Prior to any bone marrow transplant, we will need patients to:
* Answer questions about their medical history;
* Undergo a physical examination;
* Have tests done to see how well the lungs are working;
* Have a chest x-ray;
* Have an EKG to look at the heart;
* Have an MRI \& MRA (Magnetic Resonance Angiography, which looks at the blood vessels and the blood flowing through them). These 2 tests will look to see if the patient has had any strokes;
* Have a PET scan to look at the head and body;
* Have a liver biopsy to determine if the liver has been damaged (which can happen from iron overload that happens after many transfusions). Too much liver damage would mean a transplant cannot be done.
For the liver biopsy, the skin is numbed with medicine, and a special needle goes into the liver. The needle removes a very small piece of the liver (tissue). The tissue is taken and examined.
Also, about 30 cc (2 tablespoons) of blood will be drawn to test the blood for viruses, including HIV (the virus that causes AIDS). If the HIV test is positive, a transplant will not be done because it would be too dangerous for the patient.
At least 2 weeks before the bone marrow infusion, the patient will be immunized with Prevnar 7. Prevnar 7 is a vaccine that is used in children to protect against some types of bacteria called Streptococcus pneumoniae, which can cause the lung infection called pneumonia. People with Sickle Cell anemia are at a higher risk of dying from an infection from this type of bacteria. Although children are regularly given the Prevnar 7 vaccine, it is not common to test a child's immune response to the vaccine. In this study, we will check the immune system's response to the vaccine by drawing an extra 3 mL (less than 1 teaspoon) of blood 3 weeks after the patient gets the Prevnar 7 vaccine.
Just before the bone marrow transplant, we must kill the cells in the bone marrow that make the abnormal red blood cells found in patients with severe thalassemia or sickle cell disease. We will do this by using 3 drugs: busulfan, cyclophosphamide, and campath-1H. Campath-1H is used to prevent the body from rejecting or refusing to let the donor blood cells grow in the body. MESNA is given with the cyclophosphamide to prevent kidney damage. Methotrexate and cyclosporin are also given to prevent graft-versus-host disease (GVHD); methylprednisolone will be given after the bone marrow infusion if the patient develops GVHD. A drug will also be given to prevent seizures (either dilantin or lorazepam).
Graft-versus-host disease (GVHD) is a possible side-effect of the transplant. In GVHD, some cells in the donor marrow attack cells in the patient's body. This causes skin, liver, and bowel problems, and may damage other parts of the body. Often, these problems are fairly mild, but they can be severe or even cause death. Severe GVHD is likely to occur in about 10% of patients.
After the patient gets the drug treatment, they will be given bone marrow from a brother or sister who has healthy bone marrow that matches the patients. The healthy bone marrow will be put into a vein (given IV) in the same way that blood transfusions are given. The marrow cells then travel to the right places in the body, where they should grow and make new normal blood cells.
This is the treatment schedule:
Protocol Day \& Treatment:
14 or more days before the bone marrow infusion -- Prevnar 7 vaccine
10 days before the bone marrow infusion -- Begin Dilantin or Lorazepam (to prevent seizures)
9 days before the bone marrow infusion -- Busulfan
8 days before the bone marrow infusion -- Busulfan
7 days before the bone marrow infusion -- Busulfan
6 days before the bone marrow infusion -- Busulfan
5 days before the bone marrow infusion -- Campath 1H, Cyclophosphamide, and MESNA
4 days before the bone marrow infusion -- Campath 1H, Cyclophosphamide, and MESNA
3 days before the bone marrow infusion -- Campath 1H, Cyclophosphamide, and MESNA
2 days before the bone marrow infusion -- Campath 1H, Cyclophosphamide, MESNA, and cyclosporin
1 day before the bone marrow infusion -- DAY OF REST
Day "0" -- bone marrow infusion given
1 day after the bone marrow infusion -- Methotrexate
3 days after the bone marrow infusion -- Methotrexate
6 days after the bone marrow infusion -- Methotrexate
11 days after the bone marrow infusion -- Methotrexate
After transplant, Filgrastrim, a growth hormone for the bone marrow, may be given intravenously (through a vein), if medically necessary.
Sometimes, the donor's bone marrow does not grow. Then, the patient would be without working bone marrow cells. So that we will be ready to treat this problem if it happens, we will take bone marrow from the hip bone before the patient gets the drug treatment. The patient will be asleep (sedated) when the marrow is taken, and they will be given medicine for any pain they have afterwards. This bone marrow will be frozen and stored or preserved. If the donor bone marrow does not grow, we will thaw the stored marrow and put it back into the body. This stored bone marrow should grow and produce working blood cells. If the stored bone marrow must be given back, the disease will not be cured.
To tell whether the transplant has worked or "engrafted", we will take samples of bone marrow (bone marrow aspirate). We will do this 3 weeks after the transplant to make sure the new cells are beginning to grow. We will take another marrow sample at 3 months after the transplant. We want to make sure the new cells are still growing. This test will take about 30 to 45 minutes. Because this test is painful, the patient will be given pain medicine before, during, and after the test.
The patient will need to be in the hospital for at least 3 weeks after the transplant to make sure the transplant has engrafted. We will do several tests (of the lung, kidney, and liver) before and after the bone marrow transplant. We want to find out how much the treatment has helped the patient and how much it might help other patients. Most tests will be done every week for 4 months and at each visit to the hospital. Also, we will be looking at the immune function. To do this, we will take about 8 ml (less than 2 teaspoonful) at 6 months, 1 year, and 2 years after the transplant. When possible, we will take the blood from an IV line that the patient already has. However, at times we will have to draw the blood with another needle stick. A total amount of 200 mL (about 13 tablespoons) of blood will be collected from the patient during the entire study.
After 4 months, if the patient's health is good, they will not need to come to the hospital so often. The visits to the doctor should be more like they were before the bone marrow transplant. Since problems may happen months after the transplant and this is a new way to treat sickle cell disease and thalassemia the patient will need to have exams and blood tests done every few months during the first and second years after their transplant. After that, if all is well, the patient will need to be examined and have blood tests 4 times a year.
