How the bone marrow functions
Hematopoietic stem cells are found in the peripheral blood and the bone marrow, which is the soft, spongy center of your bone. These stem cells develop into all types of blood cells, including white blood cells, red blood cells, and platelets.
- White blood cells of various kinds make up part of your immune system for fighting infections.
- Red blood cells are responsible for carrying oxygen throughout your body.
- Platelets clot your blood to prevent bleeding.
Stem cells are constantly being produced by your bone marrow and will develop into the types of cells your body needs.
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| Blood and Marrow Transplant |
Types of bone marrow transplants
Most people who need to undergo a blood or marrow transplant have cancer, such as leukemia, lymphoma or multiple myeloma. There are different types of transplants. The type and severity of your disease determine what type of transplant you will need.
An allogeneic transplant involves receiving donor bone marrow, umbilical cord stem cells, or peripheral stem cells. This donor is genetically matched and can be related or unrelated to you.
An autologous transplant involves receiving your own peripheral blood stem cells. A syngeneic transplant involves receiving your identical twin's bone marrow or peripheral stem cells.
Here is more information about the specific types of blood or marrow transplants:
- An allogeneic transplant involves receiving very high-doses of chemotherapy and/or radiation therapy, followed by the infusion of your donor's bone marrow or peripheral blood stem cells. The high-dose cancer-fighting treatments are given to eliminate the cancer in your body. The infusion of the new marrow, cord blood, or peripheral stem cells from the donor replaces the bone marrow destroyed by the chemotherapy and/or radiation therapy. Allogeneic transplant patients have the risk of developing a complication called graft-versus-host disease or GvHD. GvHD is a condition where donor cells from the graft attack the patient's (or host's) organs or tissues. The condition can be mild and treated on an outpatient basis, or it can be severe and require treatment in the hospital. You might be a potential candidate for an allogeneic transplant if you have leukemia, aplastic anemia, myelodysplasia, myelofibrosis, high-grade lymphoma or other types of cancers.
- A reduced intensity allogeneic transplant involves receiving lower doses of chemotherapy and radiation therapy followed by the infusion of your donor's bone marrow or peripheral blood stem cells. The objective is to suppress your own bone marrow by receiving just enough chemotherapy and radiation therapy to allow your donor cells to engraft and grow within you. The hope is these donor cells will mount an immunologic attack against your underlying cancer, generating a response called the “graft-versus-leukemia” effect or “graft-versus-cancer” effect. You might be a potential candidate for this type of transplant if you have a slow-growing ("indolent") disorder, such as chronic leukemia, multiple myeloma, myelodysplasia, and low-grade lymphoma.
- An autologous bone marrow transplant involves receiving very high-dose chemotherapy followed by the infusion of your previously collected peripheral stem cells or bone marrow. The high-dose chemotherapy treatments are given to eliminate the cancer in your body. The infusion of your new marrow or peripheral stem cells replaces the bone marrow destroyed by the chemotherapy and/or radiation therapy. You might be a potential candidate for an autologous transplant if you have lymphoma, multiple myeloma, Hodgkin's disease, germ cell cancer, or certain types of leukemia.
Pre-transplant evaluation
Before a blood or marrow transplant can be approved as a treatment option, you will have a pre-transplant evaluation. This evaluation includes a complete physical, consultations with members of the Transplant Team, and a comprehensive series of tests. A pre-transplant evaluation provides complete information about your overall health and helps determine if you are eligible for a blood or marrow transplant.
Blood or marrow transplantation as a treatment option
After your transplant doctor has determined you are a good candidate for a transplant, a date for the transplant will be determined and the process of insurance clearance will begin. Please understand that insurance reimbursement for transplantation is not automatic.
If you are to be admitted to the hospital for your transplant, you can expect your stay to be about 3 to 4 weeks, depending on your recovery. During your recovery, you will learn about your new medicines, how to recognize signs of complications and infections, and when you can return to your normal activities.
If an allogeneic transplant or inpatient reduced intensity transplant has been approved for you, you and your designated care partner will be required to stay within a 1-hour drive of Cleveland Clinic’s main campus for approximately 100 days after your transplant. After you go home, you can expect to recover gradually.
If an outpatient reduced intensity allogeneic transplant has been approved for you, you will be required to stay within a one-hour drive of Cleveland Clinic’s main campus for at least 100 days after your transplant. At that time, your doctor will evaluate your medical condition to determine where you can continue your follow-up care.
