Bone Marrow Transplant (BMT) Unit in IKM-HUKM
BMT Unit is a specialized center that cares for peripheral blood stem cell
transplant patient (BMT). It is located at the 2nd floor in HUKM. We have been
in operation on this floor since April 1999.
BMT is a process by which non-functioning, deficient bone marrow or malignant
cells are eliminated using high dose chemotherapy with or without radiation
therapy followed by peripheral blood stem cell (PBSC) replacement or rescue in
order to restore haematologic & immunologic function.
THE FUNCTION OF BMT UNIT
Handling services & Intensive care for:
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Mobilization / stem cell collection & infusion.
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Chemotherapy for pre - transplant
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Pre & post care for Transplant patients.
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The BMT Units consists of:
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4 Isolation rooms for immediate & critical care of bone marrow
transplant.
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4 Isolation Rooms for bone marrow transplant and immediate care,
takes about 2-3 weeks.
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8 Single Rooms for Post Transplant Care about 10-14 weeks.
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1 Rooms as Clinic / for /Counseling / Mini Library
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1 Study Room
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1 Treatment Room
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1 Staff Room
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1 Pantry (Patients)
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1 Store Room
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1 Sluice Room |
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4 Isolation rooms for Bone marrow transplant & Post Transplant
Care.
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- Critical area 1:1
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- Semi critical area 1:2
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Range of admissions is a between 4 to 8 patients at any one time.
The patients stay in BMTU about 2 months.
There is one doctor who is in charge of the ward, he/she makes a morning round
and is contactable when the nurses need the doctor. She does another round in
evening just before the doctor goes off duty.
There is one doctor from the Hematology list of doctors who will be on call at
BMTU. Grand Ward Rounds are done on Tuesdays,Wednesdays and Fridays at BMTU,
Male and Female Hematology Rooms in the male and female medical wards.
Cases for Transplant are selected from the ward rounds to see if they are
autologus or allogenic.
FLOW CHART OF TREATMENT PROCESS:
| Step 1
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Patient/Donor is
selected |
| Step 2
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An Appointment with IMR for HLA
(Human Leukocyte Antigen) typing class 1 & 2 |
| Step 3
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Recipient and 5 Siblings from the
same mother and father is informed |
| Step 4
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First Counseling done by doctor |
| Step 5
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Blood HLA taken & sent to IMR
(takes 3 weeks for the result) |
| Step 6
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If HLA Class 1 is matching (100%)
only one donor is selected for class 2 |
| Step 7
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Appointment for HLA Class 2 is
made with IMR |
| Step 8
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Doctor does the 2nd counseling
with Recipient & Donor
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| Step 9
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Blood HLA Class 2 is taken &
sent to IMR (3 weeks for the result) |
| Step 10
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Date scheduled for Transplant
when class 2 matches |
| Step 11
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Recipient & Donor informed |
Note: If Class 2 fails then MUD (Match Unrelated Donor) search
is made through IMR.
Pre Screening for Recipient & Donor taken 2 weeks prior to admission.
Donor is registered
Investigations area as follows:
Electro-Cardio-Gramme
Chest
X Ray
Lung
Function Test
Serology
Liver
Function Test
Renal
Profile
Full
Blood Gases
G6PD
Short
Tendon Repeat
Prothrombin
Time
Activated
Prothrombin Time
Dental
Clearance
Throat
& Rectal Swab for Culture and Sensitivity
DONOR
The donor too is admitted.
General condition is assessed to prevent from any infection.
Subcutaneous GCSF (Granocyte Colony Stimulating Factor) is given for 4-5 days.
Blood for FBC (Full Blood Count) & CD 34 (Target Cell Count) is done daily.
One day before the harvesting, a femoral catheter is inserted
HARVESTING - Stem Cell
The donor empties his bladder and then he/she is sent to the Blood Bank Unit.
Complete rest in bed is observed.
Under aseptic technique the femoral catheter is connected to the machine.
2 tablets of calcium Lactate is served to prevent cramps before the procedure
and repeated hourly if the donor complains of cramps.
Vital signs are monitored every 15 minutes for one hour and 30 minutes every
three hourly.
