What is a Bone Marrow Transplant (Stem Cell Transplant)?

A bone marrow transplant is a medical treatment that replaces bone marrow with healthy
cells. The replacement cells can either come from own body or from a donor.

A bone marrow transplant is also called a stem cell transplant or, more specifically, a
hematopoietic stem cell transplant. Transplantation can be used to treat certain types of
cancer, such as leukemia, myeloma, and lymphoma, and other blood and immune system
diseases that affect the bone marrow.

What are stem cells? What is bone marrow?

Stem cells are special cells that can make copies of themselves and change into the many
different kinds of cells that the body needs. There are several kinds of stem cells and they are
found in different parts of the body at different times.

Cancer and cancer treatment can damage hematopoietic stem cells. Hematopoietic stem cells
are stem cells that turn into blood cells.

Bone marrow is soft, spongy tissue in the body that contains hematopoietic stem cells. It is
found in the center of most bones. Hematopoietic stem cells are also found in the blood that is
moving throughout the body.

When hematopoietic stem cells are damaged, they may not become red blood cells, white
blood cells, and platelets. These blood cells are very important and each one has a different
job:

Red blood cells carry oxygen throughout the body. They also take carbon dioxide to the
lungs so that it can be exhaled.

White blood cells are a part of the immune system. They fight pathogens, which are the
viruses and bacteria than make sick.

Platelets form clots to stop bleeding.

A bone marrow/stem cell transplant is a medical procedure by which healthy stem cells are
transplanted into bone marrow or blood. This restores the body’s ability to create the red
blood cells, white blood cells, and platelets it needs.

What are the different types of transplants?

There are different types of bone marrow/stem cell transplants. The 2 main types are:
Autologous transplant. Stem cells for an autologous transplant come from their own body.
Sometimes, cancer is treated with high-dose, intensive chemotherapy, or radiation therapy
treatment. This type of treatment can damage stem cells and the immune system. That's why
doctors remove, or rescue, stem cells from blood or bone marrow before the cancer treatment
begins.

After chemotherapy, the stem cells are returned to the body, restoring the immune system and
the body's ability to produce blood cells and fight infection. This process is also called an
AUTO transplant or stem cell rescue.

Allogenic transplant. Stem cells for an allogenic transplant come from another person,
called a donor. The donor's stem cells are given to the patient after the patient has
chemotherapy and/or radiation therapy. This is also called an ALLO transplant.

Many people have a “graft-versus-cancer cell effect” during an ALLO transplant. This is
when the new stem cells recognize and destroy cancer cells that are still in the body. This is
the main way ALLO transplants work to treat cancer.

Finding a “donor match” is a necessary step for an ALLO transplant. A match is a healthy
donor whose blood proteins, called human leukocyte antigens (HLA), closely match s. This
process is called HLA typing. Siblings from the same parents are often the best match, but
another family member or an unrelated volunteer can be a match too. If the donor’s proteins
closely match s, are less likely to get a serious side effect called graft-versus-host disease
(GVHD). In this condition, the healthy transplant cells attack cells.

If the healthcare team cannot find a donor match, there are other options.

Umbilical cord blood transplant. In this type of transplant, stem cells from umbilical cord
blood are used. The umbilical cord connects a fetus to its mother before birth. After birth, the
baby does not need it. Cancer centres around the world use cord blood. Learn more
about cord blood transplants.

Parent-child transplant and haplotype mismatched transplant. Cells from a parent, child,

brother, or sister are not always a perfect match for a patient's HLA type, but they are a 50%
match. Doctors are using these types of transplants more often, to expand the use of
transplantation as an effective cancer treatment.

How does a bone marrow/stem cell transplant work?

The information below tells the main steps of AUTO and ALLO transplants. In general, each
process includes collecting the replacement stem cells, the patient receiving treatments to
prepare their body for the transplant, the actual transplant day, and then the recovery period.

