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Several studies have reported an impact of adult hematopoietic stem cell donor cytomegalovirus (CMV) serostatus on allogeneic hematopoietic cell transplantation outcomes. Limited data, however, are available on the impact of cord blood unit (CBU) CMV serostatus on allogeneic umbilical cord blood transplantation (UCBT) outcomes. We analyzed, retrospectively, the impact of CBU CMV serostatus on relapse incidence (RI) and 2-year nonrelapse mortality (NRM) of single-unit CBU transplantation for acute leukemia. Data from 1177 de novo acute leukemia pediatric and adult patients transplanted within European Group for Blood and Marrow Transplantation centers between 2000 and 2012 were analyzed. CBUs were provided by the European Cord Blood Banks. The median follow-up time for live patients was 59.9 months. The recipients of CMV-seropositive and -seronegative CBUs showed a comparable RI (33% versus 35%, respectively, P = .6) and 2-year cumulative incidence of NRM (31% versus 32%, respectively, P = .5). We conclude that CBU CMV serostatus did not influence RI and NRM in de novo acute leukemia patients after allo-UCBT and should not be included as a criteria for cord blood choice.

The aim of this article is to review a number of variables that may affect the cryopreservation of minimally manipulated products containing allogeneic or autologous hemopoietic progenitor cells (HPC) used for transplantation, with particular reference to processing, type and addition of cryoprotectant, cell concentration, volume, freezing procedure, cooling rate, storage, thawing, and quality management. After defining final product's requirements in compliance with norms, laws and regulations, it is crucial to define the critical control points of the process. New approaches of processing were developed in the last few years such as automatic devices for volume reduction and high cell concentration in the frozen product. DMSO at 10% final concentration is still the most used cryoprotectant for HPC cryopreservation. Although controlled rate freezing is the recommended method for HPC cryopreservation, alternative methods may be used. Last generation vapor storage vessels ensure temperature stability better than older tanks. Their use may reduce risks of cross-contamination. Finally we review advantages and disadvantages of thawing procedures that may be carried out in the laboratory or at the patient's bedside.

BACKGROUND Techniques for banking cord blood units (CBUs) as source for hematopoietic stem cell transplantation have been developed over the past 20 years, aimed to improve laboratory efficiency without altering the biologic properties of the graft. A large-scale, registry-based assessment of the impact of the banking variables on the clinical outcome is currently missing. STUDY DESIGN AND METHODS A total of 677 single cord blood transplants (CBTs) carried out for acute leukemia in complete remission in centers affiliated with the European Society for Blood and Marrow Transplantation were selected. An extensive set of data concerning CBU banking were collected and correlations with clinical outcome were assessed. Clinical endpoints were transplant-related mortality, engraftment, and graft-versus-host disease (GVHD). RESULTS The median time between collection and CBT was 4.1 years (range, 0.2-16.3 years). Volume reduction (VR) of CBUs before freezing was performed in 59.2% of available reports; in half of these the frozen volume was less than 30 mL. Cumulative incidences of neutrophil engraftment on Day 60, 100-day acute GVHD (II-IV), and 4-year chronic GVHD were 87, 29, and 21 ± 2%. The cumulative incidence of nonrelapse mortality (NRM) at 100 days and 4-year NRM were, respectively, 16 ± 2 and 30 ± 2%. Neither the variables related to banking procedures nor the interval between collection and CBT influenced the clinical outcome. CONCLUSION These findings indicate a satisfactory validation of the techniques associated with CBU VR across the banks. Cell viability assessment varied among the banks, suggesting that efforts to improve the standardization of CBU quality controls are needed.

Transplantation-related mortality (TRM) is high after HLA-mismatched umbilical cord blood (UCB) transplantation (UCBT). In utero, exposure to noninherited maternal antigen (NIMA) is recognized by the fetus, which induces T regulator cells to that haplotype. It is plausible that UCBTs in which recipients are matched to donor NIMAs may alleviate some of the excess mortality associated with this treatment. To explore this concept, we used marginal matched-pair Cox regression analysis to compare outcomes in 48 NIMA-matched UCBTs (ie, the NIMA of the donor UCB unit matched to the patient) and in 116 non–NIMA-matched UCBTs. All patients had a hematologic malignancy and received a single UCB unit. Cases and controls were matched on age, disease, disease status, transplantation-conditioning regimen, HLA match, and infused cell dose. TRM was lower after NIMA-matched UCBTs compared with NIMA-mismatched UCBTs (relative risk, 0.48; P = .05; 18% versus 32% at 5 years posttransplantation). Consequently, overall survival was higher after NIMA-matched UCBT. The 5-year probability of overall survival was 55% after NIMA-matched UCBTs versus 38% after NIMA-mismatched UCBTs (P = .04). When faced with the choice of multiple HLA-mismatched UCB units containing adequate cell doses, selecting an NIMA-matched UCB unit may improve survival after mismatched UCBT.

On 31 May 2010, 14 072 567 bone marrow/apheresis donors registered in 44 countries and 426 501 cord blood units banked in 26 countries for public use were available to treat candidates to haemopoietic stem cell transplant lacking a family related compatible donor. Despite these impressive numbers, additional efforts are required to ensure that all patients, including those from ethnic minorities, can promptly find a suitable donor. Governments, clinicians, scientists, patients and stakeholders should share the responsibility to develop haemopoietic stem cell donation and cord blood banking models able to fully match all patient needs. In this regard, current scientific evidence and prevalent opinions among expert clinicians support solidaristic cord blood donation for public use against the alternative option of commercial autologous cord blood storage.

