Category: Medical Education

In the BMT industry, some refer to the day a patient receives their transplant as their “new birthday”.  This is because the patient will get brand new bone marrow that will produce blood that has different DNA than the original bone marrow.  Organs will remain the same as before and carry their original DNA, it is only the blood DNA that will be different.  So when the BMT is complete, Clark will carry 2 types of DNA inside of him.  In medical terms, Clark will become what is known as a Chimera.

What is even more interesting is that since the new bone marrow will effectively produce blood that is genetically the same as the donor, Clark will also receive some of the characteristics of the donor’s blood as well.  That is, Clark will share the same blood type, the same seasonal allergies as the donor, and possibly the same food allergies!

For those who are curious, the bone marrow transplant will not affect Clark’s DNA contained in his sperm.  So if Clark ever gets to the point where he decides to have children, they will definitely look like Clark, and not the bone marrow donor.  (You’re welcome.  We were just as curious once we heard this…)

As well, since Clark’s bone marrow will be starting over, he will also need to start his immunizations over again as well.  All the benefits we had with his original immunizations will be wiped out.  Not surprisingly, it will be just like starting over from when he was born!

Clark has been diagnosed with Dyskeratosis Congenita (DKC).  Our doctors point to this as the reason he has Aplastic anemia. But what does does having DKC really mean?

If you think of Hemophilia and Aplastic Anemia each as massive, monster diseases on their own, then you should consider Dyskeratosis Congenita as a lair in which monsters are continuously created and unleashed.

DKC is a congenital disease that directly affects DNA.  The condition creates abnormally short telomeres on an individual’s DNA strands.  Telomeres are the part of a DNA strand that allow it do divide and create more cells.  When telomeres become short, the cells are not able to divide and multiply.  When your cells can’t divide and multiply, this leads to a variety of problems which can include organ failure.  When people age, they naturally get shorter and shorter telomeres.  That is why people who have DKC, often get symptoms of organ failure that are somewhat similar to elderly people.

So as you might suspect, what’s most important to understand about Dyskeratosis Congenita is that it is not easily defined as “one” problem. The manifestation of short telomeres is difficult to predict.

At our meeting with our geneticists, we tried to figure out what symptoms to watch for that might be issues related to DKC.  When asked, the answer was, “well, it is hard to say, it can manifest itself in many ways”.  Ok, so then we asked what the lifespan of a person with DKC is, to which they answered “well, it is hard to say, we don’t have a lot of data on DKC”.  We continued to pepper them with questions, but most of the answers were either vague responses or shrugs.   Probably the most promising bit of information we received was that there doesn’t appear to be any correlation between intellectual function and DKC.  But, even this came with a warning of “as far as we know…”

How new is our understanding of this disease?  It was only as recent as 2003 that Richard Cawthorn at the University of Utah discovered that people over 60 with longer telomeres lived longer lives than people with short telomeres.  We are only beginning to understand the effects of short telomeres, much less the disease that causes them prematurely.

Here’s what we do know… A patient receiving  a bone marrow transplant can often look forward to complications of the liver, lungs and heart later in life.  This is a patient with otherwise healthy organs.  In Clark’s case, the short telomeres have already put him at a disadvantage.  The conditions that might be magnified in a person when they are 50, are possible when Clark is 5.

We are cautiously optimistic as we head into our BMT, but even if it is successful, we will not be able to lower our guard.  The cure is almost as bad as the disease, and there are a lot of surprises awaiting us from this disorder.

We met with our genetic councilors today, and they confirmed that Clark does in fact have Dyskeratosis Congenita (DKC).  The specific version of DKC is known as TINF2, which is a marker they have identified in Clark’s DNA.

This is about where the world’s knowledge on the topic ends.

We had prepared for this visit with the genetic councilors by writing down all our questions.  There were a lot.  This turned out to be a waste of paper.  Knowledge of this disorder spans about 10 years, and we are all learning about this in “real time”.

There is no way to tell how Clark got this disorder.  It doesn’t appear to be “x-linked”, and therefore it doesn’t appear to have been passed to him from either of us.  DKC doesn’t appear to come from exposure to chemicals or radiation, from what they know so far. From our knowledge today, it is simply a random bit of bad luck.  One in a million.  If we have another child, it will be a random chance this could happen again.

