Treatment Stages
Duration of stages
- Day 1-3: Examination and Final Decision
- Day 4: Briefing with a Doctor
- Day 5-8: Stem Cell Mobilization
- Day 9-10: Stem Cell Harvesting
- Day 11: Vacation
- Day 12-17: High Dose Immunosuppression
- Day 18: Stem Cell Reinfusion
- Day 19: MoAb-Rituximab Infusion
- Day 20-25: Hematological & Immunological Recovery — Isolation
- Day 26: MoAb-Rituximab Infusion
- Day 27-29: Final Tests And Discharge
- Day 29-365: Rehabilitation and Happy Life
Day 1-3
Examination and Final Decision
Day 4
Briefing with a Doctor
Day 5-8
Stem Cell Mobilization
Day 9-10
Stem Cell Harvesting
Day 11
Vacation
Day 12-17
High Dose Immunosuppression
Day 18
Stem Cell Reinfusion
Day 19
MoAb-Rituximab Infusion
Day 20-25
Hematological & Immunological Recovery - Isolation
Day 26
MoAb-Rituximab Infusion
Day 27-29
Final Tests And Discharge
Day 29-365
Rehabilitation and Happy Life
Stem cells stimulation
Stem cells stimulation - 4 days (sometimes 5-6 days, depending on the results of stem cell collection). Granulocyte-colony stimulating factor (G-CSF) 10 µg/kg.b.w./day (2 subcutaneous injections 11 pm and 3 am) in combination with steroid infusion (Methylprednisolone 500 mg) at 10am-11am (200 ml liquid for 20-40 min intravenous infusion). Also patient takes one antacid pill twice a day 30 mins before food (before breakfast and before dinner).
The most common side effects are:
- Bone pain
- Headache
- Bad sleep
- Fever and other flu-like symptom
Dialysis insertion
Insertion of special central venous catheter in external jugular or subclavian vein under ultrasound control for stem cell collection. Then chest X-ray control of catheter position.
Harvesting of stem cells
Collection of stem cells (1-3 days). To rebuild immune system, we need to collect more than 2 million hematopoietic stem cells per kg of body weight (>2 x 106/kg/b.w. CD34+ HSC). Stem cells collection (harvesting) takes 5-6 hours (7-8 am – 1-2 pm). Autologous stem cell harvesting is performed by Haemonetics MCS+ multicomponent collections system or Spectra Optia Apheresis System.
Removing dialysis
Removing of dialysis catheter and insertion of new ordinary triple-lumen catheter in external jugular or subclavian vein under ultrasound control for chemotherapy and further treatment
CHEMOTHERAPY
PROTOCOL 1
The most advanced and the most effective protocol nowadays
Chemotherapy (conditioning) takes 6 days
IN CASE OF 6-DAYS PROTOCOL
Cyclophosphamide with supportive medicine and Fludarabine for first two days,
and only Fludarabine for the last 3-6 days.
From the first day of chemotherapy we start antiviral, antibacterial and antifungal prophylaxis:
— Levofloxacin 500 mg/d,
— Fluconazole 200 mg/d,
— Acyclovire 1200 mg/d,
— Co-trimoxazole (Bactrim) 960 mg/d on Mon, Wen, Fri
Patient should take all tablets:
Pills for breakfast – patient takes one antacid pill before meals, other pills – after meals.
Pills for lunch – patient takes one pill after meals.
Pills for dinner – patient takes one antacid pill before meals, other pills – after meals.
Patient has additional oral medications on Mon, Wen, Fri:
Co-trimoxasole (2 white big pills –morning, evening).
We give Rituximab 500 mg/m² (1 infusion) after immune system recovery (from D+9 to D+12)
CHEMOTHERAPY
PROTOCOL 2
It is used in certain clinical situations when there are contraindications to the use of Fludarabine
Chemotherapy (conditioning) takes 4 days.
The main morning infusion of Cyclophosphamide with supportive medicine and hydration
(3 L of normal saline) and takes 3 hours (usually 10 am – 1 pm).
Second and third infusions (mesna uroprotection, nausea prophylaxis)
– in 4 and 8 hours after the first one
The most common side effects are:
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Oropharyngeal mucositis
- Alopecia
- Pancytopenia (low leucocytes, hemoglobin)
- Hemorrhagic cystitis
- Fever
TRANSPLANTATION DAY
- After finishing chemotherapy, we start stem cell infusion at 1pm and finish at 3 pm.
- We recommend not to have meals after midday (12 pm), you can drink as much as you want.
- We remove the cryopreservation bags individually from liquid nitrogen and place them immediately in the water bath and thaw it.
- When thawed (-2-3 minutes), we infuse it as quickly as possible
- Together with stem cells, we give fluids (3-4 L of saline), antihistamine, steroids and other symptomatic medications as needed.
- Also, we monitor heart rate (ECG), blood pressure, respirations, body temperature.
- Another side effects are pungent/tomato taste and smell, red-stained urine.
- We ask to urinate in special bag to assess a color of urine after stem cell reinfusion.
Possible adverse reactions:
- Nausea
- Coughing
- Vomiting
- Flushing
- Fever
- Dyspnea
- Chills
- High or low blood pressure
- Allergy
- Low or rapid ventricular rate
Isolation period
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Oropharyngeal mucositis
- Alopecia
- Pancytopenia (low leucocytes, hemoglobin)
- Hemorrhagic cystitis
- Fever
Rehabilitation of immunne system
A patient must inform medical staff immediately of any problems or changes in condition.
We monitor blood pressure, heart rate, body temperature 3 times a day.
Patient usually has supportive infusions – natrium saline, electrolytes, low-dose dexamethasone twice a day, G CSF (subcutaneous shot, once a day at 3 pm) to decrease length of neutropenic phase.
Additionally, we can use intravenous antibacterial, antivirus, antifungal medications when needed.
We provide blood component transfusion when hemoglobin or platelet level is too low (Hb<80 g/L, Plt< 20 x 109/L).
Patient has 5h Rituximab infusion on D+1 and D+8
AFTER HSCT TREATMENT
WE RECOMMEND
To avoid contacts with sick people
- Like flu or chicken pox.
- There are no special restrictions for sexual life if partner is healthy.
- We recommend to use contraception during year after AHSCT
To wear mask in public places
- To wear mask during first 3 months in public or crowded places (arriving/departure areas, supermarkets, metro etc.)
- There is no risk to be in contact with pets if they are healthy
- There is no risk to be in contact with family members if they are health
Avoid vaccinations
In vast majority of cases we don’t recommend vaccinations
- Antiviral
- Antibacterial
- Antifungal prophylaxis after lymphoablative protoco.
Patient immune system has memory, additional vaccination can cause relapse of autoimmune process.
Health monitoring
Monitoring of blood tests:
- total blood count
- biochemistry screening — serum urea
- electrolytes
- creatinine
- calcium
- uric acid
- blood sugar
- Liver function tests
- C reactive protein
Monitoring temperature of body
- To monitor body temperature every evening during 1 month.
- In case of any signs of infection patient must go to hospital.
- No matter with or without high temperature (>37.5C)
- Fever without signs of infection — patient must go to hospital
Posttransplant rehabilitation
- GP (or hematologist) examination in 2 and 4 weeks after the disсharge.
- Observation of neurologist or rehabilitation doctor physiotherapist.
- Public places like public swimming pools, gyms, health centers
Food restrictions
We recommend to be careful with fast food, to avoid raw fish, meat (sushi, carpaccio etc) within the next 3 months after discharge.
- Fresh fruit and vegetables, milk products are available.
- All food supplements, vitamins which patient used before are available
