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Bone Marrow Transplant

The soft, gelatinous tissue filling the medullary cavities at the centers of bones containing immature cells called the stem cells is known as the Bone Marrow.
There are two types of bone marrow, Yellow Bone Marrow also known as Fatty Tissue and Red Bone Marrow also known as Myeloid Tissue.
The majority of red blood cells, platelets, and most of the white blood cells are formed in the red marrow while only a few of them are formed in the yellow marrow. Bone Marrow is important for:

1) Circulatory System
2) Hemoglobin
3) Iron
4) Red Blood Cells
5) White Blood Cells
6) Lymphatic System
7) Immune System

Why is Bone Marrow Transplant Needed?

The goal of a bone marrow transplant is to cure many diseases and types of cancer. When the doses of chemotherapy or radiation needed to cure a cancer are so high that a person’s bone marrow stem cells will be permanently damaged or destroyed by the treatment, a bone marrow transplant may be needed. Bone marrow transplants may also be needed if the bone marrow has been destroyed by a disease.
What are some diseases that may benefit from bone marrow transplant? The following diseases are the ones that most commonly benefit from bone marrow transplant:

1) Leukemias
2) Severe aplastic anemia
3) Lymphomas
4) Multiple myeloma
5) Immune deficiency disorders
6) Some solid-tumor cancers

However, patients experience diseases differently, and bone marrow transplant may not be appropriate for everyone who suffers from these diseases.

What are the different procedures for Bone Marrow Transplant?

1) Autologous transplantation – This procedure involves using the patient’s own blood cells provided they are suitable. Stem cells are collected directly from the bloodstream. While stem cells normally live in our marrow, a combination of chemotherapy and a growth factor (a drug that stimulates stem cells) called Granulocyte Colony Stimulating Factor (G-CSF) is used to expand the number of stem cells in the marrow and cause them to spill out into the circulating blood. From herethrough a special machine called a cell separator, they can be collected from a vein by passing the blood, similar to dialysis. This machine separates and collects the stem cells and returns the rest of the blood to the patient. The stem cells are then processed, frozen and stored until the scheduled transplant.
autologous-haematopoietic-stem-cell

Before the transplant, the patient will be be given very high dose chemotherapy for and sometimes radiotherapy if needed, to destroy the underlying disease. This is called conditioning therapy. After this, the stem cells are thawed and reinfused through a vein into the patient’s blood stream, similar to a blood transfusion. After that, the stem cells make their way to the bone marrow where they become re-established and start making new blood cells.

autologous-transplantation

2) Allogeneic transplantation – This procedurere places damaged or destroyed bone marrow stem cells with healthy ones from a donor. The “allo” prefix means “other”, meaning that healthy cells are taken from someone.A related donor is often a brother or sister with the same tissue type as the patient. A parent’s cells may be used if there is a close match. When no relatives are available, the cells may come from a volunteer donor. Once identified, the donor will undergo tissue typing, also called human leukocyte antigen (HLA) matching. HLAs are markers the body uses to decide if a “foreign” substance belongs in the body or should be destroyed. When marrow or stem cells are rejected, the body attacks its own tissues in a process known as graft-versus-host disease (GVHD).

allogeneic-stem-cell-transplantation

Also, before stem cells are collected from blood or bone marrow, the donor must undergo a thorough physical exam and blood testing for hepatitis viruses, human immunodeficiency disease (HIV) and other infectious agents or viruses.

The most common source of stem cells for transplant is peripheral blood that flows throughout our veins and arteries.

The blood is removed from the donor and the cells collected using a process called apheresis, which involves placing a needle in the donor’s vein, usually in the arm, similar to administering a blood test. The donor’s blood is pumped through an apheresis machine, which separates the blood into four components: red cells, plasma, white cells and platelets. The white cells and platelets, which contain the stem cells, are collected, while the red cells and plasma are returned to the donor. It can take one to two sessions of apheresis to collect enough blood from a MUD.

