A Meta-Analysis of Unrelated Donor Umbilical Cord Blood Transplantation versus Unrelated Donor Bone Marrow Transplantation in Adult and Pediatric Patients

Association between haploidentical hematopoietic stem cell transplantation combined with an umbilical cord blood unit and graft-versus-host disease in pediatric patients with acquired severe aplastic anemia

Background:

Haploidentical hematopoietic stem cell transplantation (haplo-HSCT) based on granulocyte colony-stimulating factor plus anti-thymocyte regimens (‘Beijing Protocol’) provides a salvage treatment for patients of acquired severe aplastic anemia (SAA) in China. However, graft-versus-host disease (GVHD) is a major impediment of haplo-HSCT due to human leukocyte antigen disparity. Recently, haplo-HSCT combined with umbilical cord blood (UCB) (haplo-cord HSCT) is performed in clinical trials to potentially reduce the risk of severe GVHD. Nevertheless, studies comparing GVHD in pediatric patients receiving haplo and haplo-cord HSCT for SAA are limited.

Objective:

The objective of this study was to investigate the impact of UCB co-infusion on GVHD in pediatric patients receiving haplo-HSCT for SAA.

Design:

We conducted a retrospective study of 91 consecutive SAA children undergoing haploidentical transplantation based on the ‘Beijing Protocol’ with or without co-infusion of UCB in our center.

Methods:

All patients received uniform non-myeloablative conditioning and GVHD prophylaxis. We compared baseline characteristics and transplant outcomes between the haplo (n = 35) and haplo-cord (n = 56) recipients.

Results:

All 91 patients achieved hematopoietic recovery from haploidentical donors, with a higher incidence of peri-engraftment syndrome observed with the haplo-cord group as compared with the haplo group (75.0% versus 48.6%, p = 0.029). Notably, the haplo-cord group showed a lower incidence of II–IV acute GVHD (aGVHD) than the haplo group (16.1% versus 42.9%, p = 0.002). Observed incidences of chronic GVHD (cGVHD) and moderate to severe cGVHD in the haplo-cord group were also lower than that in the haplo group (25.6% versus 51.3%, p = 0.019; 16.2% versus 41.3%, p = 0.016, respectively). Haplo-cord HSCT was identified as the only factor associated with a lower incidence of II–IV aGVHD and cGVHD in multivariate analysis. However, no differences were observed between the two groups for infections and survival outcomes.

Conclusion:

Our data indicated that co-infusion of UCB in ‘Beijing Protocol’-based haplo-HSCT may be effective for reducing the risk of severe GVHD in SAA children.

Prednisolone poor response is not an indication for HSCT in pediatric B-cell precursor acute lymphoblastic leukemia in first remission: results from JACLS ALL-02 study

Approximately 90% of pediatric acute lymphoblastic leukemia (ALL) cases are curable with intensified chemotherapy, but very high-risk patients may require hematopoietic stem cell transplantation (HSCT). A suitable indication for HSCT in the first complete remission (CR1) should be defined to protect patients from long-term complications. We report the outcomes of HSCT in CR1 from the Japan Association of Childhood Leukemia Study (JACLS) ALL-02 study and reassess indications for HSCT. Of 1114 patients, 71 (6.4%) received HSCT in CR1. Indications included high-risk cytogenetic abnormalities and non-CR on day 33. Patients with B-cell precursor (BCP) ALL and a prednisolone poor response (PPR) received HSCT when leukocyte antigen-matched siblings were available. The 4-year overall survival (OS) of transplanted patients was 78.8% (confidence interval 67.3-86.6). Multivariate analysis revealed that cord blood transplantation was associated with poor OS. For BCP-ALL patients with PPR who achieved CR1 after induction therapy, HSCT in CR1 showed excellent outcomes (4-year OS 90.9%) but demonstrated no survival advantage as the outcome with chemotherapy was also excellent (4-year OS 97.0%). This study suggests that in BCP-ALL patients PPR is not an indication for HSCT in CR1. Precise evaluation of treatment responses would increase sophistication of indications for HSCT in CR1.

Comparative Study of Tacrolimus and Short-Term Methotrexate: 2-Day versus 3-Day Methotrexate as Graft-versus-Host-Disease Prophylaxis after Umbilical Cord Blood Transplantation in Adults

Methotrexate (MTX) in combination with a calcineurin inhibitor has been commonly used for prophylaxis of graft-versus-host disease (GVHD) following umbilical cord blood transplantation (UCBT) in Japan. However, the appropriate prophylactic MTX dosage in UCBT has not been established to date. To determine the preferential GVHD prophylaxis in UCBT, this study retrospectively investigated the administration of short-term MTX for 2 days versus 3 days. Of 103 adult patients submitted to UCBT enrolled in the study, 73 received tacrolimus (TAC) with 2 days of MTX given at 10 mg/m² on day 1 and 7 mg/m² on day 3 (very short-term [vs] MTX), whereas 30 patients received TAC with 3 days of MTX given at 10 mg/m² on day 1, 7 mg/m² on day 3, and 7 mg/m² on day 6 (short-term [s] MTX). In univariate analysis, neutrophil engraftment was shown to be significantly better (P = .039) in the vsMTX/TAC group. Among high-risk patients, the vsMTX/TAC group also exhibited earlier neutrophil engraftment (P = .042); however, the incidence of acute GVHD was higher in the vsMTX/TAC group (P = .035) on univariate analysis. In multivariate analysis, compared with sMTX/TAC, vsMTX/TAC was associated with lower risk of relapse (hazard ratio, .27; 95% confidence interval, .11 to .64; P = .003) . These results suggest that vsMTX/TAC can be appropriate GVHD prophylaxis after UCBT, especially in higher-risk patients.

Infectious Complications After Umbilical Cord Blood Transplantation for Hematological Malignancy

Background

Umbilical cord blood transplant (UCBT) is used for patients who do not have a matched donor, but engraftment often takes longer than with a standard allogeneic transplant, likely increasing the risk for infection. We characterized specific infections and outcomes in adults undergoing UCBT at our 2 centers.

Methods

All adults who underwent UCBT between January 1, 2006 and December 31, 2015 were included. Infectious episodes from 6 months before to 2 years after UCBT were reviewed.

Results

Fifty-seven patients underwent UCBT; 47 had neutrophil engraftment. A total of 179 infectious episodes occurred in 55 patients, 73 (41%) within 30 days post-UCBT. Viruses caused 85 (47%) infections. Cytomegalovirus caused 32 infectious episodes and was most common from day 30 to 100. Human herpesvirus 6 occurred in 28 episodes, was most common within 30 days, and caused 1 death. Bacteria were responsible for 82 (46%) infections, most commonly bacteremias due to Staphylococcus spp, Enterococcus spp, and Enterobacteriaceae. Of 11 invasive fungal infections, 9 were aspergillosis, 4 of which were fatal. Overall mortality was 56% in the first year. Thirteen deaths were from infection; 11 occurred in the first 100 days and 7 in the first 30 days post-UCBT. Of 10 patients who never engrafted, 9 died, 6 from infection, within 100 days post-UCBT.

