VA Puget Sound Health Care System

If you are receiving a donor transplant, the following information will help you better understand the process for you, your caregiver(s), and your donor.

The four primary types of allogeneic transplants are as follows:
1. Matched-Related Myeloblative Transplant (aka: "Full transplant" or "High dose conditioning regimen transplant")
2. Matched-Unrelated Myeloblative Transplant (aka: "URD Full transplant" or "URD High dose conditioning regimen transplant")
3. Matched-Related Non-Myeloblative Transplant (aka: "Mini-transplant")
4. Matched-Unrelated Non-Myeloblative Transplant (aka: "URD Mini-transplant")

The type of transplant you will receive will be determined after the pre-transplant evaluation at the Seattle VA Transplant Unit.  The type of transplant and the potential risks/benefits will be discussed with you extensively at your Pre-transplant/Data Review Conference prior to you beginning your conditioning regimen for the transplant.  During this conference, the possible risks of transplant, side effects, and other important information will be discussed.  The caregiver is required to attend this conference.   Separate patient and donor conferences can be held at the patient's/donor's request.

Allogeneic Weekly Classes/Group (for both Myeloblative & non- Myeloblative Transplants)
Care Class
Four classes are required for all patients and caregivers.  You will NOT need to attend the LTFU Care class—it's for autologous patients/caregivers only.  See the list on the Family Room door.
Facilitators:  Social Worker, Nursing, Dietitian, Pharmacist
WHERE: MTU Conference Room
WHEN: Tuesdays—11am to 12pm—until patient and caregiver have completed all 4 classes

Caregiver Support Group
This group is optional for all caregivers and donors, no patients.  A confidential time to connect, share, learn, and support.
Facilitator:  Psychologist
WHERE: MTU Conference Room
WHEN: EVERY Wednesday—10am to 11am

Multidisciplinary Long-Term Follow-up Education
This class is required for all patients and caregivers who have received a donor transplant.  You begin this class after receiving your transplant.
Facilitators:  Clinical Nurse Coordinator, Social Worker, Psychologist, Dietitian, Pharmacist
WHERE: MTU Conference Room
WHEN: EVERY Thursday—10am to 11am

Length of Stay/Time line

The amount of time required for patients and caregivers to stay in Seattle can be affected by many factors—type of transplant, infections, graft vs. host disease, etc..  Patients and caregivers need to be aware that these time-lines are estimates.

For Myeloblative Transplants (aka: "full transplant" or "high dose conditioning regimen"), the transplant conditioning process can include high-dose chemotherapy and/or radiation, depending upon the treatment protocol. 

During a Myleoblative Transplant a patient can expect to be an inpatient on the MTU for approximately 3-4 weeks for the acute healing process.  When the patient recovers physically he/she will be discharged to outpatient status to stay in the assigned MTU apartment.  Initially, the patient and caregiver will need to come daily to the MTU for continued medical observation/treatment. The frequency of these visits will gradually decrease.  The total time expected in Seattle is approximately 4 months.

The following link will give you an estimated timeline regarding what to expect during your pre- and post- transplant experience while in Seattle.  "Life After Transplant" will be explored in the weekly Allogeneic Weekly Classes/Group (for both Myeloblative & non- Myeloblative Transplants).

Link to AlloBMTUclinicalpathway.pdf 

For Non-myeloblative Transplants (aka: "Mini-transplants") the patient undergoes a reduced intensity regimen of chemotherapy and/or radiation therapy and it is done as a planned outpatient process—both pre- and post-transplant treatment and follow-up.  Non-myeloblative patients are only admitted to the hospital for significant infections, uncontrolled GVHD, or for other medically indicated reasons.  Indeed some patients remain an outpatient during their entire stay in Seattle, which is why caregiver support is critically important.  The length of time required for non-myeloblative "Mini" patients to stay in Seattle a minimum of 6 months—perhaps closer to a year.  "Life After Transplant" will be explored in the weekly Allogeneic Weekly Classes/Group (for both Myeloblative & non- Myeloblative Transplants).
When the patient is medically cleared for discharge from the MTU to return back to his/her own home, a medical follow-up plan will be discussed and a follow-up appointment will be scheduled at their referring VAMC.  Again note:  Please know that the patient will not be medically authorized to drive home, or be the passenger in a car for long distances.
When the patient and caregiver leave Seattle, a taxicab ride to the airport can be arranged and paid for by this facility.  Please discuss arrangements with the MTU Social Worker.

