Department of Blood & Marrow Transplantation

FAQ'S

What will happen if the blood cells are not produced?

The healthy production of blood cells is very important and if your body is incapable of producing these, it can make you more susceptible to infections, fatigue and bruising. 

• Lower production of neutrophils, a type of white blood cell, can lead to neutropenia 
• Lower production of red blood cells can lead to anaemia 
• Decrease in the platelet count can lead to thrombocytopenia

What is a Bone Marrow/Stem Cell Transplant?

A bone marrow or blood stem cell transplant is a medical treatment procedure in which hematopoietic (immature) stem cells are infused into another person or self after giving chemotherapy or radiotherapy. These cells are either collected from the body of a patient or a donor. The procedure makes it possible for doctors to deliver higher doses of chemotherapy, to achieve better outcomes.

Why does someone need a bone marrow or stem cell transplant?

Bone Marrow Transplant procedure is majorly used to replace damaged or diseased stem cells with healthy stem cells in patients who have been diagnosed with blood related disorders or malignancies that disrupt the normal production and function of blood cells. These are:

• Acute Leukaemia

1. Acute Lymphoblastic Leukaemia (ALL) in remission
2. Acute Myelogenous Leukaemia (AML)
3. Biphenotypic Leukemia

• Chronic Leukaemia

1. Chronic Myelogenous Leukaemia (CML)
2. Juvenile CML (JCML) or CMML

• Myelodysplastic Syndromes (MDS)
• Lymphoma

1. Non-Hodgkin’s Lymphoma (NHL)
2. Hodgkin’s Disease (HD)

• Solid Tumours

1. Neuroblastoma
2. Wilm’s Tumour

• Immunodeficiency Syndromes

1. Severe Combined Immunodeficiency Syndrome (SCID)
2. Common Variable Immunodeficiency Disease (CVID)
3. Wiskott-Aldrich Syndrome (WAS)

• Histiocytic Syndromes
• White Blood Cell Disorders

1. Leukocyte Adhesion Deficiency (LAD)
2. Chronic Granulomatous Disease (CGD)
3. Chediak Higashi Syndrome

• Red Blood Cell Disorders

1. Sickle Cell Anaemia
2. Thalassemia Major
3. Diamond-Blackfan Anaemia
4. Other transfusion-dependent Anaemias

•  Platelet Disorders

1.  Amegakaryocytic Thrombocytopenia (AMT)

• Bone Marrow Failure Disorders

1. Fanconi Anaemia
2. Dyskeratosis Congenita
3. Acquired Severe Aplastic Anaemia
4. Paroxysmal Nocturnal Hemoglobinuria (PNH)

• Inborn Errors of Metabolism

1. Mucopolysaccharidoses: Hurler Syndrome (MPI)
2. Leukodystrophies: Adrenoleukodystrophy (ALD)

• Others

1. Osteopetrosis
2. Gaucher’s Disease

A bone marrow transplant may also be performed on patients who have undergone chemotherapy or radiation therapy as such treatments can destroy the healthy bone marrow cells along with the diseased ones. 

How do doctors find the right donor?

In order to find the perfect donor, HLA Typing is done. HLA stands for human leukocyte antigen, a type of protein found in most of the cells in our body. HLA Typing is a genetic test that assesses the samples of tissues collected from the donor and the patient to check compatibility. 
HLA Typing is a must irrespective of whether the donor is related to the recipient or not. There are certain eligibility criteria that are to be met. These include:

• The HLA type of the donor and recipient should be closely matched and at least 5 of the 6 important antigens, such as 2 "A", 2 "B", and 2 "DR" antigens, must be matched. Ideally, all 6 antigens will be a match between the donor and recipient, and preferably, 10 out of 10 antigens (including 2 "C" and 2 "DQ" antigens) will match. 
• If a patient has more than one 10/10 match available, doctors prefer a male donor or a female who has never been pregnant
• If there is more than 1 match, doctors will choose the youngest donor, while keeping in view the medical history

What are the steps involved in finding an unrelated donor?

