A bond beyond words—a beautiful truth when one twin can be the sibling’s life saver: A syngeneic bone marrow transplantation in refractory acute myeloid leukemia

Vijaya Lakshmi1, Karthiga1, Booma Ravi2, Ruby Ravichandran3

1BMT, Staff nurse, Maa Kauvery, Trichy, Tamil Nadu

2DNS, Maa Kauvery, Trichy, Tamil Nadu,

3Senior DNS, Maa Kauvery, Trichy, Tamil Nadu

Abstract

A Syngeneic bone marrow transplant uses healthy blood-forming stem cells from the patient’s healthy identical twin to replace damaged or diseased cells in the patient’s bone marrow, often following chemotherapy or radiation. It is a rare procedure in which a patient receives healthy stem cells from their genetically identical twin. This process is used to replace the patient’s own bone marrow, which may be damaged or diseased by cancer or other. This report presents the challenges, outcome and nursing management in an 8-year-old girl served as a syngeneic donor for her twin diagnosed with AML.

Key words: Syngeneic bone marrow; Chemotherapy; Radiation

Introduction

Tribute to Twin -2 who donated stem cell for Twin-1

Sometimes, the most powerful lessons in life don’t come from books or speeches, they come from the quiet, selfless acts of a child. Here is a miracle wrapped in kindness, a living proof that even the smallest person can hold the power to change everything. She didn’t just offer her stem cells, she offered her heart, her strengthened spirit. This is not just about science. It’s about waking up to the extraordinary possibilities we often overlook.

How it works

The process for a syngeneic BMT is similar to other stem cell transplants but with some key differences related to the identical twin donor.

  • Conditioning therapy: The patient first undergoes high-dose chemotherapy, and sometimes radiation, to destroy the existing bone marrow and any remaining cancer cells.
  • Stem cell collection: Stem cells are collected from the healthy identical twin, either from their bone marrow or through the bloodstream (peripheral blood stem cells)
  • Transplant: The collected stem cells are infused into the patient’s bloodstream, where they travel to the bone marrow and begin to produce new, healthy blood cells.
  • Engraftment: This process, called engraftment, typically takes 2 to 6 weeks. During this time, the patient is closely monitored for infections in a sterile environment.
  • Recovery: Full immune system recovery can take 1 to 2 years, during which the patient will have regular follow-up appointments.

Advantages

Because the donor and recipient are genetically identical, there are significant advantages to this type of transplant.

  • No graft-versus-host disease (GVHD): Unlike allogeneic transplants (from a non-twin donor), there is no risk of GVHD. In GVHD, the donor’s immune cells attack the recipient’s body, which does not happen in a syngeneic transplant due to the genetic match.
  • No risk of rejection: The patient’s body recognizes the twin’s stem cells as its own, eliminating the risk of transplant rejection.
  • Cancer-free cells: The donor’s stem cells are screened to ensure they are free of cancerous cells, a risk that can occur with autologous transplants (using the patient’s own cells).

Disadvantages

Despite the benefits, syngeneic transplants also have drawbacks.

  • Higher risk of cancer relapse: The lack of a “graft-versus-tumour” effect is a major disadvantage. In other types of transplants, the donor’s new immune system can recognize and destroy any remaining cancer cells. Since the twin’s cells are identical to the patient’s, this beneficial immune response is absent, which can lead to a higher risk of the cancer returning.
  • Availability: Only a very small number of patients have a healthy, genetically identical twin who can act as a donor, making this a rare and limited treatment option

Conditions treated

Syngeneic transplants are used for many of the same blood and bone marrow diseases as allogeneic and autologous transplants. These can include:

  • Leukaemia
  • Lymphoma (Hodgkin and Non-Hodgkin)
  • Multiple myeloma
  • Myelodysplastic syndromes
  • Severe aplastic anaemia
  • Testicular cancer

History

An 8-year-old child was diagnosed as AML. After 2 courses of induction (3+7), Minimal Residual Disease (MRD) was positive (2.63%). MRD became 0.26% after 1 course of Bortezomib + Fludarabine-, Ara-cytarbine- G-CSF (FLAG). Hence child was taken for syngeneic transplant, using identical twin as donor.

Clinical findings

  • Child alert: afebrile
  • Pulse volume: good
  • Weight:19.7 kg

Vitals

  • Temp :98.6’F, HR :80/mt, RR :22/mt, SpO2 :98%

HLA Typing

  • HLA match = 10/10 (syngeneic twin)
  • Pre BMT evaluation :(For both patient and donor)
  • HIV serology – Negative, HBsAG – Negative
  • HCV serology – Negative, CMV IgG – positive

Transplant Protocol

Stem cell product: Source: PBSC
CD34+ cell dose: 10 x 106/kg
Volume 160 ml
Chimerism PCR PCR analysis confirmed identical twins
SOS prophylaxis Ursodeoxycholic acid
ID prophylaxis Caspofungin switch to PO Fluconazole later
Syp. Acyclovir
Cotrimoxazole – start after engraftment
Others Anticonvulsant: Syp Levepil
Ulcer prophylaxis: IV Pantoprazole
Antiemetics:
Inj. Emeset
Tab Domstal
TLS prophylaxis: Hydration
Transfusion Packed cells: A positive (irradiated)
Platelets: A positive (irradiated)
FFP: A positive
Monitoring Twice a week: CBC, Na/K, Creat, SGPT, Cyclosporine level
Every week: CMV PCR
Chimerism: when ANC > 500 (SOS), day 28, day 60, day 100

