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Bone Marrow Transplant

Bone marrow is the fluid present within the bones and produces the blood cells for the body. Bone Marrow Transplant is a special kind of therapy that is carried out on patients with particular cancers like leukemia, immune deficiency disorders, lymphomas and other diseases. A bone marrow transplant begins after the high dose chemotherapy is over and typically involves extracting healthy blood cells from the bone marrow of a donor and transfusing them to the receiver's blood stream, in order for him or her to produce healthy blood cells again.
Receiving a bone marrow transplant is a non-surgical procedure. It is more similar to a blood transfusion, where the healthy cells are introduced to your blood through a central venous catheter. It is painless and requires no anesthesia. Through advanced scientific technologies, it is now possible to conduct a bone marrow transplant with only a 50% match between the donor and receiver.

Need for a Bone Marrow Transplant:

Bone marrow transplant is a way of giving very high dose chemotherapy, sometimes with whole body radiotherapy. This treatment aims to try to cure some types of cancer, such as

  • Leukaemia
  • Lymphoma
  • Myeloma

A bone marrow or cord blood transplant replaces unhealthy blood-forming cells with healthy ones. Blood-forming cells are also called blood stem cells. Blood stem cells are immature cells that can grow into red blood cells, white blood cells and platelets.
  There are two types of transplant.

An autologous transplant is a way to treat cancer using very high doses of chemotherapy that destroy the bone marrow as a side effect. The autologous blood cells replace the damaged marrow. This is how autologous transplants are used to fight certain types of cancers such as lymphoma.

An allogeneic transplant also treats cancers of the blood, and offers the added benefit of using the donor’s immune system to recognize and destroy cancer cells. Allogeneic transplant is also used to treat some non-cancerous diseases such as sickle cell anemia. In non-cancerous diseases, the transplant replaces defective marrow cells with the donor’s healthy cells.

Preparing for Bone Marrow Transplant:

A bone marrow transplant requires some mental and physical planning prior to the procedure.

Preparative or conditioning regime:

Before a transplant, you will receive chemotherapy, with or without radiation. This is known as the preparative or conditioning regimen. This treatment is given in the days just prior to the infusion of blood-forming cells. In an autologous transplant, which uses the patient’s own blood-forming cells, this treatment is given in very high doses to kill any cancer cells that might be left in your body. In an allogeneic transplant, which uses blood-forming cells from a family member, unrelated donor, or cord blood unit, the preparative regimen varies in intensity from relatively mild to very intense. The level of intensity depends on the disease being treated. The treatment is given to help make sure the donor cells engraft (settle into the marrow to start making new blood cells).

Expected Results:

On the transplant day, the replacement cells are infused into your blood stream. These cells know where they belong in the body. They move through the bloodstream and settle in the bone marrow. Until your donated cells start to grow and make new blood cells, you will have low numbers of all types of blood cells (red blood cells, white blood cells and platelets). Waiting for engraftment lasts from 10 to 21 days for marrow and peripheral blood stem cells (PBSC), and up to 6 weeks for cord blood transplants. Engraftment is when the donated cells begin to grow and make new red blood cells, white blood cells and platelets. At this point, your blood cell numbers will begin to go up. Your immune system will become stronger (although it will still be weaker than usual for many months). Your transplant team will still care for you and watch you closely for complications. Engraftment and early recovery lasts from around day 30 to day 100. You will be in the hospital or nearby during this time.

Risks Associated with Bone Marrow Transplant:

Graft versus host disease (GvHD) is a complex illness that can develop when you’ve had a stem cell transplant. Every patient’s experience of GvHD is different so use this information together with the care provided by your medical and nursing team. Graft versus host disease can happen if you’ve had a bone marrow or stem cell transplant using donated cells from another person. GvHD happens when cells from the donor (graft) are attacking your own body (host). During this reaction, donor cells recognise that the recipient’s body is ‘foreign’ and mount an attack against it. Approximately 50% of patients who have an allogeneic transplant will develop GvHD. Fortunately, GvHD can be mild, causing very few problems. However, in a small minority of people, GvHD is a serious and sometimes life-threatening illness that can have a big impact on your physical and psychological well being.

Liver Transplant:

A Liver Transplant is carried out to replace a diseased, dysfunctional liver with a healthy liver from a donor. Liver donors can either be alive or deceased, though most transplants involve a live donor. In case where a first degree relative with the same blood group donates part of the liver, it is known as Liver Related Liver Transplant (LRLT).