BACKGROUND: Most hematopoietic progenitor cell (HPC) products are infused or processed shortly after collection, but in some cases this may be delayed for up to 48 hours. A number of variables such as temperature and cell concentration are of critical importance for the integrity of HPCs during this time. STUDY DESIGN AND METHODS: We evaluated critical variables using cord blood HPC units that were divided equally and stored at 4°C versus room temperature (RT) for up to 96 hours. Total nucleated cell (TNC) and mononuclear cell (MNC) counts, viable CD34+ cell counts, and CD45+ cell viability as well as colony-forming unit–granulocyte-macrophage (CFU-GM) present over time at each temperature were determined. RESULTS: Overall, the data indicate that with the exception of viable CD34+ cells, there was a significant decrease in each variable measured for 72 to 96 hours and, with the exception of viable CD34+ cells and CFU-GM, the reductions were significantly greater in RT units than 4°C units. There was an increase in viable CD34+ count for units where TNC count was greater than 8.5 × 109/L, compared with units where TNC count was less than 8.5 × 109/L, that was different for each storage temperature. CONCLUSIONS: Cord blood HPC collections maintained at 4°C retained higher TNC counts, MNC counts, and CD45+ cell viability over a 72- to 96-hour storage period.

BACKGROUND: Volume reduction of cord blood units decreases the cost of cryogenic storage. This study reports the analysis of a 10-year quality control program of a semiautomated cord blood volume reduction procedure. STUDY DESIGN AND METHODS: Cord blood was collected in a plastic bag containing 29 mL citrate-phosphate-dextrose, centrifuged at 2124 × g for 12 minutes, and processed with a semiautomated device. The procedure was aimed at removing most red blood cells and plasma and concentrating hematopoietic progenitors in the buffy coat (BC), thus reducing the unit volume and saving cryogenic space. Finally, the BC was cryopreserved with an equal volume of 20 percent dimethyl sulfoxide. Total nucleated cells (TNCs) were counted before and after processing in the 4311 units banked from 1998 through 2007, whereas CD34+ cells and colony-forming units–granulocyte-macrophage (CFU-GM) were counted in 420 random units from 2001 through 2007. RESULTS: Mean postvolume reduction annual recoveries of TNCs, CD34+ cells, and CFU-GM ranged from 82.8 ± 12.3 (standard deviation) to 91.4 ± 6.4 percent, from 87.8 ± 14.1 to 95.2 ± 23.8 percent, and from 101.5 ± 51.4 to 117.8 ± 59.5 percent, respectively. Very strong correlations were found (r > 0.87) between postprocessing versus preprocessing TNCs, CD34+ cells, and CFU-GM; a moderate correlation between initial TNC count and unit's volume (r = 0.51); and no correlation between TNC percentage of recovery in the BC and initial unit's volume. The latter data indicate that most TNCs concentrate in the BC. CONCLUSIONS: The semiautomated procedure of cord blood unit volume reduction used in this study provides high and stable cellular recoveries during several years of routine cord blood banking.

Donor killer cell immunoglobulin-like receptor (KIR)-ligand incompatibility is associated with decreased relapse incidence (RI) and improved leukemia-free survival (LFS) after haploidentical and HLA-mismatched unrelated hematopoietic stem cell transplantation. We assessed outcomes of 218 patients with acute myeloid leukemia (AML n=94) or acute lymphoblastic leukemia (n=124) in complete remission (CR) who had received a single-unit unrelated cord blood transplant (UCBT) from a KIR-ligand-compatible or -incompatible donor. Grafts were HLA-A, -B or -DRB1 matched (n=21) or mismatched (n=197). Patients and donors were categorized according to their degree of KIR-ligand compatibility in the graft-versus-host direction by determining whether or not they expressed HLA-C group 1 or 2, HLA-Bw4 or HLA-A3/-A11. Both HLA-C/-B KIR-ligand- and HLA-A-A3/-A11 KIR-ligand-incompatible UCBT showed a trend to improved LFS (P=0.09 and P=0.13, respectively). Sixty-nine donor–patient pairs were HLA-A, -B or -C KIR-ligand incompatible and 149 compatible. KIR-ligand-incompatible UCBT showed improved LFS (hazards ratio=2.05, P=0.0016) and overall survival (OS) (hazards ratio=2.0, P=0.004) and decreased RI (hazards ratio=0.53, P=0.05). These results were more evident for AML transplant recipients (2-year LFS and RI with or without KIR-ligand incompatibility 73 versus 38% (P=0.012), and 5 versus 36% (P=0.005), respectively). UCBT for acute leukemia in CR from KIR-ligand-incompatible donors is associated with decreased RI and improved LFS and OS. Supplementary information The online version of this article (doi:10.1038/leu.2008.365) contains supplementary material, which is available to authorized users.

Since the first successful haematopoietic stem cell transplantation (HSCT) using cord blood from a sibling in 1988 and the establishment of the first public umbilical cord blood bank in New York Blood Center in 1992, umbilical cord blood banks have been instituted in many countries. Funding was received from regular blood banks, health councils, charity funds or commercial investments. The international medical society is indebted to the New York Blood Center for publishing their procedures and EuroCord for fighting a patent on cord blood processing. Although it is unknown how many cord blood samples are currently banked and have been transplanted worldwide, the figures of the international registration of World Marrow Donor Association (WHDA) show an increase of cord blood use, in addition to other sources of unrelated HSCT (Fig. 1). Cord blood for HSCT is, in addition to national/regional use, exchanged worldwide. Donor counselling, human leucocyte antigen (HLA)-typing, tests for transmittable diseases and product quality control requirements to comply with (inter)national [AABB, Paul-Ehrlich-Institut, NetCord/ Foundation for the Accreditation of Cellular Therapy (FACT)] standards are expensive, making storage of cord blood for unrelated allogeneic haematopoietic transplantation currently a loss-making activity, not particularly attractive for private enterprise. In the last years, hopes have been fueled that other stem cells in cord blood may be used for future repair of metabolic or degenerative diseases. Autologous or personal cord blood banking appeals to individual initiatives and private funding; money is desperately needed by allogeneic cord blood banks, and it would be much better if it could

