How is a bone transplant done? Types and main stages of BMT - bone marrow transplantation

Bone marrow transplantation or hematopoietic stem cell transplantation is one of the treatments for a number of cancers ( leukemia, lymphoma, multiple myeloma, neuroblastoma, Ewing's sarcoma etc.), as well as a number of other conditions ( aplastic anemia, glycogenosis, mucopolysaccharidosis, immunodeficiency and etc.).

Bone marrow functions (see Fig. 1).

Bone marrow is a soft, spongy substance found in the center of most large bones in the human skeleton. The bone marrow is a hematopoietic organ and produces all the cells that make up the blood, such as red and white blood cells and platelets.

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All of these cells come from progenitor cells found in the bone marrow called hematopoietic stem cells. The human body can control the development of stem cells depending on the current needs for certain blood components. This process is extremely active, because The bone marrow produces millions of different cells per hour. Most hematopoietic stem cells reside in the bone marrow before they develop into various blood cells, which then enter the bloodstream. However, small numbers of stem cells can be found in the circulating blood, allowing them to be isolated under certain conditions. There are various ways to increase the number of stem cells in the peripheral blood before collecting them.

Bone marrow transplantation.

The most effective cancer treatments such as chemotherapy And irradiation, are very toxic to the bone marrow. The higher the dose received, the greater the damaging effect on Bone marrow.

In a bone marrow transplant, the patient receives very intense chemotherapy and radiotherapy, which kill cancer cells and destroy normal cells developing in the bone marrow, including vital cells. hematopoietic stem cells. After such treatment, a source of healthy stem cells is needed for transplantation. The transplanted cells will repopulate the bone marrow and resume producing blood cells.

Stem cells for transplantation can be obtained from bone marrow ( bone marrow transplant), from blood ( peripheral blood stem cells; this requires medication to increase the number of blood-forming cells in the bloodstream), or sometimes from blood obtained from the umbilical cord during the birth of a healthy baby ( umbilical cord blood transplant).

Types of bone marrow transplantation.

There are two main types of bone marrow transplant: autologous(taken from the patient himself) and allogeneic(taken from the donor).

At autologous transplantation The patient's own stem cells are collected and preserved before antitumor treatment. In certain cases, the cells are specially treated (purified) to remove any remaining cancer cells, and then frozen for storage and later use. After chemotherapy and/or radiation are completed, collected stem cells thaw and return the patient's blood flow.

At allogeneic transplantation Stem cells are obtained from a donor, ideally from a brother or sister with a similar genetic structure. If the patient does not have a compatible sibling, blood from another person with a similar genetic structure can be used.

Transplantation without bone marrow suppression (Non-myeloablative transplant), sometimes called a “mini” or gentle transplant, allows for a less intensive chemotherapy before bone marrow transplantation using allogeneic stem cells. This method may be recommended if standard bone marrow transplant Contraindicated due to age or concomitant diseases.

Which type of transplant is best?

The transplant doctor will determine which method is best, taking into account various factors such as the type of cancer, age and general health, and the availability of a suitable donor. Usually, autologous transplantation causes fewer side effects since the patient receives his own cells. However, autologous transplantation may be less effective than allogeneic transplantation for certain cancers.

At allogeneic transplantation The donor's immune system, transmitted through stem cells, recognizes the recipient's cells, including cancer cells, as foreign and rejects them. This beneficial phenomenon is called reaction graft versus tumor. For many types of cancer, the immune response generated by transplanted stem cells improves the overall effectiveness of treatment. This immune reaction destroys residual cancer cells in organism.

The greatest concern is the possibility of an immune response to the transplant, the so-called graft-versus-host reaction (see below " Graft versus host disease").

When transplantation is performed without bone marrow suppression, it is considered that graft versus tumor reaction, rather than intensive antitumor treatment, will help destroy cancer cells, but graft-versus-host disease is also a concern (see below "Graft-versus-host disease").

Selection of bone marrow donor.

There are several possible options for choosing a donor hematopoietic stem cells.

Compatible donor. It is best if there is a donor with a similar genetic structure, which significantly reduces the risk of complications associated with the immune response. In this case, the recipient's cells will seem "less foreign" to the transplanted donor cells. The best candidates are sibs (i.e. blood brothers and sisters), who have a one in four chance of being genetically compatible. Such compatibility is an extremely important factor for the body to accept the transplant. As a rule, parents, children and other relatives are not suitable to be donors, because... do not come from the same parents as you, and therefore differ in genetic material. The exception is haploidentical transplantation, which is used in selected cases.

Compatible unrelated donor. If there are no siblings or they are incompatible, a compatible unrelated donor can be used. The search for a suitable donor is carried out using national donor registries Worldwide.

Incompatible related or unrelated donor. Some patients may be offered bone marrow transplantation from a partially compatible family member (called an incompatible sibling donor). In this case, hematopoietic stem cells undergo special training to minimize the patient's immune response. Another alternative is umbilical cord blood, collected from healthy newborns during childbirth; this blood is extremely rich in hematopoietic stem cells.

Preparation for bone marrow transplantation.

Bone marrow transplant techniques may vary from patient to patient. This depends on the type of cancer, the treatment programs used at the medical center, the clinical trial protocol (if the patient is included in one of these studies), and other factors. The most common components of a bone marrow transplant procedure are described here. Specific details of the transplant program should be discussed directly with the treating specialists.

Assessment of general health.

Before the transplant procedure, you will need to undergo a general examination. First of all, transplant doctors will find out the patient’s medical history. Most patients will also need various laboratory tests. Sometimes a mental health check may be suggested as... Transplantation is a very serious procedure that requires great responsibility and expenditure of mental strength. Some patients need to consult a psychiatrist or psychologist to discuss their concerns and help them cope with a stressful situation.

At a meeting with the transplant coordinator or nurse, the entire bone marrow transplant process can be discussed in detail. A hospital stay can take several weeks or months, so it is important to have a clear understanding of the entire treatment process and know where and who to go with questions and help. Some patients may prefer to have a friend or relative accompany them to this meeting; others will want to record the conversation or ask for the contents of the consultation to be written down so they have the information at hand if needed.

