Bone Marrow Transplant: Procedure, Type, Side Effect, Risks

A bone marrow transplant (BMT), or haematopoietic stem cell transplant (HSCT), is the process of infusing healthy blood-forming cells into the patient’s body to replace the bone marrow that is not producing enough healthy blood cells. During a bone marrow transplant, doctors may transplant cells from the patient’s own body or a donor. 

Anatomy and Physiology of Bone Marrow

Bone marrow is a spongy tissue inside the body’s bones, particularly in the pelvic bones, sternum, and long arm and leg bones. It comprises two types of tissue: red marrow and yellow marrow. 

1. Red Marrow: Red marrow produces blood cells, like red blood cells (RBCs), white blood cells (WBCs), and platelets. It is rich in haematopoietic stem cells, which are immature cells that can differentiate into various types of blood cells. 
   Red marrow also contains specialised cells called stromal cells, which provide structural support and secrete growth factors that regulate blood cell production.
2. Yellow Marrow: Yellow marrow primarily comprises adipose tissue (fat cells) and does not produce blood cells. It can, however, be converted into red marrow in cases of severe blood loss or anaemia.

The process of cell production in the bone marrow is called haematopoiesis. It begins with hematopoietic stem cells, which can differentiate into two types of progenitor cells: 

1. Myeloid Progenitor Cells: Differentiate between red blood cells, platelets, and various white blood cells
2. Lymphoid Progenitor Cells: Differentiate between B cells, T cells, and natural killer (NK) cells

The regulation of haematopoiesis is a complex process that involves various growth factors and signalling pathways. Abnormalities in haematopoiesis can lead to various blood disorders, such as anaemia, leukaemia, and lymphoma.

A bone marrow transplant is performed for various medical reasons, mainly to treat conditions affecting the bone marrow or blood cells. Some of the most common reasons for recommending a bone marrow transplant include:

1. Chemotherapy or Radiation Therapy: Sometimes, a bone marrow transplant is performed to restore the bone marrow and blood cell production after high-dose chemotherapy or radiation therapy for cancer treatment.
2. Damaged Bone Marrow: A bone marrow transplant replaces bone marrow that is not working properly with new stem cells. 
3. Cancer: Bone marrow transplant is often used to treat bone marrow cancer, such as leukaemia, lymphoma, and multiple myeloma.

Who Needs a Bone Marrow Transplant?

Bone marrow transplant is recommended for individuals with a condition that affects the bone marrow or blood cells.It is usually recommended when people have exhausted other treatment options or have a high risk of treatment failure.A person with any of the following conditions may be an ideal candidate for a bone marrow transplant procedure:

1. Adrenoleukodystrophy (ALD): A rare genetic disorder affecting the nervous system and adrenal glands.
2. Aplastic Anaemia: it is a condition in which the bone marrow does not produce enough new blood cells
3. Congenital Neutropenia: The bone marrow does not produce enough neutrophils, a type of white blood cell, leading to recurrent bacterial infections and other complications.
4. Haemoglobinopathies: A group of inherited disorders that affect the production or structure of haemoglobin in the red blood cells, resulting in anaemia and other complications.
5. Hodgkin’s Lymphoma: A type of cancer that affects the lymphatic system
6. Leukaemia: cancer affecting the blood and bone marrow, causing an overproduction of abnormal white blood cells.
7. Multiple Myeloma: It is a type of cancer that affects the plasma cells in the bone marrow, leading to the overproduction of abnormal proteins and weakening of the bones.
8. Neuroblastoma: Cancer that develops in immature nerve cells and can occur anywhere in the body, but most commonly starts in the abdomen
9. POEMS Syndrome: Abnormal growth of plasma cells leads to the overproduction of proteins and causes nerve damage.
10. Primary Amyloidosis: An abnormal protein called amyloid builds up in organs such as the heart, kidneys, liver, and nerves, causing damage and dysfunction.
11. Sickle Cell Anaemia: A blood disorder in which the red blood cells become misshapen and fragile, leading to a decreased oxygen-carrying capacity and various health problems.
12. Thalassemia: An inherited blood disorder in which the body produces abnormal haemoglobin, resulting in a decreased ability to produce red blood cells and leading to anaemia and other complications.

