Bone Marrow Tranplantation

8/8/2019 Bone Marrow Tranplantation

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Bone marrowtranplantation

Nanis Sacharina

A week-observation in

Centro Trapianti di Midollo Osseo,Ospedale Microcitemico,

Cagliari, 7-16 Dec 2005


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Ospedale Microcitemico


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History team workStart in 1993

1 BMT unit, outpatient clinic

7 doctors, 10 nurses (+ 2 nurses for clinic)molecular laboratory:

3 doctors

1 biologist

2 technicians

Every day meeting


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Meeting


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IndicationThalassemia (110 patients)

leukemia

solid tumor

SCID

aplastic anemia


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Survival rate

Familial donor

43 patients (1-15 yo), 120 months follow-up

Disease free survival rate: 95% 2 deaths

32 patients (16-34 yo), 120 months follow-up

Disease free survival rate 88%

Non familial donor17 patients

Disease free survival rate : 65%

CTMO, Ospedale Microcitemico, Cagliari


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Survival rate (Thalassemia)36 class 1 and 2 thalassemic patients, 72 mo

follow-up

Survival rate 96%Thalasemia free survival rate 85%

Class 1: 100%, class 2: 75%

35 class 3 patients, 12 years follow-upthalasemia free survival rate 50%


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Risk classes in thalassemic

patients at the time of BMT

Risk factors class I class II class IIIHepatomegaly < 2

Only one or a

combination of

two risk factors

out of three

2

Portal fibrosis No Yes

Iron chelation regular Irregular


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Umbilical cordGraft failure 21%

Long period of aplasia

Thalassemia: 7/33 failed

Sickle cell 1/ 11 failed


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ProtocolHLA typing:

Class I: A, B, C

Class II: DQ, DR, DP

Parents/ patients agreement

Informed consent

Several work-up and laboratory test


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List serologically-identifiable HLAs

Locus A Locus B Locus C Locus DR Locus DQ

1 5: 51, 52 w1 1: 103 1: 5, 6

2: 203, 210 7 W2 2: 15, 16

3 8 w3,: w9, w10 3: 17, 18 2

9: 23, 24, 2403 12: 44, 45

13

W4 4 3: 7, 8, 9

10: 25, 26, 34, 66

11:

19: 29, 30, 31, 32,

33, 74

28: 68, 69

36

43

80

14: 64, 65

15: 62, 63, 75, 76,

77

16: 38, 39

17: 57, 58

18

21: 49, 50, 4005

22: 54, 55, 56

etc

W5

W6

W7

w8

5: 11, 13

6: 13, 14, 1403,

1404

7

8

9

10

51

52

53

4


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Compatibility and incompatibility

Full compatibility = full-house/ zero mismatch:

the best!

Donor: A26 A32 B38 B55 DR1 DR4

Receiver: A26 A32 B38 B55 DR1 DR4

Poor compatibility

Donor: A26 A32 B38 B55 DR1 DR4

Receiver: A1 A32 B17 B35 DR9 DR7


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Laboratory (donor and recipient)

Mixed lymphocyte culture

DNA extraction

4 ml of serumfT3-fT4-TSH

Lymphocyte subset

tuberculine test

Ig-C3-C4Liver and renal function test

VNTR


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LaboratoryAnti toxoplasma-CMV

antibody

anti EBV

anti herpes simplex

and zooster

anti HCV-HCV RNA

markers HBV

anti HIV

VDRL

Anti platelet antibody

ferritine

nasal and pharyngeal

culture

rectal/ preputium/

perineal swab-culture

urine culture

PT, PTTElectrophoresis Hb,

protein


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Work-upECG-cardiology consultation

echocardiography

Chest X-ray

bone age (> 2 yo)

spirometry (age 7)


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Donor preparationErythropoetin

Iron

Folic acid

Blood predeposit prevent random

transfusion


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BMT unit

2

1

3

4

kitchen

Nurse station

Doctor station

bagno

Mini lab


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Patients room

bathroom

Parents room Patients room

cupboard


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Fausto with us


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Patients room


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Patients room


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BMT Protocol (thalassemia)Vena central catheter insertion undergeneral anesthesia (7 days before day -10),

day careadmission to the BMT unit on day -10

suppress the defected marrow and preventGvHD

hydration and alkalinitation start 12 hoursbefore administration of busulfan


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Bone marrow suppressionBusulfan 4 days: 14 mg/kg

hydration 3 L/m2 until day -1

alkalinisation: NaHCO3

KCl

Furosemid

carbamazepine

Co-trimoxazole

CPA/ endoxan 4 days: 200 mg/kgmesna

hydration


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Other drugsColimicin

neomicin

nistatin

azyclovir

ondansetron

chlorpheniramin


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GvHD preventionCyclosporin A

Methylprednisolone

ranitidine

Methotrexate if necessary


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MonitoringEvery day

CBC

blood gas analysis, electrolyte (duringalkalinisation)

balance diuresis


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Bone marrow harvesting &

retransfusionUnder general anesthesia

Operating room

20 ml/ kg recipient, nucleated cells 3.5-4 x108/ kg

BM retransfusion as soon as possible

depends on ABO compatibility:plasma removal: minor

red blood cell removal: major


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After BMTGrafted or not?

VNTR: before BMT and > +10 day

Usually take 12-20 ( to 30) days

Complication

Infection: special concern of IgG EBV and

CMV positive reactivation?

Acute GvHD (familial donor 20%, non familial

60%)


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Discharge criteriaGood condition overall

No infection, GvHD

Laboratory normal


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Follow-up after dischargeFirst year: monthly

Afterwards: 2 monthly

Infection

Chronic GvHD


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Chronic GvHD

Bone Marrow Tranplantation

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