POST-TRANSPLANT CARE CHALLENGES IN NIGERIA: SYSTEMIC INSTITUTIONAL NEGLECT OF MEDICAL TOURISM.

Adeseye Michael Akinsete

College of Medicine, University of Lagos

Lagos University Teaching Hospital

• Introduction
• Evolution of care
• Why transplant
• Transplant complications
• CIBMTR guidelines
• The Lagos experience
• Case reports
• Challenges
• Mitigating strategies
• Conclusion

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CONTENTS

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• I am a consultant to Novo Nordisk

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Evolution of Care

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Chartuvedi & DeBaun : Evolution of sickle cell disease from a life-threatening disease to a chronic disease of adults, the last 40 years. Am J Haematol 2015; 91(1): 5-14

Why transplant?

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Acute physiologic disturbances

Chronic persistent debilitations

Progressive organ damage

Diminished quality of life

Lifelong healthcare costs

Reduced survival

• Why do we need long-term follow-up after transplantation?

GROWTH in long term transplant survivors

More transplants & more survivors

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Needs new focus on long term survivorship

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Majhail et al.Biol Blood Marrow Transplant. 2013;19(10):1498-501

Transplant is safer than ever before!

• Management of chronic GVHD - moving progress!
• Multiple FDA-approved therapy for cGVHD¹
• Immunomodulation (opposed to immunosuppression)

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• Management of chronic GVHD related late complications
• Aggressive management of late effects
• Transplant survivorship clinic: LTTC/ LTFU/ Late Effects Clinic, GVHD clinic, etc.

1. https://www.fda.gov/drugs/informationondrugs/approveddrugs/ucm569711.htm

LTTC: Longitudinal Long-Term Transplant Clinic; LTFU: Long-term follow-up

Long-term survival after HCT

Wingard JR et al. J Clin Oncol. 2011;29(16):2230-9.

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CIBMTR study of 10,632 allogeneic HCT recipients surviving ≥ 2 years in remission (median follow-up 9 years)

Overall survival

Non-relapse mortality

What goes wrong: the next 30+ years

Domains of health

Battiwalla M et al. Biol Blood Marrow Transplant. 2017;23(1):6-9;

Adapted from Savani BN et al. Blood. 2011;117(11):3002-9

Tichelli A et al. Cancer. 2013;119(11):2012-21.

Most long-term complications are linked to… cGVHD

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CIBMTR long-term guidelines

Screening

Immunization

GVHD screening

Ocular

Oral

Respiratory

Cardiovascular

Liver

Genitourinary

Endocrine

Psychosexual & Fertility

Pneumococcal

Acellular DPT

Inactivated Polio

HiB

Meningococcal

Recombinant Hep B

MMR

Skin/Nails

Scalp

Eyes

Mouth

Lungs

Muscles/joints

GI/Liver

Immune/Hemopoietic

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Post-transplant care in Nigeria

Post transplant clinic established in Q2 2019��

Collaboration between - Lagos University Teaching Hospital / Sickle Cell Foundation of Nigeria / Vanderbilt University Medical Center�

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30 recipients 15M:15F ��Place of transplant: 26 India, 1 Ghana, 1 Spain, 1 Poland, 1 USA��Source of graft: 25 PBSC, 5 BM��Complications: 19 with chronic GVHD, 1 cerebral infarction, 1 Post-Transplant lymphoproliferative disorder, 3 EBV reactivation, 4 graft failure��Five discontinued immunosuppression prematurely, 6 had no immunization 2 years after transplant��Mean time at commencement of clinic: D+215

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The Lagos

Experience

Case Report 1

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Case Report 2

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Endoscopic findings in patient

Case Report 3

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Chronic GVHD

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Chronic GVHD

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Case Report 4

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TRANSPLANT EXPERIENCE

• Inclusion Criteria
• Age : 5 to 55 years
• Fully matched sibling donors
• Myeloablative conditioning using Bu/Cy/ATG
• Severe disease phenotypes; stroke, AVN, TIA etc
• Other conditions; BMF, Leukemias etc

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Develop multidisciplinary team

• Physicians
• Nurses (The most important)
• Social Workers , Psychiatrists, Pharmacists
• Blood banking capacity & Stem cell processing
• Infectious disease capabilities
• Radiation Support

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Three patients so far

• 6-year-old girl with AVN
• 21-year-old medical student with chronic pain syndrome and opioid dependence
• 17-year-old medical student with severe pain despite hydroxyurea therapy
• All alive and functioning well now

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Clinical challenges

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Mitigating strategies

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Conclusion

• There is an ongoing need to develop locally adapted long term post-transplant care strategies
• Developing multidisciplinary care teams is an important requirement
• Twinning with established programs necessary for shortening the learning curve
• Local collaborations are most important
• Awareness of available services and providers will also serve to improve outcomes

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Thank you

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Referrals

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