An unrelated donor transplant involves the use of blood-forming cells taken from a donor who is not related to the patient. People who volunteer as unrelated donors are listed in various volunteer donor registries across the globe, such as NMDP, DKMS, Anthony Nolan Trust and DATRI. An unrelated donor transplant is recommended for patients who do not have a compatible related donor. 
Steps involved 

• HLA typing of tissue samples collected from the parents and extended family members is done to see if there is a compatible donor
• High-resolution HLA typing of the patient is done for 10 antigens at the allele level.
• Once the HLA type is found, doctors look for an appropriate donor in the donor registries
• If the registry confirms the possibility of a suitable HLA identical donor in the database, doctors prepare for the unrelated donor transplant
• HLA typing of the donor’s tissue sample is done for confirmation
• HLA typing is followed by physical examination and other assessments to test for infectious disease markers and other investigations for the donor’s fitness
• If the donor is fit and willing to donate, the procedure will be planned
• The blood-forming cells are collected at a designated centre and then transported to a transplant centre for the procedure

What services are offered by the Blood and Marrow Transplant Department at Sanar International Hospitals

At Sanar International Hospitals, we are committed to providing comprehensive care to patients from bench to bed. We offer the best available diagnostic facilities (Flow-Cytometric Analysis, Molecular Haematology including HLA typing and Chimerism Analysis) and treatment for Hematopoietic Disorders. For both In-patients and Out-patients, chemotherapy is administered with strict adherence to the standard treatment protocols, thereby ensuring the best outcomes. State-of-the-art services offered at the Department include:
Bone Marrow / Stem Cell Transplant 

• Allogeneic  Bone Marrow / Stem Cell Transplantation (Match Sibling Donor Transplant, Match Unrelated Donor Transplant, Haplo Identical Transplant and Cord Blood Transplant)
• Autologous Bone Marrow / Stem cell Transplantation
• Haematology services for Benign and Malignant Conditions
• Benign Haematological conditions like 

1. Red cell Disorders (iron deficiency anaemia, megaloblastic anaemia, congenital/acquired anaemia, thalassemia, sickle cell anaemia and pure red cell aplasia)
2. Platelet Disorders (ITP, Functional Platelet Disorders and Hypersplenism) 
3. Coagulation disorders (like haemophilia) 

• Malignant Hematological disorders like 

1. Acute Leukemia: Myeloid (AML) and lymphoid (ALL)
2. Chronic Leukemia – Myeloid (CML) and Lymphoid (CLL, Hairy cell Leukemia)
3. Lymphomas – Hodgkin and Non-Hodgkin Lymphoma 
4. Myeloproliferative Disorders – Polycythemia Vera, Essential thrombocytosis, Myelofibrosis 
5. Plasma cell Dyscrasias – Multiple Myeloma and Amyloidosis

How are the stem cells collected for the Bone Marrow Transplant procedure?

There are two different ways in which the blood-forming stem cells are collected from the body of the patient/donor, to be used for the transfusion. These are:

• Bone marrow harvesting - In this case, the source of the blood-forming cells is the bone marrow. Most of the children and adults who have to undergo an allogeneic bone marrow transplant for a non-malignant haematological condition/disorder, get healthy stem cells from the donor’s bone marrow. Bone marrow harvesting is done under the influence of general anaesthesia. The donor will be made to lie down on his/her stomach. Using a fine needle, the bone marrow will be collected from the posterior superior iliac spine. This requires several hip and bone punctures on each hip, however, no incisions and stitches are needed. The amount of bone marrow that is harvested depends upon the specific needs and requirements of the recipient. About 15 – 20 ml/kg (of donor’s weight) of bone marrow is harvested which roughly equals 2 % the donor’s bone marrow, which they regenerate in around 4 weeks. If bone marrow harvesting is being done for an autologous transplant, the collected bone marrow will be stored using the cryopreservation technique, to be used later. 
• Peripheral blood stem cell collection - In this case, the source of the blood-forming cells is the peripheral blood, which can be withdrawn from a vein in the arm. Prior to the blood collection, the donor has to undergo bone marrow stimulation, which is done with the help of growth factors (Filgrastim). This is usually done 4 to 5 days prior to the procedure. This helps to increase the production of blood-forming cells in the body. The donor is made to lie down on a couch. The blood is then collected and passed through a centrifuge machine, which helps to separate the stem cells. Doctors collect and store these and return the remaining blood to the donor’s body intravenously.
   

