Managing Life and Infections After Hematopoietic Stem Cell Transplantation

Potential Medical Issues After Discharge

Medical Advice
Dealing with Fever
Chronic GVHD
Explained
Blood Disorders
Liver and Kidney Issues
Safety Tips

Potential Medical Issues After Discharge

Patients and their families may feel stress and anxiety about returning home after a hematopoietic stem cell transplant. Moreover, recovery to normal daily life after the transplant does not occur in a short period of time.

Most patients will experience fatigue, weakness, and loss of appetite after discharge, so time is needed for the patient to regain the ability and strength to perform daily activities, requiring patience and effort from both the patient and their family. In addition, side effects that may appear after transplantation such as infection, bleeding, and graft-versus-host disease require continuous post-living management. Because careful attention is needed for several months after transplantation, patients and their families need to receive education about life after a hematopoietic stem cell transplant before discharge.

The following is a table of possible medical problems and symptoms after transplantation. If you have any of the following symptoms, you should visit the Catholic Hematology Hospital and receive a consultation from the Hematology or Infectious Diseases department, or a related department. (There may be limitations in accurate diagnosis and treatment when visiting a general hospital.)

Potential Medical Issues After Discharge
Medical issue	Symptoms	Remarks
Infection	A fever of 38°C (100.4°F) or higher that lasts for more than an hour Coughing, sneezing, nasal discharge, chest pain, and difficulty breathing Pain in the throat, eyes, ears, skin, joints, or abdomen, accompanied by redness and swelling Blurred vision or difficulty seeing Frequent urination and a burning sensation during urination Sores around the mouth or on the body Spreading red spots on the skin that are itchy Diarrhea accompanied by pain Vomiting accompanied by a headache and a burning sensation in the mouth	Be vigilant for infections as the immune system is immature for a year after the transplant
Bleeding	Small spots on the skin Bleeding from the gums and nose Blood in stool or urine	You may see black stools in case of upper gastrointestinal bleeding.
Acute Graft-Versus-Host Disease	Red spots on the skin, itching, and burning sensation Burning sensation in the hands and feet Persistent nausea or vomiting Increased amount of diarrhea, abdominal pain Increased liver enzymes, jaundice in the skin or eyes	It does not occur in patients who have undergone autologous hematopoietic stem cell transplantation.
Chronic Graft-Versus-Host Disease	Skin hardening as if it has been burned, change in skin color Red eyes. Dryness and lack of tears Dry mouth, difficulty in consuming irritating food due to chronic stomatitis Difficulty in breathing and coughing when moving due to fibrosis of the lungs and bronchi Narrowing of the esophagus, difficulty swallowing food Muscle weakness, limited joint movement and pain
Others	Avascular necrosis of the hip - pain during joint movement In women, amenorrhea, early menopause, infertility Abnormal thyroid function	-

Fever

Fever can be brought on by infections stemming from different sources such as bacteria, fungi, or viruses. It may also be a result of immunological reactions, such as those seen in graft-versus-host disease.

Following a transplantation, the primary cause of infection is a weakened immune system that has not yet fully recovered. The immune system's functionality is decreased due to the use of anticancer drugs, which are utilized to prepare the body for the implantation of the transplanted hematopoietic stem cells. Immunosuppressants, which are used to prevent and treat graft-versus-host disease, also play a role in this reduction. It typically takes over six months for the immune system to regain the same level of functionality as that of a healthy individual. Furthermore, when the body is in a state of immunosuppression, dormant viruses within the body can reactivate, leading to a variety of complications. These complications may include various clinical problems such as skin rashes, fever, a decrease in bone marrow functionality, gastroenteritis, pneumonia, retinitis, encephalitis, and more. Consequently, it is crucial to maintain personal hygiene and a clean environment, and to strictly adhere to the guidelines provided to you after the transplantation procedure.

In addition to infections, fever can be triggered by systemic inflammatory responses or immunological reactions. Thus, if a fever develops, it is essential to consult with the primary doctor overseeing the transplant to identify the cause and receive prompt and appropriate care.

Chronic Graft-Versus-Host Disease (cGVHD)

Acute Graft versus Host Disease (aGVHD) often shows up in the skin, digestive tract, and liver of patients who have received a transplant of blood-forming stem cells from a donor. On the other hand, chronic Graft versus Host Disease (cGVHD) can happen anywhere in the body. It's seen in about half of the patients who receive transplants and might be local (in one area) or systemic (throughout the body), depending on how severe it is. Common signs include dry eyes, dry mouth, yellow skin or eyes (jaundice) from liver problems, and skin rashes. Patients might also have joint pain, hair loss, muscle inflammation, lung disease that causes breathing difficulties, or symptoms similar to a common cold.