A bone marrow transplant is not a surgery. Instead, the procedure is similar to a blood transfusion. The patient is awake during the procedure. While the procedure for bone marrow transplant can vary depending on the specific type of transplant and the patient’s condition, it generally involves the following steps:

1. Transplantation: The harvested bone marrow or stem cells are infused into the patient’s bloodstream through a central venous catheter installed on the patient’s upper right portion of the chest. The cells migrate to the bone marrow, where they start to produce new blood cells. The transplant will typically take place during multiple sessions over several days. 
2. Engraftment: It may take several weeks for the new bone marrow cells to start producing enough healthy blood cells, a process called engraftment. The patient is at high risk for infections and other complications during this time.

Types of Bone Marrow Transplant

Two major types of bone marrow transplants depend on the source of healthy blood cells to replace the damaged bone marrow. The type of procedure used depends on the need of the procedure. The two types of transplant include:

1. Autologous Bone Marrow Transplant: Autologous bone marrow transplant is often used in treating certain types of cancer, such as lymphoma or multiple myeloma.
   1. In an autologous bone marrow transplant, the patient’s own bone marrow or stem cells are harvested and stored before undergoing high-dose chemotherapy or radiation therapy to destroy cancer cells or abnormal cells. 
   2. Once the chemotherapy or radiation therapy is completed, the stored bone marrow or stem cells are infused back into the patient’s bloodstream to help regenerate healthy blood cells. 
2. Allogeneic Bone Marrow Transplant: Allogeneic bone marrow transplant treats many types of cancers, like leukaemia and lymphoma, as well as other conditions, such as aplastic anaemia, sickle cell anaemia, and thalassemia.
   1. In an allogeneic bone marrow transplant, bone marrow or stem cells are collected from a donor, usually a close relative, such as a sibling, or an unrelated matched donor. 
   2. The donor’s bone marrow or stem cells are infused into the patient’s bloodstream, where they migrate to the bone marrow and produce healthy blood cells. 

A bone marrow transplant is a complex, multi-step procedure that requires several tests and preparations beforehand. The doctor will also explain the procedure and instructions to be followed. The following is what the patient can expect before the transplant:

1. The patient may be asked to undergo a pre-anaesthetic checkup.
2. The healthcare provider will evaluate the patient’s medical history and symptoms. 
3. The doctor will briefly explain the surgical procedure, hospital duration, estimated cost, and insurance formalities. 
4. The patient must bring a list of questions to ask the doctor. 

Since bone marrow transplants can take up to 5 to 7 days, patients must make arrangements before their first transplant session, including:

1. Taking leave from work
2. Care for children and pets
3. Arrangements for the family to stay near the hospital
4. Travel arrangements to and from the hospital
5. Insurance coverage, bills payment, and other financial concerns 

Finding a Donor

Finding a suitable donor for a bone marrow transplant is crucial for the procedure’s success. There are two main types of donors: related donors and unrelated donors.

1. Related donors are usually siblings or parents of the patient, who have a higher chance of matching the patient’s tissue type.If a related donor is not available or is not a match, doctors may look for an unrelated donor.
2. Patients need to be registered with a bone marrow donor registry to find an unrelated donor.This registry is a database of potential donors who have agreed to donate their bone marrow or stem cells to people in need.
3. When a patient needs a bone marrow transplant, doctors search the registry for a matching donor.The donor’s tissue type is compared to the patient’s tissue type to determine whether they match.
4. The human leukocyte antigen (HLA) system is a group of proteins found on the cells’ surface. These proteins are used to determine if a donor is a match for a patient.HLA matching is important to prevent graft-versus-host disease, a potentially serious complication of bone marrow transplant.
5. If a matching donor is found, the donor is asked if they are willing to donate their bone marrow or stem cells. 

Finding a suitable donor for a bone marrow transplant is a complex process requiring careful matching and coordination between doctors, patients, and potential donors.

