For your transplant journey, the transplant process is divided into six steps that guide a patient. The steps include what to expect along the way. Although the experience during these phases may be quite different for each patient, a general overview is provided. Your path will depend on many things such as the type of transplant, your overall health and your disease. Your transplant team will always be there to guide and support you.
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The picture below shows the basic steps for both an autologous transplant (using your own cells) and an allogeneic transplant (using cells from a donor).
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Evaluate the patients for BMT (WORK-UP) usually 14-30 days before.
The preparation phase begins when the patient arrives at the treatment center and begins the process of medical evaluation, orientation, informed consent, and other preliminary activities.
- Beginning Medical Evaluation: One will undergo complete medical check-up to evaluate one’s suitability to go through the BMT procedure. This involves the following:
- Blood Tests
- Chest X- ray and CT Scans
- Tests to assess the condition of heart and lungs
- Bone Marrow Tests
- Conference for Treatment Plan: Patients will be counseled in detail about the procedure, the complications, the chances of success, the cost and the possible length of stay in the hospital. Patient will be encouraged to go through the educational material/ booklet and discuss any queries or doubts that he / she might have.
- Central Venous Catheter (Hickman catheter) Insertion: A Hickman line is a central venous catheter most often used for the administration of chemotherapy or other medications, as well as for the withdrawal of blood for analysis. Some types are used mainly for the purpose of apheresis or dialysis. Hickman lines may remain in place for extended periods and are used when long-term intravenous access is required.
- Bone-Marrow/ Stem Cells Harvest: The process is a non-surgical process wherein donor’s blood is removed through the catheter (drip) and circulated into a blood separator machine which filters out Stem cells from the blood. We then collect, strengthen and store donor cells at - 170˚C until the transplant is done.
Prepare the patient for BMT (CONDITIONING) usually 2-10 days.
The conditioning phase begins the actual transplant process. High dose of chemotherapy or radiotherapy is given to destroy the diseased marrow or destroy the cancer elsewhere and the bone marrow gets damaged as a result. This is needed to create space for new blood stem celland also to suppress the patient’s own immune system (in case of allogeneic transplant), so that the blood stem cells are not rejected. Depending upon the chemotherapy agents and radiation therapy administration schedule, some conditioning therapy can be administered in the outpatient setting, thus potentially shortening the inpatient stay.
Pre-engraftment (before the transplanted blood stem cells start working): (Usually 2-3 weeks)
The transplant phase is 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.
The actual process of transplantation
The day you receive your new cells is often called “Day Zero”. It usually comes 1 or 2 days after you finish the preparative regimen.
The transplant procedure isn’t surgery it is actually fairly simple, the donor’s stem cells or bone marrow cells to be transplanted are given through the Central Venous line (CVL). The procedure is just like getting a blood transfusion, except the following precautions which has to be taken care of:
- Just before the infusion of the new bone marrow, the patient may be given medication to help avoid any allergic reactions.
- A monitor is used to check breathing, heart rate and blood pressure during the procedure. The nurse monitors closely throughout the infusion of stem cells or bone marrow.
- A doctor is available in the unit and will check the patient periodically. Medications may be given to deal with problems that may arise, such as high blood pressure or a fast heart rate.
The patients need to be kept in a clean room within the BMT unit in strict isolation during this time. They also need a lot of blood and platelet transfusion. Most patients get serious infections during this period and need treatment with antibiotics.
After patient gets the donor’s healthy stem cells, they move through bloodstream to settle into the bone marrow. In bone marrow, they begin to grow and make new red blood cells, white blood cells and platelets. This is called Engraftment. It can take days or weeks for engraftment to happen.
Engraftment is an important medical milestone after transplant. It tells doctors that the cells are working properly. With these cells, patient’s immune system begins to recover, and patients are better able to fight infections on their own. This also marks the beginning of their recovery.
This phase includes close monitoring, supportive treatment, and management of complicationswhile waiting for signs of engraftment (new cell growth).
- Support, Protection and Close Monitoring
- Watching and Managing Effects Of Treatment
Post-engraftment (after the transplanted blood stem cells start working)
Early phase (first 3 months)
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 center will begin. Engraftment is called when after transplant absolute neutrophil counts are more than 500 for three consecutive days, unsupported platelet counts of more than 20000/uL and red cell independence.
Soon after the neutrophil increase to normal or near-normal levels and if there is no other complication, the patient can be discharged home. However, regular check-up and blood tests (2-3 times a week) are required. There is also a risk of graft-versus-host disease (GVHD) at this stage.
The entire transplant process, from the start of chemo and sometimes radiation, until hospital discharge, can last weeks to months. This is followed by many months of recovery near the transplant center and at home. The transplant team will closely care for patient to prevent and treat any complications.