The whole procedure takes about 3-4 hours.
Second Day
Blood for FBC, and CD 34 is taken to confirm the target stem cell. If it is not
adequate, the same procedure is repeated like the first day.
If the count is adequate the femoral catheter is removed and the donor can be
discharged the next day.
THE RECIPIENT
Conditioning for allogenic
Regime Non myelo-obiative (chemotheropy) for 6 days
Day-8 is hyperhydration
-1 rest day
0 day transplant day
POST HARVESTING BLOOD INVESTIGATION
PT, (Prothrombin Time)
APPT, (Activated Prothrombin Time)
RP, (Renal Profile)
LFT, (Liver Function Test)
STEM CELL
Cells that can give rise to other types of cells; they are produced both during
embryonic development and in the adult body. Embryonic stem cells begin with
the ability to become any cell type, and quickly differentiate into cells
committed toward a certain type of tissue, e.g., blood, skin, or neural stem
cells.
INFORMATION about BONE MARROW & PERIPHERAL BLOOD STEM CELL TRANSPLANTATION.
A bone marrow transplant is a procedure for replacing blood-forming cells in the
bone marrow that have been destroyed by chemotherapy with healthy bone marrow,
while peripheral blood stem cell transplantation is a method of replacing
blood-forming cells destroyed by cancer treatment (also called peripheral stem
cell support). In a peripheral blood stem cell transplant, immature blood cells
in the circulating blood that are similar to those in the bone marrow are given
to the patient after treatment to help the bone marrow recover and continue
producing healthy blood cells.
There are three categories of bone marrow and peripheral blood stem cell
transplantation:
A. Autologous
B. Allogeneic
C. Syngeneic
AUTOLOGOUS bone marrow & peripheral blood stem cell transplantation
An autologous transplant is when a patient receives their own stem cells that
were removed and stored before treatment rather than receiving cells from a
donor (allogeneic transplant) or from an identical twin (syngeneic transplant).
CARE FOR POST AUTOLOGOUS STEM CELL TRANSPLANT
Recovering from the transplant
Recovery of normal levels of red cells, white cells and platelets in your blood
is called 'engraftment'. This usually occurs within eight to twelve days of the
infusion of stem cells. The most important cells to engraft are the neutrophils
which fight bacterial infection and a growth factor (GCSF) may be given to make
this happen sooner.(If the patient has temperature, he/she will be covered with
antibiotics).
The platelets are the next to return with red cells last. It is relatively
common for patients to require transfusion of red cells and platelets following
a transplant. Once the neutrophils have recovered, the body is able to fight
off infections and if you are otherwise well, you may be discharged home at
this point.
(Supportive blood products will be given to the patient as required as per
blood result, all the blood product must be irradiated)
Going home and follow-up
Most patients are more than ready to go home when the time comes. However,
leaving the protected environment of the ward, where the nurses and doctors
have been checking how you are throughout the day and night, can be scary. Once
you are home, this feeling will probably rapidly disappear and you will be
given a list of names and telephone numbers of someone to contact if you are
unwell or have a problem.
After your autologous transplant your immune system (which fights infections)
recovers fairly quickly, but patients tend to get coughs and colds more easily
and it takes longer to recover from them. It is usual to be reimmunised about a
year after transplant with the immunisations you received in childhood (polio,
tetanus, haemophilus influenza B, ptussis, rubella etc).
Patients should be wary of live vaccines and should ask their own transplant
team about their suitability for vaccination. If you receive total body
irradiation as part of your conditioning, this damages the functioning of your
spleen. In this case your doctor may advise that you be given a special
immunisation (pneumococcal) which would be given prior to the transplant.
Please discuss this with the Transplant Team.
CLINICS : We have dedicated follow-up
clinics for transplant patients to deal with side-effects which
can
occur many years after the transplant procedure. This clinic operates every
Wednesday
from 8.00am to 1.00pm at HUKM (Daycare Heamatology).
MEN :
A common side-effect is men can become infertile and most will have had the
opportunity
to
freeze sperm prior to treatment.