Conclusions

Infectious complications were common after UCBT, especially in the first 30 days. Deaths from viral infections were fewer than expected. Delayed engraftment and nonengraftment continue to convey increased risk for fatal bacterial and fungal infections post-UCBT.

Reduction in Mortality after Umbilical Cord Blood Transplantation in Children Over a 20-Year Period (1995-2014)

Infections and graft-versus-host disease (GVHD) have historically resulted in high mortality among children undergoing umbilical cord blood transplantation (UCBT). However, recent advances in clinical practice have likely improved outcomes of these patients. We conducted a retrospective cohort study of children (<18years of age) undergoing UCBT at Duke University between January 1, 1995 and December 31, 2014. We compared 2-year all-cause and cause-specific mortality during 3 time periods based on year of transplantation (1995 to 2001, 2002 to 2007, and 2008 to 2014). We used multivariable Cox regression to identify demographic and UCBT characteristics that were associated with all-cause mortality, transplantation-related mortality, and death from invasive aspergillosis after adjustment for time period. During the 20-year study period 824 children underwent UCBT. Two-year all-cause mortality declined from 48% in 1995 to 2001 to 30% in 2008 to 2014 (P = .0002). White race and nonmalignant UCBT indications were associated with lower mortality. Black children tended to have a higher risk of death for which GVHD (18% versus 11%; P = .06) or graft failure (9% versus 3%; P = .01) were contributory than white children. Comparing 2008 to 2014 with 1995 to 2001, more than half (59%) of the reduced mortality was attributable to a reduction in infectious mortality, with 45% specifically related to reduced mortality from invasive aspergillosis. Antifungal prophylaxis with voriconazole was associated with lower mortality from invasive aspergillosis than low-dose amphotericin B lipid complex (hazard ratio, .09; 95% confidence interval, .01 to .76). With the decline in mortality from invasive aspergillosis, adenovirus and cytomegalovirus have become the most frequentinfectious causes of death in children after UCBT. Advances in clinical practice over the past 20years improved survival of children after UCBT. Reduced mortality from infections, particularly invasive aspergillosis, accounted for the largest improvement in survival and was associated with use of voriconazole for antifungal prophylaxis.

The role of policies and networks in development of cord blood usage in China

Research regarding the use of cord blood (CB) has focused on antigen match and the number of stem cells, with policies and networks related to its use being under researched. This article is based on fieldwork in China from 2013 to 2015 and examines ways that the studied CB bank enhances CB usage in China. This article identifies that in addition to finding a match, CB use is linked to the policies and networks, release fee and public awareness that enable CB usage development.

Awareness of cord blood collection and the impact on banking

BACKGROUND

Umbilical cord blood (UCB) is an important source of hematopoietic stem cells for transplantation especially in minority populations with limited chances of finding a histocompatible volunteer donor in the registry. UCB has the advantages of early availability, successful outcomes despite some histocompatibility mismatch, and low incidence of chronic graft-versus-host disease. Public cord blood banks that disseminate UCB products for transplant depend on voluntary donation at participating hospitals and obstetrical providers for collection.

PROCEDURE

Using survey questionnaires, we evaluated attitudes toward UCB donation, the frequency of donation, and provider opinions on UCB collection in the greater St. Louis metropolitan area that caters to minority ethnicities in significant numbers.

RESULTS

Our data suggest that nervousness and lack of information regarding the donation and utility of the product were ubiquitous reasons for not donating. Additionally, irrespective of age or level of education, women relied on healthcare providers for information regarding UCB donation. Providers reported primarily time constraints to discussing UCB donation at prenatal visits (54%). Of the interviewees, 62% donated UCB. Fallout due to refusal or preferring private banking was miniscule.

CONCLUSIONS

These results suggest that dedicated personnel focused on disseminating information, obtaining consent, and collecting the UCB product at major hospitals can enrich cord blood banks especially with minority cords. Sustained and focused efforts could improve upon a relatively high wastage rate and ensure a robust supply of UCB products at local public banks.

Umbilical cord blood cells from unrelated donor as an alternative source of hematopoietic stem cells for transplantation in children and adults

Umbilical cord blood (CB) is an alternative source of hematopoietic stem cells (HSC) for patients requiring allogeneic HSC transplantation but lacking a suitable human leukocyte antigen (HLA)-matched donor. Using CB has many advantages, including lower HLA-matching requirements, increased donor availability, and low rates of graft-versus-host disease. Furthermore, with over 630,000 cryopreserved volunteer CB units currently stored in international CB banks worldwide, CB is rapidly available for those patients requiring urgent transplantation. However, concern remains over the low HSC doses available in CB grafts, resulting in delayed engraftment and poor immune reconstitution. This article reviews the current use and future developments of unrelated allogeneic CB transplantation (CBT). An overview of the encouraging results of CBT and the comparisons with other HSC sources and transplant strategies both in children and adults with malignant and non-malignant diseases are shown. We will discuss important factors that need to be considered when selecting CB units for transplantation to further improve the results of CBT.

Umbilical cord-derived mesenchymal stem cells alleviate liver fibrosis in rats

AIM: To evaluate the efficacy of umbilical cord-derived mesenchymal stem cells (UC-MSCs) transplantation in the treatment of liver fibrosis.

METHODS: Cultured human UC-MSCs were isolated and transfused into rats with liver fibrosis induced by dimethylnitrosamine (DMN). The effects of UC-MSCs transfusion on liver fibrosis were then evaluated by histopathology; serum interleukin (IL)-4 and IL-10 levels were also measured. Furthermore, Kupffer cells (KCs) in fibrotic livers were isolated and cultured to analyze their phenotype. Moreover, UC-MSCs were co-cultured with KCs in vitro to assess the effects of UC-MSCs on KCs’ phenotype, and IL-4 and IL-10 levels were measured in cell culture supernatants. Finally, UC-MSCs and KCs were cultured in the presence of IL-4 antibodies to block the effects of this cytokine, followed by phenotypical analysis of KCs.

RESULTS: UC-MSCs transfused into rats were recruited by the injured liver and alleviated liver fibrosis, increasing serum IL-4 and IL-10 levels. Interestingly, UC-MSCs promoted mobilization of KCs not only in fibrotic livers, but also in vitro. Co-culture of UC-MSCs with KCs resulted in increased production of IL-4 and IL-10. The addition of IL-4 antibodies into the co-culture system resulted in decreased KC mobilization.

CONCLUSION: UC-MSCs could increase IL-4 and promote mobilization of KCs both in vitro and in vivo, subsequently alleviating the liver fibrosis induced by DMN.

