Bone Marrow Transplant

Syngeneic Bone Marrow Transplantation

This is a procedure in which an individual receives bone marrow that is donated by his or her healthy identical twin.

Pre-Blood and Marrow Transplant Eligibility Test

Prior to beginning any treatment, the transplant nurse coordinator and financial coordinator will be required to submit the required documentation.

You will also have to be approved by the transplant team for receiving any sort of transplant. The aim of this is to make sure that you are receiving the best care and treatment based on your diagnosis and individual scenario.

Required Testing

• Blood work
• A 24-hour urine specimen for evaluation of kidney function
• EKG (electrocardiogram)
• Chest x-ray
• CT scans: chest and sinus, and abdomen and pelvis if required
• Bone marrow diagnostic test, if required
• MUGA scan or echocardiogram to evaluate heart function
• Pulmonary function test to check lung function
• Consultation with the psychology department, if suggested

Your nurse coordinators can work with you to regulate your treatment. There are different phases of treatment for various types of transplants.

Objective

• To learn what the bone marrow transplant procedure and peripheral blood stem cell transplant are and how they are used as treatments for a few diseases
• To understand what one can expect through each phase of the transplant
• To learn what steps need to be taken before the treatment is started
• To prepare you mentally and physically for your transplant
• To answer queries related to the transplant

Getting Started

Starting any medical treatment can be very stressful. There are several queries that you may have during this time. Your transplant nurse coordinators are the primary point of contact in the whole transplant procedure. They can be contacted to answer your queries and to offer guidance during your treatment procedure

• You and your family should choose someone to be your caregiver. He or she will be accountable for assisting you in your daily activities and for medication.

Source

Bone marrow is a semi-solid tissue that is found among the spongy parts of the bones. It is made up of hematopoietic cells, marrow adipose tissue, and stromal cells. In adult humans, bone marrow is primarily found in the ribs, vertebrae, sternum, and bones of the pelvis. Bone marrow makes around five % of the total body mass in adult humans; for example, a man weighing 73 kg can have around 3.65 kg of bone marrow.

 

All sorts of hematopoietic cells, together with myeloid and lymphoid lineages, are created in the bone marrow, but lymphoid cells later migrate to different lymphoid organs (e.g. thymus) so as to complete their maturation.

Bone marrow transplants may be performed to treat severe diseases of the bone marrow, as well as specific forms of cancer, such as leukemia.

Process

To understand what a bone marrow transplant procedure is basically like, it would help to think about it as a sort of blood transfusion. The concept is simple: Replace damaged bone marrow cells with healthy ones.

If the healthy cells come from your own bone marrow, it’s an autologous transplant, and if they come from someone else (a donor), it’s an allogeneic transplant.

In both procedures, there are three basic steps that are followed:

• Collect healthy cells from stem.
• Get your body ready to collect them (conditioning).
• Place the new cells into your body.

The steps may be done in a hospital, patient clinic, or a combination of the two.

Collect Stem Cells

You can get healthy stem cells from 3 places:

Blood

This is the foremost choice and the most common source for healthy cells.

When it’s time to gather the cells, your medical team will take blood out from one arm through a thin tube and let it flow into a machine that filters out your stem cells. The remainder of the blood flows out of the machine and back into your body through your arm.

You’re awake throughout the whole procedure, and it takes approximately 2 to 3 hours. It does not hurt, and you should not be required to stay in the hospital overnight. However, you may need to do this a few times to get enough cells.

Your stem cells are then frozen and held on to till the time you require them.

If you’re receiving bone marrow from s donor, the donor goes through the same procedure. But these cells won’t be frozen as you’ll receive them as soon as possible.

Bone Marrow

For this, your doctor uses a needle to get bone marrow from particular parts of your hipbone. It generally takes 1 to 2 hours, and you’ll be given medication to help you sleep through the procedure. Afterwards, you’ll have giant bandages over your hips which will be required to stay on for 24 hours, and you may also be a little sore for some days.

