Lucilla Lecchi

KIR-ligand incompatibility in the graft-versus-host direction improves outcomes after umbilical cord blood transplantation for acute leukemia.

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.

Banking together. A unified model of informed consent for biobanking

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).

Effect of HLA-Matching Recipients to Donor Noninherited Maternal Antigens on Outcomes after Mismatched Umbilical Cord Blood Transplantation for Hematologic Malignancy

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.

Iron status in red cell pyruvate kinase deficiency : study of Italian cases

Summary. 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 μg/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.

Long-term expansion and maintenance of cord blood haematopoietic stem cells using thrombopoietin, Flt3-ligand, interleukin (IL)-6 and IL-11 in a serum-free and stroma-free culture system

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.

Cost of umbilical cord blood units released for transplantation

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.

Recipient cytokine genotypes for TNF-α and IL-10 and the minor histocompatibility antigens HY and CD31 codon 125 are not associated with occurrence or severity of acute GvHD in unrelated cord blood transplantation: A retrospective analysis

Background. 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)-&agr; 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). Methods. DNA samples of 115 CB recipients and their unrelated CB grafts were analyzed for genotype associated with TNF-&agr; (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. Results. 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. Conclusions. 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.

Reasons for discard of umbilical cord blood units before cryopreservation.

Umbilical cord blood (UCB) may be an alternative to bone marrow and mobilized peripheral blood as a source of transplantable hematopoietic progenitor and stem cells for selected recipients.1 Because UCB banking requires significant financial investment2 and organizational efforts, banking efficiency should be optimized. An important determinant of banking efficiency is the proportion of collections that can be cryopreserved and supplied for transplantation. An estimate from a study in the United States suggests that this proportion may not exceed 30 percent.3 Other estimates have been reported with different criteria.4,5 Recently, Jefferies et al.6 reported the results of evaluating deferral rates for 285 maternal–neonatal donor pairs in a tertiary-care hospital, who had been selected because of the high percentage of African Americans among the maternal population. In this study, only 44 percent of donor pairs were considered eligible for allogeneic UCB donation. In view of the impact that different settings may have on banking efficiency, we report the reasons for discarding UCB units that had been collected for banking in 1997 and 1998 at the Milano Cord Blood Bank. UCB collections were performed in a closed plastic bag system by trained midwives on the obstetric staffs of seven delivery collection centers in Milan and seven additional sites located not more than 80 km from our UCB bank. Three collection centers began collections in 1993, eight in 1997, and three in 1998. Collections were performed from Sunday to Friday, to facilitate cryopreservation within 24 hours of collection. Units were banked if they fulfilled the following criteria: 1) absence of family history of inherited diseases, paternal risk factors, preterm delivery (<35 weeks) and congenital abnormalities, and history of positive serologic tests for syphilis, hepatitis B surface antigen (HBsAg), anti-HIV-1/2, anti-hepatitis C virus (HCV), and anti-human T-lymphotropic virus types I and II (HTLV-I/II) in either parent; 2) the mother’s written informed consent to the collection, banking, and use of UCB for allogeneic unrelated transplantation, to undergo infectious-disease testing, to attend a 6month check, and to store data in the registry; 3) freezing of UCB units within 24 hours of collection; 4) volume of UCB units greater than 40 mL and total nucleated cell number >500 × 106 from January 1997 to June 1998 and volume greater than 60 mL and total number of nucleated cells >800 × 106 from July 1998 to December 1998; 5) correct identification of the unit and related samples; 6) negative test results on mother’s serum for syphilis, HBsAg, anti-HIV-1/2, antiHCV, and anti-HTLV-I/II; 7) absence of bacterial contamination with recognized pathogens such as Streptococcus pyogenes or Streptococcus agalactiae, as determined with a set of aerobic and anaerobic blood culture bottles (Bactec, Becton Dickinson, Sparks, MD) and standard identification tests (cases of positive bacterial contamination with low pathogenicity such as skin contaminants are disclosed to the transplant center, and the use of such units is the responsibility of the transplant center); 8) negative test results on mother’s serum sample at 6 months for syphilis (Treponema pallidum hemagglutination assay [TPHA]), HBsAg, anti-HIV-1/2, anti-HCV, and anti-HTLV-I/II and uneventful follow-up of the baby at 6 months; and 9) an absence of problems with processing and freezing, such as clots, damaged collection, or freezing of the bag. UCB collections were performed while the placenta remained in utero. Local obstetric practices with regard to the time of cord clamping were not modified. Of the 3842 UCB collections during the study period, 2153 (56%) were discarded, 82 (2%) were used for research, and 1607 (42%) were banked. The number of discarded units and the reasons for discard are shown in Table 1. The main reasons for discarding UCB collections were low volume, clinical reasons, and low cell count; these accounted for 90.4 percent of all discards. Of the 243 UCB units that were discarded for reported clinical reasons, 33 percent were for a parental history of positive syphilis (TPHA), HBsAg, anti-HIV-1/2, anti-HCV, or anti-HTLV-I/II serologic test, 14 percent for a parent’s previous transfusion, 9 percent for parental (illegal) drug use, 7 percent for parental history or presence of malignancy, 7 percent for a family history of inherited disease, 4 percent for hematologic diseases (in all these cases, a complete family history could be obtained after UCB collection), 4 percent for positive antiHCV or anti-HIV-1/2 (all reactive in enzyme-linked immunosorbent assay and negative in Western blot assay), and 22 percent for other reasons. Our study showed that more than half of the units collected for banking were discarded. Most important, our study identified specific areas for improvement in donor selection and UCB collection. In fact, 74 percent of the unit discards for clinical reasons occurred because the patient’s disqualifying medical history was obtained after the UCB collection.

Cord blood banking

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

Multiple-laboratory comparison of in vitro assays utilized to characterize hematopoietic cells in cord blood.

BACKGROUND:  Understanding the variability in results obtained by multiple laboratories is important because cord blood units are distributed worldwide for transplantation.