Preparatory Regimen

Day Date Drugs
-8 (Before the stem cell transplant) 13/08/2025 Admission and CVC insertion
-7 14/08/2025 Inj. Thiotepa
-6 15/08/2025 Inj. Fludarabine
Inj. Busulfan
-5 16/08/2025 Inj. Fludarabine
Inj. Busulfan
-4 17/08/2025 Inj. Fludarabine
Inj. Busulfan
-3 18/08/2025 Inj. Fludarabine
Inj. Busulfan
-2 19/08/2025 Start Inj. Cyclosporine
-1 20/08/2025 Rest
0 (After the stem cell transplant) 21/08/2025 PBSC infusion
+1 22/08/2025 IV Methotrexate
IV Leucovorin rescue (24 h later)
Start Caspofungin and Acyclovir
+3 24/08/2025 IV Methotrexate & Leucovorin rescue
IV Leucovorin
Further Methotrexate omitted in view of syngeneic twins

Post BMT course

  • Child developed febrile neutropenia – managed with IV Cefoperazone + Sulbactam. Cultures negative
  • Child had severe mucositis with anorexia – managed with IV Fluids, Aminoven, Analgesics
  • Dyselectrolytemia – low Potassium and Magnesium levels, managed with IV correction.
  • Child had one episode of upper GI bleed – managed with platelet and FFP transfusion, gut rest, IV Pantocid and IV Tranexamic acid – improved.
  • Cytopenia – managed with multiple irradiated blood products.
  • Platelet & Neutrophil engraftment on day + 12
  • Child discharged on day + 15

Nursing Management of the young donor during stem cell harvest

Harvesting stem cells from a young donor is a highly sensitive and complex process that requires specialized nursing care throughout every stage. The nursing management focuses not only on clinical safety but also emotional support, family involvement and minimizing physical and psychological trauma for the child

Pre-Procedure Nursing Care

Psychological and emotional preparation

  • Prepared the child and family for the Procedure using age-appropriate communication
  • Play therapy
  • Helped the child to understand what’s happening and to reduce anxiety
  • Built the child’s trust through consistency and comfort measures
  • Encouraged parental presence during pre-operative procedure.

 

 

Medical preparation

  • Ensured informed consent is signed by both the parents after thorough explanation by the medical team
  • Preoperative assessments including, Full blood work, Infectious disease screening, Cross matching
  • Central line inserted under local anesthesia
  • NPO status as per guidelines
  • Administration of GCSF (Granulocyte – colony Stimulating Factor for 5days) and monitored closely for side effects that is bone pain, Low grade fever and irritability and provided analgesics accordingly

Intra procedure nursing care

  • Assisted for IV sedation and provided emotional support to the child and parents
  • Prepared and kept all emergency equipment
  • Fluid replacement as per pediatric intensivist’s advice
  • Maintained aseptic technique throughout the procedure
  • Monitored vital signs & Hemodynamic status closely throughout the procedure
  • Monitored closely for signs of hypocalcemia that is tingling, muscle cramps, irritability and administered calcium gluconate as prescribed appropriately to prevent such symptoms
  • Kept the child warm and calm throughout the procedure

Post procedure nursing care

  • Monitored vitals, bleeding at harvest site, pain and signs of infection closely and administered analgesics as prescribed by the pediatric intensivist.
  • Monitored urine output and the child was hydrated appropriately
  • Encouraged parenteral involvement in comforting the child during recovery period
  • Provided reassurance and built a sense of safety.
  • Started early oral feeds

Discharge Planning of the Donor

Family educated on:

  • Pain management at home
  • Signs of infection / Complications
  • Follow up appointments

Nursing Management of Recipient

  • Comprehensive assessment & Monitoring
  • Close monitoring of vitals and PEWS
  • Daily weight and fluid balance to detect early signs of fluid overload or dehydration
  • Regular assessment for signs of infection and Graft- Versus-Host Disease (GVHD)
  • Monitoring of hematological parameters (Hemoglobin, Platelets, WBC) and organ function

Infection prevention and control

  • Maintained strict neutropenic precautions i.e. protective isolation, hand hygiene, visitors ‘restriction, safe nutrition
  • Ensure central line care using aseptic technique to prevent CLABSI
  • Appropriate administration of antibiotic, anti-fungal and anti-viral

Medication administration and monitoring

  • Administration of immunosuppressant as ordered, with close monitoring for side effects like renal toxicity
  • Timely administration of supportive medication like Anti emetics, Pain relief & growth factors.
  • Preparation of medication in chemo hood

 

Nutrition and hydration support

Collaborated with dietitian for individualized nutrition plan (TPN & Oral feed as tolerated)

Developmental and emotional Support

  • Provided age-appropriate stimulation to support developmental milestones
  • Supported bonding with care givers, encouraging skin to skin contact and presence of parents within infection control limits
  • Ensured emotional comfort with consistent, gentle care and soothing techniques

Co-ordination of Multi-disciplinary team

Collaborated with physicians, pediatric intensivists, nutritionists to participate in daily rounds care planning to ensure comprehensive patient centered care.

Family education and support

  • Infection prevention at home, Medication regimen, signs of complications (Fever, GVHD signs) and about vaccination (not to vaccinate without consulting doctor). Psychological support offered to reduce anxiety and promote confidence

Recipient was discharged on: 05.09.2025

Conclusion

The Successful completion of this syngeneic bone marrow transplant marks a profound milestone in the patient’s treatment journey. Leveraging the rare opportunity of a genetically identical donor, the transplant proceeded without the immunologic hurdles, most notably, the absence of Graft-versus-host disease and rejection risk. Engraftment was prompt with hematologic recovery exceeding expected benchmarks. This case exemplifies the optimal clinical scenario for hematopoietic stem cell transplantation where genetic identity translates directly into enhanced safety, efficacy and long-term disease control. Continued monitoring will focus on sustained remission, immune reconstitutions and overall quality of life, but the transplant outcome thus far reflects the full potential of precision matched cellular therapy.

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