What are the common side effects of transplant

If you are undergoing a bone marrow transplant, it is important to understand that the procedure has certain side effects as well and although the benefits of the procedure out weigh these, we cannot completely ignore them. Some of the common side effects of bone marrow transplant include:

• Mucositis - A painful condition marked by inflammation and development of ulcers in the mucous membrane lining of the GI tract and mouth. The former is known as Gastrointestinal Mucositis and the latter is known as Oral Mucositis. 
• Infections - Patients undergoing a bone marrow transplant are at a high risk of developing infections. When their blood count is low, they are more susceptible to bacterial and fungal infections, and once the procedure is complete, there is increased likelihood of developing viral, fungal and rare bacterial infections. In the case of an allogeneic transplant, immune reconstitution occurs after 12 to 24 months, whereas in the case of an autologous transplant, it happens after 6 months.
• Regular transfusion - When a patient is undergoing high dose chemotherapy and transplant, there is going to be a drastic drop in the number of mature blood cells in the body. The condition is commonly known as Cytopenia. To make up for the same, the patient will need regular transfusions of red blood cells and platelets. 
• Graft Vs Host Disease - GVHD is a problem faced by patients undergoing an allogeneic transplant. It is said to happen when the recipient’s body rejects the blood forming cells taken from the donor. This can happen even if the donor is a perfect match. GVHD is caused by the patient’s immune response and is most likely to affect the patient’s skin, GI tract and liver. It is broadly classified into two types:

1. Acute GVHD, which can be seen within 100 days following the transplant
2. Chronic GVHD, which can be seen after 100 days following the transplant 

• Hepatic Veno-Occlusive disease - Also known as Sinusoidal Obstruction Syndrome (SOS), VOD is a very common and potentially serious complication seen in patients undergoing Myeloablative Hematopoietic Stem Cell Transplantation (HSCT). It is marked by severe blockage of the veins within the liver, which disrupts normal blood flow. Clinical diagnosis of hepatic VOD is based on three classic symptoms, which include  

1. Painful hepatomegaly, i.e. enlargement of the liver 
2. Hyper bilirubinemia, i.e. excessive build-up of bilirubin in the blood
3. Edema, i.e. Unexplained fluid retention

• Graft failure - It is serious complication in which the immature blood forming cells do not develop into mature cells. This is very rare in the case of an allogeneic bone marrow transplant. Graft failure can be primary or secondary

1. In the case of primary graft failure, the patient’s body does not accept the graft at all
2. In the case of secondary graft failure, the patient’s body accepts the graft initially, but rejects it later.

Post discharge – Do’s and Don’t’s

Even after you have been discharged from the hospital, you are still in the recovery phase and need to be careful about certain things. Our Transplant Team at Sanar International Hospitals will brief you about all the challenges that you are likely to experience, as well as how you can overcome these. Here are some important facts that you need to know: 

• Avoid infection - Following the transplant, you are at a high risk of developing infections. Hence you should:

1. Avoid coming in close contact with any visitor
2. Avoid being around sick people 
3. Wash your hands more often
4. Use disposable tissues while sneezing or coughing
5. Wear a mask, especially when you are stepping outside

• Immunization - It is very important to consult your doctor before getting any vaccinations or boosters. Immunization is usually done after 12 months following the transplant. Till then you need to avoid the following:

