HSCT indication guidelines by international institutions, such as the European Group for Blood and Marrow Transplant (EBMT) [42] and the American Society for Blood and Marrow Transplantation [43, 44], are easily available and should be the base for local HSCT indications. Biological, economical and social issues, as well as health service conditions and outcomes differ widely from one country to the other so indications in a well-resourced country may not be sensible in a limited resource country. Isolated published case reports or clinical trials from well-resourced countries do not necessarily constitute standard indications for HSCT. At the beginning of an HSCT program, standard of care indication for HSCT should be performed mainly with autologous and related allogeneic grafts. Once standard of care HSCT is mastered, non-routine HSCT could be performed in a few instances, i.e., HI in children with Primary Immune Deficiency and UCB transplants in patients with very high-risk acute lymphoblastic leukemia (ALL) without a family donor. Worldwide populations are ethnically diverse and HLA differs widely; on the other hand cord blood banks and donor registries are located mainly in Western Europe and North America, that’s why population from countries with different ethnic background is not well represented in those registries. Only recently cord blood banks and donor registries are becoming available in other globe regions [45–50], but they face many difficulties [51] and most of them are not accredited [52]. At our program as in others, only 20 % of children have a suitable match sibling donor (MSD), and our population is not well represented in the registries and sometime we don’t find any donor even in the cord blood banks; using an HI donor and reduced-intensity conditioning (RIC) regimen for high-risk pediatric leukemia and non-oncological diseases, although difficult, has been proven feasible in limited resource settings [53].

We strongly recommend constituting an HSCT medical committee with representatives from the HSCT unit and the referring centers. Such a committee may review indications and should discuss all cases and establish patients’ priority taking into account only medical conditions.

HSCT is a very dynamic field and indications for the procedure are always changing; thus periodic review is mandatory. Our indications have been changing every 5 years approximately; as an example present indications for acute leukemias are summarized in Table 27.3.

In order to perform a safe procedure, a comprehensive pre-transplant evaluation must be done in a systematic manner and include a proper patient clinical history, details of disease status, thorough physical examination of the recipient and donor, blood biochemical studies, baseline immune status, assessment of infection risk, and evaluation of social service, mental health, and dental services [54, 55]. Patients and donors might require special investigations according to risks of specific transplant procedures; see Table 27.4.