and drugs to manage side effects.

When the patient recovers his or her blood counts and is physically active and able to take in adequate amount of calories, he or she will be discharged to home or to housing within the area for 100-120 days. During this time, the patient is kept in isolation, and needs a caregiver. Loyola University Health System (Loyola) patients are monitored closely by home nurses or followed in the outpatient unit either daily or several times a week for follow-up.

Outpatient Bone Marrow Transplant
An outpatient Bone Marrow Transplant is called a peripheral blood stem transplant. In this procedure, the stem cells are collected from the patient after being mobilized through growth factors, and then collected through a process called apheresis. Once the cells have been collected through a central venous catheter, they are preserved and stored.

The patient is admitted to the outpatient unit daily for high-dose chemotherapy and /or radiation therapy. When the treatment is completed, the patient is infused again with the stored cells, using the central venous catheter. The infusion is a painless procedure similar to a blood transfusion. The patient may experience some nausea or slight chest tightness from the preservative used in storing the cells, although some patients experience no side effects.

Once the patient has received the cells, he or she remains in the outpatient unit on a daily basis to receive supportive care to manage any side effects of the high-dose therapy. Antibiotics and blood transfusions are given as needed. During this time, when not at the outpatient unit, the patient is at home in isolation with a caregiver, followed by home nursing. When blood counts have recovered, and the patient is active and able to eat and drink, he or she is discharged to home or to nearby housing.

Stem cell transplants are usually done as an outpatient in our High Dose Unit. If at any time a patient does not have the resources to support him or her through an outpatient transplant, the procedure can be done as an inpatient transplant.

Transplant Steps

• Pre-transplant evaluation (1 – 4 weeks)
• Initial consult with transplant physician to determine suitability for transplant
• Additional therapy prior to transplant may be recommended at this time
• Insurance benefits verified
• HLA typing obtained if not done previously for allogeneic transplants

  Patient and Immediate Family Members Typed

• If no family members available or HLA-matched, search for unrelated bone marrow donor or cord blood source started
• Search for unrelated donor source may take several weeks to months
• Work-up testing ordered
• Information submitted to insurance company for pre-certification of transplant procedure
• Remainder of process depends on type of transplant

  Transplant Phases
  Autologous Transplants
  Stem cell mobilization and collection (1 – 3 weeks)
  Pheresis catheter placed

• Growth factors (with or without chemotherapy) given to increase peripheral blood stem cell count
• Daily apheresis (3 – 4 hours) for stem cell collection (usually 3 – 5 sessions, but varies)
• Cells stored in bag and frozen after each pheresis
• Some patients may have bone marrow taken from their hip bones in addition to pheresis
• Rest period of a few days (varies) before starting high dose therapy
• Admission to inpatient or outpatient transplant unit (approximately 17 – 21 days)

  High dose therapy

• Chemotherapy with or without radiation therapy over 4 – 8 days, depending on the type of cancer being treated
• One to 2 days of "rest" before the transplant during which time no therapy is given

Transplant

• Each bag of frozen stem cells thawed and given back through central venous catheter, similar to a blood transfusion

Engraftment

• Growth factors given to stimulate growth of new blood cells
• Blood and platelet transfusions as needed
• Daily monitoring of lab values
• Intravenous fluids and antibiotics as needed
• Supportive care for side effects
• Discharge from hospital or outpatient unit with follow-up in clinic and by home care nurse
• Protective isolation continues for up to 30 days until white cell count recovers

  Allogeneic Transplants
  Related or unrelated donor source of stem cells identified (one week to several months)
  Admission to inpatient transplant unit (28 – 35 days)

High dose therapy

• Chemotherapy with or without radiation therapy over 7 – 8 days, depending on the type of cancer being treated
• One to two days of "rest" before the transplant during which time no therapy is given

Transplant

• When the bone marrow donor is a relative, the donor is taken to the operating room and bone marrow is removed from the hip bones on the day of transplant.
• When an unrelated bone marrow donor is used, the donor is taken to an operating room near the donor’s home and the bone marrow is removed from the hip bones and flown to the transplant center that same day.
• When a cord blood stem cell source is used, the cord blood unit is sent to Loyola University Health System (Loyola) prior to your admission and stored frozen in the transplant lab. On the day of transplant, the cells are defrosted and given to you.
• Regardless of the source, the stem cells are given through a central venous catheter, similar to a blood transfusion.

Engraftment

• Medications given to suppress the immune system
• Growth factors given to stimulate growth of new blood cells
• Blood and platelet transfusions as needed
• Daily monitoring of lab values
• Intravenous fluids, nutrition, and antibiotics
• Supportive care for side effects
• Discharge from hospital with follow-up in clinic and by home care nurse
• Protective isolation continues for up to 100 – 120 days

Work-Up
The pre-transplant evaluation may include a variety of diagnostic tests depending on the disease being treated: complete blood count, serum chemistry panel, 24-hour urine for creatinine clearance, infectious disease testing, pulmonary function tests, nuclear medicine heart scan, bone marrow aspiration and biopsy and radiology exams.

Waiting
For autologous and related allogeneic transplants the time line is fairly predictable. For unrelated allogeneic bone marrow and cord blood transplants the time frame is highly variable due to the donor search process.

Related Links
Transplantation Services
Bone Marrow Transplantation
BMT Clinical Update Newsletter
Bone Marrow Transplant Brochure (2380K)