Liver transplant is reserved for people who are critical ill, as the number of transplant receivers is much higher than available donors. Depending on the type and criticality of the case, some patients may need a liver right away from a relative in case of a LRLT, while others may have to wait for several months.

To carry out a liver transplant, the blood type and liver size of the donor and receiver must be compatible. A donor needs to only donate a section of his liver. Since the liver has a special property of regenerating, the donated liver will grow to the optimum size in a few weeks. The donor’s liver will also grow back to its normal size.

Need for a transplant:

A liver transplant might become a last treatment option for patients with extreme or final-stage liver cirrhosis, who suffer from failing liver function and reduced quality of life. Patients with liver cancer in early stages with cirrhosis may also be advised a liver transplant. Liver Transplant is advised to only those patients who are fit for anesthesia with no other major medical problems.

Some conditions that require a liver transplant are:

  • Chronic Hepatitis B and Chronic Hepatitis C with Cirrhosis or Hepatoma:
Chronic Hepatitis is a type of hepatitis that lasts for more than 6 months. It is a serious and infectious disease that attacks the liver and is commonly caused due to hepatitis B & Hepatitis C viruses. Hepatitis B is spread due to exposure to infected bodily fluids, and can be easily prevented by an effective vaccine. Hepatitis C, on the other hand is spread due to exposure to contaminated blood. Chronic hepatitis can result in cirrhosis after several years, with an enlarged spleen, accumulation of fluid within the abdomen, and deterioration of brain function. These patients also have an increased risk of liver cancer.
  • Primary Liver Cancer:

Liver Cancer or Hepatocellular Carcinoma is a very common type of cancer especially in India thanks to the high incidence of Hepatitis B & C virus. Liver cancer is also caused due to alcohol abuse leading to cirrhosis among others. Similar to other cancers, Cancer of Liver can remain undetected until it reaches an advanced stage. Upon suspicion, it can be confirmed through a simple blood factor named Alpha Feta Protein (AFP) along with a Triple Phase CT-Scan of the liver. A liver biopsy is not required in many cases. Cancer that has arisen from the liver is termed Primary Liver Cancer. Often, cancer from elsewhere can spread to the liver. The selection of a liver transplant receiver with Liver Cancer is done on the basis of size and number of tumors. In some cases, the liver is afflicted with cirrhosis as well as cancer at the same time. In such cases, a transplant can be the best option.

  • Alcoholic Liver Disease:

Alcoholic Liver Disease is developed due to excessive intake of alcohol. The disease progresses through three stages. In the first stage, the liver accumulates excessive fat inside its cells. This condition is called Fatty Liver, where the liver becomes enlarged and causes abdominal stress. The second stage begins when the liver cells begin to die and acute inflammation of the liver occurs. This is called Alcoholic Hepatitis Stage. This is followed by the third and final stage called Alcoholic Cirrhosis, which is characterized by the complete destruction of healthy liver tissue into non-performing scar tissue. Restoration of liver function and repair is possible till the first stage, however once the cirrhosis sets in it is impossible to revert the damage caused to the liver. However, stopping alcohol intake delays the progression to liver failure.  In end stage cirrhosis, a transplant is the only option available.

Bile Ducts transport a secretion named bile from the liver and gallbladder to other organs in the digestive system. Bile is secreted by the liver in order to digest fats. Primary biliary cirrhosis occurs when the bile ducts are progressively scarred and inflamed because of blockages in the ducts caused due to automimmune process. Eventually due to the blockages and the scarring, cirrhosis sets in and the liver begins to fail. In some cases, the disease spreads quickly. Liver transplant may be the only alternative in advanced cases of biliary disease.

  • Autoimmune Hepatitis A PSC (Primary Sclerosing Cholongitis)

These are other forms of autoimmune disorders which progress over the years to result in cirrhosis of the liver and eventually liver failure. AIH is common in females and PSC affects younger patients.

Acute Liver Failure is a result of reduced liver function caused by viral hepatitis, alcoholic liver diseases, drug reaction or overdose among others. Liver failure occurs when a large part of the liver is damaged and may rapidly develop over weeks, as acute or over a period of years as chronic. Liver failure results in permanent loss of liver function, leading to conditions like jaundice, coagulopathy, portal hypertension, fluid accumulation inside the abdomen, deterioration of brain function and immune system malfunctions. Patients tend to be very sick and need ICU support. Many would die without an urgent Liver Transplant.