At the Hospital

While preparing for the transplant, the patient may need a hospital stay of about 5 to 7 days to undergo some tests and procedures. Here’s what the patient can expect at the hospital before the procedure:

Pretransplant Tests

The patient may need to go through a series of tests and procedures for several days to ensure they are physically prepared for the transplant. 

1. These tests may include blood tests to evaluate the patient’s blood counts, blood type, and other important health markers. 
2. Other tests may include imaging tests, such as X-rays, CT scans, or MRI, to assess the patient’s organ function and identify structural abnormalities.
3. If the patient is getting treated for cancer, they may need to get bone marrow aspiration (a procedure to remove a sample of the liquid portion of bone marrow for testing a disease) and bone marrow biopsy (a procedure to remove a sample of solid bone marrow for testing) done too. 
4. The patient will undergo a procedure to place a catheter into a large vein, typically in the chest or neck, for the duration of the treatment to facilitate the infusion of stem cells, medication, and blood products into the body.

Collecting Cells for Autologous Bone Marrow Transplant

Before a bone marrow transplant, the patient must undergo a procedure to collect the bone marrow or stem cells used in the transplant. If the cells are being collected from the patient, i.e., an autologous transplant, the cells can be collected in two ways:

1. Bone marrow harvest: The patient will undergo a surgical procedure under general anaesthesia to remove a bone marrow sample from the hip bone using a special needle.The procedure takes one to two hours. The collected marrow is processed and stored until it is needed for the transplant.
2. Apheresis: A machine called an apheresis machine is used to collect stem cells from the patient’s bloodstream.A catheter is placed in the patient’s vein, and blood is drawn from the catheter and circulated through the apheresis machine, which separates the stem cells from the other blood components.The remaining blood is returned to the patient’s body. The stem cells are then collected and stored until needed for the transplant. The entire procedure usually takes about 2 to 4 hours. 

Collecting Cells for Allogeneic Bone Marrow Transplant

If the cells are being collected from a donor, i.e. an allogeneic transplant, the donor can donate bone marrow or stem cells in three ways:

1. Bone marrow donation: The donor undergoes a surgical procedure under general anaesthesia to remove a sample of bone marrow from the hip bone using a special needle. The collected marrow is processed and stored until it is needed for the transplant.
2. Peripheral blood stem cell (PBSC) donation: The donor receives a medication that stimulates the production of stem cells in the bloodstream, and the stem cells are then collected using apheresis.
3. Umbilical cord donation: Cord blood transplants are another type of allogeneic transplant that uses stem cells from the blood of umbilical cords that mothers donate after their babies’ birth. The blood from these umbilical cords is frozen and stored until needed for a bone marrow transplant. 

Conditioning

After completing the pretests and before the transplant, the patient receives high-dose chemotherapy or radiation therapy to:

1. Suppress the immune system
2. Destroy the abnormal cells in the bone marrow 
3. Make room for new cells to grow

The type of conditioning process depends on several factors, such as the type of transplant planned, the disease being treated, and the patient’s overall health. The side effects of the conditioning process may include:

1. Nausea and vomiting
2. Hair loss
3. Diarrhea
4. Mouth sores and ulcers
5. Bleeding
6. Infection
7. Fatigue
8. Cataracts
9. Anaemia
10. Heart, lung, or liver failure

After the transplant, the patient will remain under close medical care. While some people can leave the hospital soon after the transplant, others may need to remain there for several weeks or even months. How long a patient stays at the hospital depends on several factors, such as:

1. The medical centre’s procedures
2. The type of transplant
3. Development of complications related to the transplant 

The Recovery Process in the Hospital

During the hospital stay, patients can expect to undergo a variety of post-transplant procedures and tests, including:

1. Monitoring of vital signs: The medical team will closely monitor the patient’s vital signs, such as blood pressure, heart rate, and oxygen levels, to ensure that they remain stable and that there are no signs of infection or other complications.
2. Blood tests: The patient will undergo regular blood tests to monitor their blood counts and ensure that the donor’s stem cells are engrafting properly.
3. Medications: The patient will need to take various medications to help prevent the rejection of the donor’s stem cells and to manage any side effects of the transplant. These medications may include immunosuppressive drugs, antibiotics, antifungal medications, and pain medications.
4. Blood transfusions: The patient may also need to undergo periodic transfusions of red blood cells and platelets until the bone marrow produces enough cells.  
5. Nutritional support: The patient may require nutritional support, such as intravenous fluids or feeding through a tube, to ensure they get the necessary nutrients to support their recovery.
6. Rehabilitation: Depending on the patient’s overall health and physical condition, they may require physical therapy or other forms of rehabilitation to help them regain their strength and mobility.

