At a Glance: Transplantation
When you are asked to provide medical coverage for a hematopoietic cell transplant, it is helpful to have a general understanding of the entire transplant process.
Pre-transplant
1. Deciding to transplantWhen a physician is planning for an immediate transplant or is considering a hematopoietic cell transplant as part of a treatment plan, the decision involves:
- Investigating treatment options for the disease
- Referring the patient for transplant, including:
- Assessing the disease status and the patient's overall health
- Tissue typing the patient and the patient's family to determine the transplant type
- Verifying insurance coverage
- Identifying a caregiver
- Referring the patient to a transplant center
More information: Steps: Deciding to transplant
2. Searching for an unrelated donor or cord blood unit
When the physician, along with the patient, has decided that an allogeneic transplant is the best therapy option, the next step is to identify hematopoietic cells that closely match the patient's human leukocyte antigen (HLA) type. A high degree of HLA matching is one critical factor for a successful transplant outcome. (Other factors include patient co-morbidities, disease, disease stage and transplant timing.)
Ideally, a family member would be a close match. However, 7 out of 10 patients will not have a family member that matches or is able to donate. These patients will need an unrelated donor or a publicly banked cord blood unit.
NMDP RegistryThe National Marrow Donor Program (NMDP) manages the national Registry that includes nearly 7 million potential donors and 70,000 cord blood units. The NMDP Registry also provides physicians and patients with access to an additional 4 million potential donors and cord blood units listed on international registries.
Preliminary and formal searchThe search to identify unrelated hematopoietic cells that closely match the patient’s HLA type begins with a preliminary search followed by a formal search.
A preliminary search is a free snapshot of potential donors or cord blood units that may match the patient's HLA type at a given time. Using results from the preliminary search, an NMDP or transplant center HLA expert begins a formal search by HLA testing potential donors or cord blood units. By initiating a formal search, the NMDP Registry is searched continually for added donors and cord blood units or for those whose HLA information has been updated. More information: Steps: Searching for unrelated hematopoietic cells
3. Procuring unrelated hematopoietic cells
The physician chooses the hematopoietic cell source based on:
- Published outcomes data.
- Availability of an appropriately matched donor or cord blood unit.
- Patient's disease, status and age.
- The urgency level of the patient's need for transplant.
- When considering cord blood, the cell dose (number of stem cells per cord blood unit) of matching cord blood units in relation to the patient's weight. Depending upon the cell dose and the patient's weight, more than one cord blood unit may be needed.
The collection and delivery vary by cell source.
Marrow or PBSC
First, the donor:
- Attends an informational session
- Signs a consent document to donate
- Receives a physical exam
Then, the marrow or peripheral blood stem cells (PBSC) is collected from the donor and delivered to the transplant center within 12 hours after collection.
Marrow is collected during a surgical procedure requiring an operating room, anesthesia and sometimes an overnight stay for the donor.
PBSC is collected during an outpatient procedure performed at an apheresis center (hospital lab or blood center). Five days before collecting PBSC, the donor receives daily injections of a synthetic growth hormone, filgrastim (G-CSF or granulocyte-colony stimulating factor). Filgrastim increases the number of hematopoietic cells and moves those cells out of the marrow and into the blood.
Cord blood
When a physician selects a cord blood unit as the best choice for a patient, the HLA of the cord blood unit is verified. The cryopreserved cord blood unit is then requested and delivered to the hospital approximately one week before the transplant date. At the hospital, the cells are thawed and prepared for transplant.
More information: Steps: Procuring unrelated hematopoietic cells
Transplant
4. Transplant and engraftment
Shortly before transplant, the patient receives a pre-transplant treatment called a preparative regimen or a conditioning regimen. The preparative regimen destroys the patient’s diseased cells using chemotherapy and sometimes radiation. The preparative regimen may last four to ten days, depending upon the patient's disease, disease status, age and any previous treatments.
One or two days after the preparative regimen is completed, the donor cells are transplanted (infused). The infusion of hematopoietic cells is similar to a blood transfusion.
During the next 14 to 30 days, the patient is monitored to ensure engraftment occurs. Engraftment occurs when the donated hematopoietic cells regenerate new blood-forming cells. If engraftment does not occur within this time, the patient may receive additional treatments or another transplant.
Within the first 100 days after transplant the patient is usually able to leave the hospital, but must remain nearby. The transplant center determines when the patient is healthy enough to return home.
More information: Steps: Transplant
Post-transplant
5. Recovery and long-term follow-upThe physician and transplant center work together to develop a treatment plan to ensure the patient receives appropriate monitoring to reduce the potential for post-transplant complications.
When the patient returns home, the focus is on preventing infection and returning the patient to his or her lifestyle as much as possible. The return to daily lifestyle, which may be different than before transplant, can take up to a year or longer.
A diligent caregiver can influence outcomes by recognizing signs of infection and graft-versus-host disease (GVHD), contacting the patient's physician when needed, and making sure the patient takes medications as prescribed. More information: Steps: Recovery and Long-term Follow-up; Patient care post-transplant (marrow.org)
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