Comprehensive banking of sibling donor cord blood for children with malignant and nonmalignant disease

Family cord blood banking for sickle cell disease: a twenty-year experience in two dedicated public cord blood banks

Efforts to implement family cord blood banking have been developed in the past decades for siblings requiring stem cell transplantation for conditions such as sickle cell disease. However, public banks are faced with challenging decisions about the units to be stored, discarded, or used for other endeavors. We report here 20 years of experience in family cord blood banking for sickle cell disease in two dedicated public banks. Participants were pregnant women who had a previous child diagnosed with homozygous sickle cell disease. Participation was voluntary and free of charge. All mothers underwent mandatory serological screening. Cord blood units were collected in different hospitals, but processed and stored in two public banks. A total of 338 units were stored for 302 families. Median recipient age was six years (11 months-15 years). Median collected volume and total nucleated cell count were 91 mL (range 23-230) and 8.6×108 (range 0.7-75×108), respectively. Microbial contamination was observed in 3.5% (n=12), positive hepatitis B serology in 25% (n=84), and homozygous sickle cell disease in 11% (n=37) of the collections. Forty-four units were HLA-identical to the intended recipient, and 28 units were released for transplantation either alone (n=23) or in combination with the bone marrow from the same donor (n=5), reflecting a utilization rate of 8%. Engraftment rate was 96% with 100% survival. Family cord blood banking yields good quality units for sibling transplantation. More comprehensive banking based on close collaboration among banks, clinical and transplant teams is recommended to optimize the use of these units.

Family directed umbilical cord blood banking for acute leukemia: usage rate in hematopoietic stem cell transplantation

Family-directed umbilical cord blood (UCB) collection and banking is indicated in women delivering healthy babies who already have a member of their own family with a disease potentially treatable with an allogeneic hematopoietic stem cell (HSCs) transplantation (HSCT). The rapid availability of UCB is an important issue in HSCs procurement particularly for recipients with acute leukemia who urgently need HSCT. The aims of this study were to assess the usage rate of family UCB collections directed to patients with acute leukemia and to investigate the factors influencing the usage rate. A total of 113 families were enrolled, 118 UCB units were successfully collected and one collection failed due to emergency occurred during delivery. Among these, 7 collections were required for children who were in urgent need of a transplant: three HLA-matched units were successfully transplanted, respectively after 2, 5 and 6 months from collection; three collections resulted HLA-mismatched, while HLA-typing is pending for one unit. The remaining collections were mostly required for potential future use, among these units only one was transplanted in a HLA compatible sibling after 3 years and 4 months from collection. After a median time of storage of 8.5 years (range 0.1-20 years) a total of 4/118 (3.4 %) collection has been transplanted. During this time interval, considering only patients who have had the need of a transplant, the main factor influencing low utilization rate of UCB collections was due to HLA disparity, indeed among typed UCB unit mostly (77 %) resulted HLA mismatched with the intended recipient.

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.

The Role of HLA in Cord Blood Transplantation

In recent years, umbilical cord blood (CB), a rich source of hematopoietic stem cells (HSC), has been used successfully as an alternative HSC source to treat a variety of hematologic, immunologic, genetic, and oncologic disorders. CB has several advantages, including prompt availability of the transplant, decrease of graft versus host disease (GVHD) and better long-term immune recovery, resulting in a similar long-term survival. Studies have shown that some degree of HLA mismatches is acceptable. This review is intended to outline the main aspects of HLA matching in different settings (related, pediatric, adult, or double-unit HSCT), its effect on transplantation outcome and the role of HLA in donor selection.

Allogeneic hematopoietic stem cell transplantation in children with sickle cell disease

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) represents the only curative treatment for sickle cell disease (SCD), being successful in around 85-90% of patients. Mortality and long-term morbidity (including infertility, gonadal failure, and chronic graft-vs.-host disease) associated with conventional approaches curtail the number of patients who undergo allo-HSCT. Recently, it has been demonstrated that cord blood is as effective as and possibly safer than bone marrow in pediatric patients with SCD. Likewise, transplant strategies based on the use of reduced-intensity regimens and the induction of mixed chimerism have been explored to decrease allo-HSCT short- and long-term complications.

