Risks & Complications

Graft-versus-host disease (GVHD) is one of the most critical complications following an allogeneic bone marrow transplant. It occurs when the donated immune cells recognize the recipient’s body as foreign and begin attacking healthy tissues and organs. GVHD can be acute or chronic, with symptoms appearing either within the first 100 days or much later after the transplant.

Common symptoms of GVHD include:

• Skin rashes, dryness, or discoloration
• Jaundice, liver inflammation
• Diarrhea, nausea, and abdominal pain
• Dry eyes or mouth, vision problems
• Joint stiffness and fatigue

Risk factors:

• Mismatch in human leukocyte antigen (HLA)
• Older donor or recipient age
• Female donor to male recipient transplants

GVHD can range from mild to life-threatening. Management typically involves immunosuppressive medications like corticosteroids, tacrolimus, or cyclosporine. In cases of steroid-refractory GVHD, biologic therapies such as ruxolitinib or extracorporeal photopheresis may be required. Preventive strategies include close donor-recipient matching and prophylactic immunosuppressants initiated post-transplant.

While GVHD can be severe, it also has a dual role in some cases by helping to fight residual cancer cells—a phenomenon called the graft-versus-leukemia (GVL) effect. Nonetheless, it requires careful clinical balance to harness benefits while minimizing harm. Long-term follow-up is essential to detect and manage chronic manifestations of GVHD.

Infection is one of the most frequent and potentially dangerous complications after a bone marrow transplant. Due to the use of high-dose chemotherapy and immunosuppressive therapy, the patient’s immune defenses are significantly reduced, particularly during the engraftment phase. This immunocompromised state makes them highly vulnerable to bacterial, viral, and fungal infections.

Types of infections commonly seen:

• Bacterial: Pneumonia, bloodstream infections, urinary tract infections
• Viral: CMV reactivation, herpes simplex, Epstein-Barr virus
• Fungal: Aspergillosis, candidiasis

High-risk periods:

• First 30 days post-transplant: Neutropenic phase
• 30–100 days: Intermediate immune recovery
• After 100 days: Risk decreases but persists for months

Preventive and supportive strategies:

• Broad-spectrum antibiotics during neutropenia
• Antiviral prophylaxis and periodic viral load monitoring
• Antifungal agents for high-risk patients
• HEPA-filtered hospital rooms to reduce airborne pathogens
• Routine vaccinations starting 6–12 months post-transplant

Persistent fever, chills, cough, or gastrointestinal symptoms warrant immediate medical attention. Early identification and aggressive treatment are crucial in preventing sepsis and organ failure. Patients are also educated on hygiene practices and dietary precautions. Despite the risks, advances in antimicrobial therapies and infection surveillance have significantly improved post-transplant infection management.

Organ toxicity or damage is a significant concern during and after a bone marrow transplant. High-dose chemotherapy, radiation, and immune reactions can affect multiple organ systems. These complications may be temporary or evolve into chronic conditions, depending on the severity and early intervention.

Organs commonly affected:

• Liver: Sinusoidal Obstruction Syndrome (SOS), elevated liver enzymes
• Lungs: Interstitial pneumonitis, pulmonary fibrosis
• Kidneys: Acute kidney injury, nephrotoxicity from drugs
• Heart: Arrhythmias, myocarditis, cardiomyopathy

Key contributing factors:

• High-intensity conditioning regimens
• Previous chemotherapy or radiation exposure
• Drug toxicity from medications like amphotericin B or calcineurin inhibitors
• Graft-versus-host disease involving specific organs

Preventive and monitoring approaches:

• Pre-transplant cardiac and pulmonary evaluations
• Adjusting chemotherapy doses based on organ function
• Using less toxic agents where possible
• Regular imaging and blood tests during follow-up
• Prompt response to any symptoms of organ distress

Symptoms such as shortness of breath, jaundice, swelling, or changes in urine output require immediate evaluation. With vigilant monitoring and supportive care, many of these complications can be reversed or managed effectively. Personalized transplant planning helps reduce the likelihood of severe organ toxicity in high-risk patients.

Graft rejection is a serious complication in which the transplanted stem cells fail to engraft or are destroyed by the recipient’s immune system. This results in the inability to produce sufficient blood cells, leading to prolonged pancytopenia, increased infection risk, and, in severe cases, death.

Types of rejection:

• Primary graft failure: No engraftment occurs after transplant
• Secondary graft failure: Initial engraftment happens, but the graft is later lost

Causes and risk factors:

• Inadequate stem cell dose
• HLA mismatch or partial compatibility
• Immune-mediated rejection due to residual host T-cells
• Prior sensitization from transfusions or transplants

Signs of rejection:

• Persistently low white blood cell, red cell, or platelet counts
• Infections that do not respond to standard treatment
• Bleeding tendencies due to thrombocytopenia

Management and preventive strategies:

• Use of high-resolution HLA typing for donor selection
• Immunosuppressive therapy to reduce host immune response
• Second transplant in cases of irreversible rejection
• G-CSF administration to stimulate marrow activity

While rejection is less common due to better donor matching and supportive protocols, it remains a clinical emergency requiring swift intervention. Regular blood count monitoring during the early weeks post-transplant helps detect early signs of graft failure, increasing the chance of timely rescue therapy.

Bone marrow transplant survivors often face a range of long-term side effects, some of which can persist for years after the initial treatment. These chronic complications can impact physical, psychological, and social well-being, necessitating continued medical follow-up and rehabilitation.

Common long-term effects:

• Chronic GVHD: Affecting skin, eyes, mouth, and internal organs
• Endocrine issues: Thyroid dysfunction, infertility, growth delays in children
• Secondary cancers: Higher risk of leukemia, skin cancer, and solid tumors
• Cognitive changes: Memory problems, attention deficits
• Fatigue and muscle weakness: Due to prolonged inactivity or treatment side effects

Contributing factors:

• Intensity and duration of conditioning therapy
• Chronic immunosuppressive medication use
• Age and underlying health conditions

Long-term care strategies:

• Routine endocrinological and gynecological assessments
• Psychological counseling for mood disorders or cognitive challenges
• Physical therapy and exercise programs for strength recovery
• Cancer surveillance including skin exams and mammograms
• Re-vaccination for childhood diseases after immune recovery

Survivorship care plans tailored to the patient’s history and risk profile are vital. Despite the challenges, many patients return to fulfilling lives, careers, and family roles. Awareness and early detection of long-term effects significantly improve the post-transplant quality of life.

Undergoing a bone marrow transplant is a complex medical journey marked by both hope and risk. While the procedure holds the potential for cure or long-term remission in life-threatening diseases, it is not without its challenges. Risks such as GVHD, infections, organ toxicity, and graft rejection demand vigilant care, multidisciplinary expertise, and patient commitment throughout the recovery phase.

At Kannappa Memorial Hospital, we are committed to delivering comprehensive bone marrow transplant care backed by cutting-edge medical infrastructure, experienced specialists, and an unwavering focus on patient safety. Our approach combines scientific precision with personalized attention, helping patients navigate each stage—from transplant preparation to long-term survivorship. With continuous monitoring, prompt intervention, and tailored follow-up programs, we ensure that complications are managed efficiently and recovery remains on track. Choosing an experienced and well-equipped facility significantly increases the chances of a successful outcome and a return to a meaningful, healthy life.