After hospital discharge, the recovery process continues for 2-3 months, during which time the patient needs to stay near the Hospital for weekly follow-up, checkups and tests with the Doctor.
EXPECTED LENGTH OF STAY:
For Donor: 1 Day in Hospital and 1 week in India
For Patient: 4 weeks in Hospital, 2 or 3 months after discharge.
TOTAL STAY FOR PATIENT: 3 or 4 months in India
Late Phase (3 months-12 months)
The long-term recovery phase involves leaving the treatment center and going back home, dealing with any ongoing clinical issues, and re-establishing life patterns. Patients need to follow up for long term complications of BMT if it occurs.
The immunity against viruses takes a very long time to recover. Even though some of the immunity is restored, the patient is still at risk of infections with viruses and fungus. This is more so if they are being treated for GVHD, which can become chronic and lingering. If the patient is well, the frequency of check-ups and blood tests reduce over several months.
After going back to home country Patient & Family will be in touch with our Team of Doctors through email/ phone/ video call whenever required. If required you can visit India with the patient for check up after one year.
BMT Clinic can help you learn more about the transplant process. If you are planning for bone marrow transplant for your loved one, CONTACT US now.
A bone marrow transplant (BMT) is a procedure to replace damaged or destroyed bone marrow with healthy bone marrow stem cells. It is the soft, fatty tissue inside your bones which produces blood cells. Stem cells are immature cells in the bone marrow that give rise to all of your different blood cells. BMT procedure involves transplanting blood stem cells, which travel to the bone marrow where they produce new blood cells and promote growth of new marrow which in turn gives a normal & healthy life to the patient.
However, the experience during and after BMT Procedure may be quite different for each patient. A patient’s path will depend on many things such as the type of transplant, overall health and disease. Our transplant team will always be there to guide and support the patient and their family at each step.
Below is the Success Story of Patient Edria Israel from Nigeria, victory over Sickle Cell Anemia by Bone Marrow Transplant at the hands of Dr. Vikas Dua published in an International Sickle Cell Magazine.
“Edria has been in perfect health since his transplant,” Says Aunt who accompanied him to India.
The outcome of BMT depends on four factors:
- Fitness of the patient
- Choice of Conditioning
- Choice of Donor
- Nature of Disease
Fitness of the Patient
The ability of various organs of the body to withstand the assault of high dose chemotherapy is the key to the success of BMT. We can assess the suitability of the patient to undergo a particular type of conditioning by several scoring systems such as HCT-CI (Haematopoietic Cell Transplantation – Co-morbidity Index). For example, if the HCT-CI score is 0, the chance of transplant related mortality is only 10%. On the other hand, if the HCT – CI score is 3, the chance of transplant related mortality is 40%.
Choice of Conditioning
The aim of conditioning is to eliminate the diseased bone marrow, whether it is Sickle Cell, Leukemia or Thalassemia. In addition, the patient’s immune system needs to be dampened, so that the donor cells are not rejected.
The backbone of conditioning has been total body irradiation. However, this has a lot of short and long term side effects, especially in children. Hence, only chemotherapy based conditioning has been developed particularly for children.
Over the last decade, several ground breaking researches have shown that high dose chemo-radiotherapy might not be essential to prevent rejection or eliminate the disease, when the patient has low disease burden. This is called REDUCED INTENSITY CONDITIONING (RIC). The Results of RIC in most conditions are similar to conventional conditioning.
In older patients, we prefer RIC. In younger patients and in those with high risk leukemia or lymphoma, conventional conditioning is preferred.
Choice of Donor
Matched Family Donor is always the preferred choice irrespective of all other conditions. However, only 20% of patients have a matched family donor.
The other donors are called alternative donors and are as under:
- Matched or Mismatched unrelated donor from Volunteer Registries
- Matched or Mismatched Unrelated Cord Blood Unit from Public Cord Blood Banks
- Half Matched Family Donor (Haploidentical)
Nature of Disease
It is now well established that the chances of success are highest if a patient with leukemia undergoes BMT when the disease is in remission (not detected by routine testing). When leukemia recurs, the chances of cure are reduced by 50 – 80%, even with BMT. In addition, certain leukemia are at high risk of relapse because of the aggressive nature inherent in the chromosomes of the cancer cells.
Similarly, the best results in non-malignant diseases such as Thalassemia, Sickle Cell Anaemia and Aplastic Anaemia are obtained when they are transplanted early.
If you have any questions or worries, you can CONTACT US anytime- Phone/ WhatsApp No.: +91-7015677759 Email ID: firstname.lastname@example.org.