Bone marrow transplant options and preferences in a sickle cell anemia cohort on chronic transfusions

BACKGROUND

Bone marrow transplantation (BMT) using human leukocyte antigen (HLA)-matched sibling donors can be curative for children with sickle cell anemia (SCA). However, minimal data exist regarding availability of HLA-identical matched siblings for transplant-eligible children, and family interest in pursuing transplantation.

METHODS

We retrospectively analyzed a pediatric SCA cohort receiving chronic transfusions between July 2004 and January 2011. Data were analyzed regarding the number of full siblings and half-siblings, availability, and family interest in HLA testing the full siblings, and interest in proceeding with HLAmatched transplantation.

RESULTS

Among 113 patients, 46 (41%) had at least 1 full sibling and 40 (35%) had an unaffected full sibling who could serve as a BMT donor. The families of 23 of these patients (58%) agreed to HLA-type sibling, 8 of whom (35%) were matched. Transfusion indications for families agreeing to HLA typing included stroke (46%) abnormal TCD (29%), acute chest syndrome (21%), and other CNS reasons (4%). Common reasons to decline HLA typing or transplantation included fear of the process, toxicities of the procedure, and comfort with current quality of life on transfusions. Only 8 of 113 (7%) were eligible for matched BMT, and only 3 (3%) underwent HLA-matched transplantation. Two unmatched children received haploidentical transplantation.

CONCLUSIONS

Most families of children with SCA on chronic transfusions choose to proceed with HLA typing. However, when a matched sibling was identified, most families declined to proceed with matched-sibling transplantation. Discussing BMT as a treatment option, offering HLA typing and identifying barriers may improve acceptance of this treatment modality.

Family-directed umbilical cord blood banking

Umbilical cord blood transplantation from HLA-identical siblings provides good results in children. These results support targeted efforts to bank family cord blood units that can be used for a sibling diagnosed with a disease which can be cured by allogeneic hematopoietic stem cell transplantation or for research that investigates the use of allogeneic or autologous cord blood cells. Over 500 patients transplanted with related cord blood units have been reported to the Eurocord registry with a 4-year overall survival of 91% for patients with non-malignant diseases and 56% for patients with malignant diseases. Main hematologic indications in children are leukemia, hemoglobinopathies or inherited hematologic, immunological or metabolic disorders. However, family-directed cord blood banking is not widely promoted; many cord blood units used in sibling transplantation have been obtained from private banks that do not meet the necessary criteria required to store these units. Marketing by private banks who predominantly store autologous cord blood units has created public confusion. There are very few current validated indications for autologous storage but some new indications might appear in the future. Little effort is devoted to provide unbiased information and to educate the public as to the distinction between the different types of banking, economic models and standards involved in such programs. In order to provide a better service for families in need, directed-family cord blood banking activities should be encouraged and closely monitored with common standards, and better information on current and future indications should be made available.

Long-term follow-up and factors influencing outcomes after related HLA-identical cord blood transplantation for patients with malignancies: an analysis on behalf of Eurocord-EBMT

We analyzed risk factors influencing outcomes after related (R) human leukocyte antigen-identical cord blood transplantation (CBT) for 147 patients with malignancies reported to Eurocord-European Group for Blood and Marrow Transplantation. CBT has been performed since 1990; median follow-up was 6.7 years. Median patient age was 5 years. Acute leukemia was the most frequent diagnosis (74%). At CBT, 40 patients had early, 70 intermediate, and 37 advanced disease. CB grafts contained a median of 4.1 × 10(7)/kg total nucleated cells (TNCs) after thawing. The cumulative incidence (CI) of neutrophil recovery was 90% at day +60. CIs of acute and chronic graft-versus-host disease (GVHD) were 12% and 10% at 2 years, respectively. At 5 years, CIs of nonrelapse mortality and relapse were 9% and 47%, respectively; the probability of disease-free survival (DFS) and overall survival were 44% and 55%, respectively. Among other factors, higher TNCs infused was associated with rapid neutrophil recovery and improved DFS. The use of methotrexate as GVHD prophylaxis decreased the CI of engraftment. Patients without advanced disease had improved DFS. These results support banking and use of CB units for RCBT. Cell dose, GVHD prophylaxis not including methotrexate, and disease status are important factors for outcomes after RCBT.

