TYPES OF BMT
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Bone Marrow Transplant (BMT) actually means infusion of stem cells (collected either from bone marrow or peripheral blood or cord blood) into the recipient. The type of bone marrow that is used for the transplant distinguishes the different types of BMT.
There are 2 common types of BMT:
- Autologous transplant – uses your own blood-forming cells
- Allogeneic transplant – uses blood-forming cells donated by someone else
- Matched Sibling Donor Transplantation
- Matched Unrelated Donor Transplantation
- Haploidentical Family Donor Transplantation
- Unrelated Cord Blood Transplantation
Some other term or type of transplant:
- Syngeneic BMT: A syngeneic transplant is an allogeneic transplant from an identical twin. Identical twins are considered a complete genetic match for a transplant. In cases where the donor is the identical twin of the patient, the transplant is essentially like an autologous transplant, as the cells are genetically identical.
- Mini Transplant: Mini transplant is termed coined on the basis of conditioning regimen before transplant (“Non-Myeloablative” or, more accurately, “Reduced-Intensity Conditioning” transplant). This type of transplant makes the procedure safer in patients of older age or with pre-existing health problems.
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For an autologous transplant, patient’s own blood-forming cells are collected, frozen and stored. Then, they’re given back to patient after chemotherapy (chemo) and possibly radiation. Doctor will decide the best time to collect patient’s cells. After they are collected, the cells can be frozen for months or years until patient need them for his/ her transplant.
How are patient’s cells collected?
There are 2 options. Your doctor will decide which is best for you.
- Peripheral blood stem cell (PBSC) collection: The cells are collected from your bloodstream. This process is called apheresis. Before apheresis, you get shots for a few days to increase the number of blood-forming cells in your bloodstream. During apheresis, blood is removed from your vein through an intravenous (IV) line, passed through a machine, and put back into your vein. The machine takes out the blood-forming cells that will be used for your transplant. Most patients who have an autologous transplant collect their cells this way.
- Bone Marrow Collection: The cells are collected from the pelvic (hip) bone during surgery. You get anesthesia so you don’t feel pain. A doctor uses a special needle to take out the blood-forming cells from your bone marrow.
An Allogeneic bone marrow or stem cell transplant is one where cells from a donor are introduced to the patient in order for the new, donated cells, to reproduce, enabling the patient to recover healthy bone marrow and healthy blood. The donated cells can come from a relative, sibling or an unrelated donor (this includes umbilical cord blood) who is a close genetic match to the recipient. Sometimes, people get donated blood-forming cells from umbilical cord blood. This is the blood collected from the umbilical cord and placenta after a baby is born.
There are majorly 4 major types of Allogeneic Transplants:
- Matched Sibling Donor Transplantation
- Matched Unrelated Donor Transplantation
- Haploidentical Family Donor Transplantation
- Unrelated Cord Blood Transplantation
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In Allogeneic Transplants, firstly Doctor looks for a matching donor in your family usually a brother or sister by performing Human Leukocyte Antigen (HLA) typing test of the patient and all the siblings from same parents. That’s because we inherit HLA markers from our parents as each person has a number of pairs of HLA antigens. Each brother and sister has a 25% (1 out of 4) chance of completely matching the patient.
The best transplant outcomes (results) happen when a patient’s HLA completely matches the donor’s HLA. The Success rate of Matched Sibling Donor Transplant is the highest of all ranging around 95% as a close HLA match also helps lower the risk for problems after transplant. So the most ideal allogeneic transplant donor is a Human Leukocyte Antigen (HLA) Matched Sibling Donor (MSD). An HLA-MSD is available only in 30–40% of the patients.
How well the donor’s and recipient’s HLA tissue types match plays a large part in whether the transplant will work. A match is best when all 10 of the known major HLA antigens are the same – a 10 out of 10 match. People with these matches have a lower chance of graft-versus-host disease, graft rejection, having a weak immune system, and getting serious infections.
