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Bone marrow (stem cell) transplant

A bone marrow transplant is used to replace your bone marrow if it isn’t working properly. If you have a stem cell transplant, your damaged cells are replaced with new ones.

You’ll meet the doctor carrying out your procedure to discuss your care. It may differ from what’s described here because it will be adapted to meet your individual needs.

Bone marrow is a spongy substance in the centre of your bones. It makes special cells called stem cells, which aren’t fully developed yet. When they mature, they make other cells in your body.

Some of the stem cells in your bone marrow mature to make certain types of blood cells. These include the following:

  • white blood cells, which help your body fight infections
  • red blood cells, which carry oxygen around your body
  • platelets, which help your blood to clot

Once these blood cells are fully developed, they are then released from your bone marrow into your bloodstream.

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Details

  • When are they used? When are bone marrow transplants used?

    If you have a bone marrow transplant, your unhealthy bone marrow will be replaced with healthy stem cells. You may need a bone marrow transplant because you have a condition that affects your bone marrow or your red blood cells. These include the following.

    • Cancers that affect your bone marrow, such as leukaemia, lymphoma and myeloma.
    • Conditions affecting your blood cells, such as sickle cell anaemia and thalassaemia.
    • Conditions that affect your immune system.

    The stem cells can come from another person (a donor) – this is called an allogeneic transplant. For example, you may have a related donor such as a brother or sister, or a matched unrelated donor. If the stem cells come from your identical twin, this is called a syngeneic transplant. The cells can also come from your own bone marrow, which is called an autologous transplant. But this can only happen if your stem cells are removed when they are healthy.

    Having a stem cell transplant means you may be able to have higher doses of chemotherapy treatment. Treating cancer with high-dose chemotherapy and a bone marrow transplant may cure your cancer, keep it under control or stop it coming back. Examples of conditions treated by an autologous stem cell transplant include myeloma and lymphoma.

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  • Preparation Preparing for a bone marrow transplant

    Once you’ve decided to have a bone marrow transplant, your doctor or nurse will explain how to prepare for it. They will start looking for a suitable stem cell donor if your stem cells are coming from another person. Your donor will ideally be a close relative (usually a brother or sister). This is because their blood cells are likely to be similar to yours. If your doctor can’t find a relative who is a close match, they will look for someone who isn’t related to you.

    You and any possible donors will need to have some blood tests. Your doctor will compare your blood cells with those of the donor to see whether the donor is a good match for you. Your doctor will ask the donors about their medical and family history too. Your doctor may find a suitable donor who isn’t related to you through the British Bone Marrow Registry or the Anthony Nolan Trust.

    If your own stem cells are being used, you may need to have a general anaesthetic beforehand. This means you’ll be asleep during the procedure. You’ll also be asked to follow fasting instructions. This means not eating or drinking anything, usually for about six hours, before your surgery. It’s important to follow your anaesthetist’s advice. This method of collecting stem cells is now used less commonly. Instead, stem cells are more commonly collected from the blood stream.

    After you have a bone marrow transplant, you’ll need to stay in a hospital room on your own for a while. This could be for about four weeks. It will reduce your chances of catching an infection while your immune system recovers. When you’re packing your hospital bag, take some personal things with you, such as photographs, books and magazines, to make your room more homely. Taking a mobile phone, electronic tablet or laptop might help you to pass the time and keep in touch with relatives and friends.

    Your nurse or doctor will discuss with you what will happen before, during and after your procedure, including any pain you might have. If you’re unsure about anything, don’t be afraid to ask. No question is too small. It’s important that you feel fully informed so you feel happy to give your consent for the procedure to go ahead. You’ll be asked to do this by signing a consent form.

  • Alternatives What are the alternatives to a bone marrow transplant?

    Doctors are now using bone marrow transplants to treat a wide range of conditions. But these transplants aren’t suitable for everyone. Your doctor will take your age and general health into account when they decide whether the procedure is right for you. For example, if you’re having a stem cell transplant from a donor, you generally need to be under 70 years old. Your doctor will need to find a compatible stem cell donor if your own cells aren’t suitable.

    Stem cells can also come from blood found in babies’ umbilical cords. Previously, this treatment was only considered suitable for children and small adults. This is because umbilical cord blood contains only small amounts of stem cells. But new research is exploring whether cord blood can be used in all adults.

  • The procedure What happens during a bone marrow transplant?

