The transplant process involves a series of steps, from the initial decision to proceed with transplantation, through the patient's pre-transplant assessment and hospital admission, to long-term follow-up after returning home. Before the procedure, the transplant coordinator gives the patient detailed information, answers all their questions about the procedure and arranges an appointment for the initial assessment at the bone marrow transplant clinic. The transplant specialists inform the patient about possible complications, success rates and long-term outcomes. The results of the clinic assessment make the transplant possible. The patient is asked to sign an informed consent form. The procedure begins with the tests related to preparing the graft.
Initial assessment
The assessment begins with a consultation with the transplant physician at the bone marrow transplant clinic. During the consultation:
The physician reviews the patient's general medical history and treatment in detail, discusses the treatment options and presents the recommended treatment plan.
The transplant coordinator nurse shows the patient around the bone marrow transplant unit.
The coordinator nurse refers the patient to the appropriate department to arrange the formalities relating to payment of medical costs or to obtain a second opinion. The patient is asked to sign the form confirming consent to the transplant. Once the form is signed, the following steps begin:
1- Initial planning:
Caregiver (support person): the patient chooses a friend or relative who will accompany them throughout all stages: they monitor the patient's state of health, provide physical support, help them take their medication, handle administrative formalities at the hospital, liaise with the physician and nurse, and offer emotional and psychological support. The transplant coordinator nurse will prepare this person.
Stay in Istanbul or Kocaeli: the patient is told that they will need to live close to the hospital for 1 to 4 months after the transplant. The international services team helps with the necessary arrangements.
Financial support: financial matters are planned for the entire duration of the transplant procedure.
2. Preparing for the transplant
Donor selection
Allogeneic transplant: the first step in an allogeneic transplant is to find a brother, sister or parent with a compatible HLA type.
Autologous transplant: in an autologous transplant, the donor is the patient themselves.
Depending on the patient's condition and diagnosis, the transplant team determines the type of bone marrow mobilisation, its timing and how it is used.
Donor assessment at Anadolu Medical Center: the donor (the patient, siblings, etc.) is first examined at the hospital.
First visit: the physician and nurse assess the patient at the transplant clinic, clarify their history, carry out a clinical examination and blood tests, and introduce them to the transplant unit.
Briefing the donor and the patient's family: the following day, the physician and nurse hold a meeting with the patient and their family/friends, explain the transplant procedure, its benefits and risks, and then take the time needed to answer questions.
Assessment: to determine the patient's general state of health, outpatient tests are carried out over 1 to 2 weeks, along with additional tests such as a bone marrow aspiration, a chest X-ray and an ECG; if the transplant is autologous, the type of bone marrow cell mobilisation is defined. Depending on the method chosen, the mobilisation procedure can last from 7 to 20 days.
3. Conditioning procedure
The patient is admitted to hospital for treatment comprising chemotherapy and/or radiotherapy. This treatment is specially designed by the physician to destroy bone marrow cells completely (myeloablative) or partially (known as reduced-intensity or non-myeloablative). The duration of treatment varies according to the type of disease; on average it is 2 to 8 days. This treatment weakens the immune system and makes the patient susceptible to infection. It causes symptoms such as nausea, difficulty swallowing, stomach discomfort, fatigue and loss of appetite. Preventive measures are taken to keep discomfort to a minimum.
4. Cell transfer
One or two days after the conditioning procedure ends, the cells are infused in the same way as a blood transfusion.
Whether the transplant is autologous or allogeneic, the bone marrow cells or stem cells collected from the donor and then frozen are thawed at the patient's bedside after the necessary preparation. They are then given intravenously through a catheter.
Bone marrow cells or peripheral blood stem cells can be collected directly from the donor and given to the patient without freezing. The donor begins a mobilisation protocol before the transplant. The bone marrow is collected on the day of the transplant and given intravenously without freezing.
The donor's bone marrow is collected in the operating theatre on the day of the transplant and transferred to the patient without delay. This is the best method for patients with aplastic anaemia or chronic myeloid leukaemia.
5. Waiting for engraftment:
Engraftment refers to the transplanted bone marrow successfully establishing itself in the patient's body and, ultimately, beginning to produce blood cells. This process can take from 10 to 35 days. During this period, the most significant complications are infection and bleeding. Neutrophil engraftment is considered successful when more than 500 neutrophils are achieved for two consecutive days. Platelet engraftment is considered successful when more than 20,000 platelets are achieved for two consecutive days. The time needed to reach neutrophil recovery can be shortened by 2 to 3 days through the use of growth factors known as G-CSF. During this period, the patient remains in hospital. After engraftment, the conditions and date of discharge are determined according to factors such as infection, the use of intravenous medication and sufficient oral nutrition.
6. Recovery after the transplant
The first signs of recovery after the transplant appear about three months later. This period takes place close to the hospital, in Istanbul or Kocaeli. During this period, the patient is called to the hospital for regular blood tests (weekly, or even more often). The caregiver must be ready to help the patient during this period. The patient and their caregiver receive instructions on this. During this period, the physician or nurse can be contacted by telephone at any time, both to obtain information and to report a complication. As the patient recovers, check-ups become less frequent.
7. Long-term follow-up after recovery
Once engraftment is complete and the recovery process begins, the patient and their caregiver are informed about long-term follow-up after the transplant. A detailed assessment is carried out for the patient and a report is drawn up for their physician for follow-up. The discharge consultation takes place in the presence of the physician and nurse; they give the patient and their companion detailed information on what to do, which situations to report, which parameters to monitor, lifestyle, diet and physical activity. Long-term follow-up is provided by the treating physician. In general, the patient is called for a first assessment about three months later. The long-term follow-up programme is drawn up individually for each patient, according to the medication they are taking, the speed at which their immune system recovers, complications related to graft-versus-host disease and other possible complications. Patients are also invited to take part in a vaccination programme 12 and 24 months after the transplant.
Zafer Gülbaş
MD, Prof. Dr. of Internal Medicine and Haematology
Oncology – Haematology-Oncology
Zafer Gülbaş
MD, Prof. Dr. of Internal Medicine and Haematology
Oncology – Haematology-Oncology
Education and career
• Hacettepe University, Faculty of Medicine
• Anadolu University, Faculty of Medicine
• Atatürk Chest Diseases and Thoracic Surgery Centre
• Hadassah Medical Center, Israel
• Fred Hutchinson Cancer Research Center, United States
• M.D. Anderson Cancer Research Center, United States
• Princess Margaret Hospital, University of Toronto, Canada
Areas of specialisation and medical interest
• Treatment of haematological tumours
• Stem cell transplantation
• Platelet function
• Flow cytometry
• Blood banks