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Bone Marrow Transplant in India

In this article, we have covered the following aspects of Bone Marrow Transplant:

  • Best Hospitals for Bone Marrow Transplant procedure in India
  • Top Haematologists expertised in Bone Marrow Transplant
  • Cost of the procedure in India
  • Understanding Bone Marrow Transplant procedure

Best Doctors and Hospitals for Bone Marrow Transplantation in India

Following is a list of the most reputed specialists in India for Bone Marrow Transplant.
Please click the ‘contact doctor‘ button on the right side for seeking opinion or requesting an appointment with your chosen specialist.
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Doctor ImageDr. NameSpecialtyHospital AssociatedContact DoctorCity
Dr. Rahul BhargavaDr. Rahul BhargavaHaemato OncologistFortis Memorial Research InstituteGurgaon
Dr. satya prakash yadavDr. Satya Prakash YadavHaemato OncologistMedanta - The MedicityGurgaon
Dr. Vikas DuaDr. Vikas DuaHaemato OncologistFortis Memorial Research InstituteGurgaon
Dr Santanu SenDr. Santanu Sen Haemato OncologistKokilaben Dhirubai Ambani HospitalMumbai
Dr Dharma ChoudharyDr. Dharma ChoudharyHaemato OncologistBLK Super Specialty HospitalDelhi
Dr. Sharat DamodarDr. Sharat DamodarBone Marrow TransplantNarayana Multispeciality HospitalBangalore
Dr Rakesh ChopraDr. Rakesh ChopraMedical OncologistArtemis HospitalGurgaon
Dr. Ashok Kumar VaidDr. Ashok Kumar VaidMedical OncologistMedanta - The MedicityGurgaon
Dr Niti Raizada NarangDr. Niti Raizada NarangMedical OncologistFortis HospitalBangalore

Cost of Bone Marrow Transplant Procedure

Autologous BMT costs between USD 25,000-30,000 in India & Allogenic BMT costs between USD 32,000-37,000 USD. Please discuss to know the differences.

Bone Marrow Transplantation

Over the last 50 years, bone marrow transplantation and hematopoietic stem cell transplantation have been used frequently to treat numerous malignant as well as nonmalignant diseases.

In 1968, the first major landmark in bone marrow transplantation happened after successful allogeneic transplantations performed on an infant . then successful attempts were made on aplastic anaemia and later on in leukemia patients.

Bone marrow donor registries, such as the National Marrow Donor Program (NMDP), have facilitated the listing of unrelated donors, helping the number of patients who can receive transplant.

In 1988, successful transplantation happened in a young boy with Fanconi anemia using umbilical cord blood collected from his sibling after his birth. first cord blood transplantation happen in leukemia patient in 1992. Cord blood has been used to transplant in any disease state for which bone marrow can be used for transplantation. The limited number of cells in cord blood restricted its use to children and young adults.

Hematopoietic stem cell is the most important and necessary cell for successful transplantation.

Autologous & Allogenic Transplants

Major sources of stem cells are:

  • Bone marrow
  • Peripheral blood
  • Umbilical cord blood

They are obtained from:

  1. Autologus(taken from recipient only)
  2. Allogenic (taken from other then recipient)

Allogenic sources are as follows:

  • Syngeneic (obtained from identical twin)
  • Related
  • Unrelated

The best possible match results in less complications. For allogeneic transplants, immediate family members undergo HLA histocompatability using serology. Class I and class II HLA antigen compatibility is tested and compared.

  • Class I à HLA-A, HLA-B, and HLA-C
  • Class II à HLA-DR, HLA-DP, and HLA-DQ

6-of-6 match means testing of HLA-A, HLA-B, and HLA-DR, each of which has 2 alleles.
Involves checking for these 6 antigens among family members.

  • Mismatched donor-If donor and recipient are not  6-of-6 match
  • Haplotypic donor- When only 3 of 6 match .

Unrelated-donor search registries

When a related donor are not identified, a search for an unrelated donor is often initiated. This usually consists of a search of marrow donor registries and cord blood banks. The largest donor registry is the NMDP, which is responsible for providing marrow and stem cells

Unrelated-donor search process

DNA-HLA typing of the recipient is done which is more accurate then serological method. Registry databases are explored.  When a potential donor is found, series of confirmatory tests are been done including class II typing of potential donors and confirmatory typing of selected matches. When donor are matched , they undergo a workup that includes laboratory testing ,viral screening, physical examination, and an informational session to counsel about the procedure. When donor& consent has been obtained, a date is set for the collection. Harvesting of Bone marrow or PBSCs are done on the same day of transplantation with the intent to infuse the same in recipient within 24 hours of the harvest. In case of cord blood, it is shipped to the transplant center prior to the onset of the recipient’s conditioning regimen.