In many cases, bone marrow transplantation is performed against the background of remission of the underlying disease. The patient may feel that he is undergoing a cure, but he must be prepared to feel unwell for some time after the procedure. It should be well understood that intensive monitoring and treatment will be required, but significant improvement should be expected as a result.

Solving everyday issues. Patients who will spend the coming weeks or months in the hospital need to resolve issues related to family, household and pets, finances and employment.

When preparing for a transplant, you should also think about drawing up detailed instructions in case the condition does not allow you to independently express your will. Such instructions may include a will, a general power of attorney, or the appointment of a personal medical representative. A social worker or lawyer can explain what documents may be needed for this.

Installation of a central venous catheter. Numerous medications may be required in preparation for, during, and after a bone marrow transplant. To avoid repeated intravenous infusions, most patients are assessed before starting treatment. central venous catheter. This is a short surgical procedure in which a thin, flexible plastic tube is inserted into a large vein in the upper chest area. The catheter usually has two or three channels for infusing medications and blood products (including blood-forming stem cells), as well as for collecting blood for tests.

The central venous catheter site should be kept clean. It is also necessary to monitor for signs infections(pain, redness, swelling, discharge from the catheter insertion site, chills, fever).

Collection of hematopoietic stem cells.

If planned autologous transplantation, then before intensive chemotherapy and/or radiation, the patient’s own hematopoietic stem cells will be collected. The main sources of stem cells are Bone marrow or peripheral blood.

If the bone marrow is infiltrated by malignant cells, one or more courses of chemotherapy may be necessary first. Extraction (collection) of bone marrow stem cells is performed under general or epidural anesthesia. During the procedure, a long needle is used to pump out bone marrow tissue from various areas of the pelvic and femur bones (see Fig. 2).

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Collection of stem cells from peripheral blood performed using an apheresis machine during the blood filtration process. Blood is taken from the vein, undergoes a filtration process and returns to the venous bed at another location. The procedure does not require pain relief. To ensure a sufficient number of stem cells in the peripheral blood, the patient or donor must undergo prior treatment to stimulate the production of hematopoietic cells. Healthy donors receive only growth factor treatment; Patients with malignant disease may be prescribed both chemotherapy and growth factor. Most commonly used granulocyte colony-stimulating factor(G-CSF or NEUPOGEN ®).

Obtaining allogeneic bone marrow. Bone marrow collection from the donor is usually carried out on the day of transplantation or the day before it. The procedure is usually performed under general anesthesia.

Pain after bone marrow puncture in most cases they are minor and can be easily relieved with painkillers (paracetamol). The donor may be hospitalized overnight after surgery, and the recovery period takes one to two weeks.

Myeloablative treatment (bone marrow suppression). As mentioned above, many patients will have to undergo myeloablative treatment before a bone marrow transplant. This is an intensive treatment for cancer that also destroys bone marrow. The goal of this treatment is to reduce the number of tumor cells in the body, as well as suppress the immune system to reduce the likelihood transplant rejection. Depending on the underlying disease and other factors, this stage of treatment may include intensive chemotherapy, whole-body radiation, or both.

Prevention of infections. As a consequence of bone marrow suppression, there is an increased risk of developing severe infections because The production of white blood cells (leukocytes), which serve as the main means of combating them, temporarily stops. In addition, there is an increased risk of excessive bleeding due to the reduced number of platelets in the blood.

After myeloablative treatment, it is very important to avoid any sources bacterial, viral and fungal infections. Even small amounts of infectious agents (to which we are exposed in everyday life) can lead to the development of a serious infection.

Patients undergoing allogeneic transplantation are usually placed in an isolation ward. The air in such a room undergoes special filtration. In addition, the room is pressurized so that when the door is opened, air flows out rather than in. This isolation and poor health as a result of treatment can make patients nervous and depressed.

Special precautions apply to all visitors. Thorough hand washing is one of the most effective measures to significantly reduce the likelihood of infection transmission. Visitors are prohibited from bringing fresh fruits, vegetables or flowers because they may contain dangerous microorganisms.

Most patients are allowed to shower. It is believed that showers can spray fungal spores, so some health centers recommend only bathing or wiping. You can dress in hospital pajamas or use personal, clean clothes.

Transfusion of blood products. During times when the bone marrow is not working, replacement transfusions of blood products such as red blood cells (erythrocytes), which provide oxygen delivery to body tissues, or platelets, which help prevent bleeding. These blood products are cleared of white blood cells and irradiated to reduce the risk of an immune reaction.

Bone marrow transplant procedure.

After completing the intensive chemotherapy and/or exposure, a transfusion of previously collected bone marrow or hematopoietic stem cells is performed. Transfusion is carried out intravenously, usually through a central venous catheter. The procedure takes about an hour and does not cause pain (see Fig. 3).

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The "transplanted" cells penetrate the bone marrow and resume normal blood cell production, a process called engraftment. It is important to correctly determine when engraftment occurred, since this determines when it will be possible to relax security measures and/or return home. If engraftment is slower than usual, bone marrow stimulating drugs are used.

The progress of the engraftment process is checked using daily blood tests. Neutrophils, a type of white blood cell (leukocyte), serve as an indicator of engraftment. When the absolute neutrophil count reaches at least 500 for three consecutive days, it is considered that graft engraftment happened. This can happen as early as 10 days after the transplant, although bone marrow or stem cell transplants usually require 15-20 days. Patients who have undergone hematopoietic cell transplantation from cord blood, it may take 21 to 35 days for engraftment.

Platelet count monitoring can also be used to determine engraftment. It should be in the range of 20,000-50,000 (if the patient has not received a platelet transfusion). This usually occurs simultaneously with or shortly after neutrophil engraftment, but may take up to 8 weeks for transplantation umbilical cord blood stem cells.

Side effects of bone marrow transplantation.

The high-dose chemotherapy and whole-body radiation required for a bone marrow transplant can cause serious side effects. Before making a decision about the procedure, you should discuss with your doctor the possible complications, toxicities, and other dangers associated with the transplant. The patient will be asked to sign a consent form confirming that he has received oral and written information about the benefits and possible dangers of the proposed treatment, alternative treatments, and that all questions have been answered.

