Bone Marrow Transplant

Overview

Despite the name, a bone marrow transplant today rarely involves an operation on anyone's bones. It is closer to a long, carefully managed course of treatment followed by something that looks like a blood transfusion.

Bone marrow is the soft tissue inside large bones that makes blood. It contains stem cells (immature cells that grow into red cells, white cells and platelets). When the marrow is diseased or destroyed, the body cannot make healthy blood. A transplant first clears the marrow with high dose chemotherapy, sometimes with radiation, a stage called conditioning. Healthy stem cells are then dripped into a vein. They travel to the bones, settle there and start producing new blood cells. Doctors call this engraftment.

Because most stem cells are now collected from the bloodstream, many doctors use the term stem cell transplant. Both names mean the same treatment.

Autologous and allogeneic transplants

There are two main types, and the difference shapes everything that follows.

Autologous transplant uses your own stem cells. They are collected while your disease is under control, frozen, and returned to you after high dose chemotherapy. No donor is needed and there is no risk of the body rejecting the cells. It is used mostly for multiple myeloma and some lymphomas.

Allogeneic transplant uses stem cells from a donor. The donor's cells build a new blood and immune system, and that new immune system can also attack any remaining cancer cells. The trade off is graft versus host disease (GVHD), in which the donor's immune cells attack the patient's skin, gut or liver. Doctors use medicines to prevent and treat it.

Who needs it

The haematologist (blood specialist) recommends the type of transplant based on the diagnosis, how the disease has responded so far and the patient's fitness. Conditions often treated with a transplant include:

• Acute myeloid and acute lymphoblastic leukaemia, usually allogeneic.
• Multiple myeloma and relapsed lymphoma, usually autologous.
• Aplastic anaemia, where the marrow stops making enough blood cells.
• Thalassaemia major and sickle cell disease, inherited blood disorders that are more common in South Asia, Africa and the Middle East, usually allogeneic.
• Myelodysplastic syndrome and some rare immune disorders.

Timing matters. For many blood cancers, the team wants the disease in remission (no detectable disease, or very little) before transplant.

HLA matching and finding a donor

For an allogeneic transplant, donor and patient are compared using HLA typing. HLA (human leukocyte antigens) are markers on the surface of cells that the immune system uses to tell its own cells from foreign ones. The closer the match, the lower the chance of rejection and GVHD. The test needs only a blood sample or a cheek swab.

You inherit half your HLA markers from each parent, so full brothers and sisters are tested first. Each has about a one in four chance of being a full match. If no sibling matches, there are two main options. A haploidentical donor is a half matched relative, often a parent, child or sibling, and this approach is now common with special medicines given after transplant. A matched unrelated donor can be searched for in national and international registries, which takes longer and adds cost. When you compare hospital quotes, ask which donor types each hospital works with.

Stem cell donation by a relative carries lighter legal checks than kidney or liver donation, but each country and each hospital sets its own requirements. Expect to provide identity documents and proof of the relationship and of free consent, sometimes a letter from your embassy, and possibly a committee interview. MediCurage never finds or pays donors. The hospital's transplant coordinator confirms exactly what applies before you travel.

How it is done

Before you travel

Send us the diagnosis report, the latest bone marrow biopsy, recent blood counts, treatment so far and any HLA results. If brothers and sisters can have HLA typing done at home, send those too. Name a preferred country on the quote form, or let partner hospitals in several countries review the case; each quotes, and you choose. We request the hospital's visa letter and help the donor and the caregiver each prepare their own application. Attendant rules differ by country; if you are treated in India, up to two attendants can travel with a patient (three for Bangladeshi nationals on the regular medical visa), which covers a sibling donor and one caregiver. The hospital treats; MediCurage books the flights and looks for a stay within a short drive of the transplant unit, with a kitchen and rooms that are easy to keep clean, because you may be living there for two months or more after discharge and freshly cooked food matters while the immune system recovers.

After you arrive

A driver or representative we book meets you in the arrivals hall with a board showing the patient's name. We send you their name and number before you fly. After you arrive, the first one to two weeks are for tests: heart scan, lung function, dental check, infection screening and repeat marrow tests if needed. A central line is placed, which is a thin tube in a large vein in the chest or arm. It is used for chemotherapy, the stem cell infusion, blood tests and transfusions.

Stem cells are usually collected by apheresis. The donor, or the patient in an autologous transplant, receives growth factor injections for about four to five days to move stem cells from the marrow into the blood. A machine then draws blood from one arm, separates out the stem cells and returns the rest through the other arm. This takes a few hours and is sometimes repeated the next day.

Conditioning lasts about a week. On transplant day the stem cells are given through the central line, often in less than an hour.

Recovery and how long you stay

The weeks after infusion are the hardest. Blood counts drop very low before the new cells take over, which usually takes about two to four weeks. During this time patients stay in a room with filtered air, visitors are limited, and the team gives transfusions, antibiotics and treatment for mouth sores and nausea. Hospital stay is usually about three weeks after an autologous transplant and four to six weeks after an allogeneic one.

After discharge, you stay near the hospital for clinic visits, several times a week at first. Autologous patients can often fly home about four to six weeks after transplant. Allogeneic patients are usually asked to stay for around three months after transplant, because GVHD and infections are most likely in this period. One family member needs to be with the patient all day, every day, and your coordinator and interpreter support that person too.

Questions to ask your doctor

• Which type of transplant do you recommend, and why?
• Should my disease be in remission first, and how will you check that?
• If no sibling matches, would you use a half matched relative or search a registry?
• What conditioning treatment will I receive, and what side effects should we expect?
• How will the room and visiting rules work during the low count period?
• What signs of GVHD or infection should we watch for after we go home?
• Which tests can be done in my own country later, and how will results reach you?

One question is easy to forget: blood products at home. Many transplant patients need irradiated blood and platelets (treated so the donor's white cells cannot attack the patient) for a period set by the transplant unit. Before you fly home, ask whether your home hospital can supply them, and ask the unit to write that requirement clearly in the discharge summary.