Donors (if receiving a matched-related allogeneic transplant)

Related donors for patients undergoing stem cell transplant should expect to be in Seattle working with the transplant center for approximately 4 weeks.  This includes 1 week for medical evaluation to determine if donor is medically appropriate for stem cell collection.  It also includes time for the medical team to clear the patient for transplant and for a finalized plan for treatment to be determined. 

The stem cell harvest process is done on an outpatient basis at the Seattle Cancer Care Alliance (Fred Hutchinson Cancer Research Center Campus). This process involves 5 days of daily injections of GCSF/Neupogen (granulocyte colony stimulating factor) followed by a minimum of 2 days of stem cell collection, possibly more.  The stem cell collection (also called apheresis) is done at the Seattle Cancer Care Alliance facility.  The MTU Ward Clerk will schedule the harvest appointments when the attending physician deems the donor ready for collection.  The actual infusion of the stem cells (the transplant) is conducted at the Seattle VA on the MTU.

Unrelated Donor Transplants

If you are receiving an unrelated donor transplant (either Myeloblative or Non-myeloblative), the Unrelated Donor Coordinator/Data Manager, Becky Porter (206)764-2189, can help with any questions you have regarding unrelated donor issues.

Total Body Irradiation brochure 

Correct Deep Breathing instruction 

Graft-Versus-Host-Disease (GVHD)

Graft-versus-host disease is a frequent complication of allogeneic transplants. The "graft" is the donated bone marrow, and the "host" is the patient or transplant recipient.In GVHD, the donor's bone marrow attacks the patient's organs and tissues, impairing their ability to function and increasing the patient's susceptibility to infection.

The donor's marrow contains T-cells. When transplanted into the patient, the donor's T-cells may look at the HLA markers on the patient's cells, identify the cells as "non-self" and unleash an attack on the patient's tissues and organs. Because the patient's own immune system is suppressed prior to the transplant, it cannot launch a counter attack. This condition is called graft-versus-host disease (GVHD).

Approximately 50% of patients undergoing an allogeneic transplant with a related HLA- matched donor develop GVHD. Fortunately, the majority of cases are mild.

GVHD is often discussed as if it were a single disease. It is, in fact, two diseases; acute GVHD and chronic GVHD. Acute and chronic GVHD differ in their symptoms, clinical signs and time of onset.  GVHD can be a temporary inconvenience or a serious, life-threatening disease. Older transplant patients are more likely to develop GVHD then younger patients. The incidence and severity of GVHD is also higher among patients whose bone marrow donor is unrelated or not perfectly matched.
T
he symptoms of GVHD are many and varied. The list may at first be overwhelming. Keep in mind however that most patients undergoing an allogeneic transplant with a related HLA-matched donor develop only a mild or moderate case of GVHD. Although GVHD can be life-threatening or fatal, most patients survive the disease without long-term disabling side effects. GVHD can help fight your disease also.

Acute GVHD

Acute GVHD usually occurs during the first hundred days following an allogeneic transplant. T-cells present in the donor's bone marrow at the time of transplant identify the BMT patient as "non-self" and attack the patient's skin, liver, stomach, and/or intestines.

The earliest sign of acute GVHD is often a skin rash that usually first appears on the patient's hands and feet. The rash may spread to other parts of the body and develop into a general redness similar to sunburn; with peeling or blistering skin. Cramping, nausea and diarrhea are signs of GVHD in the stomach or intestines. Jaundice (yellowing of the skin and eyes) indicates that acute GVHD has affected the liver.

Physicians grade the severity of acute GVHD according to the number or organs involved and the degree to which they are affected. Acute GVHD may be mild, moderate, severe or life-threatening.