What we did learn, is that worrying about DKC in your child is like worrying about Down Syndrome.  When you are told that your child has Down Syndrome, you don’t really argue that the child has the disorder, but you become very concerned about what the effects will be.  Will they be able to function normally?  Will it be only cosmetic?  How bad will the brain damage be? etc…  In all cases, doctors will tell you they aren’t sure, and that time will only tell.

DKC is identical in this scenario.  Doctors know Clark has DKC, and that this can cause short telomeres, which can lead to organ failure.  But what organs?  When could they fail?  What symptoms should we watch for?  Well, there isn’t any good answers to this.

Previously, people who are born with DKC didn’t live very long. Only about 10 years ago, did we even come up with a test to identify this disorder.  So there simply isn’t any good data on the subject.  Clark will unfortunately be more valuable to mankind as a data point, than the reverse.

One thing that became clear in our visit with the geneticists, is that Clark’s liver, lungs and heart will be more delicate than those of a normal healthy human being.  His body’s ability to maintain cellular structure of these organs is compromised.  So like a muscle that repairs itself to remain strong, Clark is less likely to be able to make these repairs.  When you combine this with a bone marrow transplant, the situation becomes morbid.

An otherwise healthy patient that receives a bone marrow transplant will run the risk of having liver, lung and heart conditions many years later.  Pulmonary fibrosis at 50 might be one example of this.  But in Clark’s case, his organs are already compromised by having DKC.  So maybe it will be age 10 that Clark gets this – or maybe not.  There is no way to predict any of this.

There was a sliver of positive news, in that “as far as we know…” intellectual function is not affected by DKC.  With today’s information, there doesn’t appear to be any known correlation.

When it comes to how long Clark will live, or what lies ahead, it will be a waiting game to see what comes next.  For “known conditions”, doctors always point to Aplastic anemia as a “worst case” scenario.  Clark is already there.  So would you take this as the worst is known… or a warning as to what is ahead?

Here’s what it will be like for Clark to get his bone marrow transplant.

1. Over the next two months, UCSF and bethematch.org are working together to identify the best possible bone marrow donor they can find for Clark.  The ideal match will need to be young, of similar genetic background (Irish and German primarily), not have any life threatening diseases, and has never been exposed to the CMV virus.
2. After identifying a match, they then begin the process of double checking to see if the person is still willing to donate, going through a ton of paperwork and more detailed tests, and if this individual still doesn’t bolt by this stage, the donor will finally be ready to set a date to extract.
3. Clark will need to be brought into the hospital ahead of the extraction date, and started a conditioning treatment (Chemotherapy).  This treatment will effectively kill all the white blood cells as well as the bone marrow in his body.  It will return Clark to a state of zero immunity, similar to how he was in the uterus 4 months before he was born.
4. He will then be given the bone marrow cells in the form of a drip. This part of the procedure is very quick (and very cool).  The cells just need to be dropped into the blood stream.  They know where to go and what to do.
5. Once given the drip, Clark will begin to re-grow his bone marrow.  But during this time, he will be susceptible to bacteria, virus and fungus.  So Clark and Beth will need to be kept in a special isolated room for the first 6 weeks of treatment.  This room will have special ventilation that will be purifying all the air coming into the room. Even with filtered ventilation, bacteria found naturally on and in the human body will also be a risk for Clark.  Antibiotics, anti-fungal medicine, as well as antihistamines will be given regularly during this time.
6. Connor will not be allowed to visit at all due to the risk of virus and bacteria.  I will be allowed to visit, assuming I don’t have a hint of cold or sickness, and I will have to be scrubbed down before entering.
7. After the 6 weeks in intensive care, we will hopefully see white blood cells rising.  If this is the case, we are on a track to success (but far from cured).  We will then be sent home to continue recovery.
8. Clark will need to continue to be kept in isolation after returning home.  If we want Clark and Connor to spend time together, then Connor will need to be isolated from other children as well.  No pre-school or playing at the park with other children.
9. Hopefully between 4-9 months after being sent home, all 3 of Clark’s blood cell counts will rise, and he will effectively be cured.  If so, he will have brand new bone marrow and will not need to take any ongoing drugs.