WOMEN : Some women
(particularly if they have had irradiation treatment) will experience an early
menopause
and part of regular follow-up will be to monitor for this.
Neutropenia
A condition in which the number of neutrophils (white blood cells) in the blood
is abnormally low and which can result in the body allowing infections to
develop. When your white cell count is low it is important to look out for
signs of infection and to contact the doctor as soon as possible if you see
any. You will be given 24 hour contact numbers by the Transplant Unit. Some
symptoms to watch out for are fever, temperature greater than 38oC on two
occasions within 2 hours, diarrhoea, redness/swelling around your central line,
cystitis or pain on urination, rigors (shaking or shivering) and
cough.?Infection can be very serious. It is better to contact the doctor with a
false alarm than to stay at home and let any infection develop into a
potentially dangerous situation.
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Do's
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Don'ts
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| Taking Care of Yourself |
You should have a daily bath or shower and make sure your clothing is washed
regularly in the post-transplant period.
Your treatment might make your skin dry for some months unless you moisturise
it regularly. Use hypoallergenic cosmetics.
If you have had radiation therapy you must wear a sunblock when out in the sun,
as the affected skin will remains extra sensitive to the effects of UV rays.
You should drink plenty of fluids and clean your teeth regularly (or clean
dentures after meals and at night).
Make sure you keep your refrigerator clean and at 5o or lower.
Keep your kitchen and all your equipment clean and always wash your hands
before handling food.
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Do not eat:
Soft (e.g. Brie, Camembert) cheese
Unpasteurised cheese
Blue Cheese
Pate
Soft ice cream
Shellfish/uncooked fish
Raw eggs (e.g. in meringue,'home-made' mayonnaise, mousse)
Soft-boiled eggs
Unwashed salad
Be careful:
Pre-cooked meals from a delicatessen counter
Reheated food especially chicken
Dishes containing cream that have not been kept in the fridge
Food beyond the 'use by' dates |
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Pets |
Ensure they are free of infection and ask relatives or friends to
clean out pet litter trays, bird cages or fish tanks
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Avoid contact with other people's pets |
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Socialising |
If you are eating out, choose restaurants which you know to be clean and choose
food which is well-cooked (See Taking Care of Yourself) Immediately following
the transplant you should avoid mixing with people who have colds, flu and
other infections.
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It is especially important to avoid people who have measles,
shingles or chicken-pox.
Avoid crowded pubs and cinemas etc and ask your doctor when you can mix freely
with people again
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| Exercise |
At first you will feel more tired than usual but this will gradually improve.
You will be encouraged to exercise whilst you are on the ward and walking is a
particularly good exercise as you can choose to do as much or as little as you
feel able to.
Pease check with your doctor before resuming these activities.
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Contact sports should be avoided until your platelet counts have recovered |
| Holidays |
Please let your doctor or nurse know when you are going on holiday particularly
if you are going abroad. They will be able to advise you with regard to whether
you need reimmunisations and whether these can be given.
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| Back to Work |
Time taken for you to feel fit enough to return to work varies from person to
person. If you have an office job which is not too demanding then you might
feel able to return to work earlier than someone who has a very active or
stressful job.
You may choose to work part-time first.
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If you are attending school or college, then discuss with your doctor when he
feels you are able to attend full-time and arrange for him to contact your
tutors so that they are aware of what is going on. ?
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| Sex |
After your illness or treatment you may find that you lose interest in sex but
don't worry, this is not unusual. Sexual feelings will usually return once you
(and your partner) have recovered from the stresses of your treatment. It will
be important for you to share your thoughts about this with your partner.
Feel free to discuss any worries you have with your doctor or nurse and it may
help to find out as much as possible about how your treatment may affect you
prior to the transplant. If your doctor or nurse is unable to help you, then
they should be able to refer you to someone who can.
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Patients are usually advised to avoid sexual activity until the platelet count
is above 20 x 10/9/litre but you should discuss this with your doctor in the
clinic.
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ALLOGENEIC bone marrow and peripheral blood stem cell transplantation
An allogeneic transplant is when the patient receives stem cells from someone
other than the patient (autologous transplant) or identical twin (syngeneic
transplant). The donor may be the patient's sister, brother, or sometimes a
person not related to the patient.
