red cells from cord blood - a new product for the blood bank?? elisabeth semple, phd scientific...
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Red cells from Cord Blood-
a new product for the Blood Bank??
Elisabeth Semple, PhDScientific DirectorCells for Life Cord Blood InstituteToronto
Learning objectives:
• Understand the difference between cord blood and adult blood
• Understand the benefits and risks with using red cells from cord blood
Out-line of talk
• General about cord blood• Cord blood collection• Specific properties of Cord Blood• Use of Cord blood for transfusion• Clinical benefits and risks
What Is Umbilical Cord Blood?What Is Umbilical Cord Blood?
• Blood remaining in the umbilical cord and placenta after birth
• The blood is rich in stem cells derived from the baby
• Other types of stem cells/progenitors that can give rise to other body tissues– Mesenchymal cells
• Fetal RBC– HbgF (50-95% of all Hbg)– Higher O2 affinity (19 vs 26 mmHg)– Replaced by HbgA by 12 weeks
after birth
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Embryonic vs umbilical vs bone Embryonic vs umbilical vs bone marrow??marrow??
Stemness = the ability of unspecialized cells to renew themselves as unspecialized cells but still retain the ability to specialize.
• Leukaemia• Lymphoma• Sickle cell anaemia• Thallasaemia• Immune system
disorders• Following
chemotherapy for cancer
• Inborn metabolic errors– Krabbe’s– Hurler’s
>70 diseases
Which Diseases Can Be Treated?Which Diseases Can Be Treated?
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1600
Hem
atol
ogic
mal
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Bon
e m
arro
wfa
il.
Imm
une
def
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Met
abol
ic
His
tocy
tic
Red
cel
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Neu
robla
stom
a
Data from NYBC
• Clinical trials underway:– Juvenile diabetes (autologous)– Repair of heart valves (auto)– Cerebral Palsy (auto)– Spinal cord injury (auto/allo)
• Research is underway for other diseasesand conditions
Alzheimer’s Disease Liver Disease Muscular Dystrophy Parkinson’s Disease
Future Potential of UCB Stem CellsFuture Potential of UCB Stem CellsType I Diabetes: Infused within the first year after diagnosis.
Decreased need of insulin
Protective mechanism??
(Haller et al, Exp Hematol 2008)
Celebral PalsyDr Kurtzberg at DUKE:
108 patients enrolled, 14 have been followed up
8 have shown functional improvement
Is going to start a blinded study
Repair of heart valves
Seed cord blood stem cells onto a biodegradable heart valve scaffold.
Cells grew and formed an extracellular matrix – valve
Sodian et al. Am Heart Ass Nov 2008
Today’s topic:
Cord blood
(whole blood or red cells)
as a blood component for transfusion?
Potential benefits
• Autologous use: –pre-term infants–surgeries done shortly after birth
• Allogeneic use: –avoid disease transmission
•E.g. in malaria endemic countries
–intra-uterine transfusions•HbgF
10
Collection Objective:Collection Objective:
To collect the maximum volume of To collect the maximum volume of anticoagulated umbilical cord blood anticoagulated umbilical cord blood by aseptic techniqueby aseptic technique
Bigger is better!
Ballen et al, Bone Marrow Transplant 2001, Donaldson et al, Br J Haematol 1999Ballen et al, Bone Marrow Transplant 2001, Donaldson et al, Br J Haematol 1999
Big Baby
Big placenta
Large volume cord blood
Higher number of cells!!
Big Baby
Big placenta
Large volume cord blood
Higher number of cells!!
Can we predict the volume??
Relationship: TNC vs Collected volume
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500.0
1000.0
1500.0
2000.0
2500.0
3000.0
3500.0
60.0 80.0 100.0 120.0 140.0 160.0 180.0
Volume including 35 ml anticoagulant (ml)
TN
C x
10
E6
/un
it
Ex- utero– After the delivery of the placenta.– Away from the mother/ in another
room
In-utero– After clamping of the umbilical
cord– With the placenta still in utero
Vaginal delivery – C-section
Collected CB volume/collection method
0
20
40
60
80
100
120
140
160
Surbek(1998)
Surbek(2000)
Pafumi(2002)
Pafumi(2002)
Kogler(1996)
Wall(1997)
Yamada(2000)
Reborero(2000)
Diaz(2002)
Vol
ume
w/o
CP
D (
ml)
In-utero Ex-utero Ex-utero, in frame
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• Cord blood is separated into RBC, plasma and buffy coat
• Volume reduced, closed systems– AXP, Sepax– Manual methods
• Stem cells are located in the buffy coat
• RBC a bi-product after extraction of the stem cells
How Is Cord Blood Processed?How Is Cord Blood Processed?
Whole blood or RBC?
• Whole blood– High number of stem cells
• Autologous – no problem• Allogeneic
– Transient increase in circulating CD34+ cells– No GvHD detected (Bhattacharya, 2006)– Can be filtered
– Remove the WBC• Filter – requires >60 ml volume• Fetal RBC have higher MCV – increased loss in filter?
– Inconsistent volume of whole blood in a constant volume of CPD
• Usually 35 ml CPD + 20-200 blood• Increased risk for cardiac problems?
