Detailed Information On Bone Marrow Transplant by Apollo Hospitals Delhi

1
CENTER FOR BONE MARROW TRANSPLANT AT NDRAPRASTHA
APOLLO HOSPTAL
2
ABOUT APOLLO
3
Indraprastha Apollo Hospitals, Indias first JCI
accredited hospital, is a joint venture between
the Government of Delhi and Apollo Hospitals
Enterprise Limited. Commissioned in July 1996, it
is the third super-specialty tertiary care
hospital set up by the Apollo Hospitals Group.
Spread over 15 acres, it houses 57 specialities
with more than 300 specialists and more than 600
operational beds, 19 operation theatres, 138 ICU
beds, round-the-clock pharmacy, NABL accredited
laboratories, 24-hour emergency services and an
active air ambulance service. Apollo Hospitals
Delhi has the leading programme in kidney and
liver transplant in the country. The first
successful paediatrics and adult liver
transplants in India were performed at
Indraprastha Apollo Hospitals. The hospital is
at the forefront of medical technology and
expertise. It provides a complete range of
latest diagnostic, medical and surgical
facilities for the care of its patients. The
Hospital has introduced the most sophisticated
imaging technology to India with the introduction
of 64 slice CT and 3 Tesla MRI, Novalis Tx ,the
integrated PET Suite and Tomotherapy.
Indraprastha Apollo has also pioneered the
concept of preventive health check programmes and
has created a satisfied customer base over
decades. The Hospital has been consistently
ranked amongst the best 10 hospitals in India by
The Week survey for the past few years.
4
What is Bone Marrow Transplant (BMT)?
Bone marrow transplant also called as
hematopoietic stem cell transplant (HSCT) is the
procedure that is used to replace the unhealthy
bone marrow with new and healthy bone marrow.
This is an intensive medical procedure and
curative treatment option for cancerous non
cancerous diseases of blood and disorders of
metabolism Immune system. Bone marrow is the
soft, spongy tissue inside our bones and is the
factory that makes blood. It is responsible
for producing white blood cells (to protect
against infection), red blood cells (to carry
oxygen around the body) and platelets (to
prevent bleeding). Stem cells are blood cells at
their earliest stage of development in the bone
marrow, before they have become committed to
developing into white cells, red cells or
platelets. They replace the diseased marrow as
well as provide immunity against cancers and
infections.
What are the diuerent types of bone marrow
transplants or stem cell transplants?
Autologous bone marrow transplant (high dose
chemotherapy Autologous stem cells rescue)- In
such transplants patient is himself / herself the
donor The stem cells are taken from the patient
prior to procedure, frozen and stored and then
reintroduced in the patients system after the
patient has received chemotherapy, through a
vein. This type of bone marrow transplant is
typically used for cancers and solid cancer like
neuroblastoma, medulloblastoma. Wilms tumor,
Germ cell tumor, lymphomas, multiple myeloma etc
and also for autoimmune diseases like multiple
sclerosis etc.
5
Allogenic bone marrow transplant-
In this type of transplant, stem cells donated by
someone else are used. Depending on the donor, it
can be further divided into

• Matched related donor transplant- Donation made
  by a HLA matched family member like brother
  sister and sometimes father, mother, son and
  daughter.
• Matched unrelated donor transplant- Donation is
  made by someone other than a family member who
  is found to be complete HLA match with the
  recipient.
• Haplo-identical transplant- Donor and the patient
  are a half match like a parent and offspring
  etc. (Any match
• lt90 is considered as half match).
• Umbilical cord blood transplant- Umbilical cord
  blood rich stem cells are taken from the
  umbilical cord and placenta of the baby. It is
  frozen and stored for use in the time of need.

• A word about Haploidentical transplant
• T-Cell depletion is mandating in haploidentical
  transplant.
• T-Cell depletion can be done in two ways INVIVO
  ( T cell depleted by using high dose of
  chemotherapy inside the body) or INVITRO ( T
  cell depletion by using a machine outside the
  body). Both these modalities have their
  advantages and disadvantages. Choice depends on a
  number of patient and donor related factors.