D uring the past 10 years, human biological material—body fluids, cells, tissues, intracellular substances or DNA—and the related data have become an important resource for academic medical research, and for the industrial development of diagnostics and therapeutics (Godard et al, 2003). The increasing creation and use of biobanks that store both the material and the related data bears witness to their scientific value, but there is still no consensus— either internationally, or at the European or national levels—about the regulations that should govern biobanks in ethical or legal terms (Cambon-Thomsen et al, 2007; Kaye, 2005). In particular, consent models designed to appropriately regulate biobankbased research are characterized by a maze of laws, policies and ethical recommendations that range from strict (specific informed consent) to basically unrestricted use (broad consent; Boggio et al, 2007).

Biobanking is an emerging specialty in which competencies in cellular and molecular biology, medicine, genetics, cryobiology, bioengineering, information technology and ethics merge into a service

Techniques for banking cord blood units (CBUs) as source for hematopoietic stem cell transplantation have been developed over the past 20 years, aimed to improve laboratory efficiency without altering the biologic properties of the graft. A large-scale, registry-based assessment of the impact of the banking variables on the clinical outcome is currently missing.A total of 677 single cord blood transplants (CBTs) carried out for acute leukemia in complete remission in centers affiliated with the European Society for Blood and Marrow Transplantation were selected. An extensive set of data concerning CBU banking were collected and correlations with clinical outcome were assessed. Clinical endpoints were transplant-related mortality, engraftment, and graft-versus-host disease (GVHD).The median time between collection and CBT was 4.1 years (range, 0.2-16.3 years). Volume reduction (VR) of CBUs before freezing was performed in 59.2% of available reports; in half of these the frozen volume was less than 30 mL. Cumulative incidences of neutrophil engraftment on Day 60, 100-day acute GVHD (II-IV), and 4-year chronic GVHD were 87, 29, and 21 ± 2%. The cumulative incidence of nonrelapse mortality (NRM) at 100 days and 4-year NRM were, respectively, 16 ± 2 and 30 ± 2%. Neither the variables related to banking procedures nor the interval between collection and CBT influenced the clinical outcome.These findings indicate a satisfactory validation of the techniques associated with CBU VR across the banks. Cell viability assessment varied among the banks, suggesting that efforts to improve the standardization of CBU quality controls are needed.

We developed a laboratory model of a unit of hemopoietic progenitor cells (mock-HPC unit) suitable for the validation of HPC cryopreservation procedures. The project was prompted by the practical and ethical difficulty of using real HPC units collected from healthy donors and patients for validation purposes. Mock-HPC units of different volumes ranging from about 120 to about 540mL were prepared by pooling a routinely discarded by product of our procedure to prepare platelet concentrates from buffy-coats, a standard procedure in most blood centers in Europe. Five ABO/Rh identical buffy coats each of 50mL volume, obtained from 450mL whole blood units by hard spin, were pooled with 300mL of a commercial platelet additive solution. After soft spin, the supernatant platelet concentrate pool was removed. The bottom fraction of this procedure, which contains RBC, WBC, HPC and platelets, constitutes a mock-HPC unit of about 120mL volume. Several bottom fractions may be pooled to obtain a mock-HPC unit of the desired volume. We used 20 mock-HPC units to validate an automatic procedure of HPC cryopreservation with a controlled rate freezer. In particular, we documented the standardization of critical points of the cooling profile, such as the correspondence of the crystallization phase with the theoretical freezing temperature of the product, the temperature peak rise above the theoretical freezing temperature of -5.7 degrees C and the automatic achievement in the chamber of a constant minimum temperature during supercooling (about -37 degrees C) with mean chamber loading volumes ranging from 231.8 to 1027.2mL.

Umbilical cord blood banking raises several issues in legal and ethical terms, from the determination of ownership of biological material to the respect of the right of self determination–namely, the right to give an informed consent–of the individuals involved (newborn, parents), to the commercialization of cord blood banks and to the related autologous use of donated placental blood. Recently these issues have been considered by the European Group on Ethics in Science and New Technologies to the European Commission (EGE) in the Opinion on “Ethical aspects of umbilical cord blood banking” (Opinion No. 19 of 16 March 2004). They have also been part of a wide and intense international debate. This paper aims at examining these themes–ownership, informed consent, and commercialization of cord blood banking–with particular regard to the EGE Opinion on the ethical aspects of umbilical cord blood banking. Such opinion focuses on private cord blood banks for autologous use and underlines the legitimacy conditio...