Alternative donors: cord blood for adults

Allogeneic hematopoietic stem cell transplantation (HSCT) is a curative treatment for patients with hematological diseases. The probability of finding a human leukocyte antigen (HLA)- identical donor among family members is around 25% and 30% that of having a full matched unrelated donor in the registry. Patients in need may also benefit of a HLA-mismatched HSCT either from an haploidentical donors or from umbilical cord blood (UCB). Much has been learned about UCB transplant (UCBT) since the first human UCBT was performed back in 1988. Cord blood banks have been established worldwide for the collection, cryopreservation, and distribution of UCB for HSCT. Today, a global network of cord blood banks and transplant centers has been established with a large common inventory of more than 650,000 UCB units available, allowing for more than 40,000 UCBT worldwide in children and adults with severe hematological diseases. Several studies have been published on UCBT, assessing risk factors such as cell dose and HLA mismatch. Outcomes of several retrospective comparative studies showed similar results using other stem cell sources both in pediatric and adult setting. New strategies are ongoing to facilitate engraftment and reduce transplant-related mortality. In this issue, we review the current results of UCBT in adults with hematological malignancies and the clinical studies comparing UCBT with other transplant strategies. We provide guidelines for donor algorithm selection in UCBT setting.

[Efficacy analysis of unrelated cord blood transplantation for 58 acute myelogenous leukemia patients]

目的

探讨非血缘脐血移植(UCBT)治疗急性髓系白血病(AML)的疗效及影响疗效的相关因素。

方法

回顾性分析接受UCBT治疗58例AML患者的临床资料。中位年龄14.5(3~36)岁，中位体重45(12~90) kg。FAB分型：M₀ 1例、M₁ 1例、M₂ 35例(包括骨髓增生异常综合征转AML 1例)、M₄ 3例、M₅ 14例、M₆ 3例、混合细胞白血病1例。移植时处于第1次完全缓解期(CR₁)36例，第2次完全缓解期(CR₂)14例，未缓解(NR) 8例，其中高危难治患者43例(74.1%)。单份UCBT 49例(84.5%)，双份UCBT 9例(15.5%)。所有患者均采用强化清髓预处理方案，采用环孢素联合霉酚酸酯预防移植物抗宿主病(GVHD)。

结果

全部58例患者中56例(96.6%)获得造血重建，中性粒细胞植入、血小板植入的中位时间分别为17(12~37) d、33(17~140) d。24例(42.9%)患者发生急性GVHD，其中Ⅱ~Ⅳ度急性GVHD的发生率为30.4%(17/56)。在可评估的49例患者中，7例(14.3%)出现慢性GVHD(均为局限型)。预期3年累积总体生存(OS)率和无病生存(DFS)率分别为(60.3±6.4)％和(60.1±6.5)%。3年非复发死亡率为33.3%，复发率为9.1%。UCBT时疾病为CR患者(50例)的3年OS率高于NR患者(8例)[(66.0±6.7)％对(25.0±15.3)%，P=0.013]。

结论

UCBT治疗AML安全有效，慢性GVHD发生率和复发率较低。

Robust Vaccine Responses in Adult and Pediatric Cord Blood Transplantation Recipients Treated for Hematologic Malignancies

Because cord blood (CB) lacks memory T and B cells and recent decreases in herd immunity to vaccine-preventable diseases in many developed countries have been documented, vaccine responses in CB transplantation (CBT) survivors are of great interest. We analyzed vaccine responses in double-unit CBT recipients transplanted for hematologic malignancies. In 103 vaccine-eligible patients, graft-versus-host disease (GVHD) most commonly precluded vaccination. Sixty-five patients (63%; engrafting units median HLA-allele match 5/8; range, 2 to 7/8) received protein conjugated vaccines, and 63 patients (median age, 34 years; range, .9 to 64) were evaluated for responses. Median vaccination time was 17 months (range, 7 to 45) post-CBT. GVHD (n = 42) and prior rituximab (n = 13) delayed vaccination. Responses to Prevnar 7 and/or 13 vaccines (serotypes 14, 19F, 23F) were seen in children and adults (60% versus 49%, P = .555). Responses to tetanus, diphtheria, pertussis, Haemophilus influenzae, and polio were observed in children (86% to 100%) and adults (53% to 89%) even if patients had prior GVHD or rituximab. CD4(+)CD45RA(+) and CD19(+) cell recovery significantly influenced tetanus and polio responses. In a smaller cohort responses were seen to measles (65%), mumps (50%), and rubella (100%) vaccines. No vaccine side effects were identified, and all vaccinated patients survived (median follow-up, 57 months). Although GVHD and rituximab can delay vaccination, CBT recipients (including adults and those with prior GVHD) have similar vaccine response rates to adult donor allograft recipients supporting vaccination in CBT recipients.

Alternative donor transplantation--"mixing and matching": the role of combined cord blood and haplo-identical donor transplantation (haplo-cord SCT) as a treatment strategy for patients lacking standard donors?

In the past decade, haplo-cord stem cell transplantation (SCT) using myeloablative or reduced intensive conditioning regimens has been shown to result in reliable and fast engraftment of neutrophils and platelets comparable to HLA-matched donors and much faster than after cord stem cell transplant. Haplo-cord SCT also has a low incidence of early non-relapse mortality, low incidences of acute and chronic graft-vs-host disease (GVHD), and excellent graft-vs-leukemia (GVL) effects. Favorable long-term outcomes for high-risk patients with hematologic malignancies have been reported, including older patients. Haplo-cord SCT will likely overcome the limitations of cell dose during cord stem cell selection and might significantly expand the use of cord stem cell transplant in the adult population. The comparable survival outcomes of matched related donor (MRD), matched unrelated donor (MUD), and haplo-cord stem cell transplant strongly argue that haplo-cord SCT should be considered as effective alternative stem cell transplant for high-risk patients lacking standard donors. Further improvement in supportive care and incorporation of a better understanding of the human fetal immune development into the haplo-cord SCT are required to further improve this strategy.

Unrelated hematopoietic stem cell transplantation in the pediatric population: single institution experience

OBJECTIVE

Hematopoietic stem cell transplantation has been successfully used to treat the pediatric population with malignant and non-malignant hematological diseases. This paper reports the results up to 180 days after the procedure of all unrelated hematopoietic stem cell transplantations in pediatric patients that were performed in one institution.

METHODS

A retrospective review was performed of all under 18-year-old patients who received unrelated transplantations between 1995 and 2009. Data were analyzed using the log-rank test, Cox stepwise model, Kaplan-Meier method, Fine and Gray model and Fisher's exact test.

