Complications and Side Effects

Chemotherapy, radiation therapy and other agents used in transplant can cause unpleasant side effects. Each child may experience these symptoms differently. A number of steps are taken to minimize the risk of complications.

Complications may vary depending on the following:

• Type of transplant
• Underlying disease and remission status
• Conditioning (preparative) regimen
• Age and overall health of the recipient
• Presence of other medical conditions
• Donor characteristics

Complications

Nausea, Vomiting, Diarrhea

Nausea, vomiting and diarrhea may occur with chemotherapy, radiation and/or gastrointestinal (GI) irritation. Antiemetics will be given as needed to control nausea and vomiting. The loss of fluids caused by diarrhea and vomiting may result in dehydration. Fluids may be given intravenously to prevent and correct dehydration.

Mucositis and Pain

High doses of chemotherapy and radiation target rapidly dividing cells, such as cancer cells. However, some normal cells, such as those that line the mouth, throat and gut, are often temporarily damaged by the treatment. Pain related to sores in the mouth and throat (mucositis) is common. Mucositis generally makes eating difficult or impossible. Other causes of pain include: skin irritation from conditioning therapy, medical procedures (bone marrow aspirations, lumbar punctures, skin biopsies, intravenous line placement), Neupogen and catheter-site infection.

If your child develops mucositis, the following measures may help:

• Mouth wash with topical anesthetic
• Narcotics such as morphine may be given, when indicated
• Treatment of viral and fungal infections
• Antiseptic mouth care to prevent infection
• Calories and proteins may be given through an intravenous (IV) line (Total Parenteral Nutrition) until your child is able to eat again and the diarrhea has resolved

Low Platelet and Red Cell Counts

Thrombocytopenia (low platelet count) and anemia (low hemoglobin or red cell count) are a result of non-functioning bone marrow. Thrombocytopenia can cause bleeding in the lungs, gastrointestinal (GI) tract, brain and other parts of the body that may at times be serious. Anemia can cause fatigue, lack of appetite, irritability, rapid heart rate and other symptoms. Most children undergoing BMT will require multiple platelet and red blood cell transfusions. The need for blood product support declines as the new stem cells start to work.

Infections

Infections are likely in a child with severe bone marrow suppression. Bacterial infections are the most common. Viral, fungal and other infections can also occur. Some infections can develop later on, weeks to months after the transplant. Infections can cause extended hospital stay, prevent or delay engraftment, cause organ damage, and may be life threatening.

Antibiotics, anti-fungal medications and anti-viral medications are often given to prevent or treat serious infections. Blood tests and other appropriate studies are performed to detect and to treat infections in a timely fashion. Often, multiple antibiotics are started if an infection is suspected.

Preventive measures are taken to minimize exposure to viruses, bacteria and other pathogens during the transplant period. These may include some or all of the following:

• HEPA-filtered rooms
• Strict hand washing
• Isolation precautions
• Use of face mask outside the room
• Restriction of visitors
• Diet and hygiene

See Minimizing the Risk of Infection for information about ways to prevent infection after discharge.

Fluid Overload

Fluid overload can lead to respiratory difficulty, liver damage and high blood pressure. During transplant therapy, your child will be assessed for signs and symptoms of fluid overload. The patient will be weighed at least once daily, intake and output will be recorded carefully, and blood chemistries will be monitored. Medications for elimination of excess fluid and preservation of organ function may be given.

Veno-occlusive Disease (VOD)

Veno-occlusive disease is a condition in which the blood flow to the liver is partially or completely obstructed. This can result in jaundice, liver dysfunction, weight gain and swelling of the abdomen. In most cases VOD is mild or moderate and can be managed successfully. Severe VOD can sometimes be serious and even life threatening. Measures will be taken for early detection and management of this condition.

Respiratory Distress

Respiratory function may become compromised during the transplant treatment. Pneumonia, inflammation (swelling) of the airways, graft-versus-host disease and bleeding are some of the things that singly or in combination may cause difficulty in breathing. Your child's condition will be closely monitored using pulse oximetry and chest X-rays. Measures such as antibiotics, fluid restriction and oxygen therapy will be administered as appropriate. If the condition worsens, your child may need to be transferred to the intensive care unit and connected to a machine to support breathing.

Graft-versus-host Disease (GVHD)

Graft-versus-host disease can be a serious and potentially life-threatening complication of allogeneic BMT. GVHD occurs when the donor's immune system reacts against the recipient's tissue. The new cells recognize the tissues and organs of the recipient's body as foreign. The most common sites for GVHD are the skin, gastrointestinal tract, liver and lungs.

GVHD can develop suddenly (acute) or over a period of time (chronic). Your child will be monitored closely for signs and symptoms of GVHD. Skin rash, diarrhea, nausea, abdominal pain and abnormal liver function tests are some of the manifestations of acute GVHD.

A number of measures are taken prior to transplant to reduce the risk of this complication. If GVHD becomes a significant medical problem, medications such as steroids and cyclosporine are commonly utilized for its treatment.

Graft Failure

Rarely, the infused bone marrow or blood stem cells fail to take over the role of producing blood cells for the host's body. This potential complication is called graft failure. It may occur as a result of infection, recurrent disease or if the stem cell count of the donated marrow was insufficient to cause engraftment. Graft failure may be treated with another transplant, which would include a conditioning regimen and an infusion of bone marrow or blood stem cells, or it may be treated by giving a second infusion without using a conditioning regimen. In either case, the infused stem cells may be from a different donor and/or from a different source (i.e., from bone marrow instead of cord blood) than was used for the first infusion.

Organ Damage

Temporary or permanent organ damage may be caused by high doses of chemotherapy and radiation, infection, graft-versus-host disease, fluid overload, medications or prolonged use of intravenous nutrition. Close monitoring of your child's vital signs, frequent check-ups and laboratory testing will be important in detecting and minimizing any organ damage that has occurred. Your child will require long term follow-up to watch for any late effects of therapy.

Disease Recurrence (Relapse)

Although the goal and hope of blood or marrow transplantation is to cure the patient, the possibility exists that the disease may return at some time in the future following this procedure. Should a relapse occur, your child's oncologist will discuss his/her treatment options with you. This may include additional chemotherapy, donor leukocyte infusions, experimental therapy or, rarely, another BMT.