Allogeneic Bone Marrow Transplant — Graft-Versus-Host Disease: Prevention and Engraftment
One complication that is unique to an allogeneic bone marrow transplant is called graft-versus-host disease, or GVHD. Graft-versus-host disease is a condition that occurs after a bone marrow transplant, in which the donor’s immune cells in the transplanted marrow make antibodies against the host’s (patient's) tissues and attack vital organs. The condition may be acute or chronic, mild or severe. Severe cases can be life-threatening. Signs of GVHD include reactions occurring in the skin, mouth, gut or liver. To prevent this, we usually give a combination of two drugs. Cyclosporine, FK506 or Prograf is given intravenously starting the day before the transplant and then changed to oral capsules and continued until Day 100. Methotrexate is given by injection for three-four doses on Day 1, Day 3, Day 6 and possibly Day 11. Methotrexate is good at preventing graft-versus-host disease but can cause mouth ulcers (mucositis), especially after the last dose. These ulcers normally persist until the white cells engraft.
Engraftment generally occurs within 10 to 14 days after the stem cell infusion. The word “engraftment” refers to the return of red cells, white cells and platelets in the blood. The most important cell to return is a type of white blood cell known as the neutrophil. Neutrophils are important in fighting bacterial infections. It is important to get the neutrophil level close to normal.
The neutrophils are usually the first cells to return, especially if a growth factor, like G-CSF, is given. The platelets are next to return. Platelets are fragments of cells that live in the bone marrow. They play an important role in clotting – in other words, they help stop bleeding after a cut or other injury. Sometimes, if not enough stem cells could be collected, the platelets may take much longer to recover even though the neutrophils returned on time. The red cells usually start growing at this stage too, but because the red cells last so long compared to the other cells (120 days) it is not uncommon for patients to need a blood transfusion after going home.