It is now day 60 following my donor (allogeneic) stem cell transplant, and I wanted to give an update on how it has gone and what is in store.

As with an autologous (self) stem cell transplant, everyone talks about the first 100 days as the critical period. This is true even more so with the donor transplant.

As I mentioned in my last column ^[1] about my transplant, the intensity of the treatment, the need for close monitoring, and the number of things that can go wrong seems much greater with the donor transplant.

After my donor, a 21-year-old female from Germany, was found, I was admitted to the hospital to begin high-dose chemotherapy and immunosuppressive medications.

The chemotherapy was melphalan ^[2] (Alkeran); the same as what is frequently used for autologous transplants. The side effects are the same, regardless of the type of transplant, and included extreme fatigue, diarrhea, nausea, and loss of appetite.

Fortunately, as the nurses advised, sucking on ice during the melphalan infusion was extremely helpful at avoiding mouth sores.

After five days of chemo and a day of rest, I received my “transplant,” an infusion of a bag of donated stem cells.

Then the waiting began for engraftment, the process in which the stem cells take hold and start to build a new immune system. This usually takes about 10 to 14 days, during which you are extremely susceptible to infection.

For me, this period went fairly smoothly, just requiring support with fluid, blood, and platelet transfusions. I started to engraft around day 12, and my white blood cell count started to recover.

That’s when the problems started to hit. It seems everyday brought a new issue to address. The doctor’s common refrain was, “Oh yes, this is common,” or, “We see this sometimes.”

First, as we were starting to talk about discharge, I was delayed by a fever. I then developed shortness of breath and chest tightness, due to fluid around my heart and lungs. It was decided that this was a side effect of the chemo. “We see this,” I was told.

The two immunosuppressive medications I took were Prograf (tacrolimus) and Rapamune (sirolimus or rapamycin).

As a side effect of these medications, I developed something called thrombotic microangiopathy or TMA. This is a build up of strands of fibrin in the blood vessels, forming a net that causes blood cells and platelets to break apart. This can be a very serious problem, causing kidney problems, increased transfusion requirements, and jaundice.

Fortunately again, this was caught early. Changing medications reversed the problem. “This is common,” I was told. “We see this.”

Next came an episode of atrial fibrillation, where my heart went into a rapid abnormal rhythm, causing my blood pressure to drop and sudden dizziness. Again, fortunately this resolved by itself in a couple of hours. “This is common. We see this,” I was told.

After two previous autologous transplants, I knew this donor transplant was a whole different ball game.

The transplant team did a great job of addressing every problem quickly, and things finally seemed to settle down. I was discharged on day 17 after my transplant.

In the period after discharge, there are two main issues to worry about. One is infection; the other is graft-versus-host disease, where the new donor cells identify the body as foreign and attack the body’s healthy cells. Follow-up at the clinic begins on an almost daily basis.

Graft-versus-host disease comes in two types: acute and chronic. Acute graft-versus-host disease usually begins around day 30 and can occur during the first three months. Chronic graft-versus-host disease can show up three to six months down the road. Acute graft-versus-host disease most commonly attacks the skin as skin rash, the gastrointestinal tract (causing diarrhea, nausea, and vomiting), or the liver.

In my case, I was doing great until about day 40, when the skin rash stared to hit. It began with some itching and flushing of my face, and then it attacked me full blown on my abdomen, chest, and arms with a raised, red rash and irritating itching.

I have been told over and over again that some graft-versus-host disease is good. It is thought to be accompanied by the graft-versus-myeloma effect, in which the new immune system fights any remaining myeloma cells.

The treatment was topical steroids and to increase my immunosuppressant medications and oral prednisone ^[3]. The increased immunosuppressant medications and prednisone do, however, increase the risk of a serious infection.

The increased meds seem to be bringing the rash under control. In order to try to get off the steroids, my doctor has proposed a novel next step.

It is known that Velcade ^[4] (bortezomib) has an anti-graft-verus-host effect and has been used for this purpose. Since I have been very refractory (resistant) to Velcade, he has proposed trying Kyprolis ^[5] (carfilzomib), both for the graft-versus-host effect and the anti-myeloma effect. It has not been tried yet in this setting, but everything seems to indicate it should work. I am game.

Even as a physician, I am continually impressed with the complexity of the donor stem cell transplant process and the number of potential complications. Every decision the doctors make is walking a tight rope of competing factors.

In the mean time, I am feeling good and regaining strength and energy. I am trying to get out and about a little bit but am very cautious about exposure to crowds and germs.