    There are usually three steps involved in having a bone marrow transplant:

    • collecting the stem cells from you or a donor
    • having high-dose chemotherapy and/or radiotherapy
    • transplanting the new stem cells

    Collecting the stem cells

    The first step is to collect, or ‘harvest’, the stem cells from you or your donor. There are two main ways to do this. The first way is to collect the stem cells from you or your donor’s blood. This is called a peripheral blood stem cell harvest (PBSCH). The other way is to collect the stem cells directly from you or your donor’s bone marrow.

    If you have a PBSCH, you’ll first be given injections of a growth factor. Most of your body’s stem cells are found in your bone marrow. The growth factor triggers your stem cells to mature more quickly so that they leave your bone marrow and move into your bloodstream. Then your nurse will put two drips into your arms and use a machine to collect these cells from your blood.

    If your stem cells are collected from your bone marrow, you’ll usually have a general anaesthetic, which means you’ll be asleep during the procedure. Alternatively, you may be able to have an epidural. This completely blocks pain from your lower body, but you’ll stay awake during the procedure. Your doctor will then insert a needle into your pelvic bone, or sometimes breast bone, to take stem calls out of your bone marrow.

    The collected stem cells will be given back to you through a drip in your arm. You may need to have other treatments first, such as high-dose chemotherapy.

    High-dose chemotherapy

    Next, you’ll be treated with high-dose chemotherapy, sometimes with high-dose radiotherapy (called total body irradiation) as well. This completely destroys your own bone marrow, creating room for the new bone marrow cells. If you’re being treated for cancer, this step may also aim to destroy any remaining cancer cells in your body. This treatment usually takes about four to seven days. It can make you feel sick or vomit and feel generally unwell. Your doctor or nurse will give you medicines to help relieve this.

    The transplant

    After you’ve finished chemotherapy, the new stem cells will be fed through a drip into your bloodstream. During this simple procedure, you usually lie in bed for a few hours with the drip in your arm. The stem cells will find their way to your bone marrow where they will begin to make new cells. It will take between two and four weeks before there are enough new stem cells in your bone marrow to start making new blood cells.

  • Aftercare What to expect afterwards?

    After a bone marrow transplant, you’re likely to have low levels of blood cells in your body. You may need to have a blood and platelet transfusion to correct this. You’ll also need to take antibiotics to protect you from infections. Your immune system won’t be working properly because your body will contain only low levels of white blood cells. You may need to stay in a room on your own in hospital until your blood cells have gone back up to a safe level.

    A transplant using your own stem cells usually causes fewer side-effects than a transplant using stem cells from a donor. This is because your body is less likely to reject stem cells that have come from its own bone marrow or blood.

    Immediately after a bone marrow transplant, your mouth may feel sore and you may find it difficult to swallow. Your doctor may suggest that you’re fed through a tube placed in one of your veins or directly into your stomach until your mouth recovers.

    The overall success of a bone marrow transplant depends on many factors. These include what condition you have, how far it’s progressed, your age, and how good a match your donors are. If you’d like more information, speak to your nurse or doctor. Donor stem cell transplants are physically and emotionally demanding so it’s important that you prepare yourself and have the support of friends and family. If you’re worried about any aspect of your transplant, speak to your doctor or nurse.

  • Recovery Recovering from a bone marrow transplant

    How long it takes to recover fully from your bone marrow transplant will depend on whether or not your stem cells were from a donor. This can vary from person to person, so it’s important to follow your doctor’s advice. It can take months or sometimes even years to recover properly as your body gets used to the newly transplanted cells.

    Once the number of blood cells in your body has returned to a safe level, you’ll be able to leave the hospital. You may be advised to avoid eating certain foods, which could be contaminated with bacteria or fungi. These foods include raw or lightly cooked shellfish, blue cheese and raw or undercooked eggs. You’ll also need to be very careful with food hygiene, for example when you prepare, cook, eat out or store food. You should continue to follow this food safety advice for at least six months after being discharged from hospital.

    After a bone marrow transplant, you lose your immunity to common childhood infections. You’ll need to be vaccinated again to protect you against conditions such as tetanus and diphtheria. You’ll usually have these vaccinations about 12 months after your transplant. Your doctor will suggest that you are re-immunised against the flu as well.

  • Side-effects Side-effects of a bone marrow transplant

    After your bone marrow transplant, you may have some side-effects, such as diarrhoea, which should be mostly temporary.

    Straight after your transplant, the levels of blood cells in your body will be very low. This may cause the following.

    • Having a low immunity to infections, due to a lack of white blood cells.
    • Anaemia – a condition in which you have too few red blood cells or not enough haemoglobin in your blood. Haemoglobin is a protein found in red blood cells that carries oxygen and carbon dioxide around your body in your bloodstream.
    • Bleeding because of a lack of platelets in your blood – these normally help your blood to clot.
    • Problems eating as a result of feeling sick, not feeling hungry or having a sore mouth after treatment.