RESULTS

This study included 118 patients (46.8%) who received bone marrow and 134 (53.2%) who received umbilical cord blood transplants. Engraftment occurred in 89.47% of the patients that received bone marrow and 65.83% of those that received umbilical cord blood (p-value<0.001). Both neutrophil and platelet engraftments were faster in the bone marrow group. Acute graft-versus-host disease occurred in 48.6% of the patients without statistically significant differences between the two groups (p-value=0.653). Chronic graft-versus-host disease occurred in 9.2% of the patients with a higher incidence in the bone marrow group (p-value=0.007). Relapse occurred in 24% of the 96 patients with malignant disease with 2-year cumulative incidences of 45% in the bone marrow group and 25% in the umbilical cord blood group (p-value=0.117). Five-year overall survival was 47%, with an average survival time of 1207 days, and no significant differences between the groups (p-value=0.4666).

CONCLUSION

Despite delayed engraftment in the umbilical cord blood group, graft-versus-host disease, relapse and survival were similar in both groups.

Similar outcomes of allogeneic hematopoietic cell transplantation from unrelated donor and umbilical cord blood vs. sibling donor for pediatric acute myeloid leukemia: Multicenter experience in China

In a multicenter study, we have conducted a retrospective study on 73 pediatric AML patients who were primary refractory or in greater than CR1 and investigated MSD (or MMSD) (n = 20), URD (n = 23), and UCB (n = 30) HCT between January 1998 and October 2009. The median day to neutrophil engraftment was similar in all groups. The median day to platelet engraftment was longer in the UCB group. The number of HLA mismatch was higher in the UCB group (p = 0.034); however, the cumulative incidence of grade III-IV aGVHD was not different among all groups (p = 0.125); furthermore, cGVHD was lower in the UCB group (p = 0.078). The risk of relapse did not differ among all groups (RR = 1.28, p = 0.125), but the patients of MSD (or MMSD) grafts had a trend of higher risk recurrence. Sixty-two patients survived with a median follow-up of 58.2 months. Five-yr LFS was 73.1%, 59.8%, and 59.6% for URD, UCB, and MSD (or MMDS), respectively (p = 0.426). Five-yr LFS in CR1 was 68.9%, with a significantly better result compared to 41.7% in CR2 (p = 0.025). Our comparisons suggest that pediatric AML patients receiving UCB had a higher early TRM, a lower cGVHD rate, and a similar long-term survival. The outcome of URD and UCB is comparable to that of a suitable sibling for pediatric AML.

Umbilical cord blood transplantation supplemented with the infusion of mesenchymal stem cell for an adolescent patient with severe aplastic anemia: a case report and review of literature

Delayed hematopoietic recovery and increased rate of engraftment failure limit the use of umbilical cord blood transplantation (UCBT). We describe a case of severe aplastic anemia treated by UCBT combined with mesenchymal stem cells. Our case reveals that infusing mesenchymal stem cells early (about 40 days) after UCBT may promote hematopoietic recovery. This experience will guide clinical scientists, especially hematologists, to deal with similar situations and encourage them to widen this strategy.

Expansion and homing of umbilical cord blood hematopoietic stem and progenitor cells for clinical transplantation

The successful expansion of hematopoietic stem and progenitor cells (HSPCs) from umbilical cord blood (UCB) for transplantation could revolutionize clinical practice by improving transplantation-related outcomes and making available UCB units that have suboptimal cell doses for transplantation. New cytokine combinations appear able to promote HSPC growth with minimal differentiation into mature precursors and new agents, such as insulin-like growth factor-binding protein 2, are being used in clinical trials. Molecules that simulate the HSPC niche, such as Notch ligand, have also shown promise. Further improvements have been made with the use of mesenchymal stromal cells, which have made possible UCB expansion without a potentially deleterious prior CD34/CD133 cell selection step. Chemical molecules, such as copper chelators, nicotinamide, and aryl hydrocarbon antagonists, have shown excellent outcomes in clinical studies. The use of bioreactors could further add to HSPC studies in future. Drugs that could improve HSPC homing also appear to have potential in improving engraftment times in UCB transplantation. Technologies to expand HSPC from UCB and to enhance the homing of these cells appear to have attained the goal of accelerating hematopoietic recovery. Further discoveries and clinical studies are likely to make the goal of true HSPC expansion a reality for many applications in future.

Comparison of cord blood transplantation with unrelated bone marrow transplantation in patients older than fifty years

We retrospectively compared the transplantation outcomes for patients 50 years or older who received umbilical cord blood transplantation (UCBT) with those who received unrelated bone marrow transplantation (UBMT) for hematologic malignancies. A total of 1377 patients who underwent transplantation between 2000 and 2009 were included: 516 received 8/8 HLA allele-matched UBMT, 295 received 7/8 HLA allele-matched UBMT, and 566 received 4/6 to 6/6 HLA-matched UCBT. Adjusted overall survival (OS) was significantly lower in those who underwent UCBT than those who underwent 8/8 HLA-matched UBMT but was similar to that of 7/8 HLA-matched UBMT (the 2-year OS after 8/8 HLA-matched UBMT, 7/8 HLA-matched UBMT, and UCBT were 49% [95% confidence interval (CI), 45% to 55%], 38% [95% CI, 32% to 45%], and 39% [95% CI, 34% to 43%], respectively). However, adjusted OS was similar between 8/8 HLA-matched UBMT and UCBT receiving ≥.84 × 10(5) CD34(+) cells/kg among those with acute myeloid leukemia and those with acute lymphoblastic leukemia (the 2-year OS was 49% [95% CI, 43% to 55%], and 49% [95% CI, 41% to 58%], respectively). These data suggest that UCB is a reasonable alternative donor/stem cell source for elderly patients with similar outcomes compared with UBM from 8/8 HLA-matched unrelated donors when the graft containing ≥.84 × 10(5) CD34(+) cells/kg is available.

[Current indications of allogeneic stem cell transplant in adults with acute myeloid leukemia]

Allogeneic stem cell transplantation (SCT) is an increasingly important therapeutic option for the treatment of adult patients with acute myeloid leukemia. Here we review the current indications of SCT in this disease. While patients with favorable cytogenetics should receive consolidation chemotherapy, patients with unfavorable karyotype are prime candidates for SCT or new approaches to SCT (which should be done in first complete remission). Patients with intermediate prognoses should also receive SCT in first complete remission. In the absence of a suitable matched related donor, most patients will be able to find an alternative donor to proceed to a potentially curative allogeneic transplantation. The use of reduced-intensity conditioning regimens before SCT has allowed patients in the sixth or seventh decades of life to be routinely transplanted. Despite major differences among transplant centers in the intensity and composition of the conditioning regimen and immunosuppression, choice of graft source, postgraft immune-modulation, and supportive care, there has been a dramatic improvement in terms of tolerance. Although it is presumed to be a curative strategy, major complications of SCT remain graft-versus-host disease, delayed immune recovery, multiple comorbidities, and relapse after transplant.