– Excess CPD will bind Ca ions in the recipient
• RBC concentrate– Bi-product after processing for stem
cells– Low volumes
• Abut 20-25 ml packed RBC
– Requires storage solution• SAGM/PAGGS or plasma• How does it store??
Whole blood or RBC?
Storage of RBC from CB?
Parameter SpecificationsCBS (RBC) Widing et al
(RBC)Brune et al(RBC)
Sterility No growth - 1/37 0/12
Hemolysis <1% at expiry0.3 ± 0.1 1.0 or 0.5
(SAGM or PAGGS)
1.1 ± 0.7
Supernatant Potassium
<45 mmol/l at expiry
29 ± 2.4 70 -
pH >6.2 at expiry6.7 ± 0 - 6.1 ± 0.1
Widing et al. Transfusion 2007;47:1481-7 Brune et al. Transfusion 2007;47:2271-5
Most studies expire CB RBC after 14-21 days.
Potential benefits
• Autologous use: –pre-term infants–surgeries done shortly after birth
• Allogeneic use: –avoid disease transmission
•E.g. in malaria endemic countries
–intra-uterine transfusions•HbgF
Eichler et al. Transfusion 2000;40:1111-7
Aim:Investigate the feasibility and safety of collection and transfusion of RBC from CB.
Patients:n=47, treated in the Pediatrics Dept.
21 needed transfusion
Diagnosis:Respiratory distress syndromeDisorders of pulmonary adaption + Infection, apnea bradycardia syndrome, anemia
CB was collected and centrifuged to remove the plasma/CPDSAGM was added
Autologous use
Eichler et al. Transfusion 2000;40:1111-7
Results:Collected volume: 56 ±33 mlRBC volume (after processing): 29 (range: 6-87ml)Bacterial contamination: 9% of unitsStorage time: max 14 days
CB – K+: 23 mmol/L, Hs: 0.9%RBC: K+: 15 mmol/L, Hs: 0.1%
21/47 infants got transfusedtotal: 4 autologous and 62 allogeneicthe most immature (and smallest) needed most
transfusionsmost transfusions >14 days after birth.No baby only got autologous blood
Cost: approx 11 times higher then standard blood
Autologous use
Eichler et al. Transfusion 2000;40:1111-7
Conclusion:
“.. The collection and preparation and of autologous RBC components from CB is technically possible in principle. However, there are major concerns as to weather such preparation are of benefit in ensuring safe care of neonates with blood components, considering the high rate of bacterial contamination…”
“.. This is not a reliable and cost-effective way of enhancing the safety of the blood supply for pre-term infants.”
Autologous use
Brune et al. Autologous placental blood transfusion for the therapy of anaemic neonates. Biology of the neonate 2002;81:236-43
Aim: Show improved collection and processing techniques and
investigate the clinical applicability in different patient groups.
Patients:n=141
Cord blood:Collected from 131 babies, spun and separated. RBC in
SAGM.
Result:22/131 received autologous CB RBCOnly 6 got just autologous RBC
Autologous use
Brune et al. Autologous placental blood transfusion for the therapy of anaemic neonates. Biology of the neonate 2002;81:236-43
Important points:No bacterial contamination in any of the CB units
others: 0-9%Maternal cell contamination
found in gel test for ABO typingStored the RBC for 35 days
Conclusion:
“.. Effective in a high percentage of cases in preventing the need for allogeneic transfusions in preterm newborns with a birth weight of >1000 g and in term newborns requiring blood transfusions, e.g. in the case of surgical interventions after birth.”
Autologous use
Khodabux et al. Transfusion 2008;48:1634-43
Important points:Of the 325 infants needed to power the study, only 101 units were collectedOnly 64 CB RBC components were available in the end.
4% bacterial contamination
A 25% reduction in allogeneic RBC transfusions in infants born 28-32 weeks of gestation.
Cost was x15 of a standard transfusion
Most of the units with good volumes were never transfusedfrom infants with low transfusion need
Could replace allogeneic blood for 27% of infants needing transfusion
Autologous use
Conclusion:
Maybe good for preterm (28-32 weeks) infants if allogeneic transfusion should be avoided.
High cost
High bacterial contamination risk
Clinical benefit questionable
Autologous use
Allogeneic useBhattacharya N. J Am Coll Surg 2005; 200:557-63, Clin Exp Obstet Gynecol 2006 (various papers)
Treated children and adults with whole cord blood stored up to 72 h.
Diagnosis:Treatment of anaemia in Malaria, diabetes, HIV, cancer,
thallassemia, SLE…
No adverse reactions
Transient increase in CD34 positive cells if blood not filtered
HbgF in adults with anaemia???
Allogeneic use
Hassall et al. Lancet 2003
Propose to use CB for pediatric transfusions
One unit can raise Hbg with 30 g/L
May have lower risk of diseaseStill high bacterial contamination
Clinical benefits with using RBC from CB??
• HbF– High affinity for O2
• Autologous use– Will it reduce donor exposure??
• In-utero transfusion
Risks
• Bacterial contamination– 5-10% in clinical studies
Conclusions
• A lot of work for little benefit…• Malaria endemic countries??
• Use the cord blood to obtain the stem cells
Red cells from Cord Blood-
a new product for the Blood Bank??
Questions??
Elisabeth Semple, PhDScientific DirectorCells for Life Cord Blood InstituteToronto
Happy Holidays!