Challenges in performing umbilical
cord blood transplants in developing
countries
Dr Revathi Raj
Consultant Pediatric Hema...
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
...
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
siblin...
Apollo Speciality data on matched
sibling cord transplants in children
TYPE OF CORD MATCHED SIBLING
NUMBER 14
100 DAY MORT...
What about 3/6 matched cords?
INDICATION MALIGNANCIES THALASSAEMIA
NUMBER 3 3
100 DAY
MORTALITY
66% 0%
REJECTION 33% 100%
...
Conclusions
• Avoid use of mismatched family cord blood for
thalassemia patients
• Add bone marrow from new baby to help e...
Unrelated cord blood
transplantation – 2007
• “Things don't go
wrong and break
your heart so you
can become bitter
and giv...
Issues in India
• Marketing for private cord banking
• Cell dose / CD 34 – not standardised
• HLA search support
• Screeni...
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...
Infrastructure
Steps involved in import of cords
• Payment in dollars to cord company
• Invoice from courier
• Permission from Drugs Cont...
Processing – bedside thawing
DMSO toxicity
• Infusion of cord
blood stem cells in
our BMT unit after
high dose
chemotherapy
• Cord infusion
protocol wi...
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 ...
Lessons learnt so far
• Patient selection is the key to success
• Reduced intensity conditioning is safer
• Mismatched cor...
Our success stories
Cord for regenerative medicine
“Continuous effort - not strength or intelligence - is
the key to unlocking our potential.”
Winston Churchill
Thank you!
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Challenges in Performing Umbilical Cord Blood Transplants in Developing Countries

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Challenges in Performing Umbilical Cord Blood Transplants in Developing Countries

  1. 1. Challenges in performing umbilical cord blood transplants in developing countries Dr Revathi Raj Consultant Pediatric Hematologist Apollo Speciality Hospital, Chennai, India
  2. 2. Good afternoon!
  3. 3. • Disclosures – none • All clinical photographs with permission
  4. 4. Percentage below poverty line
  5. 5. Rich and poor coexist uncomfortably!
  6. 6. Growing population
  7. 7. Transplant centers in the US >80
  8. 8. Population of 1 billion and growing! On average 300 transplants a year
  9. 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. 10. Educate obstetricians about cord blood harvesting
  11. 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. 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. 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. 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. 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. 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. 17. India’s first unrelated transplant • Fanconi anaemia • Child from Uganda • Doing well 5 years post transplant
  18. 18. Problems faced • Registration with the National Marrow Donor Program • Lack of data manager / search coordinator • Need to educate our nursing team
  19. 19. Infrastructure
  20. 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. 21. Processing – bedside thawing
  22. 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. 23. Post infusion care • Care of a neutropenic child for 3-4 weeks • Trophic elemental nasogastric feeds • Zinc and vitamin D
  24. 24. Infection control • Gram negative sepsis rates high • Carbapenam resistance over 40% • Antibiotic abuse in the community
  25. 25. Tropical infections too! • Malaria • Dengue • Typhoid • Leptospirosis • Tuberculosis • Kala Azar
  26. 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. 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!
  28. 28. Our success stories
  29. 29. Cord for regenerative medicine
  30. 30. “Continuous effort - not strength or intelligence - is the key to unlocking our potential.” Winston Churchill
  31. 31. Thank you!

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