MS Stem Cell Transplant

You will need a wide range of tests to ensure it is clinically appropriate for you to undergo a stem cell transplant for Multiple Sclerosis.

These may include:

• Routine blood tests
• MUGA (multiple gated acquisition)
• ECG (electrocardiogram)
• GFR (glomerular filtration rate)
• Lung function test (known as a pulmonary function test)
• A bone marrow test or biopsy
• CT scan (computerised tomography)
• PET scan (positron emission tomography)
• MRI scan (magnetic resonance imaging)

Stem cells usually reside in low numbers in the bone marrow. We can increase the numbers of stem cells and encourage them to come out into the blood through a process called mobilisation. This involves chemotherapy, followed by injections of growth factor (G-CSF) under the skin. For MS patients, this requires an initial two-night stay for the cyclophosphamide infusion.

The next step is to harvest your stem cells. You will be given the growth factor drug injection (G-CSF) under the skin for about ten days to stimulate your body to produce more stem cells and release them from the bone marrow into the peripheral blood.

They will be collected using a process called Peripheral Blood Stem Cell Harvesting (PBSCH) or apheresis. For the PBSCH, a cannula is inserted into each arm. Blood is removed from you, circulated in an apheresis machine, the stem cells are extracted and your blood is then returned to you via the other arm. This usually takes place as a single day case procedure, although some patients may require additional days to enable enough stem cells to be collected for transplant.

Your stem cells will be processed at a specialist laboratory, frozen and then stored in liquid nitrogen. These cells can be kept for up to five years. After harvesting, you will be given at least a 3-4 week period for your body to recover before being admitted for your transplant.

For the transplant itself, you will be admitted to a private, en-suite room which has been specially designed to protect patients from infection. This stage of treatment lasts typically four weeks, depending on your diagnosis and clinical needs.

For the procedure, you will have a central venous catheter inserted, which is used to reinfuse your cells. You will then receive a high dose of chemotherapy and immunotherapy, which is known as the preparative or conditioning regime, and takes six days to complete.

Your haematology Clinical Nurse Specialist and attending consultant will visit you daily throughout your treatment. Our nursing teams have been specifically trained to care for stem cell transplant patients. You will also be seen by our specialist dietitians, who will oversee your overall diet and nutrition, and our physiotherapists will assist in keeping you active.

Your stem cells will then be thawed and reinfused. The day you receive your stem cells back is known as ‘Day Zero’. This process will take place in your private room. Generally, this takes an afternoon. The stem cells are reinfused similarly to a blood transfusion.

After reinfusion, the stem cells will find their way back to the bone marrow and will start to divide and repopulate the bone marrow and the immune system. This is called the aplastic phase, where it’s likely you will be placed in isolation as you are most at risk from infection.

The engraftment period occurs when the blood cells start to recover to a safe level. This occurs over a few days and it is usually the white blood cells (neutrophils) which will recover first.

Most patients will stay in hospital for around three weeks from ‘Day Zero’, however this can vary depending on recovery rates. You will be discharged when it is medically safe for you to be at home, although full recovery post-AHSCT will take many weeks.

Once you have been discharged from hospital, you will continue to be closely monitored through regular blood tests and scans, initially at least weekly for the first month, then fortnightly for an additional month, then at increasing intervals as dictated by your clinical condition.

Clinical Nurse Specialists and others in the team are on hand to provide any support should you require it. You will also be given detailed information on post-transplant care, including any signs and symptoms to look out for and general rehabilitation advice during the early months.

Your consultant neurologist or GP should provide the following information:

• Documented diagnosis of Multiple Sclerosis by a neurologist with the date of the diagnosis.
• A record of the ability to walk 20 metres without resting or needing, at most, bilateral assistance with two sticks or a rollator frame.
• If you have relapsing MS, documentation to show that treatment with one of the high-efficacy disease modifying drugs has been unsuccessful.
• If no high-efficacy DMT has been tried, the reason for moving directly to HSCT needs to be recorded.
• MRI scans showing activity within the last 12 months compared to a comparative scan that was done in the previous two to three years. The radiology reports from both time frames should be included with the written referral.

This information will form the basis for an initial consultation with your assigned neurologist, Dr Ben Turner or Dr Eli Silber.