Stem cell transplant program

Journey to "Day 0" and beyond

Day Zero

The day that a stem cell transplant is performed is known as “Day Zero.” Negative (or minus) numbers are assigned to the days leading up to and preparing for the procedure. After a transplant is performed, the count forward begins with many milestones of recovery occurring within the first 100 days. While the stem cell transplant team tries to standardize guidelines and recommendations for patients, each family's journey through transplant is unique. The timeline is intended to serve as a framework for understanding the transplant process, while realizing that each patient's progress is individualized and may vary depending upon the original diagnosis, the child's response to chemotherapy and various medications, and complications that may occur throughout the transplant period.

Transplant timeline of steps leading to "Day 0"

	Day -180 to -30	Day -100 to -20	Day -30 to -1	Day 0
→	→	→	→	→
Diagnosis of malignant cancer, immunodeficiency disease or blood disease	Transplant conference/Donor selection	Pre-evaluation testing/Peripheral blood harvest of autologous hematopoietic progenitor cells	Chemotherapy and/or radiation, if required/Admission to the hospital, if required	Day of Transplant/Giving the stem cells to the child
Physicians consider the type of disease, its stage of progression, and the age and general health of the child prior to recommending a hematopoietic progenitor cell transplant *Progenitor stem cells* may also be called: Cord blood Bone marrow Peripheral blood	The patient and family come for their pre-transplant conference to discuss whether an HPC transplant would benefit them, and which type would be most beneficial. A child who requires an allogeneic donor source must have his/her tissue type identified and matched with a suitable donor. Siblings are the most likely related donors. If no donor source is found in the immediate family, a search is conducted with a national registry. This can take up to several months.	Progenitor cells are gathered from the blood stream through an intravenous or dialysis catheter. The apheresis machine separates the progenitor cells from the rest of the blood. The progenitor cells are preserved for infusion later, and the remaining blood is re-infused to the donor. Two to four weeks before transplant, the patient goes through his/her “pre-evaluation." This involves thorough testing to assess the health and ensure ‘fitness' for transplant.	Chemotherapy and / or radiation are given to eradicate the disease and to eliminate the patient's own immune system so it won't fight the new cells when they are introduced. When patients receives the cells, their immune systems are 'blank slates." If a child needs to be admitted to the hospital for the transplant, it occurs during this time frame. He would then be placed in a “transplant room” for isolation at Day -1.	The child receives the new stem cells as an infusion through the central venous access catheter. He is pre-medicated with specific medications to help his body accept the cells.

Transplant timeline of steps after “Day 0”

Day + 1 to +30	Day +10 to +32	Day +15 to +30	Day +30 TO +100	Day +100 and On
→	→	→	→	→
Protective isolation	Engraftment	Discharge from hospital	Home care and outpatient management	Graduation
Since the child's immune system has been depleted by chemotherapy, he is extremely vulnerable to infection. To avoid potentially deadly infections, strict protective isolations must be observed. Depending upon the preparative chemotherapy and/or radiation used, this may include being confined as an inpatient to a "transplant room" and having limited contact with visitors and items brought from outside. Good hand washing is very important.	Caregivers and the stem cell transplant team watch for signs that the new cells have found their way into their new "home" (the patient's bone marrow), and are starting to produce new blood cells. They also watch for complications associated with engraftment.	If a patient has been hospitalized for his transplant, discharge often occurs during this time frame. He is a candidate for discharge once the white blood cell count shows that they are beginning to regain the ability to fight infection. Normally a patient would transition to Kohl's House for several weeks before going home.	Still vulnerable to infection, isolation precautions must continue to be observed, whether the patient is at Kohl' House or their own home. The child returns to the ASCU once to several times a week, so the doctors and nurses can monitor his progress, blood counts, engraftment status, vital signs, and any complications.	For most patients, the 100-day mark is a sign that their immune system has “reconstituted,” or is able to more normally and effectively coordinate a response to an infection. However, some patients who are experiencing problems with chronic graft versus host disease (GVHD) remain on significant immune suppressants and are still vulnerable to infection. These patients must continue to take protective measures and be monitored more frequently. This may mean continued weekly ASCU visits.