Directed sibling donor cord blood banking for children with beta-thalassemia major in Greece: usage rate and outcome of transplantation for HLA-matched units

Several cord blood banks store cord blood units from healthy siblings of patients, who are candidates for stem cell transplantation. We analyzed the quality characteristics of 50 cord blood units collected from families with beta-thalassemia major and the outcome of subsequent stem cell transplantations during a 15-year period. All cord blood units were found suitable for banking based on a minimum net volume of 40 ml. The mean volume of the units was 98.9 ml; the mean total nucleated cell count (NC) was 7.8 x 10(8) and the mean CD34+ cell count was 2.8 x 10(6). Eight out of twelve HLA matched collections were released for transplantation. All but one recipient belonged to Pesaro II-III risk classes. Three patients received a cord blood graft with >5 x 10(7) NC/kg . One of them with Pesaro class I disease engrafted, whereas the other two who failed to engraft, were re-transplanted with bone marrow from the same donor later. Cord blood grafts containing NCs <4 x 10(7)/kg combined with reduced volume bone marrow from the same donor were used in all 5 remaining cases and stable engraftment was achieved. All patients survived, 7/8 thalassemia-free. Cord blood banking from healthy siblings of children with beta-thalassemia major can result in a successful transplantation in cases in which there is HLA compatibility. However, in high-risk patients, the use of combined cord blood and bone marrow grafts seems necessary in order to ensure stable engraftment, especially when cord blood unit cell counts are low.

Hematopoietic stem cell transplantation for hemoglobinopathies: current practice and emerging trends

Despite improvements in the management of thalassemia major and sickle cell disease, treatment complications are frequent and life expectancy remains diminished for these patients. Hematopoietic stem cell transplantation (HSCT) is the only curative option currently available. Existing results for HSCT in patients with hemoglobinopathy are excellent and still improving. New conditioning regimens are being used to reduce treatment-related toxicity and new donor pools accessed to increase the number of patients who can undergo HSCT.

Cord blood stem cell transplantation for haemoglobinopathies

Despite improvements in supportive care, patients with beta-thalassaemia major or sickle cell disease (SCD) may benefit from haematopoietic stem cell transplantation at some point during their lives. Human leucocyte antigen (HLA)-matched sibling bone marrow donors are not always available and alternative sources of stem cells have been sought, including related and unrelated donor cord blood transplants (CBT). The outcome of CBT from related donors for the treatment of both thalassaemia major and SCD is now approaching that for bone marrow transplantation, with around 90% of patients surviving disease-free. The main complication is graft rejection, which may be reduced by increasing pretransplant immune suppression. Transplant-related mortality following HLA-identical matched related donor CBT is extremely low but is significant in the small series of unrelated and/or mis-matched donor CBT. The principal limitation to extending the use of CB stem cells for the cure of haemoglobinopathies is the need to better understand the mechanisms of action and optimal conditioning regimens used to secure long-term engraftment while minimizing morbidity and mortality. Further biological studies and clinical trials are needed to address this aim.

Allogeneic hematopoietic stem cell transplantation using a reduced-intensity conditioning regimen in infants: experience at a single institution in Mexico

The authors report their experience with allogeneic hematopoietic stem cell transplantation in infants at a university hospital in México. Five infants had one of each of the following diagnoses: acute lymphoblastic leukemia, osteopetrosis for which the patient underwent 2 procedures, acute disseminated multiorgan Langerhans cell histiocytosis, and two cases of hemophagocytic lymphohistiocytosis. The source of stem cells for grafting in 2 children was peripheral blood, and in 3 children was unrelated cord blood. A reduced-intensity conditioning regimen including fludarabine, cyclophosphamide, and melphalan was administrated. Three patients are disease-free transplant survivors without graft-versus-host disease after 46, 34, and 16 months.