If enough stem cells can’t be retrieved from apheresis, they can be removed directly from the bone marrow. This requires the donor to undergo a minor outpatient surgical procedure. While the donor is under anesthesia, the surgeon inserts a hollow needle into the donor’s pelvic bones just below the waist and removes liquid marrow. This is done a number of times until several pints of marrow are collected. The donor’s body naturally replaces the marrow soon after the procedure. The marrow that’s removed (harvested) passes through a series of filters to remove bone or tissue fragments and is then placed in a plastic bag from which it can be infused into the recipient’s vein. The marrow is usually given to the patient within a few hours and almost always within 24 hours. If necessary, however, marrow can be frozen and stored and will remain suitable for use for years.

A rich source of stem cells for blood cancer patients are the stored stem cells collected from the umbilical cord and placenta after a baby is born, called the cord blood unit. Parents may choose to have the cord blood unit collected after delivery. Healthy parents with healthy children and no transplant candidate in the family can choose to donate their newborn’s cord blood to cord blood banks or research programs at participating hospitals. Parents with a child or a family member who could be a candidate for transplantation should discuss with their doctor the potential benefits of saving their newborn’s cord blood for possible family use.

Conditioning

As part of conditioning, the patient will be given a range of medicines which involves a tube to be inserted into a large vein near the heart of the patient. This is known as a central line and is used instead of many (often painful) injections.The conditioning process involves using high doses of chemotherapy and sometimes radiation. It’s carried out for three reasons:

a) to destroy the existing bone marrow cells to make room for the transplanted tissue
b) to destroy any existing cancer cells
c) to stop your immune system working, which reduces the risk of the transplant being rejected
The conditioning process usually takes between four and seven days.

Recovery

The first stage of the recovery process involves waiting for the stem cells to reach the bone marrow and start producing new blood cells. This is known as engraftment and usually occurs 15-30 days after the transplant takes place. During this period, the patient will need to have regular blood transfusions, as he’ll have a low number of red blood cells.

Bone Marrow Transplant

Bone marrow Transplantation is a medical procedure done to replace damaged bone marrow with healthy bone marrow cells. Mostly, the stem cells are collected via peripheral vein. The whole procedure is like donating blood or platelet. The stem cells from the bone marrow are responsible for producing blood cells like white blood cells, red blood cells and platelets, which later are injected in a recipient after a short course of chemotherapy called as Conditioning.

The procedure is required for treating several cancerous and non-cancerous conditions like leukemia, multiple myeloma, thalassemia and several others. The procedure is extremely safe for the donor and the patient can return to normalcy within 6 months-1 year post successful transplant. Max Hospitals are designed with High-Efficiency Particulate Air filter (HEPA filter) for protective isolation so that risk of infections is minimized. We utilize Brachytherapy system for treating cancers and Flow Cytometry for cell counting and cell sorting.

The success of bone marrow transplant usually depends on a stage of disease, duration of disease and patient’s condition at the time of transplantation. With modern day medicines and technological advancements, one can expect a cure rate of 90% if BMT is performed at age of 3 years for thalassemia while it drops to 80% if done at the age of 7 years.

Procedures & Surgeries

An interesting observation here is that the type of bone marrow used for transplant is different from the different types of BMT. There are two types of BMT:

Allogenic BMT: Donor and Recipient are two separate individuals and BMT is done using the stem cells of donor. It may be:

1. Matched Related, where donor is HLA matched relative usually a sibling.
2. Matched Unrelated, where donor is not a relative of patient and usually found from one of the various national or international registries.
3. Partially Matched Related, where donor is from a patient’s family but partially matched (haploidentocal).

Autologous BMT:  Donor and Recipient are same individuals. BMT is done using the patient’s own stem cells. The procedure involves giving high dose chemotherapy to patient in order to remove primary disease. Thereafter, an autologous transplant is conducted to rescue damaged bone marrow. This type of transplant has minimal complication and is preferred for diseases like multiple myeloma.

Although the experience during these phases may be quite different for each patient, a general overview is provided. There are three main phases to the BMT process, which will be reviewed here:

Transplant Treatment Process

For your transplant journey, the transplant process is divided into five steps to guide a patient. The steps begin with how to prepare for the journey and include what to expect along the way.