BACKGROUND: Understanding the variability in results obtained by multiple laboratories is important because cord blood units are distributed worldwide for transplantation. STUDY DESIGN AND METHODS: Four exercises were conducted by multiple laboratories to assess assay variability on nucleated cell (NC), mononuclear cell (MNC) by hematology analyzers [HAs], and CD34+ cell (flow cytometry) measurements. Exercise 1 was an intralaboratory exercise in which the reproducibility of cell measurements was determined. Exercises 2 and 3 involved the shipment of identical processed cord blood samples. In Exercise 2, laboratory-specific methods were utilized. In Exercise 3, two commercial CD34+ cell methods (Stem-Kit and TruCOUNT) were used. In Exercise 4, CD34+ cell levels were determined on repetitive regating of identical list-mode files. RESULTS: Intralaboratory reproducibility was highest for NC measurements and lowest for CD34+ cell measurements. In Exercise 2, all laboratories except one utilized HA with an impedance technology and determined comparable results for NC and MNC levels, whereas the other laboratory utilized a HA with an optical counting method. Substantial variation was observed on measuring CD34+ cells with ranges of 32 to 141, 32 to 66, and 25 to 116 CD34+ cells per µL for the three identical samples. In Exercise 3, on the use of one specific commercial assay, the ranges of CD34+ levels were 214 to 411 and 62 to 178 cells per µL for the two identical samples. Nearly all participating laboratories determined comparable CD34+ levels on the use of identical list-mode files. CONCLUSION: These studies indicate that substantial variability in CD34+ cell levels were determined with flow cytometry. The variability in NC and MNC levels was minimal with HA methodology.

In spite of abundant literature on cryobiology, relatively limited published information is available on specific features of the facilities where biological materials are stored. In this article the repository facility of a large cord blood bank is described. The 122 sq m biostorage area, which is part of the 226 sq m Milano Cord Blood Bank, is located in the basement of a hospital blood transfusion service. The repository area was designed to contain 35 liquid nitrogen (LN) tanks equipped with an automated refilling system. It was constructed according to Italian and French norms and guidelines. The current setting includes the following elements: an outdoor 6000 L reservoir connected to the area through a LN vacuum line, 30 LN tanks, a ventilation system interfaced to six oxygen sensors and a management system based on a programmable logic controller (PLC) linked to commercial proprietary software for continuous and real time monitoring of LN tanks and of the safety parameters of the repository area. T...

on behalf of Eurocord, Cord Blood Committee EBMT and Netcord; International audience; Umbilical cord blood transplant recipients are exposed to an increased risk of graft failure, a complication leading to a higher rate of transplant-related mortality. The decision and timing to offer a second transplant after graft failure is challenging. With the aim of addressing this issue, we analyzed engraftment kinetics and outcomes of 1268 patients (73% children) with acute leukemia (64% acute lymphoblastic leukemia, 36% acute myeloid leukemia) in remission who underwent single-unit umbilical cord blood transplantation after a myeloablative conditioning regimen. The median follow-up was 31 months. The overall survival rate at 3 years was 47%; the 100-day cumulative incidence of transplant-related mortality was 16%. Longer time to engraftment was associated with increased transplant-related mortality and shorter overall survival. The cumulative incidence of neutrophil engraftment at day 60 was 86%, while the median time to achieve engraftment was 24 days. Probability density analysis showed that the likelihood of engraftment after umbilical cord blood transplantation increased after day 10, peaked on day 21 and slowly decreased to 21% by day 31. Beyond day 31, the probability of engraftment dropped rapidly, and the residual probability of engrafting after day 42 was 5%. Graft failure was reported in 166 patients, and 66 of them received a second graft (allogeneic, n=45). Rescue actions, such as the search for another graft, should be considered starting after day 21. A diagnosis of graft failure can be established in patients who have not achieved neutrophil recovery by day 42. Moreover, subsequent transplants should not be postponed after day 42.

BACKGROUND: A routine program of evaluating mothers and infants 6 months after umbilical cord blood donation was started at the Milano Cord Blood Bank (MCBB) in 1996. This study evaluated the main outcomes of this program. STUDY DESIGN AND METHODS: All mothers donating cord blood at this bank from February 1996 through May 1999 were invited to visit the bank or the collection suite 6 months after delivery to report on the health condition of their babies and to provide a fresh blood sample for repeat basal serologic tests (HBsAg, anti-HCV, anti-HIV-1/2, and syphilis). A bank volunteer contacted the mothers by telephone to schedule their visits just before the expiration of the 6-month period. Before collection of the new sample, a trained operator interviewed the mothers to review the mother's medical history information collected at donation and to obtain the baby's postnatal medical history. RESULTS: Of the 2450 mothers enrolled in the study, 2315 (94.5%) attended the bank in agreement with the program, 4 promised to attend, 95 could not be traced, 26 declined the invitation, and 10 were unable to attend. Of the 135 mothers who could not be traced, 29 (21.4%) belonged to non-European ethnic groups. The average time spent with each mother was approximately 20 minutes. In serologic testing, one indeterminate anti-HCV seroconversion (c22) was detected. Collection of the baby's postnatal history reported one case of congenital urinary malformation not known at delivery, one of protein C deficiency, one of phenylketonuria, one of mucoviscidosis, and one of 10q- chromosomal abnormality. The cord blood components from all these births were discarded. CONCLUSION: These data support the feasibility of a routine 6-month program of evaluating mothers and babies giving cord blood at a cord blood bank. Such programs may increase the quality of components stored for transplantation.

Although cord blood (CB) compares favourably with other haematopoietic stem cell (HSCs) sources, its use in large patients is limited by the low number of cells available. Ex vivo expansion of CB HSCs has been used to overcome this limitation. In this study, we investigated the effect of different cytokine cocktails, including interleukin (IL)-6, IL-11, Flt3-ligand (FL) and thrombopoietin (TPO) combined with serum or serum-free medium on the ex vivo expansion of CD34+ cells from CB. Initial experiments showed that expansion could be slightly improved using serum, but we chose to use serum-free medium in the subsequent investigations to apply good medical practice (GMP) conditions suitable for clinical use. The highest expansion of CD34+ cells was obtained with a cocktail containing FL + TPO + IL-6 + IL-11. The median (range) fold expansions of CD34+ cells at 5 and 10 weeks with serum-free medium were 235·6 (131·3–340) and 5205·6 (4736·6–5674·7) respectively. The absence of IL-11 was associated with a similar fold expansion after 5 weeks (median 215·6, range 149·8–281·5), but after 10 weeks expansion was slightly lower (median 1314·7, range 645–1984·4). Our data support the possibility of maintaining long-term expansion of CB HSCs in a simple stroma- and serum-free system.

