The Wake Forest Baptist team of transplant physicians are committed to caring for the needs of our patients, both physically and emotionally. We journey with the patient and their caregivers to provide individual treatment plans that fit the needs of the people we see.
The Medical Center has housed a continuously operating bone marrow transplant (BMT) program since inception of our program in 1990 by Dr. David Hurd. Our program has performed just under 3000 transplants to date. We have been affiliated with the National Marrow Donor Program since 1991, performing stem cell collections, transplants and bone marrow harvests.
Transplant can be an overwhelming process. When you come to Wake Forest Baptist, you will meet a transplant physician as well as a transplant nurse coordinator who will walk you through each step.
During transplant, our focus is providing comprehensive care to each individual. Along with standard of care treatment plans, we also participate in clinical research trials as well as continuous process improvements in order to provide the highest level of patient-centered care. Our team will work closely with you to ensure your transplant is successful. Our commitment to you and your caregivers continues through active transplant treatment and into cancer survivorship.
What is a Transplant?
A bone marrow transplant, or stem cell transplant, is performed to treat many diseases. During a stem cell transplant, healthy bone marrow cells, specifically stem cells, are transplanted into a person who has received chemotherapy and/or radiation therapy. Stem cells are found in the bone marrow. Bone marrow is the soft, fatty tissue inside your bones. The bone marrow produces blood cells. Stem cells are immature blood cells in the bone marrow that give rise to all of your different blood cells.
The stem cells then grow to be healthy white blood cells, red blood cells, and platelets. The terms "bone marrow transplant" and "stem cell transplant" are often both used to mean the same thing.
There are different types of stem cell transplants available:
- Autologous stem cell transplant. The term auto means self. Stem cells are removed from you before you receive high-dose chemotherapy or radiation treatment. High dose chemotherapy or radiation therapy is usually given to treat a blood related cancer. The stem cells are stored in a freezer. After high-dose chemotherapy or radiation treatments, your stems cells are put back in your body to make normal blood cells.
- Allogeneic stem cell transplant. The term allogeneic means other. Stem cells are removed from another person, called a donor. About 30 percent of patients have a family member, most often a brother or sister, who matches the patient’s HLA type and is able to donate bone marrow or stem cells. If a patient doesn’t have a full match in the family, the transplant team will search the volunteer registries for a donor; almost 65 percent find a complete match. When the donor and the patient’s HLA typing are the same, we use the term "complete match" or "full match". If the donor is not a complete match to the patient, we use the term "mismatched".
Donor Selection for Allogeneic Transplant
- Matched Related Donors. When available, matched siblings are preferred over other types of donors. A matched related transplant uses bone marrow or stem cells from a sibling who is an HLA match. We will do HLA testing on your brothers and/or sisters in order to find a match in the family.
- Matched Unrelated Donors. A matched unrelated transplant uses bone marrow or stem cells from a person who is not related to the patient. Since many of us share similar genetic backgrounds, someone who is not related to the patient may have similar HLA proteins.
- Syngeneic Donors. A syngeneic transplant uses bone marrow or stem cells from an identical twin. Identical twins have the same genes and are perfect matches. Graft-versus-host disease (GVHD) will not occur in syngeneic transplant, however, there is a higher chance of relapse with this type of transplant. This is because the donor cells do not recognize the patient as different.
Alternative Donor Transplants are performed when a fully matched donor is not available. There are different types of alternative donor transplants such as:
- Haplo-identical Donors. A haplo-identical donor is one who matches at least 50% of the HLA proteins with the patient. Potential haplo donors include biological parents, biological children and full or half siblings. Extended family members such as aunts and uncles may be considered if necessary.
- Mismatched Unrelated Donors. A mismatched unrelated transplant uses bone marrow or stem cells from a person who is not related to the patient. Since many of us share similar genetic backgrounds, someone who is not related to the patient may have similar HLA proteins. If the donor is not a complete HLA match to the patient, we use the term "antigen mismatched". There is a higher chance for GVHD when using a mismatched donor.
Stem cells can be collected in two ways:
- Mobilization and Apheresis. Mobilization is the way we increase the number of stem cells created in the body. You (or your donor) will receive growth factor (G-CSF) injections to stimulate the bone marrow to produce stem cells. During apheresis, blood is removed from the body through an IV line. The part of white blood cells that contains stem cells is then separated by a machine and the rest of the blood is returned back to the body.
- As an alternative to apheresis, a bone marrow harvest may be used to collect stem cells. This minor surgery is done under general anesthesia. The bone marrow is removed from the back of both hip bones. The amount of marrow removed depends on the weight of the person who is receiving it.