Finding a matching donor can be a challenging and lengthy process, especially if a sibling match is not available. Voluntary marrow donors are registered in several national and international registries. A bone marrow search involves searching these registries for donors whose blood most closely resembles or matches the individual needing the transplant. Registries serve as matchmakers between patients and volunteer donors. They can search for and access millions of possible donors and hundreds of thousands of cord blood units.
About 70% of patients (7 out of 10) who need a transplant don’t have a close match in their family. If you don’t have a match in your family, the next option available is to search the World Wide Bone Marrow Donation Registries for a .
The process begins with a simple blood test or HLA test through Buccal Swab by collecting Cheek cells designed to evaluate the recipient's HLA genes. This test, called HLA typing, identifies antigens or proteins located on the surface of their cells that are important for immune function.
Once the patient's HLA-type is known, a preliminary search can be performed in the National & International Bone Marrow Donation Registries. The preliminary search is a computerized search designed to identify potential bone marrow donors that have similar HLA antigens. The preliminary search is free of charge and no donors are contacted during this phase of donor searching. If the preliminary search is successful in identifying potential donors and the recipient and doctor decide an unrelated transplant is necessary, a formal search can be initiated.
Keep in mind that there are stages to this process – there may be several matches that look promising but don’t work out as hoped. The team and registry will keep looking for the best possible match for the patient. If our team finds an adult donor through a transplant registry, the registry will contact the donor to set up the final testing and donation. If our team finds matching cord blood, the registry will have the cord blood sent to our transplant center.
Finding a donor can take time, so contact BMTClinic.com now to start a donor search as soon as possible. We can look for a donor even if you don’t need a transplant right away.
Once a Matching Unrelated donor is found through worldwide registries, the Stem Cells are procured from the particular registry and sent to the Transplant centre where the patient is admitted. The cost of Matched Unrelated Donor Transplant goes very high almost the double cost of Haplo-identical/ Half Matched Transplant because the Transplant Centre needs to procure Stem Cells from the Unrelated Donor who can be anywhere in the world and then perform the Allogeneic BMT of the patient.
Haploidentical or half matched donor BMT is the only treatment option available for patients of blood disorders, who have been advised BMT, but do not have a fully HLA matched family donor or a matched unrelated donor.
A Haploidentical Transplant is a type of Allogeneic Transplant. It uses healthy, blood-forming cells from a half- matched donor to replace the unhealthy ones. The donor is typically a family member. Doctor tests patient’s blood to find out your Human Leukocyte Antigen (HLA) type. Doctors look for a donor or umbilical cord blood that closely matches your HLA.
But sometimes they can’t find a close HLA match. Then, a haploidentical transplant may be an option. This is a type of allogeneic transplant where the donor matches exactly half of your HLA.
A haploidentical, or half-matched, donor is usually your mom, your dad or your child. Parents are always a half-match for their children. For some people a transplant from a half-matched donor, or a haploidentical transplant, is a treatment option. Siblings (brothers or sisters) have a 50% (1 out of 2) chance of being a half-match for each other. It’s very unlikely that other family members (like cousins, aunts or uncles) would be a half-match. And thus these donors are readily available for most patients.
These transplants were so far associated with a relatively high rate of rejection, slow immune recovery, and a substantial risk of treatment-related mortality but with better knowledge transplant immunology and improved techniques of T cell depletion has led to sea change in the success of Haploidentical Bone Marrow Transplant. The key to success in Haploidentical HSCT is T cell depletion.
What is Haploidentical Transplantation?
Haploidentical Bone Marrow Transplantation (BMT) is a procedure in which, instead of fully HLA matched family donor, a half HLA matched parent or sibling is the donor for bone marrow or blood stem cells.
How is Haploidentical BMT different from other forms of BMT?
BMT from a Haploidentical family donor is associated with a higher risk of both GVHD and Graft Failure. Thus, the success of such BMT depends on the following:
- Selection of the right Haploidentical Donor amongst the family members.