To minimize the risk of graft rejection and GVHD, allogeneic transplant patients are given drugs to prevent GVHD before and after transplant that suppress the immune system. Use of these drugs however increases the risk of infection. Precautions taken to limit the patient's exposure to harmful bacteria, viruses and fungi during this period may include special air-filtering equipment in the patient's room and frequent hand washing by visitors.

Patients over the age of 30 are more likely to develop acute GVHD than younger patients. Patients receiving marrow from a female donor who has had two or more viable pregnancies also are more likely to develop acute GVHD.

Prevention and Treatment of Acute GVHD

Although GVHD is not yet preventable, steps can be taken to reduce the incidence and severity of GVHD.
Administration of immunosuppressive drugs such as cyclosporine or Tacrolimus has proven effective in reducing the incidence and severity of GVHD. They may be administered for several months post transplant, particularly if acute GVHD progresses or if the patient develops chronic GVHD.

Cyclosporine or Tacrolimus weaken the ability of the donor's T cells to launch an attack against the patient's organs and tissues. These drugs have potential side effects. Cyclosporine and Tacrolimus can be very toxic to the kidneys, cause increased hair growth on the body and on rare occasions can result in neurological problems such as seizures, confusion, anxiety and changes in thought processes. Methotrexate may cause inflammation of the mouth, nose and/or throat. Side effects of steroids include weight gain, fluid retention, elevated blood sugar level, high blood pressure, mood swings and/or confused thinking. These side effects are temporary and disappear over time once use of these drugs is discontinued.

Chronic GVHD

Chronic GVHD usually develops after 100 days post transplant. Scientists believe that new T-cells produced after the donor's bone marrow has engrafted in the patient may cause chronic GVHD.  Most patients with chronic GVHD experience skin problems that may include a dry, itching rash, a change in skin color, and tautness or tightening of the skin. Partial hair loss or premature graying may also occur.  Liver abnormalities are seen in many patients with chronic GVHD. This is usually evidenced by jaundice and abnormal liver test results.

Chronic GVHD can also attack glands in the body that secrete mucous, saliva or other lubricants. Patients with chronic GVHD usually experience dryness or stinging in their eyes because the glands that secrete tears are impaired.
Glands that secrete saliva in the mouth are often affected by chronic GVHD and less often, those that lubricate the esophagus, making swallowing and eating difficult. It's common for patients with chronic GVHD to experience a burning sensation in their mouths when using toothpaste or eating acidic foods. Good oral hygiene is imperative to minimize the risk of infection.

Chronic GVHD may attack glands that lubricate the stomach lining and intestines, interfering with the body's ability to properly absorb nutrients. Symptoms include heartburn, stomach pain and/or weight loss.
Occasionally patients with chronic GVHD experience contractures—a  tightening of the tendons that makes extending or contracting their arms and legs difficult. Chronic GVHD can also affect the lungs—causing wheezing, bronchitis, or pneumonia.

As is the case with acute GVHD, older patients are more likely to develop chronic GVHD than younger patients. Seventy to 80% of patients who develop chronic GVHD will previously have had acute GVHD. Chronic GVHD is also more common in patients whose donor is unrelated or whose marrow is not perfectly matched.

Treatment of Chronic GVHD

Chronic GVHD is usually treated with cyclosporine, Tacrolimus or steroids—all drugs which suppress the patient's immune system. Antibiotics such as Bactrim or penicillin or both are usually taken to reduce the risk of infection while chronic GVHD is being treated.

Long Term Concerns

Although most patients recover from GVHD, some symptoms may persist even after the disease has been completely resolved. Patients who have had GVHD usually experience long-term skin sensitivity and must avoid prolonged exposure to sunlight, using sunscreen on any exposed skin. Scarring of the skin may also occur.

Eye irritation sometimes persists long-term and is usually managed with eye drops. Chronic diarrhea and failure of the stomach to properly absorb nutrients may also continue after all clinical signs of GVHD disappear. Some patients experience persistent liver problems and less frequently problems or contractures.    

GRAFT VERSUS HOST DISEASE SYMPTOMS