This is the plan, as long as there aren’t complications… Complications on this path are far and wide.

1. Finding a good match is the first major hurdle. Doctors have assured us that this should be fairly successful, as the vast majority of the donor pool is of European decent.
2. We have to be worried about his body rejecting the cells that are donated to him.  This rejection can happen in one of two ways:
   A) His body could attack the cells as they are coming in, never letting them root.
   B) Or worse, something called Graft-versus-host disease (GvHD).  This is where the new donated bone marrow takes root, and then starts to attack the recipient’s host cells.  This can take up to 2 years to show itself!
3. Through the whole procedure, we have to be constantly vigilant to ensure Clark doesn’t get a whole host of problems while his immune system is compromised.  Pulmonary infection is the leading cause of mortality with children receiving bone marrow transplants.

We are cautiously optimistic about this procedure and wary of its risks, but we are very glad there is at least hope in curing Clark.

When it became clear to us that Clark’s brother might have to donate bone marrow to keep Clark alive, we were very curious as to what the procedure was like, and how painful it was.  So here is the low-down:

When you donate bone marrow, liquid is essentially drawn from your hip bone with a needle. This liquid contains cells that will be put intravenously into the recipient.  Depending on the amount that is needed (babies need a very small amount, adults need more), and how “robust” your bone marrow is (generally based on how old you are), this may be a couple to a few pokes into your hip to draw liquid.  The hip bone is the primary source for extraction, as it is the largest and easiest bone to draw from.

The entire procedure is done while under general anesthesiology, so you will be fast asleep when it happens.  When you wake up, you will have an achy hip for a day or two.  Somewhat like if it was bruised from a “hip check” in soccer or hockey.

And that’s it, you are a hero, and you’ve saved someones life.  No long term side effects.  Well, not physical ones…

Now is surgery emotionally traumatic?  I would say yes.  I’ve had my bicep sewn to a bolt that was drilled into my forearm.  I was very nervous going into that procedure, as there was a chance I would never use my dominant hand again.  And when I woke up, it was a year long recovery.  Compared to that? Well, let’s say bone marrow donation is a walk in the park.

That said, surgery is surgery, and it can be emotionally traumatic no matter if it is your molars or a hip replacement. So you do have to come to terms with that. That said, for all the different acts of heroism in the world, this is definitely one of the easiest by far.

I get a lot of great friends and family asking if they can be the ones to donate bone marrow to Clark for his transplant. It’s a great question, and we really appreciate the offers, but unfortunately most will not be a match.

About 70% of patients who need a transplant do not have a suitable donor in their family. Half of Clark’s HLA genetic markers are inherited from myself (his mother) and from Patrick (his father). Each sibling has only a 25% chance of matching. We already know that Connor is not a match (unfortunately). Likewise, it is highly unlikely that other family members will match Clark. Under very rare circumstances, family members other than siblings may be tested.  Case in point might be where 2 sisters married 2 brothers.  Cousins from the other couple might be a great match.  No such luck in our case.

Human leukocyte antigen (HLA) typing is used to match Clark with a donor for bone marrow. This is not the same as ABO blood typing. HLA is a protein – or marker – found on most cells in your body. Your immune system uses HLA markers to know which cells belong in your body and which do not.  It is “acceptance” that is being sought after here.  If the body rejects the transplant, it can be a catastrophe.

There are 12-13 genetic markers that are tested to define a bone marrow “match”. The odds that two random individuals are HLA matched exceeds one in 20,000.  This is why it is so important for eligible donors to register.

The factors for Clark are largely Irish and German (with some Welch, Norwegian and other European Countries). So if you are full Irish, or half Japanese, then you most definitely won’t match. But if your grandfather was Irish, and your grandmother was German, there might be a match there. We are basically looking for people that might have been from the same “village” (back in the days those existed).

However, even if you are of a different nationality than Clark, please consider donating “in kind” for Clark. Donating actually isn’t a huge procedure, and you very easily could save someones life.