Hematopoietic progenitor cells from different sources have been widely characterized, but their ultrastructural morphology has never been described in detail. In this study, imunomagnetically separated CD34+ cells from normal bone marrow (BM), mobilized peripheral blood (PBSC) and human umbilical cord blood (CB) were studied by transmission electron microscopy (TEM) using a cytochemical method which reveals endogenous myelo-peroxidase (MPO) activity. This technique is particularly suited for detecting early signs of the myeloid commitment. The CD34+ cells from PBSC were morphologically very homogeneous and 94.7+/-4.5% of these cells were MPO-: these ultrastructural features are generally considered typical of immature cells. The CD34+ BM cells were instead more heterogeneous, with 24.6+/-7.4% showing intense MPO activity. The ultrastructural characteristics of CB cells fell between those observed in PBSC and BM, but there was a high percentage of morphologically immature cells with no evidence of MPO activity (about 83%). The number of apoptotic cells within samples from different sources was also examined both by TEM and flow cytometry. The percentage of apoptotic cells was 0.7% in PBSC, 2.3% in BM, 2.9% in CB from vaginal delivery and 11.6% in CB from cesarean section. These observations confirm the relative phenotypic immaturity of CB in comparison with BM cells; they also suggest that CB collected after cesarean section may be associated with reduced stem cells viability.

A "NEW METHOD" of "hematopoietic transplantation by means of fetal (cord) blood" was described by M. Ende and N. Ende in the March 1972 issue of Virginia Medical Monthly. 1 That article reports a series of eight transfusions administered between February 25 and March 16. 1970. to a 16-year-old black patient with acute lymphoblastic leukemia on conventional therapy. The transfusions consisted of 30 to 85 mL placental/ umbilical cord blood (PB). They were administered "'to establish a hematopoietic transplant." even though no myeloablative therapy was given to the patient. In discussing their findings and the potential benefits offered by PB as compared with adult bone marrow, Ende and Ende foresaw the development of PB banking by pointing out that "any active obstetrical service offers the potential of providing many donors of cord blood over a relatively short period of time." A quarter of a century after this report, the international scientific and lay communities are challenged with the implementation and management of large-scale PB banking programs suitable to provide sufficient numbers of high-quality PB units for the treatment of patients in need of hematopoietic reconstitution. This challenge is the result of hallmark contributions to the field of stem cell transplantation that appeared in the scientific literature over the last 10 years, which include the seminal paper on the first PB transplantation from a sibling donor performed in 1988, 2 the results of the first 44 children transplanted with PB units collected from siblings? the detailed analysis of 25 consecutive patients transplanted in a single center in the United States with allogeneic PB units from unrelated donors provided by the New York Blood Center Placental Blood Program, 4 the initial experience on 143 cases transplanted during 1988 to 1996 in 45 European centers contributing their data to the Eurocord program, 5 and the recent analysis of 562 patients transplanted with units provided by a single PB bank. 6 Besides the implications for the scientific community, the general interest and appeal raised in the public by this topic is also witnessed by the 21 websites that were accessible in September 1998 via the Yahoo search engine with the search terms cord blood. We discuss herein the main practical aspects of PB banking. Because some practical options depend on specific positions pertaining to a number of ethical issues concerning PB banking and transplantation, we start our discussion with a section on these matters. Other important topics such as the biology, immunology, and clinical use of PB are only marginally touched here, because they have been addressed extensively in other publications. 2-10 Because the area of PB banking is relatively novel and the whole field is evolving very rapidly, the reader is warned that some material that we have referenced has not been published in full in peer-reviewed journals. Moreover, it is possible that our understanding of the literature is biassed by our own experience, collected in the development of Milano Cord Blood Bank. Therefore, to facilitate the identification of our position, we conclude our review with a short description of the PB banking process at Milano Cord Blood Bank.

BACKGROUND: A large number of institutions have started programs banking umbilical cord blood (UCB) for allogeneic unrelated-donor and related-donor transplantation. However, limited information is available on the financial issues surrounding these activities. STUDY DESIGN AND METHODS: The aim of this study was to determine the fee per UCB unit released for transplantation that would allow cost recovery after 10 years. Three organizational models were considered suitable to provide units for five UCB transplants per 1 million population per year, a figure that would translate into an annual need for 280 units in Italy. Models A, B, and C included, respectively, seven networked banks, each with an inventory of 1,500 units; two networked banks, each with an inventory of 5,000 units; and one bank with an inventory of 10,000 units. It was estimated that it would take 3 years to develop the cryopreserved inventory and that approximately 3 percent of the inventory could be released and replaced each year during the 7-year interval between the fourth and tenth years of activity. The data on the costs of labor, reagents and diagnostics, disposables, depreciation and maintenance, laboratory tests, and overhead, as well as the operational data used in the analysis were collected at the Milano Cord Blood Bank in 1996. RESULTS: Fees of US $15,061, $12,666, and $11,602 per unit released during the fourth through the tenth years of activity allow full cost recovery (principle and interest) under Models A, B, and C, respectively. CONCLUSION: Although UCB procurement costs compare favorably with those of other hematopoietic cell sources, these results and the current fee of US $15,300 used in some institutions show that UCB is an expensive resource. Therefore, judicious planning of banking programs with high quality standards is necessary to prevent economic losses. The advantages of lower fees associated with the centralized banking approach of Model C should be balanced with the more flexible collection offered by Model A.