Expanded umbilical cord blood T cells used as donor lymphocyte infusions after umbilical cord blood transplantation

BACKGROUND

Umbilical cord blood (UCB) is an alternative graft source for hematopoietic stem cell transplantation and has been shown to give results comparable to transplantation with other stem cell sources. Donor lymphocyte infusion (DLI) is an effective treatment for relapsed malignancies after hematopoietic stem cell transplantation. However, DLI is not available after UCB transplantation.

METHODS

In this study, in vitro-cultured T cells from the UCB graft were explored as an alternative to conventional DLI. The main aim was to study the safety of the cultured UCB T cells used as DLI because such cell preparations have not been used in this context previously. We also assessed potential benefits of the treatment.

RESULTS

The cultured UCB T cells (UCB DLI) were given to 4 patients with mixed chimerism (n = 2), minimal residual disease (n = 1) and graft failure (n = 1). No adverse reactions were seen at transfusion. Three of the patients did not show any signs of graft-versus-host disease (GVHD) after UCB DLI, but GVHD could not be excluded in the last patient. In the patient with minimal residual disease treated with UCB DLI, the malignant cell clone was detectable shortly before infusion but undetectable at treatment and for 3 months after infusion. In 1 patient with mixed chimerism, the percentage of recipient cells decreased in temporal association with UCB DLI treatment.

CONCLUSIONS

We saw no certain adverse effects of treatment with UCB DLI. Events that could indicate possible benefits were seen but with no certain causal association with the treatment.

The role of microglia in human disease: therapeutic tool or target?

Microglia have long been the focus of much attention due to their strong proliferative response (microgliosis) to essentially any kind of damage to the CNS. More recently, we reached the realization that these cells play specific roles in determining progression and outcomes of essentially all CNS disease. Thus, microglia has ceased to be viewed as an accessory to underlying pathologies and has now taken center stage as a therapeutic target. Here, we review how our understanding of microglia's involvement in promoting or limiting the pathogenesis of diseases such as amyotrophic lateral sclerosis, Alzheimer's disease, Huntington's disease, multiple sclerosis, X-linked adrenoleukodystrophy (X-ALD) and lysosomal storage diseases (LSD) has changed over time. While strategies to suppress the deleterious and promote the virtuous functions of microglia will undoubtedly be forthcoming, replacement of these cells has already proven its usefulness in a clinical setting. Over the past few years, we have reached the realization that microglia have a developmental origin that is distinct from that of bone marrow-derived myelomonocytic cells. Nevertheless, microglia can be replaced, in specific situations, by the progeny of hematopoietic stem cells (HSCs), pointing to a strategy to engineer the CNS environment through the transplantation of modified HSCs. Thus, microglia replacement has been successfully exploited to deliver therapeutics to the CNS in human diseases such as X-ALD and LSD. With this outlook in mind, we will discuss the evidence existing so far for microglial involvement in the pathogenesis and the therapy of specific CNS disease.

Fetal stem cells and skeletal muscle regeneration: a therapeutic approach

More than 40% of the body mass is represented by muscle tissue, which possesses the innate ability to regenerate after damage through the activation of muscle-specific stem cells, namely satellite cells. Muscle diseases, in particular chronic degenerative states of skeletal muscle such as dystrophies, lead to a perturbation of the regenerative process, which causes the premature exhaustion of satellite cell reservoir due to continuous cycles of degeneration/regeneration. Nowadays, the research is focused on different therapeutic approaches, ranging from gene and cell to pharmacological therapy, but still there is no definitive cure in particular for genetic muscle disease. Keeping this in mind, in this article, we will give special consideration to muscle diseases and the use of fetal derived stem cells as a new approach for therapy. Cells of fetal origin, from cord blood to placenta and amniotic fluid, can be easily obtained without ethical concern, expanded and differentiated in culture, and possess immune-modulatory properties. The in vivo approach in animal models can be helpful to study the mechanism underneath the operating principle of the stem cell reservoir, namely the niche, which holds great potential to understand the onset of muscle pathologies.

Usefulness of umbilical cord blood cells in era of hematopoiesis research

Although worldwide experience with umbilical cord blood (UCB) transplantation is still relatively limited, clinical experience with UCB transplantation is encouraging. The use of UCB for hematopoietic stem cell transplantation (HSCT) has advantages and disadvantages. Among the advantages are rapid availability, ability to more rapidly schedule the transplant as the UCB units are stored and ready for use, the apparent reduced need for an exact human leukocyte antigen (HLA) match, and induction of a less severe graft versus host disease (GVHD) compared with bone marrow. The major limitation of reduced numbers of hematopoietic stem cells (HSC) in UCB is being addressed by basic research. It is promising that potential improvements in engraftment efficiency without increased stem cell numbers or actual increased stem cell numbers through dual UCB transplant or ex-vivo expansion might lead to improved treatment approaches. However, its therapeutic potential extends beyond the hematopoietic component suggesting regenerative potential in solid organs as well. Many different stem and progenitor cell populations have been postulated with potential ranging from embryonic like to lineage-committed progenitor cells. UCB derived MSCs have the differentiation capacity and also the therapeutic potential with regard to regenerative medicine, stromal support, immune modulation and gene therapy. Therefore, further advances are eagerly anticipated.

Allogeneic hematopoietic cell transplant for acute myeloid leukemia: Current state in 2013 and future directions

Acute myeloid leukemia (AML) represents a heterogeneous group of high-grade myeloid neoplasms of the elderly with variable outcomes. Though remission-induction is an important first step in the management of AML, additional treatment strategies are essential to ensure long-term disease-free survival. Recent pivotal advances in understanding the genetics and molecular biology of AML have allowed for a risk-adapted approach in its management based on relapse-risk. Allogeneic hematopoietic cell transplantation (allo-HCT) represents an effective therapeutic strategy in AML providing the possibility of cure with potent graft-versus-leukemia reactions, with a demonstrable survival advantage in younger patients with intermediate- or poor-risk cytogenetics. Herein we review the published data regarding the role of allo-HCT in adults with AML. We searched MEDLINE/PubMed and EMBASE/Ovid. In addition, we searched reference lists of relevant articles, conference proceedings and ongoing trial databases. We discuss the role of allo-HCT in AML patients stratified by cytogenetic- and molecular-risk in first complete remission, as well as allo-HCT as an option in relapsed/refractory AML. Besides the conventional sibling and unrelated donor allografts, we review the available data and recent advances for alternative donor sources such as haploidentical grafts and umbilical cord blood. We also discuss conditioning regimens, including reduced intensity conditioning which has broadened the applicability of allo-HCT. Finally we explore recent advances and future possibilities and directions of allo-HCT in AML. Practical therapeutic recommendations have been made where possible based on available data and expert opinion.