Often, a small tube may be placed in the patient's chest that remains through the transplant
process. It is called a catheter. The healthcare team can give chemotherapy, other
medications, and blood transfusions through a catheter. A catheter greatly reduces the number
of needles used in the skin, since patients will need regular blood tests and other treatments
during a transplant.

Please note that transplants are complex medical procedures and sometimes certain steps may
happen in a different order or on a different timetable, to personalize specific care. Ask health
care whether, will need to be in the hospital for different steps and if so, how long. Always
talk with the health care team about what to expect before, during, and after the transplant.

How does an AUTO transplant work?

Step 1: Collect stem cells. This step takes several days. First, will get injections (shots) of
medication to increase stem cells. Then health care team collects the stem cells through a vein
in the arm or chest. The cells will be stored until they are needed.

Step 2: Pre-transplant treatment. This step takes 5 to 10 days. will get a high dose of
chemotherapy. Occasionally, patients also have radiation therapy.

Step 3: Getting stem cells back. This step is transplanting day. It takes about 30 minutes for
each dose of stem cells. This is called an infusion. health care team puts the stem cells back
into the bloodstream through the catheter. might have more than one infusion.

Step 4: Recovery.  The doctor will closely monitor the cells' recovery and growth and will
take antibiotics to reduce infection. The health care team will also treat any side effects.
Read more details below about recovering from a bone marrow transplant.

How does an ALLO transplant work?

Step 1: Donor identification. A matched donor must be found before the ALLO transplant
process can begin. HLA type will be found through blood testing. Then, health care team
will work with to do HLA testing on potential donors in family, and if needed, to search a
volunteer registry of unrelated donors.
Step 2: Collecting stem cells from donor.  health care team will collect cells from either
donor’s blood or bone marrow. If the cells are coming from the bloodstream, donor will get
daily injections (shots) of a medication to increase white cells in their blood for a few days
before the collection. Then, the stem cells are collected from their bloodstream. If the cells
are coming from bone marrow, donor has a procedure called a bone marrow harvest in a
hospital's operating room.

Step 3: Pre-transplant treatment. This step takes 5 to 7 days. will get chemotherapy, with
or without radiation therapy, to prepare body to receive the donor's cells.

Step 4: Getting the donor cells. This step is transplant day. health care team puts, or
infuses, the donor’s stem cells into bloodstream through the catheter. Getting the donor cells
usually takes less than an hour.

Step 5: Recovery. During initial recovery, will get antibiotics to reduce risk of infection
and other drugs, including medications to prevent and/or manage GVHD. health care team
will also treat any side effects from the transplant. Read more details below about bone
marrow transplant recovery.

What is recovering from a bone marrow transplant like?

Recovery from a bone marrow/stem cell transplant takes a long time. Recovery often has
stages, starting with intensive medical monitoring after transplant day. As long-term
recovery moves forward, will eventually transition to a schedule of regular medical checkups
over the coming months and years.

During the initial recovery period, it's important to watch for signs of infection. The intensive
chemotherapy treatments that get before transplant also damage immune system. This is so
body can accept the transplant without attacking the stem cells. It takes time for immune
system to work again after the transplant. This means that are more likely to get an infection
right after transplant.

To reduce risk of infection, will get antibiotics and other medications. If had an ALLO
transplant, medications will include drugs to prevent and/or manage GVHD. Follow health
care team's recommendations for how to prevent infection immediately after transplant.

It is common to develop an infection after a bone marrow transplant, even if are very careful.
doctor will monitor closely for signs of an infection. will have regular blood tests and other
tests to see how body and immune system are responding to the donor cells. may also get
blood transfusions through catheter.

health care team will also develop a long-term recovery plan to monitor for late side effects,
which can happen many months after transplant. Learn more about the possible side effects
from a bone marrow transplant.

What to consider before a transplant

doctor will recommend the best transplant option for . options depend on the specific
disease diagnosed, how healthy bone marrow is, age, and general health. For example, if
have cancer or another disease in bone marrow, will probably have an ALLO transplant
because the replacement stem cells need to come from a healthy donor.