Although placental blood has recently become a new source of hematopoietic progenitors for marrow replacement, limited attention has been given to systems suitable to ensure the short-term and long-term quality of placental blood units used for transplantation. In this article, we describe a quality system for placental blood banking developed in accord with ISO 9002 norms at Milano Cord Blood Bank. The quality system is the organizational structure, procedures, processes, and resources needed to implement quality management. ISO 9002 is a model for quality assurance in production, installation, and servicing, which includes a number of clauses providing guidance for the implementation of the quality system. The quality system was started by the bank medical director with step 1: the general quality plan, which included (a) the written description of mission, objectives, technical and organizational policies, and staff organization chart of the placental blood bank, (b) the definition and acquisition of adequate financial, human, and structural resources, (c) the appointment of a quality system head independent from the production laboratory and reporting directly to the medical director. Tasks of the quality system head were (a) to identify the placental blood banking process together with the placental blood bank personnel, (b) to implement a documentation plan finalized at the production and maintenance of (i) the quality manual, which provides a summary on how the bank operates with a quality system in compliance with the ISO 9002 clauses, (ii) the general procedures (or quality system procedures), which provide more detail on selected clauses, including at least those prescribed by the ISO 9002 standard, (iii) the operative procedures (or process procedures), which describe in detail the process of placental blood banking and how technical activities must be performed, (iv) the work instructions, which provide stepwise descriptions of individual activities, (v) records/forms for data collection and storage, (c) to identify quality indicators, (d) to start a regular internal audit, (e) to report audit results to the medical director for review. This was followed by step 2: the job descriptions, staff training, and qualification; step 3: the documentation plan; step 4: the internal audit plan; step 5: the launch of the quality system, and step 6: the assessment by an external team from an accredited third-party organization and final certification for compliance to ISO 9002. The quality system, which must be maintained and undergo external audit at regular intervals so that certification is confirmed, ensures the high probability that placental blood units provided to clinicians conform regularly to predefined levels of quality.

Udgivelsesdato: 2008-Apr

A model of a university hospital facility for biobanking and clinical grade cell manipulation is described. The facility is based on the model of the Biological Resource Center described by the Organisation for the Economic Cooperation and Development in 1999. This model integrates several critical aspects of collection, characterization, storage and use of biological materials for research purposes and therapeutic applications, thus providing potential advantages of optimizing the use of resources, improving standardization, protecting the rights of both donors and recipients of biological materials, and facilitating international cooperation.

The blood which remains in the placenta after delivery, also known as placental or cord blood, can be easily collected by venipuncture of the cord vessels. The biological and medical interests in placental blood rose steadily in the last two decades, following the discovery that placental blood contains a number of haemopoietic progenitor cells capable of reconstituting a human myeloablated recipient [1], although the number of cells may be sub-optimal in larger adult patients [2]. Further interest was triggered by recent observations suggesting that haemopoietic progenitor cells can change their developmental programme under strict environmental control, a cell capability termed ‘plasticity’ or ‘transdifferentiation’, which is currently the object of active investigation and hot debate [3]–[11].

In HLA-identical sibling bone marrow transplantation, certain recipient cytokine gene polymorphism genotypes and minor histocompatibility differences influence the occurrence and severity of acute graft-versus-host disease (aGvHD). The present study investigated the role of cytokine tumor necrosis factor (TNF)-alpha and interleukin (IL)-10 gene polymorphisms HY, HA-1, and CD31 minor histocompatibility antigen (mHag) mismatch in the development of aGvHD after unrelated cord blood (CB) transplant (CBT).DNA samples of 115 CB recipients and their unrelated CB grafts were analyzed for genotype associated with TNF-alpha (TNFd3/d3) and IL-10 (IL-10(-1064), 11-16) and for disparities in major and three minor histocompatibility antigens, HY, HA-1, and CD31 codon 125. Results were correlated with the incidence of aGvHD grades II to IV.Neither the donor nor the recipient GvHD risk alleles TNFd3/d3 and IL-10(-1064) (11-16) were associated with the development of aGvHD grades II to IV and I to IV. Because of the heterogeneity of CBTs, the data were reanalyzed separately for patients with malignancies (n=83) or with inborn errors (n=24). No significant association was observed between the severity of aGvHD and the possession of either TNFd3/d3 or IL-10 (11-16) genotypes. Mismatches for the mHags HY, HA-1, and CD31 exon 125 between donor and recipient did not associate with aGvHD grades II to IV.In contrast to HLA-identical sibling bone marrow transplantation, in mismatched unrelated CBT, neither the cytokine genotypes TNFd3/d3 alone or in combination with IL-10(-1064) alleles nor the minor histocompatibility antigens HY, HA-1, and CD31 exon 125 were associated with aGvHD grades II to IV. Further determination of the cytokine gene polymorphism genotypes in CBTs compared with bone marrow transplants may identify those polymorphisms that could be potential predictive markers for the occurrence of aGvHD.

We describe the activities of the Milan Cord Blood (CB) Bank and of the Italian Cord Blood Network. By October 31, 1995, 763 units were banked in Milan. Of these, 8 units were used to perform 4 related and 4 unrelated transplants in 5 children and 3 adult patients. Early cord clamping after delivery was found to be crucial to increase the volume of CB collected. This procedure does not seem to be detrimental to the newborn. Of various red cell sedimenting agents used to reduce the unit volume and concentrate progenitor cells, 3% gelatin seems to be associated with the best yields. After a preliminary experience of 2 years, the Italian Cord Blood Network (Gruppo Italiano Amplificazione Cellule Emopoietiche, GRACE) was founded in 1995. The initial activities of GRACE are aimed at the development at the national level of CB banking standard operative procedures in agreement with the draft issued by The North American Task Force for The Development of Standards for Hematopoietic Cell Transplantation. Moreover, a wet workshop has been organized to standardize colony-forming unit (CFU) evaluation. The main goal in Milan is the collection of 5000 CB units. Other issues of interest include CB volume reduction, hematopoietic progenitor purification, ex vivo expansion prior to transplantation, and experimental protocols for gene transfer, such as those related to the multidrug resistance (MDR) gene.