Follow-up care after your transplant includes appointments with your transplant or local doctor and tests to assess how you are recovering.
Before a bone marrow transplant operation, certain tests are required. These include blood tests, a chest X-ray, PET scan, heart tests, and a bone marrow biopsy. Donors are also expected to complete certain tests.
Why do I need to have bone marrow pre-transplant evaluation tests?
Your pre-transplant evaluation includes a variety of medical tests that provide complete information about your overall health. These medical tests help the bone marrow transplant team identify any potential problems before your transplant and avoid potential complications after your transplant.
While each patient does not have the same tests, most of the tests included in this handout are common for all transplant patients. The tests required before the transplant are usually done on an outpatient basis. Your nurse and administrative coordinator will help arrange these for you. Please ask your nurse coordinator any questions you have.
If special instructions are required before any of these tests, you will receive a written form that explains how to prepare. After the tests are completed, your doctor will review the results with you. These results are also required by your insurance company in order to approve the medical necessity of your transplant.
Blood tests
Your health care provider or a technician will take a sample of blood from your arm or central venous catheter (if one is in place). The blood is sent to a lab where the following tests are performed:
Tissue typing (needed for allogeneic patients only)
This was done at or before your initial consultation appointment with your BMT doctor. Tissue typing is a series of blood tests that evaluate the compatibility or closeness of tissue between the organ donor and recipient. From your blood samples, the tissue typing lab can identify and compare information about your antigens (the “markers” in cells that stimulate antibody production) so they can match a bone marrow donor to you. All donors are carefully screened to prevent any transmissible diseases or detect other medical problems that might prevent them from donating bone marrow.
Other blood tests
In the laboratory, a series of tests will be performed to detect certain substances in your blood and to evaluate your general health. These blood tests might include:
Infectious disease screening for:
- Hepatitis
- HIV (human immunodeficiency virus)
- RPR (syphilis)
- Toxoplasmosis
- Varicella Zoster
- CMV (cytomegalovirus)
- EBV (Epstein-Barr virus)
- HSV (Herpes Simplex virus)
- West Nile Virus
- HTLV1/11 (Human T-Cell
- lymphotropic virus)
- Chagas
Blood work to check your organ function
- Ferritin
- Pregnancy test
- Complete Metabolic Panel
- Hemoglobin solubility
- ABO blood type
- Bleeding times
- CBC, diff, platelets
- Quantitative immunoglobulins
Other possible blood work
- Disease-specific labs for multiple myeloma
- Research samples
Other tests:
Chest X-ray
A chest X-ray provides a picture of your heart and lungs. This X-ray provides information about the size of your heart and lungs, and might detect the presence of lung disease or infection.
Pulmonary function tests (PFTs, lung tests)
Pulmonary function tests measure the capacity and function of your lungs, as well as your blood’s ability to carry oxygen. During the tests, you will be asked to breathe into a device called a spirometer.
Here are some guidelines to follow before your scheduled pulmonary function tests:
- Be sure to get plenty of sleep the night before.
- Plan to wear loose clothing during the test so you can give your greatest breathing effort.
- Limit your liquids and eat a light meal before the test. Drinking or eating too much before the test might make you feel bloated and unable to breathe deeply.
Computed tomography scan (CT Scan)
A CT scan, uses X-rays and computers to produce a detailed image of the body. Depending on the type of scan you need, an oral and/or IV contrast material might be used so the radiologist can see the extent of your disease. CT scans also might reveal the presence of other abnormalities.
If you had a CT scan within 6 months before your pre-transplant evaluation, bring the CT scan films or disc, along with a copy of the report with you. The radiologist will use them as comparison when reading these new scans.
Depending on your illness, your doctor might order additional CT scans.
Positron emission tomography (PET) scan
A PET scan is a unique type of imaging test that helps doctors see how the organs and tissues inside your body are actually functioning.
The test involves injecting a very small dose of radioactive chemical, called a radiotracer, into a vein. The tracer travels through the body and is absorbed by the organs and tissues being studied. Next, you will be asked to lie down on a flat examination table that is moved into the center of a PET scanner -- a doughnut-like shaped machine. This machine detects and records the energy given off by the tracer substance. The PET scan can measure such vital function as glucose metabolism, which helps doctors identify abnormal from normal functioning organs and tissues.