Hematopoietic cell transplantation: a curative option for sickle cell disease

Sickle cell disease is associated with considerable morbidity and premature mortality. Hematopoietic cell transplantation offers the possibility of cure and is associated with excellent results in pediatric patients receiving stem cell transplantation from a matched sibling donor. Reduced intensity conditioning regimen have the potential to further reduce regimen related morbidity and mortality. Improved understanding of the natural history of complications such as stroke and pulmonary hypertension, effects of treatments, such as hydroxyurea and blood transfusions, as well as the impact of transplantation on organ damage are likely to influence the timing and indication of transplantation. Improvements in preparative regimen may enable the safe use of alternate source of stem cells such as unrelated matched donors and further improve the applicability and acceptability of this treatment.

Directed sibling cord blood banking for transplantation: the 10-year experience in the national blood service in England

Umbilical cord blood (UCB) is an important source of hematopoietic stem cells for transplantation. Although UCB is often collected from unrelated donors, directed umbilical cord blood (DCB) from sibling donors also provides an important source of UCB for transplantation. This report summarizes the experience in collection, testing, storage, and transplantation of DCB units by the National Blood Service for England and North Wales over 10 years. Eligibility for collection was based on an existing sibling suffering from a disease that may be treated by stem cell transplantation or a family history that could result in the birth of a sibling with a disease that could be treated by stem cell transplantation. Collections were made on the provision that the sibling's clinician was willing to financially support the collection and to take responsibility for medical review of the mother and potential recipient. Given the high investment in UCB banking and the introduction of new regulations and mandatory licensing under the European Union Tissues and Cells Directive and those proposed in the U.S., this report details the procedures that we have used for DCB donations, the outcome data where donations have been used for transplantation, and it provides some timely recommendations for best practices. Disclosure of potential conflicts of interest is found at the end of this article.

Long-term results of related myeloablative stem-cell transplantation to cure sickle cell disease

Allogeneic hematopoietic stem-cell transplantation (HSCT) is the only curative treatment for sickle cell disease (SCD); nevertheless, its use has been limited by the risk of transplantation-related mortality (TRM). Between November 1988 and December 2004, 87 consecutive patients with severe SCD ranging from 2 to 22 years of age received transplants in France. Cerebral vasculopathy was the principal indication for transplantation (55 patients). All the patients received grafts from a sibling donor after a myeloablative conditioning regimen (CR). The only change in the CR during the study period was the introduction of antithymocyte globulin (ATG) in March 1992. The rejection rate was 22.6% before the use of ATG but 3% thereafter. With a median follow-up of 6 years (range, 2.0 to 17.9 years), the overall and event-free survival (EFS) rates were 93.1% and 86.1%, respectively. Graft versus host disease (GVHD) was the main cause of TRM. Importantly, cord blood transplant recipients did not develop GVHD. No new ischemic lesions were detected after engraftment, and cerebral velocities were significantly reduced. The outcome improved significantly with time: the EFS rate among the 44 patients receiving transplants after January 2000 was 95.3%. These results indicate that HLA-identical sibling HSCT after myeloablative conditioning with ATG should be considered as a standard of care for SCD children who are at high risk for stroke.

Hematopoietic cell transplantation for sickle cell disease: state of the art

Sickle cell disease is associated with considerable morbidity and premature mortality. Hematopoietic cell transplantation offers the possibility of cure and is associated with excellent results in pediatric patients receiving stem cell transplantation from a matched sibling donor. A reduced-intensity conditioning regimen has the potential to further reduce regimen-related morbidity and mortality. Improved understanding of the natural history of complications, such as stroke and pulmonary hypertension, effects of treatments such as hydroxyurea and blood transfusions, as well as the impact of transplantation on organ damage, are likely to influence the timing and indication of transplantation. Improvements in preparative regimens may enable the safe use of an alternative source of stem cells, such as unrelated matched donors, and further improve the applicability and acceptability of this treatment.

