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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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

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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

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60.0 80.0 100.0 120.0 140.0 160.0 180.0

Volume including 35 ml anticoagulant (ml)

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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

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20

40

60

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120

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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!