One of the main differences between PET scans and other imaging tests like CT scan or magnetic resonance imaging (MRI) is that the PET scan reveals the cellular level metabolism changes occurring in an organ or tissue, or the activity of cells.
Depending on your illness, your doctor may order a PET scan.
Heart tests
Because prior chemotherapy and/or radiation therapy and the chemotherapy/ radiation therapy you will receive for transplant can affect your heart, you will need heart tests to identify and treat any potential problems before the transplant procedure. The heart tests include:
- Electrocardiogram (EKG): An EKG is used to evaluate your heart rhythm. Before the test, electrodes (small, flat, sticky patches) are placed on your chest. The electrodes are attached to an electrocardiograph monitor that charts your heart’s electrical activity (heart rhythm).
- Echocardiogram: An echocardiogram is a graphic outline of your heart’s movement. During the test, a wand, or transducer, is placed on your chest. The transducer emits ultrasound (high-frequency sound wave) vibrations so the doctor can see the outline of the heart’s movement. The echocardiogram provides pictures of the heart’s valves and chambers so the pumping action of the heart can be evaluated. Echocardiogram is often combined with Doppler ultrasound to evaluate blood flow across the heart’s valves.
Bone marrow biopsy
A bone marrow biopsy is performed to evaluate your marrow’s function and to assess for disease involvement. A needle is placed in your posterior hip bone to remove a sample of bone marrow. The area will be numbed with a local anesthetic, or pain-relieving medicine, to make you feel less discomfort during the procedure. You might be given oral medicine to help you relax prior to the procedure. You should plan to have a driver take you home after this procedure since the medicine can make you drowsy.
Skeletal survey
This is a series of X-rays of the skull and long bones to assess disease involvement for patients with multiple myeloma.
Other tests may be required by your insurance company or your physician, for example: colonoscopy, PAP smear, dental exam, or mammograms.
Additional tests
After the pre-transplant evaluation appointment, the BMT team may decide if you will need any other tests. Additional tests or consultations will be performed at Cleveland Clinic. Your nurse and administrative coordinator will help you make these arrangements.
After my bone marrow pre-transplant evaluation
At the end of your pre-transplant evaluation and after the test results are complete, the bone marrow transplant doctor will decide whether or not a bone marrow transplant is the appropriate treatment for you.
Your test results will also be sent to your insurance company for the insurance approval process. Usually the insurance company will make a determination in 7 to 10 days after receiving the test results.
Please understand that abnormal test results might require further investigation.
The goal of pre-transplant testing is to ensure that you will be able to undergo the transplant and recover without increased risk of complications.
Bone marrow donor pre-transplant testing
For allogeneic and mini-allogeneic transplant patients, your bone marrow donor will also have a medical evaluation with many of the same tests. The donor must be cleared and determined medically fit to proceed as your donor.
How often should I check my temperature after my bone marrow transplant?
Knowing how many times a day to take your temperature, for what duration and when to call your healthcare provider can help catch an illness or infection early in its course. Using a thermometer to monitor your temperature can help you manage an illness. A rise in your temperature is usually caused by an illness or infection and is usually one of the first signs of a potential problem.
Autologous transplant patients: Check your temperature twice a day while you have central line and for two weeks after discharge.
Allogeneic transplant patients: Check your temperature twice a day while you are taking immunosuppressive medicines and while you have a central line.
When to call your health care provider?
For allogeneic bone marrow transplant patients, page your nurse coordinator if you have a temperature of 100.0 degrees Fahrenheit or higher. For autologous bone marrow transplant patients, page your nurse coordinator if you have a temperature of 100.5 degrees Fahrenheit or higher. This could be a sign of infection and should be treated right away.
If you have a fever and any of these other signs, call your healthcare provider right away:
- Severe headache
- Stiff neck
- Severe swelling of your throat
- Mental confusion
Although bone marrow transplantation offers hope for many patients, going through the BMT process is a difficult experience for patients and their families. Treatment is physically and emotionally challenging.
Dealing with changes and loss of control
Facing the reality of a serious illness, fearing what is involved in bone marrow transplantation, dealing with complex and unfamiliar medical information, and facing separation from family and friends can be overwhelming and difficult to endure. You and your family might experience anxiety regarding the uncertainty of what lies ahead.