Will stem cells in cord blood, amniotic fluid, bone marrow and peripheral blood soon be unnecessary in transplantation?

There are now various sources of stem cells. Those derived from blastocysts, named embryo stem (ES) cells, have attracted most attention and are highly multipotent. Human cord blood became widely used as a source of stem cells with differing properties to ES cells and their therapeutic application has grown steadily as they are stored in increasing numbers of stem cell banks. Other sources of human stem cells are derived from peripheral blood and amniotic fluid. They may arise from a common origin in epiblast. This review stresses the use of cord blood stem cells, but describes new approaches which may supersede the use of most stem cells. The advantages and disadvantages of these various classes are described in relation to potential methods involving gene conversion to change somatic cells to ES cells.

Cord blood banking for potential future transplantation

In recent years, umbilical cord blood, which contains a rich source of hematopoietic stem and progenitor cells, has been used successfully as an alternative allogeneic donor source to treat a variety of pediatric genetic, hematologic, immunologic, and oncologic disorders. Because there is diminished risk of graft-versus-host disease after transplantation of cord stem cells using matched related donors, the use of less-than-completely matched HLA cord blood stem cells may incur less risk of graft-versus-host disease than mismatched cells from either a related or unrelated "walking" donor, although this remains to be proven. Gene-therapy research involving modification of autologous cord blood stem cells for the treatment of childhood genetic disorders, although experimental at the present time, may prove to be of value. These scientific advances have resulted in the establishment of not-for-profit and for-profit cord blood-banking programs for allogeneic and autologous cord blood transplantation. Many issues confront institutions that wish to establish or participate in such programs. Parents often seek information from their physicians about this new biotechnology option. This document is intended to provide information to guide physicians in responding to parents' questions about cord blood donation and banking and the types and quality of cord blood banks. Provided also are recommendations about appropriate ethical and operational standards, including informed consent policies, financial disclosures, and conflict-of-interest policies for physicians, institutions, and organizations that operate or have a relationship with cord blood-banking programs.

Sibling Donor Cord Blood Transplantation for Thalassemia Major: Experience of the Sibling Donor Cord Blood Program

The Sibling Donor Cord Blood (SDCB) Program was initiated in 1998 as a resource to collect, characterize, and release cord blood units (CBUs) from families affected by malignant and nonmalignant disorders for transplantation. Families in the United States were recruited by telephone after referrals by community and academic physicians. Collection kits were mailed to prospective participants and family members were instructed about CBU procurement from community hospitals and shipping to a central laboratory. Data about the infant's delivery and CBU harvest, CBU processing, prethaw characteristics, sterility, and human leukocyte antigen (HLA) typing were collected. Standard outcome data were collected after CBU release for transplantation. Descriptive analyses of CBU collections, processing, release, and transplantation outcomes were performed. Currently, 1617 CBU collections have been processed from families with thalassemia (6%), sickle cell disease (28%), malignant disorders (49%), and other rare hematological disorders (17%). Thirty-two of 96 donor-recipient pairs with thalassemia major were HLA identical and 14 have received cord blood transplantation, either alone or in combination with bone marrow or peripheral blood progenitor cells (N = 4) from the same donor. Eleven of the 14 survive free of thalassemia after transplantation. These preliminary results confirm the feasibility and utility of remote-site sibling donor cord blood collection and subsequent transplantation for hematological disorders, with a very high rate of usage from a cord blood bank dedicated to performing these unique collections. It was concluded that cord blood transplantation from sibling donors represents a suitable alternative to bone marrow transplantation.

Umbilical cord blood banking: implications for perinatal care providers

OBJECTIVE

To evaluate the risks and benefits of umbilical cord blood banking for future stem cell transplantation and to provide guidelines for Canadian perinatal care providers regarding the counselling, procedural, and ethical implications of this potential therapeutic option.

OPTIONS

Selective or routine collection and storage of umbilical cord blood for future autologous (self) or allogenic (related or unrelated) transplantation of hematopoietic stem cells to treat malignant and nonmalignant disorders in children and adults.

