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Saturday, May 17, 2008

Side effects after a transplant or high-dose treatment with stem cell support

Transplant from a donor (allogeneic)

A transplant from a donor (allogeneic) is a more intensive procedure than high-dose treatment with stem cell support. The bone marrow takes longer to recover and the time you are at risk of infection is longer. Other possible complications, such as graft-versus-host disease, may also mean you have to stay in hospital for longer.

High-dose treatment and stem cell support

Recovery from high-dose treatment with stem cell support is quicker than from an allogeneic transplant. You are at risk of infection for a shorter period and there are fewer complications. As a result, your stay in hospital is usually shorter. In many hospitals you will not need to stay in a room of your own. Once the number of healthy cells in your blood begin to go up, the medical and nursing staff will start to plan your discharge home.

The following side effects are common to both treatments.

Infection

The number of white blood cells in your body will go down after your treatment. As a result, you will be very susceptible to infection caused by the bacteria which normally live in your body. These bacteria are present on your skin and in your stomach and intestine. In healthy people they are useful. However, after high-dose treatment, when the immune system is temporarily not working as well as usual, these bacteria may become harmful and cause infections. To try to avoid this, you will be given regular antibiotics and mouthwashes.

Most hospitals have their own policy on preparing food and on what you can eat. This can vary from being extremely cautious to being very flexible. You can discuss this with the doctors and nurses looking after you. Care needs to be taken that your food does not contain bacteria that could harm you. Some general precautions are:

  • food brought in for you by friends or relatives should be very carefully and hygienically prepared
  • fruit and salads (if allowed) should be washed carefully
  • avoid cream and sugary cakes
  • avoid soft cheeses and dishes made with lightly cooked or uncooked eggs
  • hot meals should be freshly prepared and thoroughly cooked (not reheated).

Our section on avoiding infection when your immunity is low, includes some tips on diet in this situation.

The hospital staff will make sure that infections are not brought into your room. The room and its contents will be thoroughly cleaned every day. Different hospitals have different policies about visitors, but you may be restricted to only a few visitors each day. They may have to wash their hands and wear protective clothing so that they do not give you any infection. People will be told not to come if they are unwell.

If you have had high-dose treatment with stem cell support you may not need to be in a room of your own and visiting may not be so restricted.

Even with these precautions, almost everyone will get a high temperature and need to have antibiotics at some point during the time while their immune system recovers.

Anaemia

The number of red cells in your blood (your haemoglobin level) may go down. This is known as anaemia and will make you feel very tired. You may need regular blood transfusions to counteract this until your body starts to make enough red blood cells again.

Bleeding

You are likely to need transfusions of platelets to make sure you have enough platelets in your blood, to reduce the risk of bleeding or bruising. Your platelet count will be checked by daily blood tests and your doctor will examine you regularly for bruises or little red spots and rashes on the skin. It is sensible to use a very soft toothbrush when you clean your teeth, to avoid damaging your gums. If you have any bleeding (eg in the mouth or when you pass urine), tell a doctor or nurse immediately.

Eating problems

You will probably see a dietitian regularly during your treatment, who will make sure that you are eating as well as possible. It is very important that you do not lose too much weight, and the nurses looking after you will encourage you to try to eat small meals and snacks. If you have eating problems, because of lack of appetite, nausea or a sore mouth, you may need to have nutritional drinks. If you find it difficult to drink these, you may need to be given a special fluid through your central line. This will give you all the necessary nutrients. As you start to be able to eat again, the amount of fluid you are given through the line will be gradually reduced.

Your mouth may become very sore while your white blood cell count is low, either from ulcers caused by radiotherapy, or from thrush – a fungal infection. You will be given mouthwashes, and lozenges to suck regularly to try to prevent soreness, and painkillers, if needed. It is important to keep your mouth clean, both for your comfort and to prevent infections developing in your mouth and spreading to other parts of your body.

You may also develop diarrhoea and a sore bottom. This normally settles within a few days. If it is severe, it can be controlled with medicine.

Most of these symptoms are worst when your blood count is at its lowest, in the second and third week after the high-dose treatment. You will feel unwell during this time. You may also not feel like eating, and may lose weight. When the number of blood cells in your blood goes up, the symptoms will start to improve:

  • your appetite will come back
  • you will be less prone to infection
  • you will not need so many blood and platelet transfusions.

You will start to feel better again, although you can still expect to get tired easily and feel fairly weak for several more months.

When the healthy cells in your blood have reached a safe level (although not yet normal) you will be allowed to go home, as long as a friend or relative stays with you. You will be given a 24-hour telephone contact number in case you have any worries, and you will need to go back frequently to the hospital as an outpatient for check-ups.

Graft failure

Sometimes the infusion of stem cells does not work and the bone marrow fails to produce enough new blood cells. This is known as graft failure and can lead to repeated infections, bruising and bleeding, and anaemia. Total graft failure is rare. However, if it happens, a second infusion of stem cells will be needed. Without another infusion of stem cells you will only live for a short time.

Veno-occlusive disease

The high-dose treatment you are given before your transplant can cause a serious liver problem known as veno-occlusive disease (VOD). This is a rare problem that happens because blood vessels in the liver become swollen and blocked. Symptoms of veno-occlusive disease include:

  • swelling and tenderness of the liver
  • weight gain
  • jaundice
  • and rarely, fluid build-up in the abdomen (known as ascites).

Your liver will not work as well as usual. Treatment can usually be given to support you until your liver recovers.

Acute graft-versus-host disease

If graft-versus-host disease happens in the first 100 days after your transplant, it is known as acute graft-versus-host disease (GvHD). Acute GvHD usually causes a severe skin rash, and if the digestive system or liver are affected you can develop sickness (nausea), vomiting, diarrhoea and a yellowing of the skin (jaundice).

Acute GvHD is more likely to affect you if you have a transplant at an older age, and when the donor is unrelated or not such a close match as usually used. A transplant from a donor who is not a close match is called a mismatched transplant.

Acute GvHD is graded depending upon how severe it is. Grade 1 is mild and may not need treatment. In grade 2 the signs and symptoms are moderate. Grade 3 is severe, and grade 4 very severe. If you develop acute GvHD, of grade 2 or above, you will usually be given treatment. This will often involve medicines to suppress the immune reaction, such as steroids. You may need to go into hospital so that your condition can be monitored and you can be given support to cope with any symptoms you have.

Chronic graft-versus-host disease

Chronic GvHD occurs more than 100 days after your transplant. It can develop after acute GvHD that has continued, or sometimes may develop when there has been no acute GvHD.

Chronic GvHD can affect different parts of the body, causing some of the symptoms listed below. It is unlikely that you will have all of these symptoms. Possible symptoms include:

  • a dry and flaky skin
  • breathlessness and asthma-like symptoms
  • a dry and swollen mouth
  • gritty and dry eyes
  • diarrhoea, stomach cramps and loss of appetite
  • repeated infections
  • muscle weakness.

Treatment for chronic GvHD will often include steroids and other medicines to stop the immune system working so well.

Via: http://www.cancerbackup.org.uk

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