Before transplant, might need to travel to a center that does many stem cell transplants.
doctor may need to go, too. At the center, will talk with a transplant specialist and have a
medical examination and different tests.

A transplant will require a lot of time receiving medical care away from daily life. It is best to
have a family caregiver with. And, a transplant is an expensive medical process.

How do know if the transplant worked?

A successful transplant may mean different things to, the family, and healthcare team. Here
are 2 ways to know if the transplant worked well.

blood counts are back to safe levels. A blood count measures the levels of red blood cells,
white blood cells, and platelets in the blood. At first, the transplant makes these numbers very
low for 1 to 2 weeks. This affects the immune system and puts at a risk for infections,
bleeding, and tiredness. The health care team will lower these risks by giving blood and
platelet transfusions. will also take antibiotics to help prevent infections.

When the new stem cells multiply, they make more blood cells. Then blood counts will go
back up. This is one way to know if a transplant was a success.

cancer is controlled. Curing cancer is often the goal of a bone marrow/stem cell transplant.
A cure may be possible for certain cancers, such as some types of leukemia and lymphoma.
For other diseases, remission of the cancer is the best possible result. Remission is having no
signs or symptoms of cancer.
As discussed above, need to see doctor and have tests regularly after a transplant. This is to
watch for any signs of cancer or complications from the transplant, as well as to provide care
for any side effects experience. This follow-up care is an important part of recovery.
Blood and Marrow Transplant Program

The mission of the Blood & Marrow Transplant (BMT) Program in the Taussig Cancer
Institute is to provide high quality specialized patient care in a setting of education and
research.

 Learn More

How the bone marrow functions

Hematopoietic stem cells are found in the peripheral blood and the bone marrow, which is the
soft, spongy center of your bone. These stem cells develop into all types of blood cells,
including white blood cells, red blood cells, and platelets.

 White blood cells of various kinds make up part of your immune system for fighting
infections.

 Red blood cells are responsible for carrying oxygen throughout your body.

 Platelets clot your blood to prevent bleeding.

Stem cells are constantly being produced by your bone marrow and will develop into the
types of cells your body needs.

Types of bone marrow transplants

Most people who need to undergo a blood or marrow transplant have cancer, such
as leukemia, lymphoma or multiple myeloma. There are different types of transplants. The
type and severity of your disease determine what type of transplant you will need.

An allogeneic transplant involves receiving donor bone marrow, umbilical cord stem cells,
or peripheral stem cells. This donor is genetically matched and can be related or unrelated to
you.

An autologous transplant involves receiving your own peripheral blood stem cells.

A syngeneic transplant involves receiving your identical twin’s bone marrow or peripheral
stem cells.

Here is more information about the specific types of blood or marrow transplants:

 An allogeneic transplant involves receiving very high-doses

of chemotherapy and/or radiation therapy, followed by the infusion of your donor’s
 bone marrow or peripheral blood stem cells. The high-dose cancer-fighting treatments
are given to eliminate the cancer in your body. The infusion of the new marrow, cord
blood, or peripheral stem cells from the donor replaces the bone marrow destroyed by
the chemotherapy and/or radiation therapy. Allogeneic transplant patients have the
risk of developing a complication called graft-versus-host disease or GvHD. GvHD is
a condition where donor cells from the graft attack the patient’s (or host’s) organs or
tissues. The condition can be mild and treated on an outpatient basis, or it can be
severe and require treatment in the hospital. You might be a potential candidate for an
allogeneic transplant if you have leukemia, aplastic anemia,
myelodysplasia, myelofibrosis, high-grade lymphoma or other types of cancers.

 A reduced intensity allogeneic transplant involves receiving lower doses of

chemotherapy and radiation therapy followed by the infusion of your donor’s bone
marrow or peripheral blood stem cells. The objective is to suppress your own bone
marrow by receiving just enough chemotherapy and radiation therapy to allow your
donor cells to engraft and grow within you. The hope is these donor cells will mount
an immunologic attack against your underlying cancer, generating a response called
the “graft-versus-leukemia” effect or “graft-versus-cancer” effect. You might be a
potential candidate for this type of transplant if you have a slow-growing ("indolent")
disorder, such as chronic leukemia, multiple myeloma, myelodysplasia, and low-
grade lymphoma.