OUTCOMES

Maternal and perinatal morbidity, indications for umbilical cord blood transplantation, short- and long-term risks and benefits of umbilical cord blood transplantation, burden of umbilical cord blood collection on perinatal care providers, parental satisfaction, and health care costs.

EVIDENCE

MEDLINE and PubMed searches were conducted from January 1970 to October 2003 for English-language articles related to umbilical cord blood collection, banking, and transplantation; the Cochrane library was searched; and committee opinions of the Royal College of Obstetricians and Gynaecologists, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists were obtained.

VALUES

The evidence collected was reviewed and evaluated by the Maternal/Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC), and recommendations were made using the evaluation of evidence guidelines developed by the Canadian Task Force on the Periodic Health Exam.

BENEFITS, HARMS, AND COSTS

Umbilical cord blood is a readily available source of hematopoietic stem cells used with increasing frequency as an alternative to bone marrow or peripheral stem cells for transplantation in the treatment of malignant and nonmalignant conditions in children and adults. Umbilical cord blood transplantation provides a rich source of hematopoietic stem cells with several advantages, including prompt availability, decreased risk of transmissible viral infections and graft-versus-host disease (GVHD) in both human leukocyte antigen(HLA)-matched and HLA-mismatched stem cell transplants, and ease of collection with little risk to the mother or newborn. Potential limitations of umbilical cord blood transplantation include insufficient stem cell dose to reliably treat larger children and adult recipients, slower rate of engraftment, and the potential for transfer of genetically abnormal hematopoietic stem cells. The optimum method of umbilical cord blood transplantation is not yet clear, though available evidence would favour collection before delivery of the placenta. There are many unresolved ethical issues related to umbilical cord blood banking, particularly related to the rapid growth of private, for-profit, cord blood banks offering long-term storage for potential future autologous or related allogenic transplantation. The financial burden to the health care system for public cord blood banking and to families for private cord blood collection and storage is considerable.

RECOMMENDATIONS

1. Perinatal care providers should be informed about the promising clinical potential of hematopoietic stem cells in umbilical cord blood and about current indications for its collection, storage, and use, based on sound scientific evidence (II-3B). 2. Umbilical cord blood collection should be considered for a sibling or parent in need of stem cell transplantation when an HLA-identical bone marrow cell or peripheral stem cell donation from a sibling or parent is unavailable for transplantation (II-2B). 3. Umbilical cord blood should be considered when allogeneic transplantation is the treatment of choice for a child who does not have an HLA-identical sibling or a well-matched, unrelated adult bone marrow donor (II-2B). 4. Umbilical cord blood should be considered for allogeneic transplantation in adolescents and young adults with hematologic malignancies who have no suitable bone marrow donor and who require urgent transplantation (II-3B). 5. Altruistic donation of cord blood for public banking and subsequent allogeneic transplantation should be encouraged when umbilical cord blood banking is being considered by childbearing women, prenatal care providers, and(or) obstetric facilities (II-2B). 6. Collection and long-term storage of umbilical cord blood for autologous donation is not recommended because of the limited indications and lack of scientific evidence to support the practice (III-D). 7. Birth unit staff should receive training in standardized cord blood unit volume and reduce the rejection rate owing to labelling problems, bacterial contamination, and clotting (II-3B). 8. The safe management of obstetric delivery should never be compromised to facilitate cord blood collection. Manoeuvres to optimize cord blood unit volume, such as early clamping of the umbilical cord, may be employed at the discretion of the perinatal care team, provided the safety of the mother and newborn remains the major priority (III-A). 9. Collection of cord blood should be performed after the delivery of the infant but before delivery of the placenta, using a closed collection system and procedures that minimize risk of bacterial and maternal fluid contamination (see Figures 1a-1c) (I-B). 10. Public and private cord blood banks should strictly adhere to standardized policies and procedures for transportation, safety testing, HLA typing, cryopreservation, and long-term storage of umbilical cord blood units to prevent harm to the recipient, to eliminate the risk of transmitting communicable diseases, and thus to maximize the effectiveness of umbilical cord blood stem cell transplantation (II-1A). 11. Canada should establish registration, regulation, and accreditation of cord blood collection centres and banks (III-B). 12. Recruitment of cord blood donors should be fair and noncoercive. Criteria to ensure an equitable recruitment process include the following: (a) adequate supply to meet population transplantation needs; (b) fair distribution of the burdens and benefits of cord blood collection; (c) optimal timing of recruitment; (d) appropriately trained personnel; and (e) accurate recruitment message (III-A). 13. Informed consent for umbilical cord blood collection and banking should be obtained during prenatal care, before the onset of labour, with confirmation of consent after delivery (III-B). 14. Linkage of cord blood units and donors is recommended for public safety. Policies regarding the disclosure of abnormal test results to donor parents should be developed. Donor privacy and confidentiality of test results must be respected (III-C). 15. Commercial cord blood banks should be carefully regulated to ensure that promotion and pricing practices are fair, financial relationships are transparent, banked cord blood is stored and used according to approved standards, and parents and care providers understand the differences between autologous versus allogenic donations and private versus public banks (III-B). 16. Policies and procedures need to be developed by perinatal facilities and national health authorities to respond to prenatal requests for public and private cord blood banking (III-C).