    You may need to have a blood transfusion to increase your levels of platelets and red blood cells.

  • Complications Complications of a bone marrow transplant

    Complications are when problems occur during or after a procedure.

    Infections are a common complication of a bone marrow transplant while your levels of white blood cells are low. The medicines that stop your body rejecting the new stem cells may increase your risk of infections even more. This is why you need to stay in a special hospital room after your transplant to limit your exposure to bacteria, fungi and viruses. You also need to be careful about what you eat and drink.

    Graft-versus-host disease (GVHD) is another possible complication of receiving bone marrow cells from a donor. This happens when the white blood cells of the donor recognise your cells as being different and attack them. You will be given medicines to prevent this, so the symptoms are usually mild, although in some people they may be more serious. See our FAQ on GVHD for more information.

    If the transplant isn’t working, your new stem cells may not produce enough, or any, new blood cells. This will show up in blood tests. If this happens, your doctor may give you growth factors to help your body make more blood cells. If the growth factors don’t work, you may need another stem cell transplant.

  • What will happen if I get GVHD? What will happen if I get graft-versus-host disease (GVHD)?

    Answer

    If you have graft-versus-host disease (GVHD), it means the new donor stem cells are attacking your body. This can happen immediately after your bone marrow transplant or several months later. In some people, GVHD causes minor symptoms, such as a skin rash, sickness or diarrhoea. In others, it can be very serious or even life-threatening. If you get GVHD, your doctor will prescribe medicines that reduce your body’s immune system response.

    More information

    If you receive stem cells from a donor, the new cells can sometimes start to attack your body, especially your liver, skin or digestive system. This is because they see your body as ‘foreign’. This can be an advantage because the new cells attack any remaining cancer cells. But it can also cause a lot of damage to your body’s organs.

    GVHD can be acute, which means it develops within 100 days of your transplant. It can also be chronic, when it develops more than 100 days after your transplant.

    Symptoms of acute GVHD can be minor or serious. These include:

    • a severe itchy or painful skin rash
    • feeling sick and vomiting
    • diarrhoea
    • yellowing of your skin (jaundice)

    Chronic GVHD can cause the symptoms of acute GVHD, as well as other symptoms including:

    • dry skin
    • weak muscles and painful joints
    • difficulty breathing
    • a swollen, dry mouth
    • dry, burning and/or irritated eyes

    Your doctor will monitor you carefully in the weeks and months after you have a bone marrow transplant. If necessary, they may prescribe medicines to weaken or switch off (suppress) your new immune system. This will make you less likely to develop GVHD.

    Your doctor may also recommend that you stay out of the sun and use high factor sun creams when you are outdoors. This is because your skin becomes more prone to sunburn if you have GVHD after a bone marrow transplant. You should also use moisturising skin creams to prevent dry skin.

    GVHD is often treated with corticosteroid medicines, which weaken your immune system. This stops the new stem cells from seeing your body cells as foreign so they no longer attack them.

  • How are stem cells removed from my donor? How are stem cells removed from my donor?

    Answer

    The stem cells can be collected (harvested) from your donor in two different ways. They can be taken from your donor’s blood or from their bone marrow.

    More information

    Collecting stem cells from your donor’s blood is called a peripheral blood stem cell harvest. This is the most common method of collecting stem cells for a bone marrow transplant. Your donor will need to be injected with a medicine called a growth factor. A doctor or nurse will usually teach your donor how to inject themselves with the medicine. This triggers stem cells to be released from their bone marrow into their bloodstream.

    Four to six days later, a nurse or doctor will then collect your donor’s blood. This is done through a drip, which will be inserted into a vein in their hand or arm. The stem cells will be separated from the other cells in their blood. The injection of the growth factors can cause muscle and joint pains, but these can be eased with over-the-counter painkillers.

    If the stem cells are collected directly from your donor’s bone marrow, a doctor will use a special needle to suck them out. The stem cells are usually taken from inside your donor’s hip bones, or occasionally from their breastbone. The doctor may need to place the needle in several different areas to collect enough of these cells. This will be necessary especially if your donor is smaller than you.

    The procedure is done with a general anaesthetic or an epidural. If you have a general anaesthetic, you will be asleep during the procedure. An epidural stops you feeling pain in the lower half of your body, but you stay awake during the procedure. Most bone marrow donors can return to work and their usual activities a couple of days after the procedure.