In Vitro- T cell depletion
6
What is the basic process?
There are three main steps in the transplantation
process- The first step- The aim here is the
collection of the bone marrow or stem cells (the
harvest) from the donor. We now know that the
umbilical cord blood is also a rich source of
stem cells. The second step- The aim in this step
is to completely destroy the existing bone marrow
and thereby help the patient receive the new
stem cells. The third step- The aim here is to
infuse the bone marrow or the stem cells through
the intravenous route, like a blood transfusion.
There may be no signs of new bone marrow growing
for 2-3 weeks, and occasionally it may be a few
months before the new bone marrow produces all
the components of the blood adequately.
When is bone marrow transplant required?
Allogenic bone marrow transplant is typically
recommended to treat certain medical conditions
where the bone marrow/immune system is
dysfunctional. Most common indications are Acute
Leukemia (AML/ALL), Myelodysplastic Syndrome,
Aplastic anemia other bone marrow failure
syndromes. Hemoglobinopathy like transfusion
dependent thalassemia, severe form of sickle cell
disease, Congenital immunodeficiency metabolic
disorders. Autologous bone marrow transplant is
recommended to treat where we need to give high
dose of chemotherapy to treat underlying disease
following which autologous harvested stem cells
is given as rescue. It can also be used to treat
various autoimmune diseases, the commonest
indication being multiple scelerosis.
7
Bone marrow
peripheral blood stem cell harvest
Most commonly stem cells are collected from the
donor just like platelets are collected. In this
process the donor receives injections in the
skin just like insulin injection for 4-5 days.
With these injections, stem cells that are
normally found in bone marrow come into the
blood stream. This blood is taken by veins and
filtered in the apheresis machine and given back
to the donor through another vein and
approximately 300ml of filtrate is collected
which is rich in blood stem cells. Sometimes,
especially for non-cancer conditions, stem cells
are collected from bone marrow, where under
general anesthesia multiple needle punctures are
made at waist bone.
What are the adverse euects?

• For the donors
• Donating stem cells is very safe. We take the
  utmost care to minimize side euects of stem cell
  harvest. However, a donor of a bone marrow
  transplant produce may experience the following
  side-euects-
• Chest pain
• Stiffness of hands also known as tetany
• Low blood pressure
• Fever, chills, flushing
• Foul taste in mouth
• Headache, Hives, Nausea, Pain
• Shortness of breath

8

• For the recipient
• While the bone marrow transplant is mostly
  considered to be a safe procedure, there are
  several factors that determine the type of
  complications that might arise after the
  transplant. The factors may result in some
  complications that the recipient of the bone
  marrow transplant might experience. Some of them
  are as mentioned below-
• Anaemia
• Bleeding in the lungs, intestines, brain and
  other areas of the body
• Graft failure, which means that the new cells do
  not settle into the body and start producing stem
  cells.
• Graft-versus-host disease in which the donor
  cells attack the recipients body.
• Infections
• Inflamation and soreness in the mouth, throat,
  oesophagus and stomach
• Pain
• Stomach problems, including diarrhoea, nausea and
  vomiting.
• Damage to the kidneys, liver, lungs and heart
• Late effects- growth issues, early menopause,
  possible infertility

• Follow up
• For the first two to three months after leaving
  the hospital, the patient will need to undergo
  frequent blood tests to monitor the blood
  counts. Regular doses of several different drugs
  to reduce the risk of infection or graft versus
  host disease will be necessary and these will
  be monitored regularly.
• It is essential that the patient takes good care
  of his/her health during this time. There are a
  number of possible problems that might occur
  because of the reduced immunity.
• The patient should get in touch with the hospital
  immediately if he or she experiences any of the
  following symptoms-
• Feels unwell
• Persistent temperature of over 37.5-degree
  Celsius for more than 2 hours
• Infections e.g. in the skin or oral cavity
• Skin rash
• Several loose motions
• Shortness of breath or breathing difficulties
• Any other untoward symptoms or incident
• How will life be after a transplant?
• For the first few months after a transplant,
  while the immune system is in the process of
  returning to normal, it is important to eat a
  healthy and balanced diet and take care to avoid
  all possible risk of infection from food. Avoid
  uncooked food, subsequently in 6-12 months immune
  system is back to normal, life returns to
  normalcy.