Characterization of banked umbilical cord blood hematopoietic progenitor cells and lymphocyte subsets and correlation with ethnicity, birth weight, sex, and type of delivery: a Cord Blood Transplantation (COBLT) Study report

BACKGROUND

The Cord Blood Transplantation (COBLT) Study banking program was initiated in 1996. The study goals were to develop standard operating procedures for cord blood (CB) donor recruitment and banking and to build an ethnically diverse unrelated CB bank to support a transplantation protocol.

STUDY DESIGN AND METHODS

The hematopoietic progenitor cell (HPC) and lymphocyte subset (LS) content of approximately 8000 CB units were characterized, and these results were correlated with donor ethnicity, birth weight, gestational age, sex, and type of delivery.

RESULTS

There was a significant correlation of CD34+ cell count with colony-forming unit (CFU)-granulocyte-macrophage (r=0.68, p<0.001), CFU-granulocyte-erythroid-macrophage-megakaryocyte (r=0.52, p<0.001), burst-forming unit-erythroid (BFU-E; r=0.61, p<0.001), and total CFUs (r=0.67, p<0.001). Nucleated red blood cell count was significantly correlated with total CD34+ (r=0.56, p<0.001), total CFU (r=0.50, p<0.001), BFU-E (r=0.48, p<0.001), and counts of CD34+ subsets (p<0.001). Caucasian ethnicity was significantly correlated with higher CD3+/CD4+, CD19+, and CD16+/CD56+ LSs. Furthermore, CD34+/CD38- and CD34+/CD61+ CB units (HPC-C) were significantly lower in African American and Asian persons compared to Caucasian and Hispanic persons. Male sex was associated with significantly fewer CD3+/CD4+, CD19+, and CD16+/CD56+ but increased CD3+/CD8+ LSs (p<0.001). Finally, cesarean section was associated with significantly higher total CFU and CD16+/CD56+ but lower CD3+/CD4+, CD3+/CD8+, and CD19+ LSs.

CONCLUSION

These results provide a standard and range for uniformly processed HPC-C progenitor cells and LSs. CB progenitor cells and/or LSs may in the future predict for rapidity of engraftment, incidence of graft-versus-host disease, speed and quality of immunore- constitution, graft-versus-tumor effects, and/or success of gene transfection after CB transplantation.

Umbilical cord blood transplantation

PURPOSE OF REVIEW

Familiar and unrelated umbilical cord blood is an appealing alternative source of hematopoietic stem cells patients undergoing transplantation for a wide variety of diseases. In the unrelated donor transplant setting, shorter time to transplant, which is particularly relevant to patients requiring urgent transplantation, and tolerance of 1-2 human leukocyte antigen mismatch, which increases the chance of finding a suitable donor, are evident advantages over bone marrow transplantation. The speed of engraftment is slower after cord blood transplantation but it is counterbalanced by a lower incidence of severe graft-versus-host disease. Cell dose and human leukocyte antigen are major factors influencing outcome after umbilical cord blood transplantation.