    Following the procedure your donor may have a blood transfusion. In some situations, you may be able to have a bone marrow transplant using stem cells from a baby’s umbilical cord. Some hospitals offer new parents the chance to collect stem cells from their baby’s umbilical cord, which are then stored. Although only a small number of cord blood cells are currently available, this may become a more common procedure in the future.

  • Why do I need a transplant if my immune system has completely failed? Why do I need a bone marrow transplant if my immune system has completely failed?

    Answer

    Your bone marrow makes stem cells, which develop and mature into the other cells in your body. These cells include white blood cells, which are an important part of your immune system. If your immune system stops working, a bone marrow transplant will trigger the production of new white blood cells.

    More information

    Bone marrow is a spongy substance in the centre of your bones. It makes stem cells, which develop and grow into the other cells in your body, including white blood cells. White blood cells are an essential part of your immune system. These are involved in spotting ‘foreign’ or different cells in your body, such as bacteria or viruses, and co-ordinating an attack against them. This helps to protect your body from infections.

    Certain illnesses can affect your bone marrow and destroy the stem cells. This means that you can’t make any, or enough, white blood cells, which makes you more likely to catch infections. A bone marrow (or stem cell) transplant can help your body to produce normal white blood cells again.

    Bone marrow transplants from donors are often carried out to treat conditions such as acute leukaemia. They can also be carried out to treat other conditions such as lymphoma, myeloma, thalassemia and sickle cell disease.

    Not all conditions or diseases that damage your immune system can be treated with a bone marrow transplant. If you’re unsure if a bone marrow transplant can help you, ask your doctor for advice.

  • Resources Resources

    Further information

    Sources

    • Hematopoietic stem cell transplantation. Medscape. www.emedicine.medscape.com, reviewed 31 March 2014
    • Bone marrow anatomy. Medscape. www.emedicine.medscape.com, reviewed 22 August 2013
    • Nursing patients with haematology problems. Oxford handbook of adult nursing (online). Oxford Medicine Online. www.oxfordmedicine.com, published August 2010 (online version)
    • Bone marrow and bone marrow failure. PatientPlus. www.patient.co.uk/patientplus.asp, reviewed 3 February 2014
    • Bone marrow transplantation. Medscape. www.emedicine.medscape.com, reviewed 7 November 2014
    • Infection after bone marrow transplantation. Medscape. www.emedicine.medscape.com, reviewed 7 April 2015
    • How we help. Donate your umbilical cord blood. Anthony Nolan Trust. www.anthonynolan.org, accessed 13 July 2015
    • Q&A. British Bone Marrow Registry. www.nhsbt.nhs.uk, accessed 13 July 2015
    • You and your anaesthetic. The Royal College of Anaesthetists. www.rcoa.ac.uk, accessed 13 July 2015
    • Nursing patients requiring preoperative care. Oxford handbook of adult nursing (online). Oxford Medicine Online. www.oxfordmedicine.com, published online August 2010 (online version)
    • Having a transplant. Cancer Research UK. www.cancerresearchuk.org, reviewed 17 March 2015
    • Haematological malignancies. Oxford handbook of clinical oncology (online). Oxford Medicine Online. www.oxfordmedicine.com, published online June 2011 (online version)
    • Hematopoietic stem cell transplantation. The Merck Manuals. www.merckmanuals.com, reviewed April 2013
    • Bone Marrow Donor Procedure. Medscape. www.emedicine.medscape.com, reviewed 11 June 2013
    • Cancer and leukaemia. Oxford handbook of nutrition and dietetics (online). Oxford Medicine Online. www.oxfordmedicine.com, published January 2012 (online version)
    • Stem cell and bone marrow transplants explained. Preparing for treatment. Your feelings. Macmillan. www.macmillan.org.uk, accessed 13 July 2015
    • Long-term effect of bone marrow transplantation. Medscape. www.emedicine.medscape.com, published 11 February 2014
    • Graft-versus-host disease. BMJ Best Practice. www.bestpractice.bmj.com, published 15 April 2015
    • Graft versus host disease. Medscape. www.emedicine.medscape.com, published 16 April 2015
    • Immune system anatomy. Medscape. www.emedicine.medscape.com, published 22 November 2013
    • Artz SA. Older patients/older donors: choosing wisely. Hematology Am Soc Hematol Educ Program 2013; 1:70−75. doi:10.1182/asheducation-2013.1.70
    • Personal communication, Dr Premini Mahendra, Consultant Haemato-Oncologist/Divisional Director, University Hospital Birmingham NHS Trust, August 2015
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    Reviewed by Hemali Bedi, Bupa Health Content Team, August 2015.

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