Your doctor will also take some red blood cells in the procedure. You’ll get those back through a thin tube that goes into your arm or hand as you recover. Again, your own cells will be frozen till you’re ready to receive them. A donor also goes through similar steps, however, you receive those cells within a day.

Cord Blood

In some cases, the stem cells are sourced from the placenta and umbilical cord of a newborn. The mother decides at a prior time if she wants to donate them, and the baby isn’t affected in any way. If donated, the cells are frozen until someone requires them.

Conditioning

When it’s nearby time for you to receive the new cells, you’ll receive chemotherapy. You may be given radiation therapy, based on the type of transplant you’re having, your illness, diseases, and your overall health.This process is referred to as conditioning, and it is carried out to:

• Clear out an area in your bone marrow for the new stem cells
• Lower the response of your immune system to reduce the probability of your body rejecting the new cells
• Kill any cancer cells, the reason you’re being treated

The process might take up to a week. If you need radiation, you may require one session, or it may be split out over many days.

Transplant

Within some days of conditioning, you’re prepared for the final step. You’ll receive your new stem cells through a thin tube, called a central line, which goes into a vein in your chest. It’ll take a few hours. You’ll be awake the whole time and won’t feel any pain.The new stem cells will navigate their own way into your bone marrow. It might take a few weeks for your blood cell counts to come back to normal.Stem cells that are frozen have a preservative in them which may cause side effects. If you utilize frozen stem cells, you’ll also be prescribed medication to help deal with any problems, and you may also receive more fluids to flush the preservative out of your body.Generally, most of the side effects of the transplant procedure are minor, and some come from the preservative. They may include:

• Chest pain
• Fever and chills
• Headache
• Hives
• Nausea
• Shortness of breath
• Taste of garlic or creamed corn in your mouth

Steps

First Step: Get the Bone Marrow Transplant Donor Ready to DonateIf you match with a patient, you will be approached to confirm that you want to donate cells. If you confirm to move forward, you’ll be asked to update your health data and to participate in extra testing to see if you are the most effective match for the patient. If you are the best match, you need to:

• Take part in an information session. Elaborate detailed information will be provided to you about the procedure of donation and the recovery process, as well as about any risks and side effects. If you confirm and agree to donate, you will need to sign a consent form.
• Get a physical exam done and give blood samples to help confirm that the donation is safe for both you and the patient.

Second Step: Donate PBSC or Bone MarrowThere are two procedures that may be followed for donation: PBSC or Bone Marrow. The health practitioner will choose which one is the best for the patient.

• PBSC (Peripheral blood stem cell) donation: This is a non-surgical procedure. For five days prior to donation, you will be given injections of filgrastim. Filgrastim is a medicine that raises the quantity of blood-forming cells in your blood. On the day of donation, blood is taken through a needle in one arm and passed through a machine that segregates the blood-forming cells. The remaining blood is sent back into your body through the other arm.
• Bone marrow transplant: The donor will undergo a surgical procedure that will take place in an Apollo Hospital operating room. The doctor will use needles to take liquid marrow from the backside of your pelvic bone. Donors will receive anaesthesia and feel no pain throughout the donation process.

Third Step: Recovery and follow-upThe time a donor takes to recover varies. It depends on the person and the type of donation. In most of the cases, donors are able to return to work, school, colleges or other activities within 1 to 7 days after the donation process.