RECENT FINDINGS

Unrelated donor cord blood transplantation is considered an acceptable option to bone marrow for pediatric transplantation, and recent data in adults point the same way.

SUMMARY

This review describes the recent clinical results of cord blood transplantation and discusses developing research strategies aimed at optimizing this kind of transplantation.

HLA-matched embryos selected for siblings requiring haematopoietic stem cell transplantation: a psychological perspective

Allogeneic haematopoietic stem cell transplantation (HSCT) is a treatment for a number of acquired and congenital diseases. An important factor in the outcome of the treatment is the degree of human leukocyte antigen (HLA) compatibility between patient and donor. HLA identical siblings therefore provide the best chance for the recipient. Preimplantation genetic diagnosis (PGD) can be used to select HLA identical embryos if there is no HLA compatible sibling in the family. The Centre for Reproductive Medicine considered it morally justified to give medical assistance to couples in need of an HLA matched sibling. Two considerations played an important role in this respect: (i) the use as a donor should not be the only parents' motive for having the child and (ii) IVF and HLA typing on the embryos would be less of a burden for the parents than other alternatives. Since the first request in 2000, 12 couples have been referred for psychological counselling. The motivation of four couples will be discussed in depth. The validity of the arguments will be checked against the experience of the actual cases. The consequences of the treatment on the welfare of the future donor child will be discussed.

Hematopoietic stem cell transplantation using umbilical cord blood progenitors: review of current clinical results

SUMMARY

Umbilical cord blood (CB) has been rapidly established as an alternative source of stem cells to bone marrow for allogeneic-related and unrelated hematopoietic transplantation. To date, almost 70 000 CB units are available for transplantation and more than 2000 CB transplants (CBT) have been performed, mostly in children, for the treatment of a variety of malignant and nonmalignant conditions. Considerable experience has been rapidly accumulated in this field and many aspects of CBT have been elucidated, while other questions remain unresolved. A concise review of the clinical results achieved after related and unrelated CBT is presented and discussed.

Sickle cell anemia and hematopoietic cell transplantation: When is a pound of cure worth more than an ounce of prevention?

Hematopoietic cell transplantation (HCT) is curative therapy for sickle cell anemia (SCA). However, its widespread use is constrained by donor availability and by concerns about its short-term and long-term toxicities. Current efforts to identify suitable candidates for HCT to decrease the toxicity of HCT, and to broaden its availability are discussed.

Cord blood units collected at a remote site: a collaborative endeavor to collect umbilical cord blood through the Hawaii Cord Blood Bank and store the units at the Puget Sound Blood Center

BACKGROUND

Umbilical cord blood is a useful source of hematopoietic stem cells, especially because compared to equivalent HLA-matched stem cells from unrelated adult donors. A network of community collection sites targeted at particular ethnic groups and serviced by a central processing and storage facility can maximize the genetic diversity of banked cord blood units (CBUs) in a cost-effective fashion.

STUDY DESIGN AND METHODS

The present study compared CBUs collected near the Puget Sound Blood Center in Seattle, WA, with those collected in Honolulu, HI, and processed in Seattle. Evaluated variables include collection volume, total nucleated cell count, cellular viability, CD34+ cell count, clonogenic activity, and donor race for a total of 1646 CBUs received from July 1998 through November 2002.

RESULTS

CBUs from the two sites did not differ with regard to volume or total nucleated cells. Those from Hawaii had significantly longer transit times (p < 0.001) and lower whole cord blood cell viability. However, the numbers of CFU and viable CD34+ cells were not affected by remote collection. CBUs screened from Seattle were largely from Caucasian donors, whereas over 85 percent of those from Honolulu were from donors of Asian-Pacific Islander or mixed ethnicity.

CONCLUSION

These studies demonstrate the feasibility of long-distance umbilical cord blood banking. Arrangements such as those described here could be used to help target cost-effective collection from minority populations and increase the HLA and ethnic diversity for CBUs.