Some of the most common side effects are mucositis(inflammation of the mucous membranes) and diarrhea. They are caused by damage to rapidly multiplying cells, such as those in the lining of the mouth and gastrointestinal tract, by chemotherapy and radiation. Severe mucositis may make eating difficult and may require intravenous nutrition ( total parenteral nutrition). In addition, painkillers are usually required. A drug currently available to prevent the development of mucositis is KGF (Kepivance®). One study found that the use of Kepivance® in patients undergoing autologous transplantation with total body irradiation significantly reduced the possibility of mucositis.

For prevention and treatment nausea and vomiting Combinations of drugs may be used, usually including a 5-HT3 receptor antagonist (dolasetron, granisetron, ondansetron, tropisetron, or palonosetron), an NK1 receptor antagonist (aprepitant (Emend®)) and steroids (dexamethasone).

Hair loss is temporary and in most cases affects the entire surface of the body. After chemotherapy and radiation are completed, hair growth resumes. Unfortunately, there is no treatment to prevent hair loss or promote hair growth.

Probability of development infertility after a bone marrow transplant depends on the type of treatment used and the dose. If the patient is of childbearing age, it is worth discussing with your doctor measures to reduce the risk of infertility and the possibility of storing eggs or sperm before starting treatment.

The lungs, liver, and bones are at greatest risk of damage from cytotoxic treatment. Cataracts may occur in individuals who have undergone total body irradiation, although this complication has become increasingly rare with the advent of modern irradiation techniques.

There is a small chance of occurrence secondary cancer after a bone marrow transplant, likely as a result of treatment of the primary cancer and transplant-related treatments. Secondary cancer may develop within several years (average 3-5) after transplantation.

In 10% to 50% of patients who received allogeneic graft, a complication may develop called graft versus host disease (GVHD). This effect can be acute (develops in the first 100 days) or chronic (develops after 100 days). This complication does not occur with allogeneic transplantation, when the patient himself is the donor. The term "graft" refers to the transplanted hematopoietic cells, and the term "host" refers to the patient's body. Thus, GVHD is a condition when the transplanted cells of the donor's immune system begin to attack the recipient's organs. GVHD, along with the underlying disease, is the main threat to successful bone marrow transplantation. To prevent graft-versus-host disease, immunosuppressive drugs, antibiotics, and sometimes corticosteroids are used. Large doses of steroid drugs are used to treat established GVHD. Symptoms of this reaction may include rash, diarrhea, liver damage, and other manifestations, depending on the organs affected.

Graft rejection is a rare complication that occurs in approximately 1% of cases after bone marrow transplantation. The risk of rejection may be increased with certain types of transplants and sources of hematopoietic cells.

There is a certain probability mortality as a result of treatment. The degree of risk depends on age, the nature of the underlying disease, the type of transplant (autologous or allogeneic) and other factors, such as the qualifications and experience of the medical institution in performing such procedures. Before agreeing to undergo a transplant, it is important to clearly understand the individual level of risk compared to the need for the procedure.

Treatment after bone marrow transplant.

Once the graft has taken hold, the number of blood cells will continue to increase and the immune system will gradually recover. All this time, the patient must be under the supervision of a transplant team.

Transplantation without bone marrow suppression (nonmyeloablative) can be performed on an outpatient basis, allowing you to stay at home overnight. All other types of transplants require hospitalization for two to three weeks after the transplant. In any case, even after discharge, frequent visits to the doctor for monitoring are necessary. You should plan to live within commuting distance of a medical center for at least 100 days after your transplant.

There is an increased risk of developing infections for many months after a bone marrow transplant. Keep this in mind and watch for signs of infection, such as fever (over 38°C), pain and chills. Prophylactic antibiotics are sometimes recommended.

Research shows that patients who successfully undergo a bone marrow transplant and become cancer-free return to a normal quality of life. Most patients can lead an active lifestyle, work, and remain in good health. Quality of life levels gradually improve over the months following the transplant.

Conclusion.

Bone marrow transplantation is used to treat certain types of cancer and other diseases. Bone marrow is the soft, spongy area in the central part of most large bones in the skeleton. The bone marrow is the source of all blood cells, such as red and white blood cells and platelets. All of these cells develop from one main type of cell found in the bone marrow called stem cells. During a bone marrow transplant, the patient receives very high doses of chemotherapy and radiation, which kills the tumor cells and also destroys all normal bone marrow cells, including critical ones. stem cells. After such aggressive treatment, the patient needs a source of healthy hematopoietic stem cells - a transplant. There are two types of transplantation – autologous and allogeneic. In autologous transplantation, the patient's own bone marrow or blood is used as a graft. For allogeneic transplantation, stem cells from a donor are used. Usually the donor is a blood relative of the patient, although sometimes donors are not related to the patient. Most bone marrow transplant patients must stay in the hospital for several days or weeks during treatment and recovery. It is important to understand and carefully follow the treatment plan to reduce the risk of complications and to know what to expect from the next step. Treatments given before and during transplantation can cause serious side effects. The patient should be prepared for the most common ones (diarrhea, nausea, vomiting, mouth ulcers) and have an understanding of possible treatments for these complications. After a bone marrow transplant, hospitalization is required for several weeks. However, the patient requires frequent visits to the doctor for another 3-6 months after discharge. Some patients may be offered participation in clinical trials. These are carefully controlled scientific studies conducted to test new treatments or combinations of already known treatments. Such research helps find new, more effective ways to treat certain diseases.

For the purpose of health education, we decided to talk not only about toxic fees as such, but also about the various components of these fees, such as medical diagnoses, so that it would be easier for the donor to understand what and why the money is being collected.

Transplantation or bone marrow transplant is a procedure that is used in the treatment of both adults and children suffering from leukemia (blood cancer), as well as aplastic anemia, lymphomas (such as lymphogranuomatosis or Hodgkin's lymphoma), multiple myeloma, and serious immune disorders.

Bone marrow - is a spongy tissue that is found in the sternum, skull bones, femurs, ribs and contains stem cells, from which blood cells are produced. Blood consists of white blood cells - leukocytes that protect the body from infections, red blood cells - red blood cells that carry oxygen, and platelets that allow the blood to clot.