Clark was born with mild Hemophilia.  And then, at his 1 year birthday, was also diagnosed with Aplastic Anemia. Both blood disorders affect clotting and bruising, and both could be fatal.  But how do they differ and how do they relate?  What does it mean to have both?

Hemophilia is genetic

Hemophilia was passed down to Clark genetically, and it is related to a missing “factor” called Factor VIII (pronounced “Factor 8”) or Factor IX (pronounced “Factor 9”).  When missing, the blood in a person isn’t able to congeal, or scab.  In severe Hemophiliacs, a person could get a small cut, or bump into a chair, and literally bleed to death.  In Clark’s case, he is mild.  Which means unless he gets into a car accident, or is having surgery, he really doesn’t have to worry too much.

Mild hemophilia, on its own, isn’t a life or death concern.  You can plan around it, and generally have a very full (albeit cautious) life with this condition.

Aplastic Anemia is deadly

Individuals can get Aplastic Anemia through several means. There are dangerous chemicals that can cause it (Benzene) and there are genetic conditions that can cause it (DKC), or it can happen without any clear cause (idiopathic).

Aplastic Anemia is where the body stops producing new blood cells.   It is characterized by 3 blood cell counts being low:

• platelets
• white blood cells
• red blood cells

As these blood counts drop, an individual is prone to spontaneous bleeding (low platelets), getting a bacterial infection and not recovering (low white blood cells), and to becoming anemic (low red blood cells).

Aplastic Anemia will kill you.  It does it from the inside out, killing your body’s ability to fight back or repair itself.  It is a very dangerous and deadly disease, and can only be treated by a couple methods.  Both of those methods have to do with repairing the bone marrow in the body.

Where they intersect

So in the case where a person with hemophilia has Aplastic Anemia, you have an individual which has both low Factor VIII and low platelets.  These two items work together to create a scab.  Platelets form a “framework” and Factor VIII creates “fibers” that bind the framework.  Not having one or the other can be a big issue, not having either can be a HUGE issue.  Where Clark is only a mild hemophiliac today, we have to treat him as though he was a severe hemophiliac when he has low platelets.

Transfusions

In both cases, there are transfusions available to shore up numbers of either Factor VIII or Platelets.  Factor VIII only lasts a couple hours, so it is only given when an injury has occurred, or a surgery will occur.  Platelets last a little longer, often a couple days to a week depending on their age and quality.  These are often given once a week depending on when a patient’s platelet numbers have declined.

When we first learned that Clark could have Aplastic anemia, we were completely naive on the disease and its effects.  Here’s a simplified version of what we’ve learned so far.

What is it?

Aplastic anemia (a-PLAS-tik uh-NEE-me-uh) is a blood disorder in which the body’s bone marrow doesn’t make enough  new blood cells.  There are 3 types of new blood cells affected, red, white, and platelets.

Red blood cells carry oxygen to all parts of your body as well as carbon dioxide back to your lungs to be exhaled. White blood cells help your body fight infections. Platelets are blood cell fragments that stick together to seal small cuts or breaks on blood vessel walls and stop bleeding.

As your body stops producing these blood cells, there are many health problems that can occur.  Heart failure, infections and spontaneous bleeding are some of the top issues.  Gone untreated, severe Aplastic anemia will most certainly lead to an early death.

Aplastic anemia and Hemophilia are completely separate diseases, and have no commonality or causality. Clark has both diseases, unfortunately.  Read this post to understand how the two relate, as well as differ.

How do people get the disease?

People of all ages can develop Aplastic anemia. However, it’s most common in adolescents, young adults, and the elderly. Men and women are equally likely to have Aplastic anemia.

The disorder is two to three times more common in Asian countries.

Your risk of getting Aplastic anemia is higher if you:

• Have been exposed to toxins (such as Benzene)
• Have taken certain medicines or had radiation or chemotherapy
• Have certain infectious diseases, autoimmune disorders, or inherited conditions (such as Dyskeratosis congenita, DKC)

Is it curable?

Short answer is: yes, but the success rate is less than 100%.

How is it cured?

