Recovery after a bone marrow transplant

Transplant day is often called day zero. NMDP, the US donor registry, says days 0 to 30 are when the new cells start to grow and make new blood cells. This is called engraftment, and it is an important milestone.

Until then, blood counts are very low. Conditioning destroys the body’s ability to make platelets for a while, so there is a risk of bleeding. The American Cancer Society says a platelet transfusion may be needed. Infections are also a danger, and conditioning can cause painful mouth sores and severe nausea.

People stay in the hospital, or are watched closely as outpatients, until their blood counts start to return to normal. The American Cancer Society says this usually takes about 2 to 6 weeks. One sign teams look for is a steady rise in neutrophils, the white blood cells that fight bacteria.

Graft failure means the new cells do not settle in and grow as they should. The American Cancer Society says it is suspected when counts do not rise within 3 to 4 weeks of the transplant.

NMDP says that during days 30 to 100, doctors watch carefully for infection and complications such as graft-versus-host disease (GVHD). Sometime in the first 100 days, people may be able to leave the hospital and continue as outpatients.

In the first weeks or months after leaving the hospital, visits to the outpatient clinic are frequent, sometimes daily, NMDP says. The American Cancer Society notes that some centers set how many minutes away a patient must live. That way a caregiver can get them there quickly if a problem comes up.

People who live far from the transplant center often stay in a hotel or apartment nearby. NCI says that after a donor transplant, a person with no problems can go home 100 days after receiving the cells. Many medicines are part of daily life in this period, and NMDP stresses food safety while the immune system is weak.

NMDP calls complications that start 100 days or more after transplant late complications. It says checkups still matter when a person feels well, because problems can start months after the transplant.

Bacterial infections are most common early, when white blood cell counts are low. Viruses the body once kept under control, such as cytomegalovirus (CMV), can become active again, and fungal infections can appear. The American Cancer Society says medicines to prevent or control infections are usually taken for about 6 months or longer.

The immune system takes much longer to recover than blood counts. NCI says full immune recovery takes several months after a transplant using a person’s own cells and 1 to 2 years after a donor transplant. The American Cancer Society says medicines for chronic GVHD can raise the risk of infection for as long as they are taken.

A transplant can wipe out the protection from childhood vaccines. Children’s Hospital of Philadelphia explains that this happens because of the illness, conditioning, the transplant itself and immune-suppressing medicines. Vaccines against diseases such as polio, measles, mumps, rubella and hepatitis B are given again, in a set order. NMDP’s guidance for doctors suggests considering inactivated vaccines from 3 to 6 months after transplant.

GVHD happens when the donor’s cells see the patient’s body as different and attack it. NMDP calls it a common, and sometimes serious, side effect of a donor transplant. It does not happen after a transplant using a person’s own cells.

Acute GVHD usually starts in the first weeks and months. Chronic GVHD usually develops within a year, NMDP says, but it can appear years later. It ranges from mild to severe and from short-lived to long-term.

NMDP’s survivorship guide lists signs of chronic GVHD to report right away. They include a rash, dry or tight skin, and dry or gritty eyes. Others are a dry or painful mouth, diarrhea or weight loss, shortness of breath or a dry cough, yellowing of the skin or eyes, and stiff joints.

Steroids are the main treatment, NMDP says. If steroids do not help enough, one option is extracorporeal photopheresis. It takes some blood out, treats the white blood cells with a medicine and light, and returns them.

NMDP says most transplant centers require patients to have a caregiver. A caregiver helps gather information, talks with doctors, helps with care and watches for new problems. The American Cancer Society says that when a transplant is done as an outpatient, the caregiver needs to be there all day, every day.

Caregiving is demanding. NMDP notes that caregivers need time to look after themselves too. It offers free programs for caregivers, including one-on-one support and a peer program that connects them with trained volunteers.

Emotional highs and lows after a transplant are normal, NMDP says. Anxiety and depression can follow, and NMDP stresses that both are very treatable. In the US, NMDP points people to 988, the national suicide and crisis lifeline, which answers calls 24 hours a day, 7 days a week.

NMDP says doctors usually suggest that people who had a donor transplant wait at least a year before going back to work. That is because the immune system takes 9 to 12 months to recover. When, or whether, to go back is up to the person and their doctor.

Tiredness can last, and NCI notes that concentration at work may be affected. Many people describe “chemo brain,” trouble with short-term memory or organizing thoughts, NMDP says. In the US, NCI notes that many employers are required by law to adjust work schedules during cancer treatment.

Children may go back to school within several months, NMDP says, or it may take a year or more. A letter from the transplant doctor, psychologist or social worker can explain the child’s needs. Support can include extra time for tests, more bathroom breaks, shorter days or home tutoring, and a formal school plan such as a 504 Plan or an IEP.

Checkups go on long after the transplant, even when a person feels well. NMDP’s survivorship guide says they help find the disease coming back (relapse) and problems caused by treatment. It recommends checkups for life, because some changes can appear many years later.

NMDP’s guidance for doctors is based on a 2023 update of international recommendations, written by experts from 29 transplant institutions. It covers 16 areas, including the heart, lungs, eyes, mouth and teeth, hormones, bones, kidneys, skin, fertility, emotional health and new cancers. Examples include a blood count at each visit for at least 10 years and thyroid tests at one year, then yearly. Dental checkups come at 6 and 12 months, then at least once a year.

Children are also checked for growth and puberty. Possible late effects include cataracts, thyroid changes, damage to organs such as the heart, lungs or kidneys, and a second cancer. The American Cancer Society says most people who have a stem cell transplant become unable to have children. It adds that the care team may be able to say beforehand whether this is likely.

The original illness can come back months or years later. A 2025 report on US transplants from CIBMTR found that it remained the most common cause of death after the first 100 days.