Allogeneic transplantation success depends to a large extent on how well the
human leukocyte antigens (HLA) of the donor's bone marrow match the HLA of the
patient's marrow. The higher the number of matching HLA, the greater the chance
of success. HLA is identified by a special blood test.
Close relatives (especially brothers and sisters) usually have a greater chance
of having HLA-matched bone marrow than unrelated donors.
CARE FOR POST ALLOGENEIC STEM CELL TRANSPLANT
In the immediate period following allogeneic stem cell transplant, the
immunosuppressed patient requires specialized care at a transplant ward with a
heath care team experienced in treating post-stem cell transplant
complications.
Transplant patients may still have special health care needs after returning
home, and physicians assuming the care of such patients work together with the
transplant team need to develop a treatment and communication plan to ensure
that the patient receives appropriate monitoring -- short- and long-term.
Complications and Common Infections
Post-transplant care is typically categorized into four general time periods.
Table below outlines possible complications and common infections in each time
period.
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Time Period
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Complication
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Common Infections
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0-1 months
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Regimen-related toxicity
Graft failure
Drug reactions
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Most
bacteria
Candida, Aspergillus
Herpes simplex
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1-3 months
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Acute GVHD
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Candida, other fungi
Pneumocystis carinii
Cytomegalovirus
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3-12 months
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Chronic GVHD
Relapse
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P. carinii
Varicella-Zoster viruses
Cytomegalovirus
Encapsulated bacteria
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> 12 months
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Chronic GVHD
Relapse
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P. carinii
Varicella-Zoster viruses
Cytomegalovirus
Encapsulated bacteria
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Graft Verses Host Disease (GVHD)
A complication called graft-verses-host disease (GVHD) sometimes occurs with
allogeneic bone marrow transplantation. White blood cells from the donor marrow
(the graft) attack the cells of the patient's body (the host) because they
identify the patient's body as foreign. GVHD can usually be treated with
steroids or other immunosuppressive agents.
By definition, acute GVHD occurs before day 100 post-transplant and chronic
GVHD occurs beyond day 100. Recent advances have reduced the incidence and
severity of this post-transplant complication, but GVHD, directly or
indirectly, still accounts for approximately 15% of deaths in stem cell
transplant patients.
Acute GVHD should be treated by the medical team at the transplant department
where the patient was transplanted. Chronic GVHD can develop months or even
years post-transplant, and so physicians assuming the care of transplant
patients need to be aware of its symptoms.
Table below outlines the major symptoms of chronic GVHD.
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Organ/Tissue
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Symptoms
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Skin/Hair
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Rash, scleroderma, lichenoid skin changes, dyspigmentation, alopecia
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Eyes
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Dryness, abnormal Schirmer's Test, cornealerosions, conjunctivitis
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Mouth
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Atrophic changes, lichenoid changes, mucositis,ulcers, xerostomia,
dental caries
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Lungs
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Bronchiolitis obliterans
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GI
tract
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Esophageal involvement, chronic nausea/vomiting, chronic diarrhea, malabsorption,
fibrosis, abdomina
l pain/cramps
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Liver
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Abnormal LFTs, biopsy abnormalities
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Genitourina
ry
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Vaginitis, strictures, stenosis, cystitis
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Musculoskeletal
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Arthritis, contractures, myositis, myasthenia, fascities
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Hematologic
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Thrombocytopenia, eosinophilia, autoantibodies
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Cyclosporine A and methotrexate are indicated for chronic GVHD, but these
should only be administered by physicians familiar with using these drugs to
treat chronic GVHD.
BMTU CLINIC DAYS
Clinic days are every Wednesdays from 8.00 am to lunch time.
Cases that are seen are the post transplant patients.
GLIVEC PROGRAMME
Glivec Programme by the Novartis Pharmaceutical Company was started in May 2003
on trial basis for the chronic myeloid leukimia and patients who have no
donors. They are on 400mg daily for a month, and the patients are followed up
every month to see how they are responding to the drug.
AUTOLOGOUS bone marrow & peripheral blood stem cell transplantation