You will experience changes and might not be as independent as you want to be. People will experience some changes and role losses that are temporary, and some longer-term changes in lifestyle might occur. While going through transplantation, common role changes might involve employment or work, parenting and family responsibilities, and physical activity. People who are used to being independent and like to feel in control might find such changes very frustrating and might find it difficult to cope.
A person’s ability to cope is strongly influenced by his or her perceptions of a situation. If you believe challenges facing you are insurmountable, you might feel helpless or hopeless. Obtaining more information, asking about how other people have coped, and turning to others for support are helpful coping strategies and might change the way you view your situation.
Give yourself permission to have bad days. You are only human and will have times when you feel discouraged or are in a bad mood. Just guard yourself against getting stuck in negative thinking and feelings.
Helpful coping strategies
Review what has been helpful and not helpful to you in the past when dealing with stressful or difficult situations. Focus on building on your strengths, and stay open to new ideas and strategies. Here are some positive coping strategies:
- Utilize your support network of friends and family: having loved ones or friends visit or call you can be very comforting. Discuss your feelings about what is happening with your friends and family. Allow family and friends to help you sort through the information you receive.
- Talk with other patients and families about bone marrow transplantation: talk with your social worker. Make use of resources and support services —these include resources at Cleveland Clinic and in the community.
- Actively participate in your treatment plan: you are a valuable and key person in your treatment plan. Stay informed and communicate your questions and ideas to the medical team. Do not be afraid to ask your doctor, nurse, or other health care provider to repeat any instructions or medical terms you don’t understand. Your Bone Marrow Transplant Team is always available to answer your questions and address your concerns.
- Focus on things you can influence: let go of things you can't change or control, and focus on doing things that will help your situation.
- Focus on what needs to be done here and now: it is easy to get overwhelmed if you think about everything you might eventually have to deal with. Focus on what you are currently dealing with and can work on now.
- Accept your reactions and your natural pace: accept how you feel about events, and give yourself time to adjust and process thoughts and feelings about what is happening.
- Give yourself things to look forward to: your energy has been focused on treatment, but there are still things you can enjoy, and you need to plan simple pleasures to which you can look forward.
- Focus on what you have: try to focus on what you still have and have gained rather than what you have lost or haven't accomplished yet.
- Accept the unexpected: accept that there are events you cannot control. Few things will happen exactly as expected. Plan for delays, setbacks, and surprises.
- Reduce stress: when you are facing BMT, stress can build up and affect how you feel about life. Prolonged stress can lead to frustration, anger, hopelessness and, at times, depression.
Here are some tips for reducing stress:
- Be assertive instead of aggressive. "Assert" your feelings, opinions, or beliefs instead of becoming angry, combative, or passive.
- Learn to relax.
- Exercise as often as you can.
- Eat well-balanced meals.
- Rest and sleep. Your body needs time to recover from stressful events.
Learn to Relax
There are a number of exercises you can do to relax. These exercises include breathing, muscle and mind relaxation, relaxation to music, and biofeedback. A few for you to try are listed below. First, be sure you have a quiet, distraction-free location. Try to find a comfortable body position. Sit or recline on a chair or sofa. Also, have a good state of mind. Try to block out worries and troubling thoughts.
Two-minute relaxation
Switch your thoughts to yourself and your breathing. Take a few deep breaths, exhaling slowly. Mentally scan your body. Notice areas that feel tense or cramped. Loosen up these areas, letting go of as much tension as you can. Rotate your head in a smooth, circular motion once or twice. (If any movement causes pain, stop immediately.) Roll your shoulders forward and backward several times. Let all of your muscles completely relax. Recall a pleasant thought for a few seconds. Take another deep breath and exhale slowly. You should feel relaxed.
Mind Relaxation
Close your eyes. Breathe normally through your nose. As you exhale, silently say to yourself the word "one," a short word such as "peaceful," or a short phrase such as "I feel quiet." Continue for 10 minutes. If your mind wanders, gently remind yourself to think about your breathing and your chosen word or phrase. Let your breathing become slow and steady.
Deep breathing relaxation
Imagine a spot just below your navel. Breathe into that spot and fill your stomach with air. Let the air fill you from the stomach up, then let it out, like deflating a balloon. With every long, slow breath out, you should feel more relaxed.
Good nutrition is a very important part of your recovery. It helps your body resist infection and repair tissue damage caused by chemotherapy and/or radiation therapy.
