Possible Complications of Autologous or Allogeneic Transplant

It is possible that high doses of chemotherapy, radiation, fluids or infections can affect your heart and lungs, decreasing their ability to function. For this reason, you will have tests before, during and after your transplant to monitor the condition of these organs.

You can play an important and active role in preventing lung complications. If you smoke, you must stop smoking prior to your admission for transplant. Smoking is not permitted while you are in the hospital, and resuming smoking after your transplant increases your risk of serious lung complications.

Kidneys help maintain the proper amount and characteristics of body fluids by producing urine. They also process some drugs and remove other waste products from your body. Because of the intensity of the transplant process, it is not unusual to develop kidney problems. Although mild kidney problems are common, they are taken seriously and treated aggressively.

Many of the chemotherapy drugs and medications you will receive may be harmful to your kidneys and/or bladder. This is why your kidney function is closely monitored throughout treatment.

Some drugs affect the nerves in the bladder and may prevent you from completely emptying your bladder. Sometimes the volume of fluid that you receive intravenously to flush out the chemotherapy drugs is so large, that you will retain fluid. If this occurs, you may be given a diuretic to increase your urine output.

Rarely, despite close monitoring and aggressive therapy, kidney failure that does not respond to medications such as diuretics may occur. In these cases, dialysis may be required to help the kidneys heal and to remove toxins that build up in the body. The need for dialysis may be temporary until kidney function returns. At times the need is permanent.

Infertility can be a devastating side effect of transplant, but not all patients undergoing a transplant will experience infertility. It is not the transplant itself, but the high-dose chemotherapy and/or radiation administered before the transplant that damages reproductive cells. Chemotherapy can damage or destroy ovarian or testicular cells from which egg and sperm evolve.

Chemotherapy or radiation induced infertility can be temporary or permanent and can occur at low doses or the higher doses given pre-transplant. Patients who have undergone standard chemotherapy or radiation therapy for their disease before considering a transplant may already be infertile. For more information:

• CNY Fertility Center

In very rare circumstances, the transplanted marrow or stem cells (donor cells or even the recipients own cells) do not repopulate the recipients marrow; this is called lack of engraftment or graft failure. When this happens, patients are predisposed to infections and other complications. They may need transfusions of blood (RBCs) and platelets for support. Treatment also can include erythropoetin and neupogen injections. Sometimes graft failure is life-long, even life threatening. Again, this is a very rare complication.

Occasionally, a transplant does not achieve its goal, and the patients disease doesnt go into remission or it comes back. Because everyone has hoped for a cure, it is natural that this outcome is devastating for the patient, his or her family and the transplant team.

Unfortunately, should this happen, options for cure are limited. Some treatments can still potentially cure the disease, although it is more difficult with recurrent disease and much less likely to happen.

Rarely, people who have had chemotherapy and/or radiation may develop a second, new type of cancer. Even though used initially to treat their cancer, these agents can possibly have long-term effects on the body.

When your doctor makes the recommendation to use these treatments, it is because he or she believes that the risk of not treating the disease is worse than the risk of possible side effects that may occur in the future.

A secondary malignancy may occur anytime after treatment, at any point in a patients life.

Sometimes a patients cancer proves to be resistant to all the therapies we have to offer, and no matter how hard the patient, family and transplant team try, occasionally the transplant does not work, or complications may arise that are insurmountable. Death always is a possibility.

Veno-occlusive disease, more recently renamed Sinusoidal Obstruction Syndrome (SOS), is a potentially serious liver problem caused by the high doses of chemotherapy and/or radiation you receive before your transplant. In patients with VOD, the blood vessels that carry blood through the liver become swollen and obstructed. This impairs the ability of the liver to remove waste products from the bloodstream. Pressure and fluid build up in the liver, causing liver swelling and tenderness. The kidneys may retain excess water and salt, causing fluid to build up in the body. Swelling of the legs, arms and abdomen may occur.

When VOD is suspected, the team will attempt to prevent the more serious complications by:

• Minimizing or eliminating certain drugs
• Prescribing diuretics to increase urine output and relieve fluid buildup in tissues
• Dialysis, if necessary
• Carefully monitoring the volume of fluids in the body
• Giving transfusions of packed red blood cells to keep the circulating blood volume high until VOD runs its course

Medications may be used to prevent and treat VOD.

