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Challenges in Performing Umbilical Cord Blood Transplants in Developing Countries
- 1. Challenges in performing umbilical cord blood transplants in developing countries Dr Revathi Raj Consultant Pediatric Hematologist Apollo Speciality Hospital, Chennai, India
- 3. • Disclosures – none • All clinical photographs with permission
- 4. Percentage below poverty line
- 5. Rich and poor coexist uncomfortably!
- 7. Transplant centers in the US >80
- 8. Population of 1 billion and growing! On average 300 transplants a year
- 9. Cord blood banking in India • Private - over 20 since the first bank in 2002 • Public – 3 with a total repository of 5000 cord units • FACT accredited – none, AABB - one
- 10. Educate obstetricians about cord blood harvesting
- 11. The learning curve • Use cords from sibling program to gain data • Cord quality • Post thaw CD34 • Bone marrow from sibling donors as back up for all children
- 12. Apollo Speciality data on matched sibling cord transplants in children TYPE OF CORD MATCHED SIBLING NUMBER 14 100 DAY MORTALITY 0% REJECTION 7% DEATH BEFORE ENGRAFTMENT 0% GVHD 21%
- 13. What about 3/6 matched cords? INDICATION MALIGNANCIES THALASSAEMIA NUMBER 3 3 100 DAY MORTALITY 66% 0% REJECTION 33% 100% GVHD 0% 0%
- 14. Conclusions • Avoid use of mismatched family cord blood for thalassemia patients • Add bone marrow from new baby to help ensure full engraftment in fully matched sibling • Post thaw CD34 loss 38%
- 15. Unrelated cord blood transplantation – 2007 • “Things don't go wrong and break your heart so you can become bitter and give up. They happen to break you down and build you up so you can be all that you were intended to be.”
- 16. Issues in India • Marketing for private cord banking • Cell dose / CD 34 – not standardised • HLA search support • Screening of mother and HLA of mother at request • Quality of unit
- 17. India’s first unrelated transplant • Fanconi anaemia • Child from Uganda • Doing well 5 years post transplant
- 18. Problems faced • Registration with the National Marrow Donor Program • Lack of data manager / search coordinator • Need to educate our nursing team
- 19. Infrastructure
- 20. Steps involved in import of cords • Payment in dollars to cord company • Invoice from courier • Permission from Drugs Controller General of India • Complete all necessary paperwork well in advance • Keep enough liquid nitrogen in our storage container
- 21. Processing – bedside thawing
- 22. DMSO toxicity • Infusion of cord blood stem cells in our BMT unit after high dose chemotherapy • Cord infusion protocol with sodium nitroprusside infusion to control hypertension
- 23. Post infusion care • Care of a neutropenic child for 3-4 weeks • Trophic elemental nasogastric feeds • Zinc and vitamin D
- 24. Infection control • Gram negative sepsis rates high • Carbapenam resistance over 40% • Antibiotic abuse in the community
- 25. Tropical infections too! • Malaria • Dengue • Typhoid • Leptospirosis • Tuberculosis • Kala Azar
- 26. Apollo Speciality data on unrelated cord transplantation TYPE OF CORD UNRELATED NUMBER 30 100 DAY MORTALITY 44% REJECTION 4% DEATH BEFORE ENGRAFTMENT 20% GVHD 80%
- 27. Lessons learnt so far • Patient selection is the key to success • Reduced intensity conditioning is safer • Mismatched cords do cause GvHD • Ethnicity matters – we need our own cords!
- 29. Cord for regenerative medicine
- 30. “Continuous effort - not strength or intelligence - is the key to unlocking our potential.” Winston Churchill
- 31. Thank you!