Treatments for Aplastic anemia include blood transfusions, blood and marrow stem cell transplants, and medicines.  Blood transfusions help only temporarily.  There are 3 ways to cure Aplastic anemia, in order of success rate:

1. Bone Marrow Transfusion from a sibling (80% chance of success)
2. Immunosuppressive Therapy (70% chance of success, if you don’t have DKC otherwise much less)
3. Bone Marrow Transfusion from a stranger (varies, depending on the quality of the match)

When it comes to Clark, #1 will not work for us, as Connor is not a match.  #2 will not work as it is suspected Clark has DKC.  So we are left with only #3, and are in process of finding a match.

What is the likelihood of finding a bone marrow match from a stranger?

To make a bone marrow transplant successful, it requires that there is a genetic “match” between the donor and the recipient.  Read more about the requirements for a bone marrow match here.

What is involved in a bone marrow transfusion procedure?

In short, it is a 1 year treatment, in which the recipients body is taken to a state of zero immunity for a period of 2 to 4 months, while the transplanted bone marrow starts to grow and “take root”.  It is a complicated procedure with many risks.  Read more about the procedure for getting a BMT.

Where can I learn more?

The National Heart, Lung and Blood institute is the best reference I’ve seen to date on Aplastic anemia.  If you prefer to read offline, use this link to print all the topics at once.

We had had several ugly situations occur where doctors and nurses were unable to draw blood from Clark, or put an IV into him. He has small, hidden veins, that tend to blow out when placing needles into them.  Unless someone is using an ultrasound machine to place an IV, we have never seen it be successful.

Through the 80 or so failed attempts we’ve seen doctors and nurses try and poke Clark, he has been incredibly stressed out as it often takes 4-5 people holding him down to try and place a needle.  He is extremely strong for his age, and he doesn’t stop fighting.

When we learned that Clark most likely had Aplastic Anemia, and that he was going to need regular treatments and blood draws, we opted to have a Broviac installed.

What is it?

A Broviac is a tube that runs through a persons chest, and attaches a catheder to a vein in your neck.  This is effectively an “open pipe” directly into your heart.  You can pull blood from it, or you can push medicine into it.  And IV can connect directly to it.  So no more needles are required.

There is a similar device, known as a Port (or Port-a-cath).  This device actually sits beneath the skin, and requires poking through the skin to access.  It has less maintenance, but also requires the individual be a certain weight.  Both have their pros and cons.

In asking our doctor which of these would be better, they recommended the Broviac for Clark.

Is it painful?

Quite the opposite. Once in place, you don’t feel any pain from blood extraction or medicine administration.  The Broviac is placed into a person though surgery.  You are placed under general anesthesia (chemically asleep) and are not aware of the procedure at all.

Why did we do it?

With the Broviac in place, Clarkie no longer requires any needles to be placed into his arms or legs.  It takes 15 seconds to hook up an IV.  Clark went from hating doctors visits, to actually enjoying them. Nurses would enter the room, and he would start screaming.  Now he waves, and loves to watch the procedures.  His stress level has been reduced to zero, and his happiness is at 11.

What is the catch?

Of course there is a catch.  Having an open pipe into your heart carries risk.  Bacterial infection being the key risk.  As such, someone has to clean and maintain this piece of equipment, otherwise Clark could very easily get sepsis and die.  So we have reduced Clark’s stress, but it doesn’t go away – it just transfers to the parents.

We now are responsible for taking care of this medical device.  It requires strict daily procedures, and even more strict weekly procedures.  Small tasks from “flushing” the line with heprin, to larger ones like blood pulls (filling tubes with blood to take to the lab) and changing his bandage (very complex procedure, fraught with risk).

Was it worth it?

Definitely. While Beth and I stress a lot about keeping this equipment clean and functioning, we are very releaved that Clark is not longer feeling pain or suffering when we have to visit the doctors.  And we visit a lot, 2-3 times a week on good weeks.

Can it be removed?

Yes, absolutely.  With very little effort, compared to the surgery to put it in.  They sedate you, tug the cable out, and apply pressure on the vein it was attached to.  It is typically done as an outpatient procedure.

Can it be accidentally removed?

Technically yes – someone could pull it, or it could get snagged, and be pulled free.  That said, the device has a “loop” inside the bandage (you can see this in the image) that allows for slack it does get pulled.  So while you have to be careful, it has been designed to be worn over an extended period of time.