Losing interest in food after a long illness is to be expected. Some of the side effects you might have experienced while in the hospital may continue even after you go home. These side effects may include nausea, vomiting, loss of appetite, taste changes, and a sore or dry mouth. With these symptoms, it may be difficult for you to imagine eating high-calorie, nutrient-rich meals.
Nutrition After Blood & Marrow Transplant
Nutrition supplements
When you are unable to eat a well-balanced diet, we recommend you try over-the-counter nutrition supplements to meet your nutritional needs, unless otherwise instructed. However, it is important to check the labels for the specific vitamin, mineral or nutrient levels. They can vary from different manufacturers. Examples of nutrition supplements are Ensure®, Boost®, Resource®, Carnation Instant Breakfast®, Boost® bars and Boost® puddings. If you have diabetes, Glucerna® and Boost® Glucose Control are options.
Several discount stores and drug stores have nutritional supplements packaged under their private label. Please check with the dietician to determine if the particular product will meet your needs.
Multivitamins
We recommend you take a daily multivitamin, after you are discharged. You can take children's chewable multivitamins twice a day if better tolerated. Excess doses of some vitamins and minerals might be unsafe at this time. For instance, it is important to choose vitamins that do not contain iron or herbs. Also, due to your numerous red blood cell transfusions, additional iron supplementation is unnecessary. Your body does not eliminate iron. If you have questions regarding your preferred multivitamin, bring your labeled vitamin bottle to your appointment for your doctor's approval.
Follow food safety guidelines when choosing any of the following foods:
Calcium and Phosphorus
Some of your medicines might deplete calcium, which is important for maintaining bone strength. When the staff reviews your medications and labs, they will inform you if this is likely to be a problem. Phosphorus is a mineral that helps to strengthen bones. Some transplant patients often need additional phosphorus. Unless you are following a special diet, we recommended you eat a diet high in calcium and phosphorus.
Your doctor might recommend calcium supplements such as Tums®, Oscal +D®, or Caltrate®. Calcium supplements with vitamin D are essential for those who require long-term steroid therapy, such as prednisone. Steroids cause bone loss, called osteoporosis. Taking these supplements, as well as exercising, can help minimize bone loss and prevent fractures. An appointment with a rheumatologist may be advised to monitor your bone density.
Potassium and magnesium
Antibiotics, diarrhea, and vomiting can cause electrolyte (mineral) imbalances. Even after your hospital discharge, it is common to require potassium and magnesium supplementation, which can be given by pill or intravenous infusion.
Potassium is an electrolyte (mineral) that maintains normal fluid balance, supports cell integrity, facilitates the making of protein, and assists in the transmission of nerve impulses and the contraction of the heart and other muscles.
Magnesium is also an electrolyte (mineral) that is involved in bone mineralization, building of protein, transmission of nerve impulses, and normal muscular contraction.
Sodium
Sodium is an electrolyte essential for water regulation and electrical activities of the body, such as nerve impulse transmission and muscular contraction. Our diets rarely lack sodium.
A healthy person requires about 200 mg of sodium daily, but the average sodium intake is estimated to be 6,000 to 18,000 mg daily. Excessive sodium intake can lead to high blood pressure (hypertension) and fluid retention. Reduce your sodium intake to less than 2,300 mg each day.
Since allogeneic transplant recipients might already be experiencing hypertension or fluid retention/swelling (edema) caused by steroids —such as prednisone, tacrolimus (Prograf®), or cyclosporine (Neoral®) — it is crucial to avoid a diet high in sodium.
Alcohol
After your bone marrow transplant, you might have decreased liver function due to the effects of high-dose chemotherapy, graft-versus-host disease (GvHD), or metabolism of medicines. Since the liver metabolizes alcohol, avoid all alcoholic beverages. Alcohol can cause malnutrition by attacking the stomach lining, leading to malabsorption and excretion of many nutrients. Before drinking beer, wine, or other alcoholic beverages, ask your BMT doctor.
Sun Exposure After Bone Marrow Transplant
Ultraviolet (UV) ray sun exposure can be harmful to the skin, causing sunburns and/or skin cancers. More importantly, sun exposure to those who have had an allogeneic bone marrow transplant can trigger or worsen skin graft-versus-host-disease (GVHD). Wear a hat, long sleeves, long pants, and sunscreen with an SPF of at least 30 if you are outside in the sun. However, avoiding sun exposure is the best prevention. Please note that even on cloudy days, skin exposure to UV rays still occurs; therefore, take precautions.
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