Avascular necrosis—the loss of blood supply to the bone, which causes bone tissue to die—is a frequent complication of using steroids long term to manage treatment side effects. The head of the femur (thigh bone) is usually affected, but the head of the humerus (arm bone) can also be involved. An early symptom is a dull aching or a pressure sensation within the hip that becomes worse by weight bearing or extremes of hip motion, so any hip or shoulder pain or discomfort, limited range of motion, or stiffness in the joint (contractures) should be reported to your doctor. Surgical intervention might be needed.

As steroids are being tapered, you might have muscle aches, mood changes, lethargy, loss of appetite and skin changes.

Other side effects of long-term use of steroids include a Cushingoid appearance (moon face), collapsed vertebrae, osteoporosis and hypertension. The list below gives more information about possible symptoms and how to deal with them:

• Sun sensitivity. Avoid sun exposure; wear sunscreen with a high sun protection factor (SPF).
• Steroid-induced diabetes/increased blood sugar. Avoid large amounts of concentrated sweets. This complication can be treated with a modified diet, oral medications and, at times, insulin.
• Increased appetite. Eat a well-balanced diet, exercise as permitted, and monitor your weight.
• Mood disturbances. Expect some variations in mood, but report marked changes in your behavior.
• Increased growth of body and facial hair. This is a common but temporary side effect.
• Stomach ulcer. Take medications with food or milk, report stomach pain, dark stools, vomiting of blood or abdominal swelling.
• Insomnia. Take steroids pills in morning, not at bedtime.

There is some degree of incompatibility among all donors and recipients (except in the case of identical twins), even if they have six matching HLA antigens, so GVHD is a common complication following allogeneic transplant. The disease can range from mild to life-threatening, with short-term or long-term symptoms.

GVHD occurs when T-cells from the immune system of the donor recognize the proteins (antigens) on your cells as foreign and then attack. While GVHD may produce a beneficial antitumor effect, too much can cause severe problems, even death.

The incidence and severity of GVHD varies, depending upon the degree and types of differences between the donor and recipient:

• If all six HLA antigens tested are compatible, GVHD is less likely to be severe, but not all people are able to find a donor who matches them completely.
• Greater incompatibility issues arise with older people, both as donors and as recipients.
• Because the donors T-cells recognize the recipient as foreign, the greater the number of donor T-cells infused, the greater the risk.
• Newer drugs available today are doing a better job of preventing and treating GVHD.

These factors can affect the success of a transplant, but to a lesser degree:

• If the donor and recipient are the same gender (Males have X and Y chromosomes, females have X and X).
• If the donor is female, how many times she has been pregnant (the less the better).
• If the recipients conditioning regimen includes TBI (total body irradiation).

GVHD can be acute or chronic. Patients may experience none, one or both types. Acute GVHD occurs within the first 100 days or so following allogeneic BMT, and chronic GVHD occurs after the first 100 days. Day 100 should be considered merely a guideline, however.

The first sign of acute GVHD is usually a mild skin rash. This may change into a sunburn-like redness. In more serious cases, skin may blister or peel. Acute GVHD can also affect the gastrointestinal tract and liver. Some combination of nausea, cramping, bloody or watery diarrhea and jaundice, a yellowing of the skin and eyes, may result.

Patients who have had acute GVHD are at greatest risk for developing chronic GVHD. However, a patient who has not had acute GVHD can still have chronic GVHD, which develops three or more months after a BMT. Skin problems, including rashes, itching, changes in skin color, lesions and tautness are typical.

Other common symptoms are liver abnormalities and infections. Chronic GVHD can attack glands, leading to dry or burning eyes, dry or burning mouth and mouth sores. Good oral hygiene is crucial to minimize infections.

Gastrointestinal irritations can make it difficult to properly absorb nutrients and lead to difficulty swallowing, heartburn, stomach pain and weight loss. At times, chronic GVHD causes skin scarring, premature graying of hair, hair loss, vision problems, liver injury and, occasionally, a tightening of the tendons in joints that can make arm and leg movement difficult.

Symptoms can range from mild to serious. They may occur alone or together.

Prior to your transplant, you will receive drugs to prevent infection and GVHD. It is imperative that you practice good hygiene throughout the transplant process.

The most common agents used to prevent GVHD are cyclosporine, tacrolimus (FK-506/Prograf), Methotrexate and steroids. Some form of prevention is always started before allogeneic transplant. It is critical that you take your anti-GVHD medications and not stop taking them without notifying your doctor or transplant coordinator.

Coping with GVHD can be very challenging for patients and their families. You may be angry that you must deal with this illness on top of everything else. Drugs you are taking may exaggerate mood swings, depression and anxiety. Please try to keep in mind that GVHDs manifestations are temporary.