9
Bone marrow transplantation in children
The procedure for transplanting bone marrow in
children is the same as those for adults. In
planning the transplants, doctors will consider
very carefully the effects of the intensive
preparatory regime to minimize the long-term
effects, for example on the childs growth,
development and future fertility. Consult your
BMT physician prior to surgical/ dental/ medical
invasive procedures, since your immunity is
still developing over 1-2-year period.

• Diseases treated by BMT
• Thalassemia
• Sickle cell disease
• Other transfusion dependent Anemia
• Aplastic anemia
• Inherited bone marrow failure syndromes including
  Fanconi anemia, diamond black fan anemia, etc.
• High risk leukemias

• Juvenile myelo monocytic leukemia
• Immunological diseases such as SCID
• Inborn error of metabolism
• High grade lymphomas
• Solid tumors
• Plasma cell disorders like Myeloma
• Auto immune diseases like multiple sclerosis

Take Home Message Bone marrow transplant is the
best and effective therapy for Aplastic anemia,
Thalassemia , Acute Myeloid and Lymphoblastic
leukemias, Multiple Myeloma and relapsed Hodgkin
and Non Hodgkin lymphoma. These patient should
be timely reffered to specialized centers to
treat these patients to get best outcome.
10
Dr. Gaurav Kharya Senior Consultant Centre for
Bone Marrow Transplant and Cellular Therapy
Paediatrics Hematology Oncology and Immunology
Indraprastha Apollo Hospitals 919213132168 Gaurav
.kharya_at_gmail.com
Dr. Gaurav Kharya is a Clinical Lead Centre for
Bone Marrow Transplant and Cellular Therapy,
Senior Consultant Paediatric Hematology Oncology
and Immunology at Indraprastha Apollo hospital,
New Delhi. He has been trained in premier
institutes in India and abroad. He did his
formal training at Sir Ganga Ram hospital, New
Delhi. There after he has been trained at The
Great North Childrens hospital, Newcastle upon
tyne, United Kingdom in paediatric
hemato-oncology, immunology and bone marrow
transplant and St. Marys hospital, Imperial
College NHS trust, London, United Kingdom in the
field of paediatric hematology and BMT. He moved
back to India in March 2014 and joined back BLK
super speciality hospital as a consultant
paediatric hemato-oncology BMT. After working
at BLK super speciality hospital, he joined
Artemis hospital in December 2016 as a Senior
consultant Head in Paediatric Hematology
Immunology Bone Marrow transplant. He expanded
the BMT program and took it to the next level
and made it one of the high-volume transplant
centres of the country Apart from paediatric
acute leukemias, lymphomas, paediatric solid
malignancies, he is keenly interested in
hematopoitic stem cell transplant especially
alternative donor transplants (voluntary
unrelated donor Haplo-identical donor). Dr.
Kharya has a vast experience in transplanting
patients with various blood disorders benign or
malignant, immunology diseases, auto immune
diseases (like multiple sclerosis), etc
nationally and internationally. He has presented
many papers in national and international
conferences and has published many papers in
national and international journals. Dr. Kharya
is credited for doing the first haploidentical
bone marrow transplant for sickle cell disease in
India and also for doing first invitro TCR
alpha beta CD 19 depleted haploidentical BMT in a
5-month-old baby suffering from severe combined
immunodeficiency which is one of the youngest
children to receive bone marrow transplant in
India. Till date Dr. Kharya has done close to
800 transplants for various diseases along with
his team members. Dr. Kharya is of the opinion
that none of the children who needs treatment for
cancer, immunological disease or bone
marrow transplant should be refrained from
treatment due to lack of funds. To fulfil this
goal, he has tie-ups with NGOs which provide
financial social support to these kids their
families. He is the recipient of the prestigious