Donor organ procurement is a world-wide problem. In Italy it is particularly so and the reasons for this are investigated. An overall increase in the number of donors has been noted in 1994 and the first 8 months of 1995, and ways of continuing this encouraging trend should be pursued by improvements in education, legislation, and hospital organization.

Clinical-grade cell purification from thawed cord blood: an example of translational research

We investigated the iron status of 33 pyruvate kinase (PK) deficient patients, most of the cases reported in Italy. Serum ferritin (SF) was higher than the upper limit of the range of matched controls in 15/25 (60%) non-transfused patients (median 228 micrograms/l, range 58-3160 v 43, 22-310). Liver siderosis and fibrosis were found in 8/9, and cirrhosis in two who died at age 39 and 42 of complications of iron overload. SF was independent of age, sex, or severity of haemolysis. The prevalence of HLA-A3 antigen in PK deficient patients was not significantly different from that of our healthy population (29.6% v 23%). The HLA-A3 positive, non-transfused patients had significantly higher SF values than the HLA-A3 negative ones (median 675 micrograms/l, range 340-3160 v 145, 58-400). A pedigree study of six high SF-probands indicated that iron overload has a multifactorial pathogenesis. In particular, the association of PK deficiency-induced haemolysis, splenectomy and an additional factor (heterozygosity for idiopathic haemochromatosis, ineffective erythropoiesis) leads to severe iron accumulation. We suggest that monitoring iron status would be useful in PK deficient patients, particularly in splenectomized and HLA-A3 positive ones, to identify those at risk of iron overload and prevent the clinical consequences of iron accumulation.

HLA class I, killer-cell immunoglobulin-like receptor (KIR) ligands which are missing in the recipient may trigger cytotoxicity of donor NK cells leading to graft-versus- host disease (GvHD) and/or graft-versus-leukemia reactions. Donor KIR(-ligand) incompatibility in the graft-versus-host (GvH) direction is associated with decreased relapse incidence (RI) and improved disease-free survival (DFS) in haplo-identical and HLA-mismatched unrelated hematopoietic stem cell transplantation (HSCT). Since it is unknown whether KIR-ligand mismatching impacts outcomes in unrelated cord blood stem cell transplantation (UCBT), we studied patients reported to Eurocord Registry with acute leukemia in complete remission (CR) with available high resolution typing of HLA-A, -B and -C in recipient/donor pairs who received a single UCBT. Patients and donors were categorized to their KIR-ligand groups by determining whether or not they expressed: HLA-C group 1 or 2, HLA-Bw4 and HLA-A3 or -A11. A total of 218 patient-donor pairs met the eligibility criteria. The patients had ALL (n=124) or AML (n=94) and were transplanted in 1st CR (n=105), 2nd CR (n=91) or >2nd CR (n=22). Median age was 13.4 yrs, weight 49 kg, and nucleated cell dose infused was 3.0×10E7/kg. The cord blood was HLA identical (6/6) in 21, 5/6 in 91, 4/6 in 91 and

Introduction: Human cord blood (CB) represents an interesting source of mesenchymal stem cells (MSCs) with different cell “competence” and feasible clinical applications. Up to now patients affected by acute renal failure (ARF) are treated by unsuccessful pharmacological therapies and it is an interesting possibility that CB MSCs or other potential progenitor cell subpopulations could be used for therapeutic purpose in renal repair. Aim of this study was to isolate and culture MSCs from full-term UCB and to test their ability to promote renal repair when transplanted into NOD-SCID mice with acute renal failure. Methods: MSCs were isolated with a lineage-depletion negative immuno-selection procedure (Rosette Sep, StemCell Technologies, Vancouver, Canada) from buffy coat of CB (n=17) without lysis of red blood cells. Cell suspension was seeded at 1×106 cells/cm2, in 35mm/tissue culture dish in the presence of αMEM, 20 % FBS, 2mM L-Glutamine and Penicillin/Streptomycin. Immunophenotype was evaluated by flow cytometric analysis while the differentiation assays were performed towards adipogenic, osteogenic and chondrogenic lineages in order to confirm their mesenchymal features. To induce acute renal failure, NOD-SCID mice (n=10) were injected with cisplatin (12.7 mg/KG s.c.). This drug is associated with renal function deterioration, measured as serum blood urea nitrogen (BUN), peaking at day 4–5. After one day the mice received i.v. saline or 5×105 CB MSCs. Renal function and histology were evaluated. Results: The success rate of isolating MSCs from CB units was 17.6%. Flow cytometric analysis showed that MSCs were positive for CD44 (69%), CD105 (26%), CD90 (99%), HLA class I (80%) and negative for CD31, CD45, CD34, HLA class II. Moreover, within the CB MSCs we identified a subpopulation (37.5%) characterized by CD146+/34−/45− and consistent with perivascular/pericyte-like cells. Moreover we demonstrated and confirmed that CB MSCs were capable to differentiate in osteogenic and condrogenic but not adipogenic lineages, as recently shown also by other groups. In vitro differentiation towards epithelial lineage is in progress. In vivo results showed that CB MSCs significantly protected cisplatin-treated mice from renal function impairment at day 4 (BUN: cisplatin+saline 115±5 vs cisplatin+CB MSCs 64±13 mg/dl, p Conclusion: These preliminary results indicate that human CB MSCs exhibit reparative potential in acute renal failure. More evidences demonstrating the plasticity of CB stem cells will provide an exciting opportunity to explore the use of this stem cell source in regenerative medicine for patients with renal disease.