Risks Involved:

Like every surgical procedure, Liver transplant also carries significant risk. To start off, the body’s immune system may consider the new organ to be foreign material and initiate an attack on the healthy liver. To avoid this, patients have to take immunosuppressant medication for the rest of their lives. Other complications include:

  1. Bleeding
  2. Biliary duct blockage, leakage or shrinkage
  3. Blood clots
  4. Infection
  5. Functional failure of the donated liver
  6. Rejection of donated liver

Many of these complications occur in the immediate postoperative period.

Preparing for the transplant:

Undergoing a liver transplantation requires prior planning and preparation. If you are to be placed on the waiting list for a transplant, you will have to undergo a complete evaluation that includes:

  1. Blood & Urine Lab Tests
  2. CT or MRI Scan of the Abdomen
  3. Detailed Cardiac Evaluation, Pulmonary Evaluation
  4. Overall Health Check, some patients might need endoscopy and colonoscopy 
  5. Dietetic Assessment & Counselling
  6. De-addiction Counseling
  7. Psychological Evaluation
  8. Financial Counseling

Based on the evaluation results, your team of doctors will consider if a liver transplant is the best method of treatment for your condition. If yes, you will then be thoroughly counseled about the procedure, its associated risks and possible outcomes. You will be asked to sign a consent form that allows the transplant to be carried out.

Donor Evaluation:

First Degree relatives who are between 18 to 55 years of age with same blood group and medically fit can be considered for LRLT. They should undergo detailed medical evaluation and should have psychiatric evaluation also.

Timing of the Transplant:

If Chronic Liver Disease or cirrhosis is suspected patients should consult hepatologist and transplant surgeon straightaway to plan future management. There are different scoring systems like MELD, CHILD-PUGHS which will guide the liver team to decide the timing of transplant. Generally Liver Transplant should be considered and planned before developing kidney impairment and various stages of Liver cancer (Encephalopathy) for better outcomes. About 50% of patients die within 2 years of developing jaundice and ascetic fluid in the abdomen.

Expected Result:

Liver transplantation is performed under a general anesthesia. To access the liver, the transplant surgeon first makes long incisions across your stomach at the site of your liver. Next, the surgeon will stop flow of blood to the diseased liver and also disconnect the bile ducts, and remove the liver. If the donation is from a live donor, then a portion of healthy liver will be transplanted. On the other hand if the donation is from a deceased donor, then the whole healthy liver will be transplanted into the site, and the concerned blood vessels and bile ducts are reconnected.  With the new liver in place, the surgeon will close the procedure and you will be transported to the ICU. The entire surgery may take up to 12 hours.

You may be required to spend around 2 weeks in the hospital to ensure a healthy recovery. Blood tests will be frequent in the first few days, and reduce over time. Anti-rejection drugs called immunosupressants will have to be taken to reduce the risk of rejection of the new liver by your immune system. Antibiotics will also be administered to avoid infections.

Once you are discharged and back home, you will still need to visit your medical team frequently to check on the progress of your recovery. Most patients who have had a liver transplant extend their lifespan upto 5 years. Some may need a second transplant incase the disease has returned. Your recovery will also depend on how ill or healthy you were prior to transplant.

Kidney Transplant

A Kidney Transplant is a procedure carried out to implant a healthy, normally functioning kidney from a healthy donor in place of a diseased kidney for an enhanced quality of life. There are two types of kidney transplant that can be adopted, those that are donated by a living donor and those that are donated by a deceased donor.  A live donor can be a family member, spouse or a relative.

Kidneys perform the function of filtering and removing excess fluid and bodily wastes. Failure of kidney function results in excessive levels of waste accumulation in the body leading to nausea, vomiting, breathlessness, heart failure and high blood pressure.

We generally use the term “End-stage kidney disease” when 90% of kidney function has been lost. This is when most patients start to develop symptoms and a kidney transplant or dialysis becomes a necessity.

Dialysis vs Transplant:

Haemodialysis is a procedure where a machine fitted with a dialyzer filters blood and removes wastes and excess fluids from the body. Dialysis helps to control blood pressure and maintain the body’s proper balance of essential elements. Although a lifesaving procedure, dialysis is able to perform only 10% of kidney function and needs to be carried out twice or thrice a week.

Despite being on dialysis, patients still experience health complications like anemia, high blood pressure, heart issues, infection among others. The average life expectancy of a patient dependant on dialysis is around 5 years.

Patients, who opt for a kidney transplant, have typically a longer life expectancy compared to those on dialysis. Patient who undergo a kidney transplant prior to dialysis achieve an added 10 to 15 years of life. Apart from a longer life expectancy, the quality of life is also raised substantially as transplant receivers have a less restricted diet, feel more energetic and have fewer health complications.