When bone marrow stem cells begin to function incorrectly, namely to produce an excessive number of defective or immature blood cells, leukemia develops, and when the bone marrow sharply reduces their production, this leads to caplastic anemia.

Defective or immature blood cells fill the bone marrow and blood vessels, crowd out normal blood cells from the bloodstream, and can spread to other tissues and organs. Large doses of chemotherapy and/or radiation therapy are required to destroy diseased blood cells and bone marrow. This treatment damages not only defective bone marrow cells, but also healthy bone marrow cells.
In a bone marrow transplant, the patient's diseased bone marrow is destroyed and the donor's healthy bone marrow is introduced into the patient's bloodstream. In a successful transplant, the transplanted bone marrow migrates into cavities in the large bones, takes root, and begins to produce normal blood cells.

If bone marrow obtained from an identical twin is used, the transplant is called syngeneic, or allogeneic if the bone marrow is obtained from a donor. In an allogeneic (i.e., non-relative) transplant, the donor bone marrow given to the patient must genetically match the patient's own as much as possible. To determine the compatibility of the donor and recipient, special blood tests are performed.

If the donor's bone marrow does not match the recipient's tissues genetically enough, it may perceive the tissues of the recipient's body as foreign material, attack and begin to destroy it. This condition is known as graft-versus-host disease (GVHD) and can be life-threatening. On the other hand, the patient's immune system may destroy the transplanted bone marrow. This is called a rejection reaction (graftrejection)
In some cases, the patient may be a bone marrow donor for themselves. This is called an autologous transplant and is possible when the disease affecting the bone marrow is in remission, or when the condition requiring treatment does not affect the bone marrow (for example, breast cancer, ovarian cancer, lymphogranulomatosis, non-Hodgkin's lymphomas and brain tumors).

PREPARATION FOR TRANSPLANT

Successful bone marrow transplant possible if the patient is “healthy enough” to undergo such a serious procedure, which is a bone marrow transplant. Age, general physical condition, diagnosis and stage of the disease are all taken into account when deciding whether a patient is eligible for a transplant. Before a transplant, a patient is given many tests.

Tests of the heart, lungs, kidneys, and other vital organs are also used to obtain baseline information so that comparisons can be made after bone marrow transplantation to determine whether any function has improved. Preliminary tests are usually performed on an outpatient basis before hospitalization.

An important role in bone marrow transplantation is played by a lot of little details, knowledge and consideration of which can very significantly affect the results of the transplant. A successful bone marrow transplant requires a highly professional medical team - doctors, nurses, and support staff - who are well experienced in this field and are ready to immediately recognize and respond to possible problems and side effects.

Therefore, choosing the right clinic for bone marrow transplantation is essential to obtain the desired result. In clinics that specialize in bone marrow transplantation, the transplant program necessarily includes providing both patients and their families with emotional and psychological support before, during and after the transplant.

RECEIVING BONE MARROW FROM A DONOR

Transplantation now saves thousands of lives every year, but unfortunately, almost 70 percent of those in need of a transplant do not undergo it because they cannot find a compatible donor.

There is only a 35% chance that a patient will have a sibling whose bone marrow is a good match. If the patient does not have a suitable relative for a transplant, a donor may be found in an international bone marrow donor registry, or an incompletely compatible bone marrow transplant may be used. Regardless of whether the bone marrow from the donor or the patient or relative is used for transplantation, The bone marrow harvesting procedure is performed in the operating room, usually under general anesthesia. This promotes minimal risk and minimizes discomfort.

While the patient is under anesthesia, a special needle is inserted into the cavity of the femur of the leg or the iliac bone of the pelvis. The amount of bone marrow required for a bone marrow transplant depends on the size of the patient and the concentration of bone marrow cells in the material taken. Typically, 950 to 2000 milliliters of a mixture consisting of bone marrow and blood are taken. Although this amount seems large, it actually represents only about 2% of a person's bone marrow volume, and a healthy donor's body replenishes it within four weeks.

After the bone marrow harvesting procedure, the donor may feel some discomfort at the puncture site; the pain is usually similar to that which occurs after a strong fall on ice and is mainly relieved with painkillers. The donor is usually discharged from the hospital the next day and can return to normal activities within the next few days.
In autologous transplantation, the harvested bone marrow is frozen and stored at -80 to -196 degrees Celsius until the date of transplantation. It may first be cleaned to remove any remaining cancer cells that cannot be identified under a microscope.

In an allogeneic transplant, the bone marrow can be processed to extract T cells to reduce the risk of graft-versus-host disease. The bone marrow is then transferred directly to the patient's room for intravenous administration.

PREPARATION REGIME FOR TRANSPLANTATION

During preparation, a small flexible tube called a catheter is inserted into a large vein, usually in the patient's neck. This catheter is required to administer medications and blood products to the patient, to take blood tests during the course of treatment, and also to avoid hundreds of punctures of the veins in the arms.

While in the bone marrow transplant unit, the patient undergoes chemotherapy and/or radiation for several days, which destroys his own bone marrow and cancer cells and makes room for new bone marrow. This is called conditioning or preparatory mode. The dose of chemotherapy that is given to the patient during preparation is significantly higher than the doses that are administered to patients suffering from diseases that do not require a bone marrow transplant. Patients may feel weak, nauseated and irritable. To minimize discomfort, most bone marrow transplant centers administer anti-nausea medications to patients.

BONE MARROW TRANSPLANT PROCEDURE

The bone marrow transplant procedure itself is performed one to two days after chemotherapy and/or radiation. The bone marrow is given intravenously, similar to a blood transfusion. The transplant is not a surgical procedure, so it is performed in the patient's room rather than in the operating room. During a bone marrow transplant, the patient is often checked for fever, chills, and chest pain.

A bone marrow transplant is a physically, emotionally and mentally difficult procedure for both the patient and his loved ones. The patient needs and should receive the best possible help to cope with all this. Imagine the signs of severe flu - nausea, vomiting, fever, diarrhea, extreme weakness. Now imagine what it's like when all these symptoms last not for a few days, but for a few weeks.