- Deliver the most suitable ‘Conditioning’ therapy to prevent Graft Failure.
- Prevent GVHD by processing the graft or using a combination of immunosuppressive drugs.
What are the indications for a Haploidentical BMT?
The indications for Haploidentical BMT are the same as Matched Family Donor BMT. Haploidentical Transplant is recommended only if the patient is symptomatic enough and have frequent Crisis or Medical Problem related to disease.
Everyone has a donor and we are showing the way!
In a country where alternate donor BMT is rarely available for patients lacking a matched family donor, Haploidentical BMT seems to be a logical option. Our BMT Centre has developed a state-of-the art infrastructure and laboratory facilities to promote the use of Haploidentical Donor BMT in India.
Unique Infrastructure for this life saving procedure “Haploidentical Bone Marrow Transplantation”
The patients undergoing intensive conditioning and T cell depleted stem cells from Haploidentical donors are at the highest risk of infections. Infections mostly come in the form of bacterial infections from the gut or skin of the patient or as resistant bacteria from other infected patients, or as fungal infection through the air. The HVAC system of highest standards has been installed in our BMT centre, which is first of its kind in the country. This ensures protection to the patient from all airborne infections, whilst inside the unit.
Total Body Irradiation is an essential part of conditioning for BMT, but often results in serious long term toxicities. With VMAT technology, we can target the entire bone marrow at much higher doses without exposing other organs such as heart, lungs, liver or kidneys to the detrimental effect of radiation. Our Radiation Oncologists have developed this technique to improve the outcome of patients undergoing BMT.
To support the hapaloidentical BMT Programme, Our BMT Lab provides
- 8-colour Flow-cytometry based diagnostics for Leukemia, Lymphoma and Aplastic Anemia
- Detection of Minimal Residual Disease (MRD)
- Molecular diagnosis for Leukemia
- HLA typing, NK Cell Genotyping and CD34 + Stem Cell Estimation
- Comprehensive donor selection for Haplo-identical BMT based on NK-KIR Profile.
- Magnetic Separation of Cells using MACS Technology.
- Long Term Cryopreservation of Stem Cells at -1960 C liquid nitrogen freezer in vapour phase
- Conventional and Real Time PCR for Viral Pathogens
- Drug Levels for BMT.
If you have questions about whether Haploidentical Transplant is right for you, contact us nowand consult Dr Vikas Dua, the person behind many successful transplants. Every person’s situation is different, and doctor can help you make choices about your treatment.
This information is for patients or parents who may be considering umbilical cord blood transplantation. It explains what it is and tells you about any possible risks or side effects.
Sometimes, people get donated blood-forming cells from umbilical cord blood. This is the blood collected from the umbilical cord and placenta after a baby is born. The stem cells are tested, typed, counted and frozen until they are ready to be transplanted. Although close matches in cord blood transplants are preferred, they are not as important as the risks of Graft Versus Host Disease are much lower with cord blood transplants (although the risk of infection is higher).
What is cord blood?
After a baby is born and the umbilical cord (the cord that joins the mother to the baby) is cut. Some blood remains in the blood vessels of the placenta and the portion of the umbilical cord that remains attached to it. After birth, the baby no longer needs this extra blood. This blood is called placental blood or umbilical cord blood: "cord blood" for short.
Cord blood transplantation from an unrelated source is referred to as Unrelated Cord Blood Transplantation or UCBT. This means that the person having the transplant (the recipient) is not related to cord blood donor (the mother / baby).
Why might I need a cord blood transplant?
Cord blood can be used for stem cell transplants in the treatment of more than 70 different diseases. The most common disease treated has been Leukaemia, followed by inherited diseases like Sickle Cell Anemia (of red blood cells, the immune system and certain metabolic abnormalities). Patients with Lymphoma, Myelodysplasia and Severe Aplastic Anaemia have also been successfully transplanted with cord blood.
