Challenges in Performing Umbilical Cord Blood Transplants in Developing Countries

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This document summarizes the challenges of performing umbilical cord blood transplants in developing countries like India. It notes that while transplant centers are common in the US, India has a growing population of over 1 billion but only conducts around 300 transplants per year. It discusses the limited public and private cord blood banking options in India. The document also reviews clinical data from Apollo Speciality Hospital on matched sibling cord transplants and 3/6 matched unrelated cord transplants. It identifies issues like marketing of private cord banking, standardized cell dosing, and a lack of search coordinators for unrelated transplants. The document concludes by highlighting lessons learned, such as the importance of patient selection and using reduced intensity conditioning, and the need to

Challenges in performing umbilical
cord blood transplants in developing
countries
Dr Revathi Raj
Consultant Pediatric Hematologist
Apollo Speciality Hospital, Chennai, India

• Disclosures – none
• All clinical photographs with permission

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

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

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!

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