 An autologous bone marrow transplant involves receiving very high-dose

chemotherapy followed by the infusion of your previously collected peripheral stem
cells or bone marrow. The high-dose chemotherapy treatments are given to eliminate
the cancer in your body. The infusion of your new marrow or peripheral stem cells
replaces the bone marrow destroyed by the chemotherapy and/or radiation therapy.
You might be a potential candidate for an autologous transplant if you have
lymphoma, multiple myeloma, Hodgkin disease, germ cell cancer, or certain types of
leukemia.

Pre-transplant evaluation

Before a blood or marrow transplant can be approved as a treatment option, you will have a
pre-transplant evaluation. This evaluation includes a complete physical, consultations with
members of the Transplant Team, and a comprehensive series of tests. A pre-transplant
evaluation provides complete information about your overall health and helps determine if
you are eligible for a blood or marrow transplant.

Blood or marrow transplantation as a treatment option

After your transplant doctor has determined you are a good candidate for a transplant, a date
for the transplant will be determined and the process of insurance clearance will begin. Please
understand that insurance reimbursement for transplantation is not automatic.

If you are to be admitted to the hospital for your transplant, you can expect your stay to be
about 3 to 4 weeks, depending on your recovery. During your recovery, you will learn about
your new medicines, how to recognize signs of complications and infections, and when you
can return to your normal activities.

If an allogeneic transplant or inpatient reduced intensity transplant has been approved for
you, you and your designated care partner will be required to stay within a 1-hour drive of
Cleveland Clinic’s main campus for approximately 100 days after your transplant. After you
go home, you can expect to recover gradually.

If an outpatient reduced intensity allogeneic transplant has been approved for you, you will
be required to stay within a one-hour drive of Cleveland Clinic’s main campus for at least
100 days after your transplant. At that time, your doctor will evaluate your medical condition
to determine where you can continue your follow-up care.

Follow-up care after your transplant includes appointments with your transplant or local
doctor and tests to assess how you are recovering.

PROCEDURE DETAILS

Before a bone marrow transplant operation, certain tests are required. These include blood
tests, a chest X-ray, PET scan, heart tests, and a bone marrow biopsy. Donors are also
expected to complete certain tests.

Why do I need to have bone marrow pre-transplant evaluation tests?

Your pre-transplant evaluation includes a variety of medical tests that provide complete
information about your overall health. These medical tests help the bone marrow
transplant team identify any potential problems before your transplant and avoid potential
complications after your transplant.
While each patient does not have the same tests, most of the tests included in this handout are
common for all transplant patients. The tests required before the transplant are usually done
on an outpatient basis. Your nurse and administrative coordinator will help arrange these for
you. Please ask your nurse coordinator any questions you have.

If special instructions are required before any of these tests, you will receive a written form
that explains how to prepare. After the tests are completed, your doctor will review the results
with you. These results are also required by your insurance company in order to approve the
medical necessity of your transplant.

Blood tests

Your health care provider or a technician will take a sample of blood from your arm or
central venous catheter (if one is in place). The blood is sent to a lab where the following
tests are performed:

Tissue typing (needed for allogeneic patients only)

This was done at or before your initial consultation appointment with your BMT doctor.
Tissue typing is a series of blood tests that evaluate the compatibility or closeness of tissue
between the organ donor and recipient. From your blood samples, the tissue typing lab can
identify and compare information about your antigens (the “markers” in cells that stimulate
antibody production) so they can match a bone marrow donor to you. All donors are carefully
screened to prevent any transmissible diseases or detect other medical problems that might
prevent them from donating bone marrow.