When Recommended

Your healthcare provider may order a bone marrow aspiration and a bone marrow biopsy if other blood tests indicate that the levels of red blood cells, white blood cells, or platelets are out of range. Very high or very low levels of these cells may indicate that you have a medical disorder, like cancer that starts in your blood or bone marrow. If you are being treated for one or more types of cancer, these tests can help find out if cancer has reached your bone marrow.Bone marrow tests are performed to:

• Find out explanations for problems related to the red blood cells, white blood cells, or platelets
• Diagnose and keep track of blood disorders, such as anemia, Polycythemia Vera, and thrombocytopenia
• Diagnose and evaluate bone marrow disorders
• Diagnose and monitor specific types of cancers, including but not limited to leukemia, multiple myeloma, and lymphoma
• Diagnose infections that may have started in or have reached the bone marrow

You will be asked to sign and date a form that gives permission to perform bone marrow tests. Make sure to ask your provider if you have any queries about the procedure.

What do the results mean?

It may take some days or perhaps several weeks to get your bone marrow test results. The results can show whether you have a bone marrow disease, a blood disorder, or cancer. If you are already being treated for cancer, the results may show:

• Whether the treatment being given to you is working
• How much your illness has advanced

If your results don’t seem normal, your healthcare provider may order one or more follow-up tests or discuss treatment options with you. If you have any queries about your results, be sure to discuss them with your healthcare provider.

Bone Marrow Transplant Advantages

With a transplant, the doctors replace diseased, unhealthy, and nonfunctioning bone marrow with healthy functioning bone marrow (for conditions such as leukemia, aplastic anemia, and sickle cell anemia). This helps revive the immune system which will fight the current or residual leukemia or other cancers that were not killed by the chemotherapy or radiation used in the transplant.The following are the diseases that are most commonly treated with a bone marrow transplant:

• Leukemias
• Severe aplastic anemia
• Lymphomas
• Multiple myeloma
• Immune deficiency disorders
• Some solid-tumor cancers (in rare cases)

However, different patients suffer from illness differently, and bone marrow transplant might not be the right option for everyone suffering from these diseases.

Conditions Treated

The following is a list of diseases treated by Apollo Hospital’s Marrow Transplant Program.

Acute myeloid leukemia (AML)

This is a sort of blood cancer in which bone marrow produces high counts of granulocytes (a type of white blood cell that generally fights infection). The term “acute” suggests that the disease progresses rapidly.

Acute Lymphoblastic Leukemia

This is cancer of the blood in which an abnormally large amount of lymphocytes, a type of white blood cell which normally fights infections, are generated by the bone marrow and by the organs in the lymph system.

Amyloidosis

A sickness characterized by an uncommon buildup of proteins (called amyloids) in different organs in the body.

Aplastic Anemia

A rare condition that occurs when the body stops generating enough new blood cells, causing fatigue and an increased risk of infections and out of control bleeding.

Chronic Myelogenous Leukemia

A chronic type of cancer that begins in the blood-forming cells of the bone marrow and affects the blood and other parts of the body over a period of time.

Chronic Lymphocytic Leukemia (CLL)

This is a category of blood cancer in which the bone marrow and other lymphatic system organs steadily make too many lymphocytes (a type of white blood cell). “Chronic” symbolizes the slow progression of the disease.

Acute Renal Failure (ARF)

This is one of the most common and potentially life-threatening complications that may be caused following bone marrow transplantation (BMT). Hepatorenal-like syndrome secondary to venoocclusive disease can occur within a month afterwards and is also the most common reason behind early ARF syndrome.

Bone Marrow Transplant for Hodgkin’s Lymphoma

HL is a type of cancer of the lymphocytes. Lymphocytes are white blood cells that guard the body against infection. In HL, unhealthy lymphocytes first show up in the lymph nodes, which are small, bean-shaped glands that are present throughout the body. As the disease gets worst, these cells spread and reach other parts of the body as well.

Fanconi Anemia

FA prevents your bone marrow from working properly and generating healthy blood cells. This is a condition that is referred to as aplastic anemia. It’s responsible for various types of physical and mental birth defects, as well as skeletal problems and uncommon skin colouring.