Some of the conditions that lead up to kidney failure are:

  • Hypertension (high blood pressure):

Hypertension, or high blood pressure is a condition where blood flowing through the body exerts an increased amount of force on the blood vessels. High blood pressure can be a result of higher blood volume caused due to excess fluid in the blood, or narrow, clogged or stiff blood vessels. Increased blood pressure can damage blood vessels in the kidneys, hampering their filtering function. In a hypertension patient, blood vessels stretch in order to facilitate easier flow of blood. Constant stretching causes damages and weakens vessels in the kidneys and through the body. The blood vessels in the kidney, upon being damaged may cease to carry waste and excess fluids from the body. This retained extra fluid increases the blood pressure even higher, causing further and faster deterioration of blood vessels.

  • Diabetes mellitus:

Diabetes is a condition characterized by imbalanced blood sugar levels. The body produces a hormone called insulin which is responsible for maintaining blood sugar levels at its optimum measures. A person who is afflicted with diabetes produces less insulin or develops resistance to the hormone. Diabetes can injure the small blood vessels which in turn puts stress on your kidneys. Kidneys of a diabetic patient will lose their ability to efficiently filter the blood, resulting in retention of water and salts. Similarly, waste gets accumulated in the blood stream leading to another host of issues. About 30% of Type 1 diabetics and 10-40% Type 2 diabetics will eventually face kidney failure and will require either dialysis or a transplant.

  • Urinary Blockages:

Blockages in the urinary tract have great influence on the functioning of kidneys. Obstructive Uropathy occurs when the flow of urine through the ureter is blocked either partially or completely, or flows backward into the kidneys instead of flowing out of the ureter. Urinary Blockages can cause swelling and scarring of tissue to the kidneys. Temporary or permanent blockages in your ureter can result from injuries such as a pelvic fracture, tumor mass that spreads to your kidneys, bladder, uterus, or colon, kidney stones trapped in the ureter, blood clots and nervous system disorders.

  • Glomerulonephritis :

Glomerulonephritis covers a range of issues that afflict the glomeruli present inside the kidney. In this condition, the glomeruli have borne some damage which has resulted in hampered functioning. Any damage to the working of the glomeruli in turn affects the kidneys and their functioning as well. Chronic glomerulonephritis can last for a long duration that can cause irreparable damage to the glomeruli and interfere with the kidney functioning and kidney failure can occur.

Risks Involved in Kidney Transplant:

Risks associated with kidney transplant are similar to those with any other surgical procedure. Kidney transplant surgery carries a risk of significant complications, including:

  • Blood clots in arteries/veins
  • Bleeding
  • Leaking from or blockage of ureter
  • Infection
  • Rejection of the donated kidney
  • An infection or cancer that can be transmitted with the donated kidney
  • Death, heart attack and stroke

Preparing for a Kidney Transplant:

Before heading for a kidney transplant, you will be tested on various levels to ensure you receive a right donor. Tests will include:

  • Blood & Urine Lab Tests
  • Renal Ultrasound ,X-Ray
  • Detailed Cardiac Exam
  • Overall Health Exam
  • Nutritional Examination & Counseling
  • De-addiction Counseling if needed
  • Psychological Evaluation
  • Financial Counseling

Based on the evaluation results, your team of doctors will consider if a kidney transplant is the best method of treatment for your condition. If yes, you will then be thoroughly counseled about the procedure, its associated risks and possible outcomes. You will be asked to sign a consent form that allows the transplant to be carried out.

Expected Results:

The Kidney transplant surgery will be carried out under general anesthesia. Throughout the procedure, the anaesthesia team will constantly monitor your heart beat, B.P. and blood oxygen level. The surgeon will begin the procedure by making an incision across the abdomen, and will place the new kidney on site. The blood vessels connecting the new kidney will be attached to the ones in the lower abdomen. Similarly, the new kidney’s ureter will be linked to the bladder. The old kidneys will be left in place unless they are a cause of complication for the patient.

A typical kidney transplant will last about three to four hours. Post surgery, you will be required to spend a few weeks in the hospital including ICU stay. During these days, your medical team will closely monitor your progress. The new kidney, if accepted by the body will produce urine immediately or in a matter of few days.

Lifelong medications will be prescribed in order to suppress your own immunity system from attacking the new organ. Additional drugs will also be prescribed to reduce the risk of infections and diseases.