1. Oral polio vaccine given in a camp facility 
2. Group or free immunization
3. Live vaccinations 

• Avoid bleeding - Once the blood-forming mature cells are transfused into your body, they start making new cells. Platelets are the slowest of the three and take more time to develop. Till this happens, the patient is likely to face problems with clotting, which can lead to unnecessary bleeding. Here are a few things that you can do to avoid the same:

1. Be extra careful to avoid any injury or accident 
2. Avoid using sharp objects
3. Use an ultra-soft brush for your teeth to avoid bleeding gums
4. Do not use too much force while blowing your nose
5. Use an electric razor instead of a manual one 
6. Avoid vomiting forcefully 
7. Refrain from taking aspirin, as well as medications containing it 
8. In case of bleeding contact your doctor immediately 

• Cleanliness - You have to be extra careful when it comes to cleanliness. The germs found inside your home can further elevate your risk of developing infections. Here are a few things that can help

1. Refrain from doing it yourself as it can expose you to dust and dirt. Take help or hire someone to do the job for you
2. Make sure that dusting and cleaning are done on a daily basis
3. Use disinfectants to clean the washroom
4. The cutlery used by the patient should be washed and cleaned thoroughly 
5. Patients need to change their towels at least twice a week
6. Bed linen should be changed every week
7. Avoid getting indoor plants as the soil may carry harmful germs 

• Pets - If you have a pet at home, here are a few tips that can help you live safely with them:

1. Wash your hands every time you touch your pet and their belongings 
2. Avoid coming in close contact with your pet too often
3. Do not keep their litter tray or cage in and around your room or kitchen
4. Take someone’s help to clean their litter tray
5.  Feed packeted food to your pet and do not give them anything raw
6. Make sure your pet does not miss the regular veterinarian visits
7.  Avoid taking your pet outdoors 
8. Do not come in contact with any pet other than yours 

• Personal hygiene - Personal care is very important to lower the risks of infection. This is not only for you but also for people who come in close contact with you. You should:

1. Wash your hands before eating your meals, after using the washroom, coming home from outside, before and after touching wounds, after playing with your pets, after touching dirt or plants, after touching your mouth or nose and after coming in contact with other people
2. Take a shower/bath every day, while paying extra attention towards the cleanliness of the underarms and groin. 

• Daily activity level - You need to maintain a balance between rest and sleep as both are equally important.

1. Start with mild activities like short walks and increase the intensity gradually, while keeping your doctor in the loop
2. If you wish to lift weights, do it after your platelets are over 50.
3. Do not indulge in rigorous physical activities.
4. Take rest in between sets 
5. Do not exhaust yourself completely 

• Going out - If you are stepping out of your home for any reason, here are a few things you should follow:

1. Make it a habit to wear a mask every time you step out
2. Avoid going to crowded places for at least first 3 months following the transplant
3. Avoid going to unhygienic places and dusty areas 
4. Avoid going near chicken coops 
5. If you have undergone radiation treatment, you have a high chance of getting a sunburn. Do not forget to apply sunscreen

• Daily meals - Following the transplant you are likely to have some dietary modifications as well. These are planned by your doctors to suit your specific nutritional requirements. Also, there are some things that you need to keep in mind.

1. You need to drink enough water, at least 2 litres a day. Make sure it is chlorinated
2. Limit your caffeine intake to 500ml/day
3. Consult your doctor before taking alcohol 
4. Avoid unpasteurized milk, fruit or vegetable juices
5. Eat healthy and well-balanced meals 
6. Avoid raw and undercooked food 
7. Refrain from eating foods that have mould in them, such as cheese
8. Eat fresh fruits and veggies that do not have any spot 
9. Check all the packed food items for broken seals
10. Make sure your kitchen is clean and dust free
11. Wash your hands before and after preparing meals
12. Wash all the veggies and fruits properly under running water
13. Use plastic cutting boards instead of wooden ones
14. Wash all the utensils with warm water and detergent 

• Follow-up - Regular follow-ups are very crucial as these help your doctors to keep a track of your prognosis. Your progress will be monitored using various modalities to ensure that your journey to recovery is swift and safe.