Long-term outcome and prognostic factors of unrelated cord blood transplantation in children with haematological malignancies: a retrospective study using the Spanish Working Party for BMT in Children (GETMON) database

Outcomes of unrelated cord blood transplants (UCBT) were assessed in 172 consecutive children, median age 5 years (range: 0.5-18), with haematological malignancies treated at nine Spanish hospitals between February 1996 and April 2009. Data were collected from the Spanish Working Party for Blood and Marrow Transplantation in Children (GETMON) database. ALL was diagnosed in 125 patients, AML in 43 and myelodysplastic syndrome in 4. Myeloid engraftment (ANC⩾0.5 × 10(9)/L) occurred in 87.2% at a median of 22 days and was associated with the total nucleated cell (TNC) dose infused and use of a TT-containing conditioning regimen. Cumulative incidence of relapse was 20% at 1 year post transplant and 29% at 3 years, being higher in patients with a diagnosis of ALL, very high risk disease and GVHD grades 0-1. Cumulative incidence of non-relapse mortality (NRM) was 19% at 100 days post transplant and 39% at 1 year. BU-FLU-TT-ATG-conditioned patients had lower NRM. Disease-free survival (DFS) was 40% at 2 years post transplant (for patients transplanted since 2006). On multivariate analysis, TNC dose infused, AML and BU-FLU-TT-ATG-conditioning regimen increased the probability of DFS. It is of paramount importance to select cord blood units with the highest cell dose. As the BU-FLU-TT-ATG-conditioning regimen was associated with better DFS owing to lower NRM, further prospective studies testing this regimen are warranted.

Engraftment Outcomes after HPC Co-Culture with Mesenchymal Stromal Cells and Osteoblasts

Haematopoietic stem cell (HSC) transplantation is an established cell-based therapy for a number of haematological diseases. To enhance this therapy, there is considerable interest in expanding HSCs in artificial niches prior to transplantation. This study compared murine HSC expansion supported through co-culture on monolayers of either undifferentiated mesenchymal stromal cells (MSCs) or osteoblasts. Sorted Lineage(-) Sca-1(+) c-kit(+) (LSK) haematopoietic stem/progenitor cells (HPC) demonstrated proliferative capacity on both stromal monolayers with the greatest expansion of LSK shown in cultures supported by osteoblast monolayers. After transplantation, both types of bulk-expanded cultures were capable of engrafting and repopulating lethally irradiated primary and secondary murine recipients. LSKs co-cultured on MSCs showed comparable, but not superior, reconstitution ability to that of freshly isolated LSKs. Surprisingly, however, osteoblast co-cultured LSKs showed significantly poorer haematopoietic reconstitution compared to LSKs co-cultured on MSCs, likely due to a delay in short-term reconstitution. We demonstrated that stromal monolayers can be used to maintain, but not expand, functional HSCs without a need for additional haematopoietic growth factors. We also demonstrated that despite apparently superior in vitro performance, co-injection of bulk cultures of osteoblasts and LSKs in vivo was detrimental to recipient survival and should be avoided in translation to clinical practice.

Umbilical cord blood transplant for malignancies: a hope or hype

Cord blood is a rich and unlimited source of hematopoietic stem cells for allogeneic stem cell transplant to treat a variety of oncologic, genetic, hematologic, and immunodeficiency disorders. Since the first successful cord blood transplant in 1988, a large number of cord blood banks have been established world over for collection and storage of cord blood for future use. Majority of such transplants are performed in children, however, the number in adults have been growing steadily in recent years. Results from various transplant registries reveals that a single cord blood provides enough stem cells to provide short and long term engraftment, and has low incidence and less severity of graft versus host disease. With a high booming birth rate and a large genetic diversity, India has potential to become the largest supplier of cord blood stem cells in world. To meet the future transplant need of the country sincere efforts from various institutes and government agencies are needed to increase the number of public cord blood banks in the country. In this article the author will focus on the issue of public and private cord blood banking; the role of physicians in educating and counseling families with regard to the utility of cord blood for donor itself as well as the future of umbilical cord blood transplant in India.

Expanded indications for allogeneic stem cell transplantation in patients with myeloid malignancies

PURPOSE OF REVIEW

Hematopoietic stem cell transplantation (SCT) can be curative for myeloid malignancies such as acute myeloid leukemia (AML). Advancements in human leukocyte antigen (HLA) typing and supportive care have improved the risk-benefit ratio for SCT, expanding its indications.

RECENT FINDINGS

Allogeneic SCT is an established treatment for AML with intermediate-risk and high-risk cytogenetics in first complete remission (CR1), from matched related donors (MRDs). Similar survival benefits are seen for AML in CR1 with unfavorable cytogenetics using matched unrelated donors (URDs). Molecular characterization has delineated patients with AML at higher risk with normal cytogenetics [e.g., FLT3-internal tandem duplication (ITD)+]. The outcomes of allogeneic SCT are comparable in patients with therapy-related or de-novo AML when adjusted for disease status and cytogenetics. In patients lacking a MRD, the majority will have a suitable alternative using an URD, umbilical cord blood, or haploidentical-related donors; outcomes are either comparable or relatively acceptable compared to a matched sibling donor. Comorbidity indices aid in identifying elderly and debilitated patients who may benefit from SCT; the application of SCT has been further increased by reduced-intensity conditioning regimens.

SUMMARY

Allogeneic SCT may be extended to almost all patients with AML, and integration of toxicity and relapse risks will determine the best approach for allogeneic SCT in the future.

Umbilical cord blood transplantation: the first 25 years and beyond

Umbilical cord blood is an alternative hematopoietic stem cell source for patients with hematologic diseases who can be cured by allogeneic hematopoietic cell transplantation. Initially, umbilical cord blood transplantation was limited to children, given the low cell dose infused. Both related and unrelated cord blood transplants have been performed with high rates of success for a variety of hematologic disorders and metabolic storage diseases in the pediatric setting. The results for adult umbilical cord blood transplantation have improved, with greater emphasis on cord blood units of sufficient cell dose and human leukocyte antigen match and with the use of double umbilical cord blood units and improved supportive care techniques. Cord blood expansion trials have recently shown improvement in time to engraftment. Umbilical cord blood is being compared with other graft sources in both retrospective and prospective trials. The growth of the field over the last 25 years and the plans for future exploration are discussed.

New strategies in cord blood cells transplantation

For patients lacking a human leucocyte antigen-matched donor, umbilical cord blood (UCB) is an ideal, alternative source of haematopoietic stem cells (HSCs) for transplantation purposes. UCB has many advantages over bone marrow or peripheral blood taken from volunteer donors. UCB is also an important source of other stem cells, including endothelial progenitors, mesenchymal stem cells, very small embryonic/epiblast-like (VSEL) stem cells, and unrestricted somatic stem cells, which are potentially suitable for regenerative medicine. However, a significant clinical problem is that the number of HSCs in one cord-blood unit is not enough for an adult transplantation. The development of new approaches including use of multiple donors, ex vivo expansion, increasing efficiency of homing and engraftment, retrieving more cells from the placenta and cord blood is of crucial importance for the delayed engraftment after UCB transplantation. In the future, UCB will emerge as a source of cells for cellular therapies associated with tissue repair and regeneration.