After the transplant is completed, days and weeks of waiting begin, during this period the patient feels very sick and weak. Walking, sitting in bed for long periods of time, reading books, talking on the phone, visiting friends and even watching television require more energy from the patient than he has. Complications that may develop after a bone marrow transplant, such as infections, bleeding, rejection reactions, and liver problems, may cause additional discomfort. In addition, sores may appear in the mouth, making it difficult to eat and painful to swallow. However, pain is usually well controlled with medication. Sometimes temporary mental disturbances occur, which can frighten the patient and his family, but one must realize that these disturbances are temporary.

BONE MARROW ENVIRONMENT

The first 2-4 weeks after a bone marrow transplant are the most critical. While the transplanted bone marrow migrates into the bony cavities of large bones, takes root there and begins to produce normal blood cells, it is very susceptible to any infection and has a pronounced tendency to bleed. Platelet transfusion helps fight bleeding. Patients after an allogeneic transplant also receive additional drugs that allow prevent and control graft-versus-host disease. To help prevent and control infection, and to minimize the patient's risk of contracting viruses and bacteria, the patient is given a variety of antibiotics and blood transfusions. Visitors and hospital staff wash their hands with antiseptic soap and, in some cases, wear protective gowns, gloves and masks when entering a patient’s room. These rules are followed by the patient himself, when leaving the room, he must wear a mask, gown and gloves, which are a barrier against bacteria and viruses, and warn others that he is susceptible to infection. Fresh fruits, vegetables, plants and bouquets of flowers are prohibited from being brought into the patient’s room, as they are often sources of fungi and bacteria that pose a danger to the patient.

Blood tests should be taken daily to determine how the new bone marrow is engrafting and to assess the status of body functions. After the transplanted bone marrow has finally taken root and begins to produce a sufficient number of healthy red blood cells, white blood cells and platelets, the patient gradually ceases to be dependent on the administration of antibiotics, blood transfusions and platelets, which gradually become unnecessary. If no additional complications develop, the patient is discharged from the hospital. After a bone marrow transplant, patients typically spend 4 to 8 weeks in the hospital.

HOW TO CANDLE EMOTIONAL STRESS

In addition to the physical discomfort associated with a bone marrow transplant, there is also emotional and mental discomfort. Some patients find that the psychological stress of this situation is even more severe for them than the physical discomfort.

Psychological and emotional stress is associated with several factors:

First, the patient undergoing a bone marrow transplant is already traumatized by the fact that he is suffering from a life-threatening disease. Although the transplant gives him hope of a cure, the prospect of undergoing a long, difficult medical procedure with no guarantee of success is not encouraging.

Second, transplant patients can feel quite lonely and isolated. Special measures taken to protect patients from infection while their immune systems are compromised can make them feel cut off from the rest of the world and from almost all normal human contact. This sense of isolation is experienced by the patient precisely when he needs physical contact and support from family and friends as much as possible.

Feelings of helplessness are also a common experience among bone marrow transplant patients, causing them to feel angry or resentful. Many of them cannot tolerate the feeling that their lives are completely dependent on strangers, and they also feel uncomfortable when forced to depend from outside assistance in daily hygiene procedures, such as washing or using the toilet.

The recovery period is like a roller coaster - one day the patient feels much better, and the next few days he may feel seriously ill again. Waiting for blood tests to return to safe values and for side effects to finally disappear adds to the emotional trauma.

DISCHARGE FROM HOSPITAL

After being discharged from the hospital, the patient continues the recovery process at home for an additional two to four months and is not able to return to his normal job for at least the next six months after the transplant. To monitor the recovery, the patient requires frequent visits to the hospital in order to convalescent medication and, if necessary, blood transfusions. Although the patient feels well enough to leave the hospital, his recovery process is far from complete. During the first few weeks, he still feels too weak to do anything other than sleep , sit, and walk a little around the house. For up to six months or more from the date of transplantation, the patient's white blood cell count is often too low to provide sufficient protection against viruses and bacteria encountered in everyday life, so contact with the general public must be limited. A person recovering from a bone marrow transplant is prohibited from visiting movie theaters, grocery stores, department stores, etc. Such people must wear a protective mask when they venture out of the house.

LIFE AFTER BONE MARROW TRANSPLANTATION

It can take up to a year for the new bone marrow to start functioning like its own. Life after a transplant can be both exciting and stressful. On the one hand, it is an exciting feeling to feel alive again after being so close to death, on the other hand, the patient always remains worried that the disease may return again. In addition, ordinary innocent words or events can sometimes trigger difficult memories of the transplant period, even long after full recovery. It may take a long time for the patient to cope with these difficulties, although most patients find that their quality of life improves after the transplant.

IS IT WORTH IT?

Yes! For most patients awaiting a bone marrow transplant, the alternative is almost certain death.

Although a transplant can be a painful time, most transplant recipients find the prospect of returning to a full, healthy life after the transplant worth the effort.

Donor. Questions and answers:

Q: How is a bone marrow or hematopoietic stem cell donor found?

O: Each person inherits a unique genotype from their parents. Naturally, first of all, a potential donor is looked for among the patient’s closest relatives. The probability that siblings can serve as a donor for each other is about 25%. In general, no more than 30% of patients have a potential related donor. If there is no related potential donor, a search for an unrelated donor is carried out. There is an international computerized database of potential unrelated donors, which contains tissue typing data for about 6 million people from around the world. Upon receiving a request to find a donor, the computer system reports the availability of suitable potential donors. After which the medical institution conducting the treatment contacts the donor registry, whose database contains the data of a specific person who has expressed preliminary readiness to become a donor. The donor registry independently contacts the donor, carries out an “activation” procedure, as a result of which the donor is either recognized as suitable for transplantation and agrees to it, or refuses or is declared unfit as a result of a thorough medical examination. If one potential donor is not suitable for transplantation, another donor is sought.

Q: By what criteria is it determined whether a donor is born or not?

A: Proteins called antigens are found on the surface of white blood cells and other tissues of the human body. There are specific antigens called HLA-A, HLA-B and HLA-DR. It is their coincidence between the donor and recipient that determines the success of bone marrow or hematopoietic stem cell transplantation. Naturally, people of the same race, ethnicity and national origin have a higher chance of matching as a donor.

