Dr Sandeep Chatrath, CEO, Dharamshila Hospital, discusses the success story of Haploidentical Transplantation with Shahid Akhter, ENN

Dr Sandeep Chatrath,
CEO, Dharamshila Hospital,

What is Haploidentical Transplantation?

Haploidentical Bone Marrow Transplantation (BMT) is a procedure in which, instead of fully HLA matched family donor, a half HLA matched parent or sibling is the donor for bone marrow or blood stem cells.

What is the scientific basis for Haploidentical Family Donor BMT? Is BMT possible from a half matched unrelated Donor?

The saying that nature is the mother of all inventions is not without reason. HLA antigens are inherited as a set from each of the parents. A mother nurtures a baby in her womb for 9 months without rejecting it even though the paternal HLA antigens inherited by the baby should cause a rejection. This is natures example of development of tolerance and thus, a child and the mother are natural donors for each other in most cases even though they are only half matched in their HLA antigens. Based on the pioneering work by doctors from Italy, BMT from a half matched (Haploidentical) donor from the family was developed. Due to the absence of this natural law of tolerance, BMT from a half matched unrelated donor is not possible.

How is Haploidentical BMT different from other forms of BMT?

BMT from a Haploidentical family donor is associated with a higher risk of both GVHD and Graft Failure. Thus, the success of such BMT depends on the selection of the right Haploidentical Donor amongst the family members, delivery of the most suitable Conditioning therapy to prevent Graft Failure and to prevent GVHD by processing the graft or using a combination of immunosuppressive drugs.

What are the indications for a Haploidentical BMT?

The indications for Haploidentical BMT are the same as Matched Family Donor BMT.

Why do we need a centre for Haploidentical BMT?

There are six private and two stateowned BMT centres in Delhi and NCR and one might query intuitively as to why another one? To answer this, we need to look at the Indian scenario in the field of BMT. It is estimated that over 30,000 patients per year in our country need a BMT to save their lives and the statistics from Indian Stem Cell Transplant Registry reveals that with over 40 centres across the country, only about 1000 transplants are performed annually. So, is our venture just to add a few numbers to the mammoth need of our population? If all the centres performed 4 transplants per month — which we are sure they are capable of– the need would be largely met.

Then, why is that not happening?

The answer lies in the fact that BMT is dependent on availability of HLA matched donors from the family. However, this is available to only 20 percent of the patients by simple law of inheritance. Yet, Europe, USA and Japan meet their needs largely through Volunteer Unrelated Donor Registries which currently boast of 20 million donors. In India, such registries are in their infancy and the chance of finding a match from the foreign registries is less than 10%. More importantly, the cost of procuring the blood or marrow products from Europe or USA ranges from 10,000-30,000 USD. Similar transplants can be performed from unrelated cord blood units at a similar cost, but the procedure is more challenging.

What are the unique features and infrastructure of this life saving procedure ?

Dr Suversha Khanna, president of dcfrc conceptualised the development of this unique one of its kind of bmt centre. It was her dream to have this state of the art facility in Dharamshila Hospital. In a country where alternate donor BMT is rarely available for patients lacking a matched family donor, Haploidentical BMT seems to be the logical option. However, lack of expertise and infrastructure halted its development. Dharamshila BMT Centre has developed state-of-the art infrastructure and laboratory facilities to promote the use of Haploidentical Donor BMT in India. The patients undergoing intensive conditioning and T cell depleted stem cells from Haploidentical donors are at the highest risk of infections. Infections mostly come in the form of bacterial infections from the gut or skin of the patient or as resistant bacteria from other infected patients, or as fungal infection through the air. The HVAC system of highest standards has been installed in Dharamshila BMT centre, which is first of its kind in the country. This ensures protection to the patient from all airborne infections, whilst inside the unit. Twenty-Four Bedded Dharamshila BMT Centre have 4 dedicated rooms for Haploidentical Bone Marrow Transplants. Each Room is equipped with dedicated Air Handling Unit, Anteroom for each BMT Room (for maintaining 12-15 hepafiltered fresh air changes per hour, with positive air pressure) as per class 1000 clean rooms; stainless steel doors, vinyl flooring and wall cladding for maintaining clean surfaces, which will definitely help in improving outcomes in Blood and Marrow stem cell transplantations. Each BMT Room has been furnished like an ICU with double outlets for oxygen, vaccum, six parameter monitors, infusion pumps, syrings pumps and crash cart. Sick patients with zero white blood counts cannot be taken out of the BMT unit, as this will entail risking their life. Therefore, there is a provision for stand-by ventilators, Dialysis machine, Ultrasound and X- Ray Machine in the BMT Unit. To support the hapaloidentical BMT Programme, Dharamshila BMT Lab provides

• 8-colour Flow-cytometry based diagnostics for Leukemia, Lym- phoma and Aplastic Anemia
• Detection of Minimal Residual Dis- ease (MRD)
• Molecular diagnosis for Leukemia
• HLA typing, NK Cell Genotyping and CD34 + Stem Cell Estimation
• Comprehensive donor selection for Haplo-identical BMT based on NK-KIR Profile.
• Magnetic Separation of Cells using MACS Technology.
• Long Term Cryopreservation of Stem Cells at -1960 C liquid nitro- gen freezer in vapour phase
• Conventional and Real Time PCR for Viral Pathogens
• Drug Levels for BMT.

Who are the team members associated with BMT programme?

Dr. Suparno Chakrabarti and Dr. Sarita Jaiswal pioneered the first Haploidenti- cal BMT program in India. Their work and research has been widely presented and published in the last two years.

What makes Dharmashila so different?

Internationally and nationally acclaimed team of Haemato-oncologists and Haematologists trained in Europe with extensive experience in BMT at Europe and India. We are the only centre with expertise and infrastructure for Haploidentical BMT (from half matched family donors). We have the highest standards of infection control and top notch technology brought together to achieve highest cure rates to transform dreams for being disease-free into reality. Add to this 21 beded BMT Centre on the top floor of Indias first NABH accredited Cancer Hospital which is operational since 1994 with 300 beds.

We have an excellent stem cell lab facilities for Collection, Processing, Enumeration and Cryopreservation of Stem Cells, HLA typing, Leukemia markers and other molecular tests. We have the support of laboratory facilities which are fully equipped to carry out routine and special tests like HLA testing, drug blood levels, bacterial and fungal cultures and viral analysis.

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