We have performed a combined Real Time Quantitative-PCR and single nucleotide polymorphisms array analyses for dissecting the clonal evolution in a childhood AML patient who experienced two relapses and for whom we had the availability of the cord blood (CB) sample. The patient was diagnosed at 6 years of age with an AML-M1 and showed normal karyotype and a FLT3-ITD mutation as a sole abnormality. She underwent autologous-BMT; however, 3.5 months later the patient relapsed, and 4 months after an allogeneic-BMT she suffered from a second relapse and died for disease progression. Highly sensitive (10−4) monitoring of FLT3-ITD was performed by patient-specific RQ-PCR, and showed a progressive decrease of minimal residual disease (MRD) during induction therapy. MRD was below the detection limit before auto-BMT, but the same FLT3-ITD clone re-emerged three months after auto-BMT, and preceded the clinical relapse. Thus, the same FLT3-ITD mutation was detected at the time of relapse, suggesting that the leukemic clone responsible for the first diagnosis was still present and could be potentially used as a marker for backtracking the leukemia into the CB. When tested by highly sensitive RQ-PCR, the DNA from CB resulted negative for the FLT3-ITD mutation. Although the relatively limited sensitivity of the technique might impair the interpretation, the FLT3-ITD negative result in CB is consistent with the hypothesis that FLT3-ITD mutations are secondary events, not sufficient by themselves to induce leukemia transformation in hematopoietic stem cells without a necessary primary event. With the aim to find additional submicroscopical genetic changes associated to the highly aggressive nature of the patient disease, we performed a genome wide SNP array analysis on the patient DNA through the clinical evolution of the disease, from birth to relapse. This new SNP array strategy is emerging as a powerful method to detect loss of heterozygosity (LOH) and/or copy number changes in a DNA sample with high resolution. The Affymetrix GeneChip® Mapping 10K platform has been used, which allows the scanning of more than 10.000 SNPs. SNP array analysis on DNA from the first relapse showed the deletion of the long arm of chromosome 9, a recurring chromosomal aberration in AML, and LOH on the whole chromosome 13 not associated with copy number changes. This latter has been confirmed by FISH, and it is consistent with uniparental isodisomy (UPD) as a responsible mechanism for the somatically acquired homozygosity of FLT3-ITD at 13q14. This mechanism is emerging as a frequent way of disease progression and represents a subsequent event to FLT3-ITD heterozygous mutation. The deletion of the wild type FLT3 allele has been confirmed by PCR. 10K SNP array analysis failed to reveal LOH or copy number changes in the diagnostic and in CB samples. These findings are compatible with a somatic post-natal origin of the FLT3-ITD positive AML subtype. Additional abnormalities can be responsible for the disease progression, via different mechanisms, including UPD. Other methods must be applied to find the primary event(s) giving rise to leukemia in association with FLT3-ITD mutation.

Clinical use of ex vivo expanded hematopoietic stem cells (HSCs) from cord blood (CB) carries important regulatory implications. In previous studies we identified a cytokine cocktail, (interleukin (IL)-6 (10 ng/ml), IL-1 (10 ng/ml), Flt-3 ligand-FL-(50 ng/ml) and thrombopoietin—TPO-(10 ng/ml) suitable to induce significant and sustained ex vivo expansion of CD34+/38− cells from CB for up to 10 weeks. In this study we expanded 4 samples each with 3 commercial media (A: StemPro 34 SFM, Life Technologies; B: CellGro SCGM, CellGenix; C: X-Vivo 10, BioWhittaker) in the presence of the same cytokine cocktail. CD34+ cells were purified from CB using an immunomagnetic column and cultured in stroma-free liquid cultures at a concentration of 5×10 3 cells/ml in 24-well plates for 2 weeks at 37°C in 5% CO 2 . The median and range fold expansions and the cell viability with different serum-free media are shown in the table: Based on these preliminary CD34+/38−/33− data, we elected to continue our studies with A and B media.

To the Editor: Among the questions to be answered regarding umbilical cord blood (CB) cell use for bone marrow reconstitution, one concerns the level of contamination with maternal lymphocytes that could be responsible for severe graft-versus-host disease (GVHD) in immunosuppressed recipients.[1][1

Human cord blood (CB), a rich source of hematopoietic stem and progenitor cells, is currently used for bone marrow reconstitution. However, the level of contamination of CB with maternal cells that could provoke graft-versus-host disease (GvHD) is a matter of concern. In the present study, 60 consecutive CB samples collected and stored in the Milan CB Bank, for which no maternal DNA was detected through genomic HLA typing, were examined to ascertain maternal cell contamination using polymerase chain reaction amplification of two minisatellites, apolipoprotein B gene (ApoB) and D1S80, followed by chemiluminescent detection. The sensitivity of the method employed in this study was 0.04%, comparable to that of radioactive methods. A maternal specific allele was found in 11 of the 60 CB units, at a level ranging from 1:100 to 1:2500. We could also detect the child paternal allele in 3 of the 30 mothers whose newborn was heterozygous at the loci examined. Our study indicates that maternal cells are present in 18.3% of the 60 samples examined. The clinical relevance of such a presence remains to be established. In our opinion, information on maternal cell contamination should be included within the quality control tests performed before delivering a unit.