Q: What are the chances that a potential unrelated donor will be found?

A: Because in many countries around the world, great efforts are being made both at the government level and at the level of public organizations in order to increase the number of potential unrelated donors and take into account all racial and ethnic groups. About 80% of all patients have at least one potential donor at the preliminary search stage. This percentage is constantly growing (in 1991 it was 41%). It is important to add that of these 80%, not all can serve as real donors, and for the remaining 20%, transplantation can nevertheless often be successfully performed from a donor who is not a perfect match. , but only partially.

Q: What happens if a donor is found?

A: If the preliminary search has identified this person as a potential donor, he or she will be contacted using the contact information provided at the stage of the preliminary conclusion of the Donation Agreement. A potential donor undergoes a medical examination and undergoes special tests to study compatibility with the patient in more detail. After which the potential donor signs a donation agreement. At this point, he should be absolutely confident in his decision, since the patient at this stage may already be preparing for transplantation and undergoing the appropriate procedures.

Q: Can a potential donor refuse to donate and what are the consequences?

A: As a volunteer, a potential donor is under no obligation. Sometimes a potential donor who is suitable in all respects may decide not to become a real donor. There are a number of reasons to refuse donation, including ill health, the investment of time and effort, and fear of the risk of complications or painful procedures. Donation imposes serious obligations on a person, since human life depends on the decision of a potential donor. Changing the decision at the last minute can lead to fatal consequences for the patient waiting for donor bone marrow; the consequences of such a decision are explained to the potential donor repeatedly and from the very beginning. Most potential donors go all the way, having weighed the pros and cons and understanding the importance of their decision not only for the patient, but also for themselves.

Q: Who can become a potential donor of hematopoietic stem cells?

A: Any person aged 18 to 55 years who has never had hepatitis B or C, tuberculosis, malaria, AIDS, malignant diseases, or mental disorders. From a potential donor, 5 ml of blood is taken from a vein for tissue typing and everything except the last point is checked. As for mental health, a certificate from a mental health center will not be required from the donor.

Q: Do I have to pay anything to become a donor? Or, on the contrary, will he be paid?

O: Neither one nor the other. Anonymity, voluntariness and gratuitousness are what any donor movement is built on and form the basis for the creation of the Hematopoietic Stem Cell Donor Register. Although, of course, almost all Registers try to encourage donors who donate hematopoietic stem cells for a patient and thus save a person’s life.

Q: Tell us about the procedure for collecting hematopoietic stem cells?

O: There are two options. You donate either some of your bone marrow or stem cells from your bloodstream. The choice usually depends on the donor, but in rare cases, it is dictated by medical necessity.
If a donor donates bone marrow, a puncture is made in his pelvic bone under anesthesia, and then the required amount of bone marrow is removed with a surgical needle. The procedure takes about 30 minutes. The donor's bone marrow is completely restored within a few weeks. After this procedure, the donor spends 1-2 days in a specialized hospital under the supervision of a doctor.
If the donor donates peripheral blood cells, then a few days before donating blood, you need to start taking a special drug Filgrastim, which promotes the release of stem cells from the bone marrow into the blood. The fact is that stem cells are taken from the bloodstream during a process called apheresis, where blood from a vein in one arm passes through a special device for separating hematopoietic stem cells and returns into the bloodstream through a vein in the other arm. Of course, this procedure is performed under sterile conditions. You need to spend 5-6 hours in a relatively motionless state, but there is no need for hospitalization or anesthesia. Recovery of the taken cells takes place in 7-10 days.

Q: What is Filgrastim?

A: Filgrastim has been used for 10 years to increase the production of leukocytes (white blood cells) in immunocompromised patients so they can more effectively fight infection. It is similar to a substance naturally produced by the human body. For the past few years, it has been given to healthy donors before bone marrow transplants to increase the amount in the bloodstream.

Q: Is there a risk to the donor's health?

A: Bone marrow donation is a surgical procedure with minimal risk. Serious complications are rare. They can be caused by individual reactions to anesthesia; cases of infection and reactions to the insertion of a surgical needle have been recorded. After bone marrow collection, the donor may experience pain in the operated area for some time. A hematopoietic stem cell donor may experience bone pain, muscle pain, nausea, insomnia, and fatigue from the drug taken before surgery. The most common side effects are headache and bone pain. These painful sensations go away immediately after the stem cells are collected. During apheresis, some donors complain of tinnitus due to the use of an anticoagulant to prevent blood clotting. At the end of the procedure, these effects gradually disappear.

Q: Can I become a donor only for my relatives or friends?

A: The database includes potential unrelated donors who are willing and ready to help any patient. If you want to undergo typing only to help a specific person, inform us of your intention, and your data will not be entered into the general donor database. When taking blood, you can ask your doctors for a copy of the immunological typing results.

Q: Can my parents sign a donation agreement for me and why can only people over 18 be a donor?

A: International standards require that the volunteer be an adult. We are talking about a surgical operation, and the person undergoing it must give his consent to it, having previously read all the necessary information. A parent or guardian is not authorized to sign a donation agreement, because unrelated donation is a voluntary procedure that does not bring any benefits to the donor. There is no talk of saving his life.

Q: Why can’t I become a donor if I am over 55 years old?

O: The number of years is not the only indicator of physiological age, but we are forced to rely on age when determining donor eligibility. With age, there is a slight increase in the risk of side effects from anesthesia. Studies have shown that patients who received hematopoietic stem cells from elderly donors have slightly worse cure rates. Age restrictions are therefore aimed both at maximizing the safety of the donor and at ensuring the best possible treatment for the patient.

Bone marrow transplantation is a fairly new medical procedure, thanks to which it is possible to achieve healing for pathologies that were previously considered incurable and fatal. Today, transplantation of this organ saves or at least prolongs thousands of lives every year. Thus, bone marrow transplantation is indicated for lymphoma and other malignant blood diseases, for severe forms of anemia, for cancer of various organs with a significant decrease in the body’s immune forces, for autoimmune pathologies, etc. Let's find out in more detail how a bone marrow transplant works and what the patient and donor can expect from this procedure.