Factors with an impact on chimerism development and long-term survival after umbilical cord blood transplantation

BACKGROUND

Umbilical cord blood transplantation (UCBT) is increasingly used and produces similar results to matched unrelated donor transplantation.

METHODS

We performed a retrospective single-center analysis of 50 umbilical cord blood transplantations UCBTs performed from 2001 to 2010, including 37 single and 13 double umbilical cord blood transplantations UCBTs.

RESULTS

The rate of engraftment of neutrophils was 88% at a median time of 29 days (range, 3-79). Complete donor chimerism (DC) within the CD19, CD3, and CD33 cell lineages was seen in 74%, 72%, and 76% of the patients, respectively. DC was associated with acute graft-versus-host disease (GVHD) grades II to IV for the CD3 cell lineage (P=0.01) and, in multivariate analysis, with total body irradiation for all lineages (P<0.01). Overall survival (OS) at 1 and 5 years was 55% and 43%. Nonmalignant diseases were associated with better 5-year OS (72%) than malignancies (28%; P=0.026). In multivariate analysis, a negative correlation was seen between OS and age (hazard ratio [HR], 1.04; 95% confidence interval [95% CI], 1.02-1.06; P<0.001), acute GVHD grades III and IV (HR, 3.43; 95% CI, 1.95-6.02; P<0.001), and mesenchymal stem cell treatment (HR, 2.66; 95% CI, 1.11-6.35; P=0.027). Transplant-related mortality at 100 days and 1 year was 16% and 30%. The incidence of acute GVHD grades II to IV was 34%. Acute GVHD grades III and IV was associated with ABO incompatibility (HR, 2.61; P=0.05) and myeloablative conditioning (HR, 4.17; P=0.047).

CONCLUSIONS

The outcome in patients with nonmalignant diseases was acceptable, but transplant-related mortality in the whole group remains high. A significantly higher rate of DC was associated with total body irradiation-based conditioning and with acute GVHD grades II and IV.

Chimerism and use of mesenchymal stem cells in umbilical cord blood transplantation

We performed a retrospective single-center analysis of 50 umbilical cord blood transplantations (UCBTs), focusing on chimerism development. Complete donor chimerism (DC) was associated with acute graft-vs.-host disease (aGVHD) grades II-IV for the CD3 (+) cell lineage (p = 0.01) and, in multivariate analysis, with total body irradiation (TBI) for all lineages (p < 0.01). Overall survival (OS) was negatively associated with patient age, (p < 0.001); aGVHD grades III-IV, (p < 0.001); and treatment with mesenchymal stem cells (MSCs) (p = 0.027). In conclusion, though multiple factors may have contributed, the association of TBI and DC might be worthy of consideration in the treatment of patients with malignant disease in the UCBT setting. The negative influence of MSCs on OS may be a reason for more careful usage of this treatment modality in combination with UCBT.

A direct comparison of expression profiles of adhesion molecules on naïve T cells between cord blood and steady-state bone marrow grafts of healthy donors

INTRODUCTION

We compared the profiles of adhesion molecule expression on naïve T cells between umbilical cord blood (UCB) and steady-state bone marrow (SS-BM) grafts.

METHODS

The expressions of 4 adhesion molecules, including very late antigen 4 (VLA-4), intercellular adhesion molecule-1 (ICAM-1), L-selectin, and lymophocyte function-associated antigen-1 (LFA-1) on naïve T cells in UCB (n = 25) and SS-BM (n = 10) were analyzed using flow cytometry.

RESULTS

The expressions of ICAM-1 and L-selectin on CD4(+) T cells and CD8(+) T cells in UCB were significantly lower than those on SS-BM (P < .05 for all). The expressions of VLA-4 and LFA-1 on CD8(+) T cells in UCB were significantly lower than those of SS-BM (P = .002 and .047, respectively). Compared with SS-BM, we observed lower expression of ICAM-1 on naïve CD4(+) and CD8(+) T cells in UCB (P < .001 for all). The percentages of interferon (IFN)-γ positive cells among naïve CD4(+) and CD8(+) T-cell subsets were significantly lower in UCB, leading to ready polarization of naïve UCB T cells from a Th1 to Th2 phenotype versus those on SS-BM.

CONCLUSIONS

Our results among UCB suggested lower intensities of ICAM-1 expression on naïve T cells and their easier polarization from Th1 to Th2 elements.

US public cord blood banking practices: recruitment, donation, and the timing of consent

BACKGROUND

Cord blood has moved rapidly from an experimental stem cell source to an accepted and important source of hematopoietic stem cells. There has been no comprehensive assessment of US public cord blood banking practices since the Institute of Medicine study in 2005.

STUDY DESIGN AND METHODS

Of 34 US public cord blood banks identified, 16 participated in our qualitative survey of public cord blood banking practices. Participants took part in in-depth telephone interviews in which they were asked structured and open-ended questions regarding recruitment, donation, and the informed consent process at these banks.

RESULTS

Thirteen of 16 participants reported a variably high percentage of women who consented to public cord blood donation. Fifteen banks offered donor registration at the time of hospital admission for labor and delivery. Seven obtained full informed consent and medical history during early labor and eight conducted some form of phased consent and/or phased medical screening and history. Nine participants identified initial selection of the collection site location as the chief mode by which they recruited minority donors.

CONCLUSION

Since 2005, more public banks offer cord blood donor registration at the time of admission for labor and delivery. That and the targeted location of cord blood collection sites are the main methods used to increase access to donation and HLA diversity of banked units. Currently, the ability to collect and process donations, rather than donor willingness, is the major barrier to public cord blood banking.

Intrabone cord blood hematopoietic stem cell transplantation in a subset of very high-risk pediatric patients: a safety and feasibility pilot study

The main limit of umbilical cord blood hematopoietic stem cell transplantation is a more difficult engraftment related to the number of cells infused per kilogram of recipient body weight. This limit makes the cord blood a suboptimal source of hematopoietic stem cells for transplantation in case of difficult engraftment situations. Direct intrabone cord blood (CB) injection has been recently investigated as a solution to cell dose problem in the adults population, but there is a lack of data concerning this approach in pediatric patients. Here, we describe 5 pediatric patients undergoing intrabone cord blood transplantation (IBCBT) for different diseases characterized by a high risk of posttransplant graft failure. The conditioning regimen differed according to the disease, whereas the GvHD prophylaxis consisted of cyclosporine, mycophenolate, and ATG. The median numbers of total nucleated cells infused and CD34(+) cells were 3.3 × 10(7)/kg, 2 × 10(5)/kg. All the patients showed complete hematological recovery and complete donor engraftment. No patient had secondary graft failure, whereas 1 patient relapsed 6 months after IBCBT. No patient died of transplant-related complications. Our results show that IBCBT is safe and feasible in pediatrics as well, and suggest that IBCBT might be an attractive option to overcome some limits of umbilical cord blood hematopoietic stem cell transplantation.