The usual way to treat this condition involves increasing the dosage of drugs that suppress the immune system, or adding new ones. Most patients get better with treatment, but in some cases, the disease doesn't improve even with various immune-suppressing drugs. Important organs like the liver and lungs can slowly get worse due to the aftereffects of GVHD, leading to serious health problems.

Most patients start diagnosis and treatment under the watchful eye of a doctor in a clinic after the transplant. However, sometimes GVHD progresses slowly with mild symptoms or occurs much later. Therefore, even after stopping the immune-suppressing drugs after the transplant, it's important to keep seeing the doctor, stay healthy with regular exercise, watch for any unusual symptoms, and see the primary care doctor if any abnormal symptoms appear to get advice from a specialist.

Hematologic Abnormalities

When the newly introduced blood-forming stem cells settle in well, the patient doesn't need more blood transfusions. This frees them from various problems caused by the body not making enough blood cells. However, there might be times when some of the functions of creating blood, like white blood cells, red blood cells, and platelets, don't recover, or they recover and then decrease again. There might also be times when the stem cells don't completely settle in, which can be caused by other things like viral infections or the immune system destroying cells. Of course, if the blood disease that was there before the transplant hasn't been completely cured or comes back, the blood tests will show abnormal results. Regular tests of a blood sample are basic, and if needed, tests of the bone marrow and various clinical pathology tests are used to find out the cause.

Liver Function Abnormalities

The liver is a vital organ that creates various substances our body needs and gets rid of metabolic waste. Problems with liver function can show up in many ways, from abnormal liver function test results in blood tests even if the patient doesn't feel sick, to serious physical signs like yellow skin or eyes (jaundice) and fluid buildup in the abdomen (ascites). Problems with liver function often happen during the transplantation process, and what's important is what's causing them and how severe they are. The causes can be many things, including the use of various drugs, especially cancer-fighting drugs given for treatment before the transplant, drugs that suppress the immune system used to prevent and treat graft-versus-host disease, liver disease that blocks small veins in the liver, serious infections, acute and chronic graft-versus-host disease, reactivation of hepatitis B virus or giant cell virus, and damage to how the liver works. The causes mentioned can lead to liver problems alone or together. Because the way to treat it changes depending on what's causing it, it's very important to find out the cause. In some cases, tests to see the blood vessels or liver tissue examination might be needed in addition to various tests for virus infection, liver ultrasound, and abdominal computed tomography. Once the cause is found, various treatments to improve how the liver works will be done along with the right treatment. What's important is to find problems with liver function early and take the right steps before the disease gets worse. Therefore, regular check-ups are very important after transplantation, and patients should go to the hospital if they have physical problems like jaundice, weight gain, ascites, or pain in the upper abdomen. Even if there are minor symptoms like feeling tired or weak, it's important to tell the primary care doctor and take the right steps as needed

Renal Function Abnormalities

The kidney, like the liver, is another organ that often has problems working right after a transplant. The main jobs of this organ include keeping the balance of body fluids and electrolytes, and getting rid of waste. If any problems happen, the balance of the whole body is thrown off due to less urine being made, swelling or weight gain because of fluid buildup, too much or too little of various electrolytes, and waste buildup in the body. Kidney problems can limit the use of medicines and the supply of blood and fluids, making it harder to treat other diseases the right way. After a transplant, kidney problems mainly happen because of drugs like ones that suppress the immune system and various antibiotics. Of course, it can also happen because of serious bacterial infections or shock, and some viruses can cause it by infecting organs in the urinary system. It's important to find kidney problems early, figure out what's causing them, and lessen things that make the problems worse. For this, it's necessary to keep getting regular tests of how well the kidney is working and check-ups from the primary care doctor.

Other Precautions

Besides the complications mentioned above, there can also be problems with the heart and blood vessels, central nervous system, growth, various hormones, reproductive system, and the quick growth of secondary cancers because of the acute side effects of radiation therapy and drugs used to fight cancer. To prevent various complications throughout the body and get the right treatment, it's important to keep getting medical care and advice from a specialized medical team at a transplant center.