Why is cord blood used for transplants?
Cord blood contains all the normal elements of blood - red blood cells, white blood cells, platelets and plasma. It is also contains stem cells, which act as a sort of repair system for the body. For blood transplants, we are particularly interested in the haematopoietic stem cells, which form blood cells.
Cord blood is a lot richer in stem cells than bone marrow. For example, a litre of bone marrow has 300 million nucleated cells (NC) per kilo, whereas 50 ml of cord blood contains 10 million NC per kilo.
How is the cord blood collected?
Cord blood is collected from the umbilical cord of a newborn after it is clamped. The placenta and the cord are waste products after birth and are usually discarded. This does not result in any harm to the baby or the mother. The cord blood is only collected with the mother’s consent.
Whose Cord Blood shall be used?
Parents i.e. the Mother consents for collection of cord blood from the Umbilical Cord after it is cut from the delivered child along with the placenta. These cord blood units are voluntarily donated and stored in Public Cord Blood Banks. No one pays for the storage upfront. The cord unit is screened and HLA typed. The details are entered in a computed registry which is accessible to transplant centres worldwide.
Once the unit is found to be suitably matched for a patient, the transplant centre requests to the particular cord blood bank to procure the unit for transplantation after fulfilling the requisite criteria and paperwork from both sides. The transplant centre is charged the amount payable for issuance of the cord blood unit. This varies between 12,000 USD to 25,000 USD per unit. This is called Unrelated Cord Blood Transplantation’.
Can I store the Cord Blood of my child for my own family?
The chances of one’s own cord blood being used for his/her own transplant is extremely remote(less than one in a million). A child can donate bone marrow or peripheral blood for any family member above the age of 2 years if desperately needed. Thus the chance of using a cord blood unit for a family member is equally remote.
However, in a family where a child is affected with Thalassemia or Leukemia for example and needs an urgent transplant, a cord blood unit from the newly born sibling if suitably matched can be used for transplantation. This is called ‘Directed Cord Blood Donation/Storage’.
As BMT physicians, we discourage private cord blood banking. We encourage donation of cord blood units to Public Cord Blood Banks to add to the pool of unrelated cord blood units available for BMT.
How much cord blood is needed?
On an average 20 million NC per kilo are needed for cord blood to engraft (in other words for the transplant to work). The higher the number of stem cells in the blood, the better the chance of survival and recovery after the transplant. The number of cells needed is related to the weight of the person having the transplant. It is easier to carry out UCBT in children and patients with low body weight.
Is this blood safe?
Cord blood is only collected after the health of the mother and the family is checked. Once collected, the cord blood is tested in a laboratory for infectious diseases, such as hepatitis and HIV. Only good quality blood with no infections is used for transplantation.
How will a match be found?
Unlike other types of stem cell transplant, cord blood transplants do not need to be a perfect match between the blood and the recipient. This matching process is known as tissue typing or HLA matching. However, we know that patients have a better chance of successful transplant and recovery when the match is closer.
Why is cord blood important for people from black and minority ethnic (BME) backgrounds?
Bone marrow registers have fewer matches for people from BME backgrounds, because:
- People from ABME backgrounds make up a smaller proportion of the population in the western countries where most public cord blood banks are located, so fewer donors are available.
- There are more differences in the tissue types of people with Asian and African backgrounds than any other group.
- People with African and Asian backgrounds have unique tissue types.
As cord blood (unlike bone marrow) does not need such a close match, it can be used to treat more people from a wider variety of backgrounds.
What are the advantages of using cord blood for a transplant?
Cord blood has advantages over bone marrow and other types of stem cells for transplantation, including:
- Lower incidence and severity of graft versus host disease (GVHD) – see under “Are there any risks or side effects?”
- Lower risk of viral contamination (similar to being polluted).
- More immediate availability.
- More flexibility; cord blood does not need to be a perfect match.
What are the disadvantages of using cord blood for a transplant?