A meta-analysis of unrelated donor umbilical cord blood transplantation versus unrelated donor bone marrow transplantation in acute leukemia patients

Umbilical cord blood has emerged as an alternative stem cell source to bone marrow or peripheral blood stem cells. Umbilical cord blood transplantation (UCBT) is also potentially curative for acute leukemia. However, the effect of unrelated donor bone marrow transplantation (UBMT) and UCBT on the outcome of patients with acute leukemia has not been systematically reviewed. In the present meta-analysis, we systematically searched Cochrane Library, MEDLINE, EMBASE, and CNKI up to May 2011. Two reviewers extracted data independently. Seven studies totaling 3389 patients have been assessed. Pooled results found that the incidence of engraftment failure and transplantation-related mortality were higher in UCBT than in UBMT, and relative risks (RRs) were 4.27 (95% confidence interval [CI], 2.94-6.21) and 1.27 (95% CI, 1.01-1.59), respectively. The rates of acute and chronic graft-versus-host disease (GVHD) in the UCBT group were significantly lower than that in the UBMT group, and RRs were 0.71 (95% CI, 0.65-0.79) and 0.69 (95% CI, 0.52-0.91), respectively. The relapse rate was similar between the UCBT and UBMT group. The leukemia-free survival (LFS) and overall survival (OS) were significantly lower in the UCBT group than in the UBMT group; RRs were 1.14 (95% CI, 1.07-1.22) and hazard ratios (HRs) were 1.31 (95% CI, 1.16-1.48), respectively. Subgroup analysis showed that in patients with acute lymphoblastic leukemia (ALL), the survival was similar between UCBT and UBMT.

Hematopoietic stem cell transplantation in children with leukemia: a single institution experience with respect to donors

Aim of this study was to compare the outcomes of transplantation by donor source and to help select the best alternative donor in children with leukemia. Donor sources included matched related donor (MRD, n = 35), allele-matched unrelated donor (M-UD, n = 10) or -mismatched (MM)-UD (n = 13) or unrelated umbilical cord blood (UCB, n = 11). UCB group had a significantly higher incidence of grade II-IV acute graft versus host disease (MRD, 11.8%; M-UD, 30.0%; MM-UD, 15.4%, UCB, 54.4%, P = 0.004) but there was no difference in incidence of chronic graft versus host disease between 4 groups. The 5-yr leukemia-free survival (LFS) was 76.7%, 60.0%, 69.2%, and 45.5%, respectively (P = 0.128). MRD group showed higher LFS rate than UCB group (P = 0.022). However, LFS of M-UD and MM-UD together (65.2%) was not different from that of MRD group (76.7%, P = 0.325), or from that of UCB (45.5%, P = 0.190). The relapse incidence at 5 yr was 17.1%, 20.0%, 15.4%, and 0%, respectively (P = 0.460). The 100-day treatment-related mortality was 2.9%, 20.0%, 7.7%, and 36.4%, respectively (P = 0.011). Despite the limitations of small number of patients, unrelated donor transplants including even allele-mismatched ones, seem to be as effective in children with leukemia lacking suitable relative donors. Also, UCB transplant may serve as another possible option in urgent transplants.

Milestones in umbilical cord blood transplantation

Since the first human cord blood transplant, performed in 1988, cord blood banks have been established worldwide for collection and cryopreservation of cord blood for allogeneic hematopoietic stem cell transplant. Umbilical cord blood (UCB) has now become one of the most commonly used source of hematopoietic stem cells for allogeneic transplantation. Today a global network of cord blood banks and transplant centers has been established for a common inventory with an estimated 600,000 UCB have been banked and more than 20,000 UCB units distributed worldwide for adults and children with severe hematological diseases. Several studies have shown that the number of cells is the most important factor for engraftment while some degree of HLA mismatches is acceptable. The absence of ethical concern, and the unlimited supply of cells explain the increasing interest of using cord blood for developing regenerative medicine.

Awareness and acceptance of public cord blood banking among practicing obstetricians in the United States

BACKGROUND

This study measured: 1) levels of awareness and understanding among practicing obstetricians regarding umbilical cord blood (UCB) donation and the use of UCB in transplant therapy, 2) motivations for obstetricians to support donation and collection for donation to a public cord blood bank (CBB), and 3) current practices for discussing this option with their patients.

STUDY DESIGN AND METHODS

Obstetricians practicing in major metropolitan areas in the United States were randomly surveyed in 2009. Of 2041 surveys mailed, 295 were returned, 139 from obstetricians with privileges at hospitals affiliated with a public CBB (affiliated) and 156 from obstetricians without such privileges (nonaffiliated). Cross-tabulation analyses were conducted to compare responses between these two groups.

RESULTS

Both affiliated and nonaffiliated obstetricians report being somewhat or very familiar with the use of cord blood in transplant therapy (88% vs. 82%, respectively; p = NS), but some misperceptions concerning clinical application exist. Eighty percent of affiliated obstetricians feel confident discussing cord blood options with their patients; however, 49% indicated that they have insufficient knowledge of cord blood donation to effectively answer patients' questions about donation.

CONCLUSION

Obstetricians are generally familiar with the utility of donated cord blood in transplantation, but could benefit from additional information regarding how cord blood is used in transplantation. Further, obstetricians play an important role in encouraging women to donate their baby's cord blood to a public CBB, are willing to do so, and indicate a desire for more information so they can effectively educate their patients.

Umbilical cord blood banking: an update

BACKGROUND

Umbilical cord blood is a potential vast source of primitive hematopoietic stem and progenitor cells available for clinical application to reconstitute the hematopoietic system and/or restore immunological function in affected individuals requiring treatment. Cord blood can be used as an alternative source for bone marrow transplantation and its use is developing into a new field of treatment for pediatric and adult patients presenting with hematological disorders, immunological defects and specific genetic diseases.

DISCUSSION

More than 25,000 allogeneic cord blood transplantations have been performed worldwide since the first cord blood transplantation in 1988. There are two banking options for storing umbilical cord blood [private (family) and public]. Cord blood stored in private banks are used for either autologous or allogeneic transplants for the infant donor or related family members but private cord blood banks are not searchable or available to the public. More than 780,000 cord blood units are stored in over 130 private cord blood banks, worldwide, and over 400,000 units in more than 100 quality controlled public cord blood banks.

CONCLUSIONS

Researchers continue to evaluate the usefulness of cord blood cells in treating human diseases or disorders for purposes other than hematological disorders including heart disease, strokes, brain or spinal cord injuries and cancer. This review summarizes the status of umbilical cord blood banking, its history and current and potential use in the treatment of human disease.