How is a bone marrow transplant done?

The first bone marrow transplant procedure with a positive result was performed back in 1968 in the USA. Since then, transplantation methods have been improved, which has made it possible to expand the range of patients for whom such an operation is possible and to reduce the risk of developing undesirable effects.

Bone marrow is a “liquid” organ that performs hematopoietic functions and contains a large number of stem cells capable of renewal. It is thanks to the introduction of stem cells from a healthy person into the patient’s body that it is possible to restore non-functioning bone marrow. The transplant procedure itself is somewhat reminiscent of an intravenous infusion and takes about an hour. The preparatory period and postoperative stage of engraftment of the transplanted organ are longer and more complex.

First of all, it is important to find a donor with the most genetically suitable bone marrow, for which special blood tests are carried out. As a rule, donors are the patient’s closest relatives (brother, sister) or unrelated people with the most suitable material who are registered in the international bone marrow donor registry. Sometimes the patient himself acts as a donor during the period of remission of the disease.

Before the transplant procedure, the patient undergoes numerous tests to assess his physical condition, which must meet certain parameters to allow the operation. Next, the patient’s own diseased bone marrow cells are destroyed through chemotherapy and.

A couple of days after this, a special catheter is installed in a large vein in the patient’s neck, through which donor material will be introduced into the body, as well as medications. The transplant procedure is performed not in the operating room, but in a regular ward. Stem cells injected into the patient's bloodstream enter the bones, where they begin to take root and divide.

Then comes the most difficult period - adaptation and waiting, which can take 2-4 weeks. During this time, the patient must take medications that reduce the risk of rejection of the transplanted bone marrow, as well as antibiotics to prevent infectious pathologies. In addition, blood transfusions are carried out, and for the patient Maximum sterile conditions in the room are ensured.

How does a bone marrow transplant work for a donor?

Bone marrow collection from the donor is carried out under. The material, mixed with blood, is removed through punctures in the pelvic and femur bones. The amount of such a mixture can range from 950 to 2000 ml. After the bone marrow collection procedure, pain in the puncture area persists for some time, comparable to the sensations after a blow or fall. The pain is easily relieved by taking anesthetics, and the donor's bone marrow volume is restored to normal values within about a month.

Bone marrow transplantation is used for severe diseases, most often cancer and blood diseases.

The patient's bone marrow can no longer produce healthy blood cells to fight the disease. In such cases, replacement of dead bone marrow cells with healthy stem cells is indicated.

It is not the bone marrow transplant operation itself that is considered the most complex and lengthy, but the preparatory and postoperative stages. This type of treatment is best done abroad.

Transplantation can be autologous or allogeneic.

Autologous bone marrow transplantation. Stem cells are taken from the patient during the period of improvement, always before radiation and chemotherapy.
Allogeneic bone marrow transplantation. Cells are collected from a donor who must at least partially match the patient genetically. Usually close relatives become such donors.

Leading clinics abroad

The transplant process itself is more similar to a regular blood transfusion; it is carried out in the patient's room and lasts only about two hours. Let's look at the stages of a bone marrow transplant and how it happens:

Before the transplant, radiation and chemotherapy are given for several days to destroy the remaining diseased bone marrow cells.
The stem cells are then injected into the patient through a special catheter directly into the bloodstream. It is very important that at the time of the procedure the patient is not infected with infectious diseases.
During the entire process, the doctor monitors the stability of the patient’s vital functions.

The transplantation procedure is quite safe, and therefore successful bone marrow transplantation is often performed even in children. Childhood diseases that were previously considered incurable are now treatable.

Leading specialists from clinics abroad

Consequences of bone marrow transplant

The main danger of complications after a bone marrow transplant is the risk of the body rejecting new cells. The immune system considers them foreign and dangerous, and therefore begins to attack.

To avoid undesirable consequences of bone marrow transplantation, the patient is prescribed immunosuppressive and antibacterial drugs in the postoperative period. If there is a relapse after a bone marrow transplant or when a repeat procedure is necessary, then bone marrow purification is required.

How effective is the transplant, and is relapse possible?

According to the results of studies by European scientists, the risk of relapse is significantly lower with the allogeneic method of transplantation.

However, the autologous method allows you to minimize the risk of bone marrow rejection, because it is taken not from the donor, but from the patient himself.

The main danger is the risk of the body rejecting new cells.

Immunologist Professor Reznik, a specialist in pediatrics and clinical immunology, talks about what a bone marrow transplant is in the video:

Cost of bone marrow transplant in Russia

In Russia, bone marrow transplantation is performed in many centers and clinics.

The cost of a bone marrow transplant in Moscow starts from 1 million rubles.
The price of a bone marrow transplant in St. Petersburg starts from 2 million rubles.

These amounts include:

search for donors,
provision of medicines
provision of necessary equipment.

Treatment in an Israeli clinic

Oncogynecology in Israel

Transfer abroad

Abroad, bone marrow transplantation is a rather expensive procedure. Let's see how much a bone marrow transplant costs in countries near and far abroad:

Ukraine. The cost of bone marrow transplantation in Ukraine can be up to 4 million rubles.
Belarus. In Minsk, a bone marrow transplant is cheaper and costs about 2 million rubles.
Israel. The average cost of a bone marrow transplant is about 30,000 Euro.
Germany. Reviews about bone marrow transplantation in Germany are very positive. German transplant centers are famous throughout the world for their quality and safety, but the cost of the procedure is quite high. The price of bone marrow transplantation in German clinics is about 90,000 Euros.

Bone marrow is a human organ responsible for the formation of new blood cells. Bone marrow is found in the cavity of the bones and contains stem cells, immature cells that can develop into any organ or tissue in the body. One of the types of stem cells is...

What is bone marrow?

One type of stem cells are hematopoietic cells - they form blood.

Bone marrow transplantation - what is it?

Bone marrow transplantation (BMT) is a procedure for implanting healthy hematopoietic cells into the patient’s body in order to resume the process of hematopoiesis.

Indications for transplantation:

Anemia
All types of leukemia
Some cancers (for example, with)

Contraindications for transplantation:

Severe pathologies of the liver and kidneys
Infectious diseases
Pregnancy
Physical weakness of the body (old age, concomitant diseases)

Bone marrow transplantation for children is performed according to the same indications and contraindications as for adult patients.