Other blood tests

In the laboratory, a series of tests will be performed to detect certain substances in your blood
and to evaluate your general health. These blood tests might include:

Infectious disease screening for:

 Hepatitis

 HIV (human immunodeficiency virus)

 RPR (syphilis)

 Toxoplasmosis

 Varicella Zoster
  CMV (cytomegalovirus)

 EBV (Epstein-Barr virus)

 HSV (Herpes Simplex virus)

 West Nile Virus

 HTLV1/11 (Human T-Cell lymphotropic virus

 Chagas

Blood work to check your organ function

 Ferritin

 Pregnancy test

 Complete Metabolic Panel

 Hemoglobin solubility

 ABO blood type

 Bleeding times

 CBC, diff, platelets

 Quantitative immunoglobulins

Other possible blood work

 Disease-specific labs for multiple myeloma

 Research samples

Other tests:

Chest X-ray

A chest X-ray provides a picture of your heart and lungs. This X-ray provides information
about the size of your heart and lungs, and might detect the presence of lung disease or
infection.

Pulmonary function tests (PFTs, lung tests)

Pulmonary function tests measure the capacity and function of your lungs, as well as your
blood’s ability to carry oxygen. During the tests, you will be asked to breathe into a device
called a spirometer.

Here are some guidelines to follow before your scheduled pulmonary function tests:

 Be sure to get plenty of sleep the night before.

 Plan to wear loose clothing during the test so you can give your greatest breathing
effort.

 Limit your liquids and eat a light meal before the test. Drinking or eating too much
before the test might make you feel bloated and unable to breathe deeply.

Computed tomography scan (CT Scan)

A CT scan, uses X-rays and computers to produce a detailed image of the body. Depending
on the type of scan you need, an oral and/or IV contrast material might be used so the
radiologist can see the extent of your disease. CT scans also might reveal the presence of
other abnormalities.

If you had a CT scan within 6 months before your pre-transplant evaluation, bring the CT
scan films or disc, along with a copy of the report with you. The radiologist will use them as
comparison when reading these new scans.

Depending on your illness, your doctor might order additional CT scans.

Positron emission tomography (PET) scan

A PET scan is a unique type of imaging test that helps doctors see how the organs and tissues
inside your body are actually functioning.

The test involves injecting a very small dose of radioactive chemical, called a radiotracer,
into a vein. The tracer travels through the body and is absorbed by the organs and tissues
being studied. Next, you will be asked to lie down on a flat examination table that is moved
into the center of a PET scanner -- a doughnut-like shaped machine. This machine detects and
records the energy given off by the tracer substance. The PET scan can measure such vital
function as glucose metabolism, which helps doctors identify abnormal from normal
functioning organs and tissues.
One of the main differences between PET scans and other imaging tests like CT scan
or magnetic resonance imaging (MRI) is that the PET scan reveals the cellular level
metabolism changes occurring in an organ or tissue, or the activity of cells.

Depending on your illness, your doctor may order a PET scan.

Heart tests

Because prior chemotherapy and/or radiation therapy and the chemotherapy/ radiation
therapy you will receive for transplant can affect your heart, you will need heart tests to
identify and treat any potential problems before the transplant procedure. The heart tests
include:

 Electrocardiogram (EKG): An EKG is used to evaluate your heart rhythm. Before the
test, electrodes (small, flat, sticky patches) are placed on your chest. The electrodes
are attached to an electrocardiograph monitor that charts your heart’s electrical
activity (heart rhythm).

 Echocardiogram: An echocardiogram is a graphic outline of your heart’s movement.

During the test, a wand, or transducer, is placed on your chest. The transducer emits
ultrasound (high-frequency sound wave) vibrations so the doctor can see the outline
of the heart’s movement. The echocardiogram provides pictures of the heart’s valves
and chambers so the pumping action of the heart can be evaluated. Echocardiogram is
often combined with Doppler ultrasound to evaluate blood flow across the heart’s
valves.

Bone marrow biopsy

A bone marrow biopsy is performed to evaluate your marrow’s function and to assess for
disease involvement. A needle is placed in your posterior hip bone to remove a sample of
bone marrow. The area will be numbed with a local anesthetic, or pain-relieving medicine, to
make you feel less discomfort during the procedure. You might be given oral medicine to
help you relax prior to the procedure. You should plan to have a driver take you home after
this procedure since the medicine can make you drowsy.

