Economical Hematopoietic Stem Cell Transplantation with a Nationally Matched Unrelated Donor

Dear Editor, Hematopoietic stem cell transplantation (HSCT) stands as the preferred curative treatment for a spectrum of hematological diseases, encompassing both benign and malignant conditions.[1] In cases where a matched-related donor is not available, matched unrelated donors (MUDs) contribute to approximately 70% of the transplantation sources.[2] Over the past few years, India has witnessed a surge in the number of HSCT procedures, attributed to the development of infrastructure and the training of health-care professionals dedicated to this specialized field.[3,4] Moreover, the presence of an increasing number of registered voluntary stem cell donors in India adds to the accessibility of HSCT services.[5] Despite these positive developments, the primary barrier to wider implementation remains the cost associated with HSCT, particularly in the context of MUD workups. The procurement of hematopoietic stem cells (HSCs) incurs additional expenses, the extent of which varies based on the donor’s geographical location, whether national or international.[3] All the registered donors from different stem cell registries are linked with each other through a central hub known as the World Marrow Donor Association (WMDA).[5] The initiation of a MUD search is dependent upon receiving a written request from a transplant physician or patient registry, prompting the utilization of the WMDA search engine to assess donor availability for the requested patient.[6] We wish to highlight the importance of national MUD donors through a case comparison of the cost involved in MUD HSCT in between a donor identified in the national (India) and global donor data pool by a workup of a young male patient. This case involved a 20-year-old male diagnosed with acute lymphoblastic leukemia, leading to the recommendation for a MUD HSCT. The transplant center (TC) initiated a preliminary MUD search based on the patient’s HLA phenotype, as represented in Table 1, and based on this, a MUD search was performed in both national and global donor data pools. Utilizing both national and global donor databases, a fully matched (10/10, HLA-A, B, C, DRB1, and DQB1 locus) donor was identified through the WMDA search tool. Following confirmation from the TC, the global donor registry was contacted for further workup, incurring a total cost of approximately INR 15,00,000 for the procurement of HSC. The patient’s family faced challenges in arranging the funds, leading to a delay. However, during this period, a surprising development occurred. A variation in the national donor search results was observed, resulting in the identification of a fully matched donor (10/10) within the national registry. Consequently, the TC requested the cancellation of the global donor workup. This variation was attributed to the addition of 25 newly registered donors to the national database during the 2-week period. The availability and willingness of the national donor were confirmed, leading to a substantial reduction (approximately 66.67%) in the MUD donor workup cost. The total expenditure for the stem cell registry in this revised workup was approximately INR 500,000. The patient underwent successful MUD HSCT with the fully matched (10/10) Indian donor, and subsequent regular posttransplant follow-up has shown the patient to be in disease-free status as of the last follow-up. The cost spent over procurement of HSC by stem cell registry is mainly spent over the search and identification of donors, sample draw for confirmatory HLA testing, infectious disease marker test, fitness evaluation, HSC collection, and transportation from collection center to TC. As per the published report, the cost of MUD HSCT in India is approximately INR 21–28 lakhs (excluding the cost of the graft).[3] In the present workup, the total cost for the procurement of HSC from the Indian donor registry was approximately INR 500,000. Hence, the leftover amount, approximately INR 1,000,000 which had been arranged by the patient family for the earlier global donor workup was used for hospital stay and other charges such as accommodation charges, pharmacy charges, and consultation. There were no major posttransplant complications were observed in this case. Hence, the entire procedure of MUD HSCT for this patient was completed at approximately INR 1,500,000 because of the national donor availability. Otherwise, this whole amount (INR 1,500,000) would have been utilized only for the procurement of donor HSC from the global registry. This workup highlights the significance of establishing a national donor database for MUD HSCT in a developing country such as India. Expanding the marrow donor pool in India requires a multifaceted approach that involves comprehensive education and awareness campaigns, organizing donor registration drives, collaborating with medical institutions, and engaging in public relations efforts among health-care professionals. By implementing these steps, it is possible to increase awareness about bone marrow donation and motivate greater numbers of Indians, including medical practitioners, to enroll with Indian stem cell registries. This will expand the pool of potential marrow donors and improve the chances of finding matches for patients in need of bone marrow transplants. Accessing a matched donor from the Indian donor pool can lead to a more economical HSC procedure, currently beyond the financial reach of many patients in need. Moreover, advocating for the expansion of the voluntary stem cell donor database in India not only increases the chances of finding a suitable donor for a greater number of Indian patients domestically but also ensures a more cost-effective treatment for them. It is essential for patients and their families to recognize that the cost of procuring HSCs depends on the donor’s geographic location (national or global), introducing potential variations in expenses. If a matched unrelated donor is identified within an Indian registry, the cost of procuring HSCs is likely to decrease, thereby making MUD HSCT more affordable and accessible for patients.Table 1: Representing age, gender, HLA-phenotype, and matched unrelated donor statusFinancial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.