- Even though it is rich in stem cells, cord blood might not have enough stem cells for some larger patients.
- Cord blood transplants generally take longer to engraft.
- There is no possibility of a second donation from the same source if the first transplant is not successful.
Are there any risks or side effects?
Although cord blood transplants are a relatively new procedure in India, over several currencies have been carried out in USA and Europe. They have also been carried out in other countries such as Japan and Australia. There are risks associated with any procedure but those specifically linked to cord blood transplantation are explained below.
- Even though the health of the mother and baby providing the cord blood are checked, the risk of transmitting a genetic disease cannot be totally removed.
- Cord blood transplants take longer to engraft (take effect); usually three to four weeks (instead of 10 to14 days for peripheral blood transplantation or bone marrow grafts). During this period, patients have fewer white blood cells (the body’s natural defence system) so are more at risk of infections. This is described as having lowered body immunity.
- General risks associated with transplantation are:
- Anaemia: caused by a fall in the number of red blood cells in your blood. It can make you feel weak and you might need blood transfusions until your body can make enough red blood cells again.
- Bleeding or bruising: caused by a fall in the number of platelets (which help your body to heal itself) in your blood. Again this can be treated by blood transfusion until your body can make enough.
- Infections: due to lowered body immunity, you will be at risk in the early phase after the transplantation. During this time, you will have to stay in isolation room of the BMT Unit at Dharamshila BMT unit. You will also be more prone to getting bacterial and at times fungal infections during this time. Once the white cells recover, the chances of getting these infections are reduced. However, there will still be a risk of getting serious viral infections and other odd infections. These are usually preventable with strict monitoring. This means that even after you leave hospital, you will have to attend the Day Care Unit for blood tests and examination. This is usually twice a week for monitoring.
- Graft versus host disease (GVHD): This is when the lymphocytes (a type of white blood cell) from the graft attacks the patient’s body. It is usually mild because you will be given medication to prevent it, but it can become more severe. In the acuteform, symptoms include:
- liver damage
It can happen up to three months after the transplant. After this time, GVHD that happens is called chronic, which can cause the same symptoms along with those of:
- dry eyes
- sore mouth
- joint pains
- tightening of the skin
- chest symptoms
Both the acute and chronic GVHD are treated with steroids and other medicines to suppress the immune system.
- Recurrence of the original disease: Although the transplantation is carried out to cure the original disease, this is not always successful. This depends on various factors, such as:
- the stage of the disease
- response to previous treatment
- how many times the disease has recurred before transplantation.
- Readmission: You might even need to come back into hospital for treatment for infections, GVHD or other problems.
I have heard of double cord transplantation – what is it?
Doctors and scientists have started to look at transplants using cord blood from two different umbilical cords. The aim of double cord transplantation is to improve the recovery and survival for patients. So far about 5000 (by the end of 2013) double cord transplantations have been carried out in USA, Europe and Japan with positive results (although a slight increase in GVHD). Please contact BMTClinic.com if you have any questions about double cord transplantation.
What happens next?
It is very important that you fully understand the treatment process, so please ask for an appointment with our experts and discuss your case and ask as many questions as you need to ask. When it is decided that Cord Blood Transplantation is the right treatment for you, our experts will explain you the next steps.
Before any surgery you will be seen by the surgeon and / or the anaesthetist when you will have another opportunity to ask questions. You will also be asked to sign a consent form.
Can Cord Blood Units be used to cure other diseases like cerebral palsy, stroke or spinal cord accident etc?
Cord blood possesses more immature stem cells compared to that of an adult bone marrow. There is a lot of research and interest in developing these cells to heal damage to other organs. However, this research is in its infancy.
Currently, there is no evidence that simple infusion of cord blood or bone marrow to an organ is of any benefit.
If you have any questions or queries, you can CONTACT US anytime- Phone/ WhatsApp No.: +91-7015677759 Email ID: firstname.lastname@example.org.