The patient will get discharged from the hospital when their condition stabilises, and they meet certain criteria, i.e., a specific blood cell count and no fever for two days.

Recovery Process/Expectation after Hospital Discharge

The typical recovery time after a bone marrow transplant can take three months. However, complete recovery can even take up to a year. The recovery process at home includes the following:

1. Diet: After the bone marrow transplant, the patient may need to make several changes to their diet to stay healthy and prevent excessive weight gain and risk of infections. These changes include:
   1. Staying hydrated at all times
   2. Eating a healthy, well-balanced diet, including plenty of fruits, vegetables, whole grains, lean proteins, and healthy fats
   3. Raw or undercooked foods, including meat, fish, eggs, and vegetables
   4. Limiting salt intake
   5. Opting for low-fat dairy products
   6. Including green cruciferous vegetables, like broccoli, cabbage, and cauliflower, in the diet
   7. Avoiding grapefruit and grapefruit juice 
2. Work and Activity: The patient can return to school or work in about two to four months after their transplant. Physical activity should be increased slowly as the patient recovers. Regular physical activity will help control weight, increase endurance, strengthen bones, strengthen muscles, and keep the heart healthy.
3. Lifestyle Changes: The patient must also incorporate some lifestyle changes to prevent the risk of infection and cancer after the transplant. These lifestyle changes include:
   1. Practice Good Hygiene: The patient should frequently wash their hands and avoid contact with sick people to help prevent infections.
   2. Avoid Crowded Places: The patient should avoid crowded places such as malls, movie theatres, and public transportation to reduce the risk of exposure to infectious diseases.
   3. Avoid Alcohol and Tobacco: The patient should avoid smoking and drinking alcohol, as these can impair their immune system and increase the risk of complications.
   4. Protection from Cancer: The patient should wear sunscreen with an SPF of 30 or above when outside in the sun and get the recommended cancer screenings.
4. Psychology Support: Bone marrow transplantation can have significant psychological impacts on the patient. Therefore, psychological support is essential to the patient’s recovery after the transplant. Here are some ways that psychology support can be provided: 
   1. Counselling: A mental health professional, such as a psychologist or a counsellor, can help the patient cope with the emotional and psychological challenges that arise after the transplant. They can provide individual or group counselling to address the patient’s concerns, fears, and anxieties.
   2. Mind-body Techniques: Mind-body techniques such as meditation, deep breathing exercises, and yoga can help the patient relax and reduce stress and anxiety.
   3. Support Groups: Being part of a support group of other transplant patients can help the patient feel less alone and more understood. These groups can provide a safe space for patients to share their experiences and challenges with others who have gone through similar experiences.
   4. Family Therapy: Family therapy can help the patient and their family members communicate effectively, understand each other’s needs and concerns, and provide support during recovery.
   5. Education and Empowerment: Patients can benefit from education about the transplant process, potential side effects, and strategies to manage symptoms. Providing patients with information and tools can allow them to participate in their recovery and feel more in control of their situation.

First Follow-Up Appointment

The first follow-up appointment after the bone marrow transplant will be scheduled within a week of discharge from the hospital. 

1. During this visit, the patient will be expected to come with a list of all the medications they are taking, along with the dosages of each one. 
2. The patient will undergo blood tests to check their blood count, electrolyte levels, and liver and kidney function. 
3. The doctor will inform them if they need a bone marrow aspiration. 
4. The patient may also need intravenous treatments like antibiotics and blood transfusions, usually scheduled on the same day as the follow-up visits. 

Bone Marrow Transplant Success Rate in India

The bone marrow transplant success rate is a staggering 60 to 90% amongst the best hospitals in India. However, the success of the transplant primarily depends on how close the donor and recipient genetically match.Sometimes, finding a good match among unrelated donors can be difficult. Furthermore, it can be difficult to predict the severity of the side effects and the success of the transplant. 