What types of transplants are there?

It is customary to distinguish between the following types of bone marrow transplantation:

Autologous transplantation is an operation in which the patient is implanted with his own cells.
Allogeneic transplantation from a relative
Allogeneic transplant from an unrelated donor
Haploidentical transplantation is a type of transplant that uses the bone marrow of a partially compatible relative. Graft survival after this procedure occurs in only 25% of patients

How do you prepare for transplantation?

Preparing the patient for transplant

The most important stage of preparation for transplantation is conditioning. This is a therapy used for cancer. It consists of taking chemotherapy drugs and immunosuppressants. This suppresses the patient’s immunity to prevent rejection of the transplanted material. The method also helps destroy cancer cells and frees up space for the transplant.

In the case of transplantation of one's own cells, a collection is first made, and then the material is frozen until the end of the chemotherapy course.

Diagnostic procedures before bone marrow transplant surgery:

Consultations with specialists, incl. dentist
MRI and CT, PET-CT (if we are talking about cancer)A
blood test (including on, etc.)
A biochemical blood test is performed to ensure that the liver and kidneys are functioning properly. Otherwise, transplantation may be contraindicated
Trephine biopsy and bone marrow aspiration. This is a puncture of bone tissue and bone marrow followed by cytogenetic analysis

If necessary, the patient undergoes treatment at the dentist. This is necessary to completely eliminate infections, since after transplantation their presence is deadly.

Preparing for donation

The donor undergoes routine testing to rule out any diseases that could be passed on to the recipient.

If the sample is taken from peripheral blood, the donor is prescribed special medications that must be taken for 5 days. They promote the active release of cells into the bloodstream.

There may be side effects from taking these medications. Usually these are short-term bone pains.

How is transplantation performed?

Stage 1. Fence

Bone marrow is collected under general anesthesia. First, the doctor makes a small incision and then uses a wide needle to puncture material from the femur.

The donor can also choose to collect cells from peripheral blood. To do this, the donor is connected to a machine that pumps blood for several hours. Through a special separator, bone marrow cells are separated from the blood and collected in a separate reservoir.

Stage 2. Transfer

Bone marrow is transplanted by intravenous injection. The procedure lasts up to 2 hours.

Stage 3. Engraftment period

The injected cells eventually take root and begin to produce new healthy blood cells.

Hospitalization lasts about 3 months.

Who can become a donor for a bone marrow transplant?

The related donor can be the patient's sibling. However, even such a donor is not always compatible. In rare cases, a haploidentical transplant is performed. The donor can be the patient's father or mother.

For an unrelated transplant, candidate selection occurs through the bone marrow donor bank database. The search usually takes about 2 weeks. The largest are the US Bone Marrow Donor Bank, European and German banks. Usually 2-3 people are selected, since a potential candidate may have temporary contraindications, refuse the procedure, or may not be in the country.

It is worth noting that there are times when it is not possible to find a suitable candidate.

Contraindications to donation are:

Infectious diseases
Autoimmune diseases
Mental disorders
Age under 18 and over 55 years old

What complications can there be after the procedure?

The most serious complications after bone marrow transplantation are rejection of the graft by the body and attack of the transplanted cells on the patient's body (graft-versus-host disease). To prevent both of these reactions, the patient is prescribed immunosuppressants - drugs that suppress the immune system.

Such therapy, in turn, exposes the patient’s body to the risk of infection. In order to minimize this risk, the patient is placed in a sterile box. This is an isolated sterile room equipped with antibacterial filters.

There is no risk of complications for the donor during a bone marrow transplant. However, there are minor side effects. Possible feelings of weakness and nausea. Hospitalization of the donor lasts one day. Pain at the puncture site disappears after a few days. The donor's bone marrow cell volume is restored after 2 weeks.

The consequences of transplantation for the patient depend on a number of factors:

Initial diagnosis
Levels of donor compatibility
Relative physical health
Compliance with the isolation regime during the engraftment period
Competent treatment protocol

If all the necessary precautions are followed and the treatment is carried out in a well-equipped center under the guidance of an experienced doctor, the chances of recovery are high. This also applies to patients with malignant diseases.

How is rehabilitation after blood-forming cell transplantation?

Conclusions about the success of the transplant can only be made after several weeks after the operation. During this time, the transplant takes root in the patient's body. During the period of graft engraftment, the patient is prescribed maintenance therapy in the form of antiviral and antifungal drugs, as well as antibiotics.

A bone marrow transplant requires recovery not only physical, but also psychological. The patient experiences severe weakness for a long time. This condition affects his mental well-being, so it is extremely important to receive professional help from a psychologist during this period. It is also necessary for the patient's family to support him during this time.

Life after bone marrow transplant

The life of transplant patients is not much different from the everyday life of an ordinary person. For some time it is necessary to follow the doctor’s instructions, but this does not significantly affect the quality of life.

What is the prognosis for life after transplantation?

Survival after bone marrow transplantation depends primarily on the initial diagnosis. Also, the experience of the oncohematologist who transplants the cells is important. Thus, in German and Turkish clinics, the average survival rate of patients after transplantation is more than 90%.

It is impossible to determine the life expectancy after a bone marrow transplant, since this indicator depends on many factors. A person is considered completely cured after surviving 5 years after the procedure.

Relapse after bone marrow transplant

There is a possibility of relapse after a bone marrow transplant. This figure varies significantly depending on the clinic where the procedure is performed. Thus, in foreign bone marrow transplant centers, the statistics of relapse are much lower than the same indicator in CIS clinics.

The more time has passed since the transplant, the lower the likelihood of relapse. If the disease returns, the transplant is repeated. The risk of disease-free survival after a second transplant depends on the time interval between the first transplant and the first relapse. If this period lasted more than a year, the chances of recovery are high.

Where is bone marrow transplant surgery performed?

Oncohematology centers in clinics in Turkey, Germany and India are considered the best. Not all foreign clinics perform bone marrow transplants for children. This must be taken into account when choosing a medical solution.

Which clinics perform bone marrow transplants?

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