1. Preparation – The preparation phase begins when the patient arrives at the treatment centre and begins the process of medical evaluation, orientation, informed consent, and other preliminary activities like

a. Complete discussion regarding the procedure and its complications

b. Central Venous Catheter Evaluation and insertion

c. Bone Marrow/Stem Cells Harvest

2. Conditioning – The conditioning phase begins the actual transplant process. Patient is admitted and during this phase, high-dose chemotherapy, radiation therapy, or both are initiated. Chemotherapy and radiation therapy are given in doses that obliterate the marrow function and result in the greatest possibility of destroying the disease.

3. Transplant – The transplant phase is actually short and involves the infusion of donor bone marrow or stem cells. After the conditioning regimen is completed, the patient receives the infusion of bone marrow or stem cells over half to one hour like blood transfusion.

4. Engraftment and Early Recovery – Approximately 10 to 28 days after transplant, signs that the new bone marrow or stem cells are engrafting (growing and developing) can be expected. Close monitoring will continue along with supportive care. Preparation for the return of the patient to the referring physician or centre will begin.

5. Long Term Recovery-The long term recovery phase involves leaving the treatment center,dealing with any ongoing clinical issues, and re-establishing life patterns. Patients need to follow up for long term complications of BMT.

BMT is required for conditions mentioned below:

Blood cancers

  • Multiple Myeloma
  • Hodgkin Lymphoma
  • Non-Hodgkin Lymphoma
  • Acute Lymphoblastic leukemia (ALL)
  • Acute Myeloid Leukemia (AML)
  • Chronic Myeloid Leukemia (CML)
  • Myelodysplastic syndrome

Non Cancerous Conditions

  • Thalassemia, sickle cell anemia, transfusion dependent anemia
  • Aplastic anemia
  • Fanconi anemia, pure red cell aplasia
  • Metabolic disorders
  • Immunodeficiency states

No, Bone Marrow Transplant is a medical procedure. Mostly, stem cells are collected via peripheral vein and the whole procedure is like donating blood or platelet. In some patients Bone marrow harvest is done which involves general anaesthesia to the donor.

Yes, Bone marrow transplant is a complex procedure that carries significant risks of serious complications.

Generally, the risks are reduced if:

  • you are young – studies have shown the younger you are, the more likely the treatment is to succeed
  • you receive stem cell donation from a sibling (brother or sister)
  • you have no serious health conditions (apart from the condition you’re being treated for)

The major problem with stem cell transplants is the recipient’s ability to withstand high doses of chemotherapy (and sometimes radiotherapy), which are often needed before the transplant.

No, there are risks to donor. BMT is an extremely safe procedure for the donor; risk of complications being very small. Most of the times donor may have some bodyache which can be managed by paracetamol tablet alone. The main risks associated with a bone marrow transplant are discussed below:

1.Graft versus host disease

In some cases, the transplanted cells (graft cells) recognise the recipient’s cells as “foreign” and try to attack them. This is known as graft versus host disease (GvHD) and often occurs after stem cell transplantation. GvHD is the most common complication seen in Allogenic BMT. About 40% of the patients develop GvHD.

There are two types of GvHD:

a.Acute GvHD usually occurs during the first three months following the transplant. It may involve skin (generalized rash or itching), Gut (diarrhoea or abdominal pain), liver (jaundice).

b.Chronic GvHD can develop at any time between three months and two years after the transplant. The symptoms can persist or may come and go for many years. They can range in severity from mild to life-threatening. Patient can have dry eyes, joint pain, skin changes, breathing difficulty, difficulty in swallowing. It develops from acute GvHD and can cause symptoms for many years.

2. Infection

After having a bone marrow transplant, your risk of developing an infection will increase. This is because the conditioning you receive before the transplant will weaken your immune system. The risk of infection may be increased further if you need to take immune suppressants.

It’s very important to prevent infections developing. If you get an infection it could quickly develop into a more serious condition, such as a lung infection (pneumonia).

An ideal situation for the donor should be to stay near transplant centre for a week or so after transplant as patient may require platelet support from his donor.

If the patient does not have a matched sibling, the other options available are matched unrelated donor and partially matched sibling donor transplant. However, cost can significantly go up in matched unrelated donor transplant because of costs involved in procuring stem cells. Partially matched transplant is another option but it involves increased risk of GvHD and infections.

Dr. Rahul Naithani

Senior Consultant

Dr. Rahul Naithani

Senior Consultant
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