Generally, when the donor is a sibling, the survival rates can range between 66% and 99%. Survival rates can range between 62% and 100% when the donor is not related to the recipient. 

1. 88% of transplant recipients survive for two years, and about 81% show no signs of the disease for two years. 
2. 91% of people who match with a sibling survive at least two years, and 83% show no signs of the disease for two years. 
3. 90% to 96% below age 14 survive at least two years after transplant, and 83% to 93% show no signs of the disease for at least two years.

Factors Affecting Success or Survival Rates

Each case is unique, and the success or survival rate can vary based on specific circumstances. Several factors can affect the success or survival rate of a bone marrow transplant. These include:

1. Age:  Younger patients usually have better outcomes compared to older patients.
2. Overall Health: Patients in good general health have a higher chance of successful transplant outcomes.
3. Disease Stage: The stage and severity of the underlying disease being treated can impact the success of the transplant.
4. Disease Type: Different diseases have different success rates with bone marrow transplants. Some diseases, such as certain types of leukemia, have better outcomes than others.
5. Donor Type and Matching: A well-matched donor, either related or unrelated, improves the chances of a successful transplant. HLA matching between the donor and recipient is a crucial factor.
6. Conditioning Regimen: The intensity and type of conditioning regimen, which includes chemotherapy and/or radiation therapy before the transplant, can affect the success of the transplant.
7. Graft-versus-Host Disease (GVHD): The occurrence and severity of GVHD, a potential complication where the donor cells attack the recipient's body, can impact the overall outcome of the transplant.
8. Infections and Complications: The risk of infections and other complications during and after the transplant can affect the success rate. Prompt identification and management of these issues are crucial.

Bone marrow transplants can provide several benefits for patients with certain medical conditions. The patient and their healthcare team should carefully consider the decision to undergo BMT, weighing the potential benefits against the risks and potential complications. The benefits include:

1. Cure or Long-Term Remission: BMT can cure or provide long-term remission for patients with certain types of cancer and blood disorders, such as leukaemia, lymphoma, and aplastic anaemia.
2. Improved Quality of Life: For patients with non-malignant blood disorders such as thalassemia and sickle cell disease, BMT can improve their quality of life by reducing symptoms, preventing complications, and improving life expectancy.
3. Decreased need for Transfusions: Patients with blood disorders may require frequent blood transfusions before BMT, which can have various complications. BMT can eliminate or reduce the need for transfusions, improving quality of life and decreasing risks.
4. Potential to Restore Immune Function: BMT can restore the immune function of patients with immune deficiencies, such as severe combined immunodeficiency, who may otherwise have a limited life expectancy due to frequent infections.
5. Improved Survival Rates: In some cases, BMT can improve survival rates compared to other treatments for certain types of cancer and blood disorders.

While bone marrow transplants can provide many benefits, certain risks and potential complications are associated with the procedure. Since it is considered a major medical procedure, it increases a person’s risk of experiencing the following:

1. A blood pressure drop
2. Nausea
3. Fever
4. Chills
5. Headache
6. Pain
7. Shortness of breath

While the above symptoms are usually short-lived, a bone marrow transplant can also cause other serious complications.
The chances of developing these complications depend on the patient’s age, overall health, the disease being treated, and the type of transplant performed.
Complications can range from mild to serious and can include:

1. Graft-versus-Host Disease (GVHD): A common and potentially serious complication that occurs when the transplanted cells attack the recipient’s body due to recognising it as foreign. GVHD can cause skin rash, digestive problems, and liver or lung damage.
2. Graft Failure: In some cases, the transplanted cells fail to engraft and grow in the recipient’s bone marrow, leading to the failure of the transplant.
3. Bleeding: Bone marrow transplants can cause a decrease in platelets, which can lead to bleeding in the lungs, brain, and other body parts. 
4. Organ Damage: High doses of chemotherapy and radiation used in preparation for the transplant can cause damage to organs, such as the liver, lungs, and heart.
5. Cataracts: Clouding in the eye’s lens caused by high-dose chemotherapy and radiation therapy. 
6. Hormonal Changes: Bone marrow transplants can cause hormonal imbalances and reproductive problems, such as early menopause, in some patients.
7. Stomach Problems: Chemotherapy and radiation therapy may damage the lining of the digestive tract causing problems like nausea, vomiting, and diarrhoea. 
8. Infection: Patients who undergo BMT are at an increased risk of infections, especially when their immune system is suppressed. Infections can seriously threaten life; therefore, immediate treatment is necessary.
9. Anaemia: Chemotherapy and radiation therapy can decrease the number of red blood cells and haemoglobin in the blood.
10. Secondary Cancers: BMT can increase the risk of developing secondary cancers, such as leukaemia, lymphoma, or solid tumours.
11. Mucositis: It is the inflammation and ulceration of the mucous membranes lining the throat, mouth, and digestive tract.

When to Consult a Doctor?

Infections after a bone marrow transplant can be life-threatening. The patient must immediately inform their doctor if they experience the following signs of infections:

1. A fever of 100℉ or higher (for allogeneic bone marrow transplant)
2. A fever of 100.5℉ or higher (for autologous bone marrow transplant)
3. Severe headache
4. Severe swelling of the throat
5. Stiff neck
6. Mental confusion

A delayed bone marrow transplant refers to a situation where a patient who would benefit from a bone marrow transplant does not receive the procedure promptly.
While the risks can vary depending on the specific condition being treated and individual circumstances, there are potential consequences associated with delaying a bone marrow transplant:

1. Disease Progression: Many conditions that necessitate a bone marrow transplant, such as leukaemia or lymphoma, are progressive in nature. The longer the disease progresses, the higher the risk of complications and reduced treatment efficacy.
   Delaying the transplant allows the disease to continue advancing, potentially making it more challenging to achieve remission or cure. 
2. Worsening Symptoms: Conditions that require a bone marrow transplant can cause symptoms such as fatigue, weakness, infection susceptibility, and anaemia.
   Delaying the transplant prolongs the period during which the patient may experience these symptoms, impacting their quality of life and overall well-being.
3. Increased Treatment Resistance: Some diseases, particularly cancers, can develop resistance to chemotherapy or other pre-transplant treatments over time.
   Delaying the transplant may allow the disease cells to acquire additional mutations or become more resistant to treatment, making it harder to achieve successful eradication.
4. Higher Relapse Risk: For certain diseases, such as leukaemia, delaying the transplant can increase the risk of relapse. If cancer cells continue to proliferate or remain in the body, there is a higher likelihood of the disease recurring after the transplant, which can affect long-term survival and treatment outcomes.
5. Deterioration of Overall Health: Delaying a bone marrow transplant may lead to a decline in the patient’s overall health.
   Prolonged exposure to disease, ineffective treatments, or ongoing symptoms can weaken the patient’s immune system and other vital functions, making the transplant procedure more challenging and increasing the risk of complications.

Bone marrow transplant cost in India ranges between ₹ 15,00,000 to ₹ 27,00,000. The actual cost of the procedure depends on the type of bone marrow transplant performed. Autologous and allogeneic are the two most common types of bone marrow transplants, whose costs are as follows:

Several tests and procedures are included in the bone marrow transplant, which may affect the cost of the procedure. The pre-procedure bone marrow transplant costs include the following:

A bone marrow transplant is a crucial procedure that can save the lives of individuals with different blood disorders and cancers. It involves replacing damaged bone marrow with healthy stem cells.

While the procedure can have potential risks and complications, the benefits can be life-changing.

With continued advancements in technology and research, bone marrow transplant offers hope for many patients worldwide. If you may need a bone marrow transplant, consult a doctor to discuss the risks and benefits of the procedure.

At HexaHealth, we aim to make the bone marrow transplant journey as seamless and stress-free as possible for our patients.

Our team offers guidance and support to patients and their families throughout the transplant process, from initial consultations to long-term follow-up care.

So if this is what you are looking for, contact an HexaHealth expert today to discuss more about bone marrow transplant meaning, benefits, side effects, procedure, and more!

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