Challenges in Performing Umbilical Cord Blood Transplants in Developing Countries

Challenges in performing umbilical

cord blood transplants in developing

countries

Dr Revathi Raj

Consultant Pediatric Hematologist

Apollo Speciality Hospital, Chennai, India

Good afternoon!

• Disclosures – none

• All clinical photographs with permission

Percentage below poverty line

Rich and poor coexist

uncomfortably!

Growing population

Transplant centers in the US >80

Population of 1 billion and growing!

On average 300

transplants a year

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

Educate obstetricians about cord

blood harvesting

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

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%

What about 3/6 matched cords?

INDICATION MALIGNANCIES THALASSAEMIA

NUMBER 3 3

100 DAY

MORTALITY

66% 0%

REJECTION 33% 100%

GVHD 0% 0%

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%

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.”

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

India’s first unrelated transplant

• Fanconi anaemia

• Child from Uganda

• Doing well 5 years

post transplant

Problems faced

• Registration with the National Marrow

Donor Program

• Lack of data manager / search coordinator

• Need to educate our nursing team

Infrastructure

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

Processing – bedside thawing

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

Post infusion care

• Care of a

neutropenic child

for 3-4 weeks

• Trophic elemental

nasogastric feeds

• Zinc and vitamin D

Infection control

• Gram negative sepsis

rates high

• Carbapenam

resistance over 40%

• Antibiotic abuse in the

community

Tropical infections too!

• Malaria

• Dengue

• Typhoid

• Leptospirosis

• Tuberculosis

• Kala Azar

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%

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!

Our success stories

Cord for regenerative medicine

“Continuous effort - not strength or intelligence - is

the key to unlocking our potential.” Winston Churchill

Thank you!