Skeletal survey

This is a series of X-rays of the skull and long bones to assess disease involvement for
patients with multiple myeloma.
Other tests may be required by your insurance company or your physician, for example:
colonoscopy, PAP smear, dental exam, or mammograms.

Additional tests

After the pre-transplant evaluation appointment, the BMT team may decide if you will need
any other tests. Additional tests or consultations will be performed at Cleveland Clinic. Your
nurse and administrative coordinator will help you make these arrangements.

After my bone marrow pre-transplant evaluation

At the end of your pre-transplant evaluation and after the test results are complete, the bone
marrow transplant doctor will decide whether or not a bone marrow transplant is the
appropriate treatment for you.

Your test results will also be sent to your insurance company for the insurance approval
process. Usually the insurance company will make a determination in 7 to 10 days after
receiving the test results.

Please understand that abnormal test results might require further investigation.

The goal of pre-transplant testing is to ensure that you will be able to undergo the transplant
and recover without increased risk of complications.

Bone marrow donor pre-transplant testing

For allogeneic and mini-allogeneic transplant patients, your bone marrow donor will also
have a medical evaluation with many of the same tests. The donor must be cleared and
determined medically fit to proceed as your donor.

RECOVERY AND OUTLOOK

How often should I check my temperature after my bone marrow transplant?

Knowing how many times a day to take your temperature, for what duration and when to call
your healthcare provider can help catch an illness or infection early in its course. Using a
thermometer to monitor your temperature can help you manage an illness. A rise in your
temperature is usually caused by an illness or infection and is usually one of the first signs of
a potential problem.

Autologous transplant patients: Check your temperature twice a day while you have central
line and for two weeks after discharge.
Allogeneic transplant patients: Check your temperature twice a day while you are taking
immunosuppressive medicines and while you have a central line.

When to call your health care provider?

For allogeneic bone marrow transplant patients, page your nurse coordinator if you have a
temperature of 100.0 degrees Fahrenheit or higher. For autologous bone marrow transplant
patients, page your nurse coordinator if you have a temperature of 100.5 degrees Fahrenheit
or higher. This could be a sign of infection and should be treated right away.

If you have a fever and any of these other signs, call your healthcare provider right away:

 Severe headache

 Stiff neck

 Severe swelling of your throat

 Mental confusion

Although bone marrow transplantation offers hope for many patients, going through the BMT
process is a difficult experience for patients and their families. Treatment is physically and
emotionally challenging.

Dealing with changes and loss of control

Facing the reality of a serious illness, fearing what is involved in bone marrow
transplantation, dealing with complex and unfamiliar medical information, and facing
separation from family and friends can be overwhelming and difficult to endure. You and
your family might experience anxiety regarding the uncertainty of what lies ahead.

You will experience changes and might not be as independent as you want to be. People will
experience some changes and role losses that are temporary, and some longer-term changes
in lifestyle might occur. While going through transplantation, common role changes might
involve employment or work, parenting and family responsibilities, and physical activity.
People who are used to being independent and like to feel in control might find such changes
very frustrating and might find it difficult to cope.

A person’s ability to cope is strongly influenced by his or her perceptions of a situation. If

you believe challenges facing you are insurmountable, you might feel helpless or hopeless.
Obtaining more information, asking about how other people have coped, and turning to
others for support are helpful coping strategies and might change the way you view your
situation.

Give yourself permission to have bad days. You are only human and will have times when
you feel discouraged or are in a bad mood. Just guard yourself against getting stuck in
negative thinking and feelings.

Helpful coping strategies

Review what has been helpful and not helpful to you in the past when dealing with stressful
or difficult situations. Focus on building on your strengths, and stay open to new ideas and
strategies. Here are some positive coping strategies:

 Utilize your support network of friends and family: having loved ones or friends visit
or call you can be very comforting. Discuss your feelings about what is happening
with your friends and family. Allow family and friends to help you sort through the
information you receive.