YOUNG ACHIEVERS 2017 award, awarded by the Times
of India group. Dr. Kharya joined Indraprastha
Apollo hospital as a clinical lead for centre for
transplant with the aim of making it one of the
best centres of the country. His future
interests are in cellular and Gene therapy.
Dr. Amita Mahajan Senior Consultant Paediatrics
Oncology and Hematology Indraprastha Apollo
Hospitals 919810734137 mahajanamital_at_gmail.com
Dr. Amita Mahajan is a Senior Consultant
Paediatrics Oncology and Hematology, with an
experience of 29 years. She pursued her MBBS in
the year 1990 from All India Institute Of Medical
Sciences, New Delhi and then went on to complete
her MD in the year 1992 from AlIMS as well. She
worked for over a years in UK at a number of
centres and gained experience in Paediatric,
Hematology Oncology and BMT. She joined
Indraprastha Apollo Hospitals in 2002 and setup
the Paediatric, Hematology Oncology service. She
is Medical advisor in a number of support groups
working in the field of Paediatric, Hematology
Oncology as well as Executive member of Indian
Paediatric Oncology. She was working as a
consultant at Llandough Hospital, Cardiff, which
was the Regional centre for Paediatric Oncology
in that region. She worked in Bone Marrow
Transplant (Royal Hospital for Sick Children)
unit, which was the busiest bone marrow
transplant unit in UK at the time and was
routinely involved in the
11
management of both children and adults. She has
been a part of International Society of
Paediatrics, Oncology Indian Academy of
Paediatrics, Thalassemics India Foundation. She
is an experienced, skilled and awarded doctor in
her field of specialization.
Dr. Shishir Seth Senior Consultant Hemato-Oncology
and Bone Marrow Transplant Indraprastha Apollo
Hospitals 9190135 86776 drssrseth_at_gmail.com
Dr. Shishir Seth is a Senior Consultant in
Hemato-Oncology and Bone Marrow Transplant at the
Apollo Cancer Institute. He is an MD and a DM in
Clinical Hematology (Mumbai). In addition, he has
completed a Fellowship in Leukemia and Blood and
Marrow Transplant (BMT) at the Division of
Hematology, Vancouver General Hospital,
Vancouver, Canada. He specialises in blood and
marrow transplant (BMT), blood cancers (leukemia,
lymphoma, multiple myeloma), anemia,
thalassemia, bleeding and clotting disorders. He
has successfully performed over 200 hematopoietic
stem cell transplants, out of which 40 percent
were allogeneic including haplo-identical and
antigen mismatch transplants. Over the years, Dr.
Shishir Seth has been associated with several
prestigious hospitals in Mumbai and Delhi. He
initially was Junior Resident at Seth GS
Medical/KEM Hospital, Mumbai, after which he
served as Senior Assistant Medical Officer (AMO)
at Bombay Hospital, Mumbai. He then was posted
as Clinical Assistant (Hematology) at the PD
Hinduja National Hospital in Mumbai. His next
two positions were in New Delhi, first as Senior
Resident at the GTB Hospital and subsequently as
Consultant at the Moolchand Hospital. He
returned to the Seth GS Medical College/KEM
Hospital in Mumbai as Senior Resident while he
pursued his DM and proceeded to Canada for the
above-mentioned fellowship at Vancouver General
Hospital. His next professional stint was as
Consultant (Hemato-Oncology and Stem Cell
Transplant) at the Rajiv Gandhi Cancer Institute,
New Delhi, before he took up his present
position at Apollo. Besides his regular
professional commitments, Dr. Seth has devoted
his time to research as well. Several of his
research papers and articles have been either
published in peer-reviewed journals or presented
at medical conferences. He is a member of various
associations and bodies related to his field.
12
Indraprastha Apollo Hospitals, Sarita Vihar, New
Delhi - 110076 Call 91 88 00 99 00 00
Email infodelhi_at_apollohospitals.com ApolloHospita
lsDelhi apollohospitalsdelhi https//delhi.apolloh
ospitals.com