Planning for Bone Marrow Surgery

Matching Donor Cells

To be a donor you would be required to have stem cells that match the person you are donating to. To screen, you have to undergo blood tests for HLA typing or tissue typing.The laboratory staff will evaluate the surface of your blood cells. They will then compare them to the surface of the blood cells of the individual needing the transplant surgery.Each person has a different set of proteins on the surface of their blood cells. The laboratory staff checks for proteins known as HLA markers and for histocompatibility antigens. The staff checks for 10 HLA markers. The results of this test show how perfect the HLA match is between you and the person who needs the cells.

Stem cell or bone marrow donation to a Relative

A brother or sister is most likely to be a perfect match. There is a one in four chance of your cells matching. This is known as a Matched Related Donor (MRD) transplant. Anyone else within the family is less likely to match, which can be terribly frustrating for relatives who are ready to help.

If you are a part match

Sometimes, if your cells are a half (50%) match, you may still be able to donate stem cells or bone marrow to a relative. This is known as a Haploidentical Transplant.

If you’re not a match

You can’t donate stem cells or bone marrow to your relative if you are not a match.Sometimes it is possible to get a match with somebody outside the family. This is known as ‘matched unrelated donor’. To seek out a matched unrelated donor, it generally requires searching through a huge number of individuals whose tissue type has been tested. Thus, doctors need to search for national and international registers to find a match in such cases.

Complications

For Autologous Bone Marrow Transplant

Before a transplant, you will receive chemotherapy with or without radiation therapy. So, some side effects of an AUTO stem cell transplant are similar to the side effects of these treatments. The most serious of these side effects is a higher risk of infections caused by a lower level of white blood cells in the body.

Infections

Treatments like chemotherapy weaken your body’s immune system. This implies that the body cannot shield itself, as it does normally, against bacteria, viruses, and other sorts of germs. The maximum risk of infection is during the first few weeks after transplant. However, your immune system is never completely the same after a transplant.After approx. 2 weeks, a part of your immune system, called neutrophils, will recover. These cells can prevent some common germs from making you ill.

Other Immediate Side Effects

The following side effects may develop after high-dose chemotherapy and are at their strongest for the next 1 to 2 weeks:

• Nausea and vomiting
• Mouth Sores
• Fatigue
• Low levels of platelets
• Low levels of red blood cells, which can lead to anemia
• Diarrhea

Long-Term Side Effects

There may be side effects of the transplant that show up months or years after treatment.

• Infertility
• Cataracts, a condition in which the lens of the eye gets cloudy and the vision is blurred
• Early menopause for women
• Thyroid issues
• Lung or bone damage
• Risk of developing some other type of cancer

For Allogeneic Bone Marrow Transplant

The complications include side effects of receiving another person’s stem cells. The most significant of these side effects is a higher risk of infections and a risk of Graft-Versus-Host Disease (GVHD).

Infection

The chances of infection from an ALLO transplant right after the procedure are similar to an AUTO transplant. But after an ALLO transplant, you face a significant risk of infections throughout your life. When you get an ALLO transplant, your doctor may prescribe chemotherapy, radiation therapy, or medication to keep your immune system from damaging the new cells. These treatments might have an effect on your immune system and raise the risk of infection. A weak immune system makes your body more likely to get infections.

Graft-Versus-Host Disease

GVHD occurs if the new stem cells start attacking your body. This can lead to inflammation. Doctors have medication for GVHD that is prescribed even if the donor was a 100% match. If you still get GVHD, your doctor can prescribe additional medication to control the condition. In rare cases, GVHD might even be life-threatening.There are 2 types of GVHD and each can range from mild to severe.

Other immediate side effects

Similar to an AUTO transplant, the following side effects may develop right after chemotherapy. People who are able to get a reduced-intensity transplant, which uses light doses of chemotherapy, may avoid some of these or may experience less severe side effects.

• Nausea and vomiting
• Mouth Sores
• Low levels of platelets
• Low levels of red blood cells, which can cause anemia
• Diarrhoea

Long-term side effects

There can be side effects of the transplant that develop months or years after the transplant.