 Talk with other patients and families about bone marrow transplantation: talk with
your social worker. Make use of resources and support services —these include
resources at Cleveland Clinic and in the community.

 Actively participate in your treatment plan: you are a valuable and key person in your
treatment plan. Stay informed and communicate your questions and ideas to the
medical team. Do not be afraid to ask your doctor, nurse, or other health care provider
to repeat any instructions or medical terms you don’t understand. Your Bone Marrow
Transplant Team is always available to answer your questions and address your
concerns.

 Focus on things you can influence: let go of things you can’t change, and focus on
doing things that will help your situation.

 Focus on what needs to be done here and now: it is easy to get overwhelmed if you
think about everything you might eventually have to deal with. Focus on what you are
currently dealing with and can work on now.

 Accept your reactions and your natural pace: accept how you feel about events, and
give yourself time to adjust and process thoughts and feelings about what is
happening.
  Give yourself things to look forward to: your energy has been focused on treatment,
but there are still things you can enjoy, and you need to plan simple pleasures to
which you can look forward.

 Focus on what you have: try to focus on what you still have and have gained rather
than what you have lost or haven't accomplished yet.

 Accept the unexpected: accept that there are events you can’t control. Few things will
happen exactly as expected. Plan for delays, setbacks, and surprises.

 Reduce stress: when you are facing BMT, stress can build up and affect how you feel
about life. Prolonged stress can lead to frustration, anger, hopelessness and, at
times, depression.

Here are some tips for reducing stress:

 Be assertive instead of aggressive. "Assert" your feelings, opinions, or beliefs instead

of becoming angry, combative, or passive.

 Learn to relax.

 Exercise as often as you can.

 Eat well-balanced meals.

 Rest and sleep. Your body needs time to recover from stressful events.

Learn to Relax

There are a number of exercises you can do to relax. These exercises include breathing,
muscle and mind relaxation, relaxation to music, and biofeedback. A few for you to try are
listed below. First, be sure you have a quiet, distraction-free location. Try to find a
comfortable body position. Sit or recline on a chair or sofa. Also, have a good state of mind.
Try to block out worries and troubling thoughts.

Two-minute relaxation

Switch your thoughts to yourself and your breathing. Take a few deep breaths, exhaling
slowly. Mentally scan your body. Notice areas that feel tense or cramped. Loosen up these
areas, letting go of as much tension as you can. Rotate your head in a smooth, circular motion
once or twice. (If any movement causes pain, stop immediately.) Roll your shoulders forward
and backward several times. Let all of your muscles completely relax. Recall a pleasant
thought for a few seconds. Take another deep breath and exhale slowly. You should feel
relaxed.

Mind Relaxation

Close your eyes. Breathe normally through your nose. As you exhale, silently say to yourself
the word "one," a short word such as "peaceful," or a short phrase such as "I feel quiet."
Continue for 10 minutes. If your mind wanders, gently remind yourself to think about your
breathing and your chosen word or phrase. Let your breathing become slow and steady.

Deep breathing relaxation

Imagine a spot just below your navel. Breathe into that spot and fill your stomach with air.
Let the air fill you from the stomach up, then let it out, like deflating a balloon. With every
long, slow breath out, you should feel more relaxed.

Good nutrition is a very important part of your recovery. It helps your body resist infection
and repair tissue damage caused by chemotherapy and/or radiation therapy.

Losing interest in food after a long illness is to be expected. Some of the side effects you
might have experienced while in the hospital may continue even after you go home. These
side effects may include nausea, vomiting, loss of appetite, taste changes, and a sore or dry
mouth. With these symptoms, it may be difficult for you to imagine eating high-calorie,
nutrient-rich meals.

Nutrition After Blood & Marrow Transplant

Nutrition supplements

When you are unable to eat a well-balanced diet, we recommend you try over-the-counter
nutrition supplements to meet your nutritional needs, unless otherwise instructed. However, it
is important to check the labels for the specific vitamin, mineral or nutrient levels. They can
vary from different manufacturers. Examples of nutrition supplements are Ensure®, Boost®,
Resource®, Carnation Instant Breakfast®, Boost® bars and Boost® puddings. If you have
diabetes, Glucerna® and Boost® Glucose Control are options.