Indications for Transplantation

Nonmalignant diseases

  • Inherited metabolic disorders
  • Inherited immune disorders
  • Acquired immune deficiency syndrome
  • Inherited red blood cell disorders like Pure red cell aplasia, sickle cell disease, beta-thalassemia, and others
  • Marrow failure states – Severe aplastic anemia
  • Autoimmune diseases

Malignant/premalignant diseases

  • Acute lymphoblastic leukemia (ALL)
  • Acute myelogenous leukemia (AML)
  • Chronic myelogenous leukemia (CML)
  • Juvenile myelomonocytic leukemia
  • Myelodysplastic syndromes
  • Plasma cell disorders
  • Hodgkin and non-Hodgkin lymphoma

The Transplant Process

It is divided into the following 5 phases:

  1. Conditioning
  2. Stem cell infusion
  3. Neutropenic phase
  4. Engraftment phase
  5. Postengraftment period

Conditioning

The conditioning period typically lasts 7-10 days. The purpose is to start chemotherapy, radiation, or both to eliminate malignancy, prevent rejection of new stem cells.

Stem cell processing and infusion

The stem cell infusion is usually performed over about an hour, but this period varies depending on the volume infused. T cell depletion is often performed before haplotype-matched transplants or other significant degree of mismatch transplants. Inflammatory reaction, volume overload, and a transient GVHD are the major potential complications involved.

Neutropenic phase

2-4 week post transplant, no effective immune system is there in body. Patient is prone to infection. Supportive care along with empirical antibiotic therapy is helpful in this phase. Hospital-acquired infections perhaps are the biggest risk because they are antibiotic resistant most of the time. Broad spectrum antibiotics along with anti fungal agents are added in the treatment. Oral intake become poor due to inflammation of mucus membrane of mouth (mucositis) so Total parenteral nutrition is provided and is usually quite necessary, especially for children.

Engraftment phase

In this period (several weeks), the healing process start with resolution of mucositis and other acquired infections. In addition, fever begins to subside, and infections often begin to subside. The greatest challenges during this period include management of GVHD and prevention of viral infections like CMV.

In solid organ transplants, rejection of the organ is the major concern but on the contrary in hematopoietic cell transplantation, the immune system is part of the transplanted organ; therefore, the new immune system can attack the entire body. When this occurs, it is termed GVHD (Graft Versus Host Disease)

It involves the skin, GI tract, and the liver, causing a rash and blistering, diarrhea, and increased bilirubin levels respectively.

Allogeneic stem cell transplant recipients are given one or more immunosuppressive medications to protect against the development of GVHD.

Postengraftment phase

This period lasts for months to years. This phase include the gradual depletion of rejection phase, weaning off of immunosuppressive drugs, management of chronic GVHD, and development of immune reconstitution. T-cell depletion or from mismatched or haplotypic source transplant patients often have delayed or incomplete immune reconstitution.

Reimmunization is needed, usually beginning one year post transplantation. To start with first tetanus (DT) is given which is age dependent, with titers obtained before and at least one month following to document a response.

Oral polio vaccine should not be administered. Instead inactivated poliovirus vaccine (IPV) is given.  Influenza vaccination should be administered to all patients every year. Haemophilus influenzae, pneumococcal, and hepatitis B series can be given once protective titer is obtained from the tetanus vaccine.

After 2 years, Post successful immunization for the above mentioned vaccine, immunization may be given for measles, mumps, and rubella using MMR vaccine. Patient having adequate rubella titers, immunization may be withheld.

Outcomes

  • Improvements in supportive care, antibiotic regimens, and DNA-HLA typing have had significant impact on improving survival and quality of life following transplant.
  • Patients with stable disease or disease in remission have better outcomes than those transplanted during a later phase of disease or with relapsed disease.
  • Young age at time of transplant show favorable outcomes
  • Likelihood of survival is more in CMV-negative status of recipient and donor.
  • A larger dose of hematopoietic stem cell given at time of transplant may fasten engraftment along with improved outcome but it may also increase the risk of GVHD.
  • Transplants for nonmalignant diseases generally have more favorable outcomes.

Future Directions

The primary end point is to do research in order to decrease toxicity and GVHD while increasing the number of potential donors by developing techniques without using traditional HLA histocompatability barriers successfully.

Transplants are performed despite increasing degrees of mismatch. Efforts are made to reduce the toxicity and transplant-related mortality.

Cord blood remains a potential source of hematopoietic stem cells. The use of multiple cord blood units for the transplant of larger individuals need to be explored.  Research suggest a possible role for transplant in the treatment of autoimmune diseases such as lupus,   multiple sclerosis, systemic sclerosis, and juvenile rheumatoid arthritis.

In addition, in utero transplant is under trial which will help in early correction of genetic disease.

Gene therapy is also in consideration. It is a type of stem cell transplantation in which the deficiency in a patient’s own hematopoietic stem cell is rectified by gene rectification or addition. It is reinfused similar to autologous hematopoietic stem cell transplantation. Smaller doses of chemotherapy for conditioning are given so that the risks for GVHD are essentially rectified.

With the advancements in techniques, indications, and supportive therapy, the transplant of hematopoietic stem cells will be an advancing field in the treatment of human disease.

Note (for foreign patients):

Besides South Asian countries (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, Pakistan, Sri Lanka), every year, India gets thousands of medical tourists from African countries- Nigeria, Kenya, Ethiopia, Sudan, Uganda, Ghana, Somalia,Gambia etc and Middle Eastern countries like Iraq, Iran, Saudi Arabia, Oman, UAE, Yemen etc. Hence, if you are a citizen of any of these countries, there is good likelihood that you will be meeting some fellow citizens or same language speakers in the major hospitals in India. Almost all the top hospitals have translators for people of these region. Our patient support team is also well placed to assist you.

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