Medicosnext
Dr. Bishesh Sharma Poudyal pioneered clinical hematology and bone marrow transplant services in the country and has performed over 70 autologous, allogenic, and haplo-identical bone marrow transplants since 2012. He is Associate Professor and Chief, FCPS Clinical Haematology Supervisor at Clinical Haematology and Bone marrow Transplant Unit in Civil Service Hospital, which is internationally recognized for providing transplant services at a very affordable price.
Can you tell us about the history of bone marrow transplant in Nepal and the recent therapeutic advances in hematology?
The country’s first bone marrow transplant was performed in Nobel Hospital, Sinamangal in 2012 by me. At that time, a lot of people came to me and advised me to start a transplant program in a government hospital. After running the program for four years in Nobel Hospital, we moved the transplant service to Civil Service Hospital in 2016. Of the two types of bone marrow transplants, initially, we only performed autologous transplant, where the patient’s own stem cells are used for the treatment. In the next phase, we began allogeneic transplant, where the stem cells are collected from matched donors. When we first performed allogeneic transplants, we started with full match transplants, but we have been doing haplo (haploidentical) transplants, which is a half matched stem cell transplant, since 2018. Currently, we are doing all kinds of bone marrow transplants in Nepal.
How many hospitals in Nepal are providing bone marrow transplants, and what types of transplants are mostly done here?
As of today, bone marrow transplant is only carried out in Civil Service Hospital. Bone marrow transplant is mainly of two types: autologous and allogeneic transplants. Allogeneic transplant is further divided into full match, half match, and match unrelated. Match unrelated donor (MUD) transplants are when a patient receives stem cells from an unrelated donor. But, the chance of finding such a match is only about one percent in the whole population. Cord blood transplant is another allogeneic transplant where stem cells are collected from the umbilical cord blood. Umbilical cord blood is left in the umbilical cord after a baby’s birth and it is collected once it has been cut. At present, we are not doing cord transplant. As of now, we are mostly doing full match, halpo, and autologous transplants.
What is the indication of bone marrow transplant in blood diseases? Could you also tell us about the success rate of different bone marrow transplants?
Bone marrow transplant is indicated in both benign and malignant diseases. The major indications in Nepal are:
1. Acute leukemia
2. Aplastic anemia
3. Thalassemia
4. Multiple myeloma
5. Relapsed lymphoma
If we could perform transplants in benign cases like aplastic anemia, thalassemia, and sickle cell disease, 80-90 percent of the disease could be cured. In case of cancer, depending upon the condition of the disease, 30-50 percent of the disease could be cured. We have been sharing all our transplant data in Asia Pacific Bone Marrow Transplant (APBMT) Registry since 2016. If you look at our transplant survival data, it is very much comparable to the Western world.
Can you help our audience know what apheresis is, what is it used for, and what are its possible complications?
Apheresis is a technology that separates the blood components like plasma and cells. We can further separate the cells like WBC, RBC, and platelets through the apheresis machine. We have been using this technology in Nepal since 2012. It was first procured in Nobel Hospital. We have two such machines in Civil Service Hospital. In the context of Nepal, it is very useful for sickle cell anemia when RBC exchange is needed. Apheresis machines are very useful to collect platelets. In the same way, it can be used in many blood diseases where you have to exchange the plasma. The machine is also used for many neurological diseases like Guillain-Barré syndrome (GBS) and myasthenia gravis, which require plasma exchange.
There are few complications associated with apheresis. Blood pressure and calcium level may drop during procedure, which are easily manageable. Apheresis is comparatively safe and we have not encountered life threatening complications yet.
What kinds of healthcare organizations would benefit from apheresis machine? Do we have any local regulations to start apheresis services?
I am not aware of any local regulations for starting apheresis services. Apheresis machine is a must in a blood bank. Even the government has made it mandatory to have an apheresis machine for ‘A category’ blood banks. It is absolutely necessary in places where hematology and neurological services, as well as solid organ transplant services, are provided.
Are there any international guidelines for the use of apheresis? If yes, where can we get it?
The American Society for Apheresis (ASFA) and The European Society for Hemapheresis (ESFH) have their guidelines, and we can get it from their websites.
Why bone marrow transplant in Nepal is considered the cheapest around the globe?
Our transplant cost is very cheap compared to the neighboring countries and the rest of the world, and everyone has recognized that. The reason for that is because we charge a very nominal fee for the transplant. In other countries, hospital, doctor, and transplant charges are exorbitantly high.
How well is Nepal bone marrow transplant program recognized outside? And how often do we get referrals from other countries?
Our program is very well recognized. Our work has been published in many reputed scientific journals, including The Lancet Hematology. We are frequently invited for a talk at major transplant meetings. Bone marrow transplant programs are unusually busy in Asian countries because they have very few transplant centers for their patient population. Last year, we got referrals from India, Bangladesh, and Vietnam. We also get frequent referrals from Australia and Europe for Nepali patients who are in need of bone marrow transplants. They are being directly referred to us by the hospitals in the respective countries, as the students are not able to afford treatment there due to lack of medical insurance.
Why did you move the transplant program from a private hospital to a government hospital?
The main reason was to make it affordable to the general public. Not everyone in our country can afford treatment in private hospitals. I’m often told that I’m probably the only doctor who started from a private setup and moved to a government hospital, which is true, but we realized that a lot of people in our country wouldn’t be able to afford private hospitals, so I closed a well running program in Nobel Hospital and came to the government hospital.
We learned that you used Viber apps for providing consultation to patients during the lockdown, how successful was it?
It was very useful, especially for acute lymphoblastic leukemia patients who need to follow-up every 15 days during the maintenance phase. As they couldn’t come during the lockdown, we provided consultation to all patients through Viber. We also wrote a paper about it. The apps has been very helpful for patients outside the Kathmandu valley, as well. A lot of patients still message me on Viber and I’m using the apps till this day. I think this paves a way towards telemedicine, because it was very successfull and most of the patients were very satisfied with this method of consultation, as they didn’t have to physically come to the hospital and queue up from early morning to get tickets. They are suggesting me not to stop Viber consultation even after the pandemic.
What would you like the government to do to support your work in blood transfusion and bone marrow transplant?
I believe that one center is not enough. And, since our center is so well recognized outside, I think it is the government’s duty to add up more beds and other facilities. At present, our maximum capacity is three transplants a month, and we continued the service even during the pandemic. The service was halted just for a month. After that, we carried three transplants every month. What I personally believe is that we need more space and more manpower to run this program. The way the government has established Sahid Gangalal National Heart Centre (SGNHC) as a heart hospital and many other specialty hospitals, it’s high time the government should think about establishing a hematology center in the country. If the government is ready, I’m more than ready to help and train more people and lead the program.
Many hematologists and faculties from abroad are also very keen to develop this program and eager to help. I feel the government needs to take this seriously, as there are many patients with blood cancer, thalassemia, sickle cell, and aplastic anemia in Nepal. If people were to get timely transplants for aplastic anemia, thalassemia, and sickle cell, more than 90 percent of the people can be cured. A lot of people are dying in the country due to lack of treatment. So, the government should come up with a plan for establishing a separate hematology center so we can treat more patients and save their lives.