Several discount stores and drug stores have nutritional supplements packaged under their
private label. Please check with the dietician to determine if the particular product will meet
your needs.
Multivitamins

We recommend you take a daily multivitamin, after you are discharged. You can take
children’s chewable multivitamins twice a day if better tolerated. Excess doses of some
vitamins and minerals might be unsafe at this time. For instance, it is important to choose
vitamins that do not contain iron or herbs. Also, due to your numerous red blood cell
transfusions, additional iron supplementation is unnecessary. Your body does not eliminate
iron. If you have questions regarding your preferred multivitamin, bring your labeled vitamin
bottle to your appointment for your doctor’s approval.

Follow food safety guidelines when choosing any of the following foods:

Calcium and Phosphorus

Some of your medicines might deplete calcium, which is important for maintaining bone
strength. When the staff reviews your medications and labs, they will inform you if this is
likely to be a problem. Phosphorus is a mineral that helps to strengthen bones. Some
transplant patients often need additional phosphorus. Unless you are following a special diet,
we recommended you eat a diet high in calcium and phosphorus.

Your doctor might recommend calcium supplements such as Tums®, Oscal +D®, or
Caltrate®. Calcium supplements with vitamin D are essential for those who require long-term
steroid therapy, such as prednisone. Steroids cause bone loss, called osteoporosis. Taking
these supplements, as well as exercising, can help minimize bone loss and prevent fractures.
An appointment with a rheumatologist may be advised to monitor your bone density.

Potassium and magnesium

Antibiotics, diarrhea, and vomiting can cause electrolyte (mineral) imbalances. Even after
your hospital discharge, it is common to require potassium and magnesium supplementation,
which can be given by pill or intravenous infusion.

Potassium is an electrolyte (mineral) that maintains normal fluid balance, supports cell
integrity, facilitates the making of protein, and assists in the transmission of nerve impulses
and the contraction of the heart and other muscles.

Magnesium is also an electrolyte (mineral) that is involved in bone mineralization, building

of protein, transmission of nerve impulses, and normal muscular contraction.

Sodium
Sodium is an electrolyte essential for water regulation and electrical activities of the body,
such as nerve impulse transmission and muscular contraction. Our diets rarely lack sodium.

A healthy person requires about 200 mg of sodium daily, but the average sodium intake is
estimated to be 6,000 to 18,000 mg daily. Excessive sodium intake can lead to high blood
pressure (hypertension) and fluid retention. Reduce your sodium intake to less than 2,300 mg
each day.

Since allogeneic transplant recipients might already be experiencing hypertension or fluid

retention/swelling (edema) caused by steroids —such as prednisone, tacrolimus (Prograf®),
or cyclosporine (Neoral®) — it is crucial to avoid a diet high in sodium.

Alcohol

After your bone marrow transplant, you might have decreased liver function due to the
effects of high-dose chemotherapy, graft-versus-host disease (GvHD), or metabolism of
medicines. Since the liver metabolizes alcohol, avoid all beverages containing alcohol.
Alcohol can cause malnutrition by attacking the stomach lining, leading to malabsorption and
excretion of many nutrients. Before drinking beer, wine, or other beverages containing
alcohol, ask your BMT doctor.

Sun Exposure After Bone Marrow Transplant

Ultraviolet (UV) ray sun exposure can be harmful to the skin, causing sunburns and/or skin
cancers. More importantly, sun exposure to those who have had an allogeneic bone marrow
transplant can trigger or worsen skin graft-versus-host-disease (GVHD). Wear a hat, long
sleeves, long pants, and sunscreen with an SPF of at least 30 if you are outside in the sun.
However, avoiding sun exposure is the best prevention. Please note that even on cloudy days,
skin exposure to UV rays still occurs; therefore, take precautions.