Choice of Conditioning Regimens
- Ablative (myeloablative) treatment. High-dose chemotherapy, radiation, or both are given to kill any cancer cells. This also kills all healthy bone marrow that remains, and allows new stem cells to grow in the bone marrow.
- Reduced intensity treatment. Lower doses of chemotherapy and radiation are given before a transplant. This allows older people, and those with other health problems to have a transplant.
- Non-Myeloablative. This type of transplant uses low doses of chemotherapy and/or radiation therapy. It causes minimal low blood counts for a shorter period, but can cause a significantly decreased immune system.
Why is a Bone Marrow Transplant Performed?
- To replace bone marrow that is not functioning due to disease
- Regenerate a new immune system to fight residual disease
- Quickly restore bone marrow that has been damaged by treatment with high dose radiation and/or chemotherapy
Your health care provider may recommend a bone marrow transplant if you have:
- Certain cancers, such as leukemia, lymphoma, myelodysplasia, or multiple myeloma.
- A disease that affects the production of bone marrow cells, such as aplastic anemia, congenital neutropenia, severe immune system illnesses, sickle cell anemia, or thalassemia.
Potential risks of an autologous transplants include:
- Infections - Often, these may be life-threatening, particularly when caused by viruses or fungi
- Bleeding - which can be life-threatening
- Rarely, death due to damage to body organs because of the cumulative effect of chemotherapy, radiation, or the above-mentioned side-effects that results in loss of normal heart, lung, liver, kidney or brain function
- In spite of the best treatment available, relapse of the disease may occur
- Unknown toxicities may occur in any individual patient due to multiple events and cumulative effects which may involve any organ, and can result in severe loss of normal functioning
- Infertility because of loss of production of viable egg or sperm needed for reproduction.
Potential risks of an allogeneic transplant include:
- Infections - Often, these may be life-threatening, particularly when caused by viruses or fungi;
- Bleeding - Which can be life-threatening;
- GVHD, either acute or chronic in nature - the degree of Graft-versus-host disease varies from mild skin reactions to widespread effects in the body involving the skin, liver, gastrointestinal tract or other organs. GVHD can be life-threatening.
- Graft failure may be associated with a high rate of death due to the failure of the new bone marrow to grow. Treating graft failure requires giving more donor cells.
- Death due to damage to body organs because of the cumulative effect of chemotherapy, radiation, or the above-mentioned side-effects that results in loss of normal heart, lung, liver, kidney or brain function;
- Despite the best treatment available, relapse of the disease may occur;
- Unknown toxicities may occur in any individual patient due to multiple events and cumulative effects which may involve any organ, and can result in severe loss of normal functioning;
- Infertility because of loss of production of viable egg or sperm needed for reproduction.
What to Expect Before the Procedure
Your provider will ask about your medical history and do a physical exam. You will have many tests before treatment begins.
Before transplant, you will have 1 or 2 tubes, called catheters, inserted into a blood vessel in your neck or arms. We use this catheter to get blood samples, to give medicines, blood products, fluids, and nutrition during transplant. You will receive your bone marrow or stem cells through this catheter. We will remove the catheter after the transplant when you no longer need blood products or IV medicines. We will teach you how to take care of your catheter at home.
Your provider will likely discuss the emotional stress of having a bone marrow transplant. You may want to meet with a counselor. It is important to talk to your family and children to help them understand what to expect.
You will need to make plans to help you prepare for the procedure and handle tasks after your transplant:
- Arrange medical leave from work
- Take care of bank or financial statements
- Arrange care of pets
- Arrange for someone to help with household chores
- Confirm health insurance coverage
- Pay bills
- Arrange for care of your children
- Find housing for yourself or your family near the hospital, if needed
- Complete an advance care directive
What to Expect After the Procedure
A bone marrow transplant is usually done in a hospital or medical center that specializes in such treatment. While inpatient, you will stay in a special bone marrow transplant unit at the hospital. This is to limit your chance of getting an infection.
Depending on the treatment and where it is done, all or part of an autologous or allogeneic transplant may be done as an outpatient. This means you may not have to stay in the hospital overnight.
How long you stay in the hospital depends on:
- How much chemotherapy or radiation you received
- The type of transplant
- Your medical center's procedures
While you are in the hospital:
- The health care team will closely monitor your blood count and vital signs.
- You will receive medicines to prevent or treat infections, including antibiotics, antifungals, and antiviral medicine.
- You will likely need many blood transfusions.
After you leave the hospital, be sure to follow instructions on how to care for yourself at home.
A bone marrow transplant may completely or partially cure your illness. If the transplant is a success, you can go back to most of your normal activities as soon as you feel well enough. Usually it takes up to 1 year to recover fully, depending on what complications occur.