• Infertility
• Cataracts
• Early menopause for women
• Thyroid problems
• Lung or bone damage
• Risk of developing other cancers

Allogeneic Bone Marrow Transplant Cost

The allogeneic bone marrow transplant cost in India can range from 20 lakhs to 35 lakhs.

Pediatric Bone Marrow Transplant

A bone marrow transplant in infants has several risks, many of which can be life-threatening. Your child’s healthcare provider and BMT team should discuss the risks and benefits with you before the procedure.The risks and complications of bone marrow transplant in children depend on several factors, like:

• The type of BMT
• The type of disease
• Medicines used before the transplant
• The child’s age
• The differences in the tissue match

Possible complications include

• InfectionsInfections are seemingly caused by severe bone marrow suppression. This happens when not enough blood cells are being produced in the bone marrow. Medication is often given to prevent and treat infections.
• Low levels of platelets (thrombocytopenia) and sickle cell anemiaThese can be serious and even life-threatening. Most children undergoing transplant may require multiple transfusions for different blood product.
• Pain Pain caused by oral sores and gastrointestinal (GI) irritation is quite common after chemotherapy and radiation. Pain medication and good mouth care might help.
• Diarrhea, nausea, and vomiting These could happen because of chemotherapy, radiation, and GI irritation.
• Fluid overloadThis most frequently happens when the kidneys can’t keep up with a large amount of IV fluids being given. Your child is going to be monitored closely for fluid overload. The child will be weighed often, have blood tests, and their urine will be measured. Medicines could also be given to help kidney function and to get rid of the excess amount of fluid.
• Breathing problems Serious respiratory issues may be caused by infections, airway inflammation, fluid overload, graft-versus-host disease, and bleeding. Your child may need supplemental oxygen to breathe better till the problems are treated.
• Organ damageShort-term or long-term liver or heart damage may also be caused by infections, graft-versus-host disease, chemotherapy and radiation, or fluid overload. Your child’s blood and vital signs are going to be monitored carefully to look for organ damage.

Post-Op Recovery

• Have a balanced diet

This is the key to getting your strength back, but it’s not easy. After a Bone Marrow Transplant, you may have some side effects like nausea, vomiting, or a sore mouth, or otherwise, you simply may not be that hungry. Your doctor could provide you with anti-nausea medication to help with these side effects.

• Stay away from these foods

These foods can cause trouble when you have a weak immune system:

• Unpasteurized raw milk
• Raw or undercooked eggs
• Raw or undercooked meats
• Deli meat, unless it’s been warmed up
• Food from bulk or self-service bins
• Exercise

A regular active lifestyle helps you manage your weight and boosts your strength and stamina. Discuss with your doctors about what level of exercise would be right for you.

• Don’t drink alcohol

After a bone marrow transplant, your liver might not work well. The reasons may be chemotherapy, medication, or graft-versus-host disease (GVHD). Your liver is responsible for processing alcohol and therefore, your doctor will most likely recommend that you stay away from beer, wine, and other spirits for some time.

• Take your medicine

If your bone marrow came from a donor, the doctor would prescribe medicine to lower the chances of your body rejecting it. This medication weakens the immune system so it won’t react to the new cells.

• Protect yourself from the sun

Your skin may also be sensitive after the transplant so it’s vital to use a sunscreen with SPF 50 and to wear long pants and long sleeves, as well as a hat if you go outside.

• Take care of your mouth

Your mouth may also be sore or dry after the transplant, so it is important that you take good care of it. Check with your doctor before you go for any dental work, including a cleaning.

• Have an emotional support system

Once the bone marrow transplant is done, it might have serious physical side effects, such as problems related to the kidneys, lungs, heart, stomach, or liver, which may be dealt with. However, what a lot of people fail to consider is that a transplant also has emotional and psychological side effects. Having an emotional support system in place to help you tide through the tough times is of utmost importance.