The wider perspective: cord blood banks and their future prospects.

Over the past three decades, cord blood transplantation (CBT) has established its role as an alternative allograft stem cell source. But the future of stored CB units should be to extend their use in updated transplant approaches and develop new CB applications. Thus, CBT will require a coordinated, multicentric, review of transplantation methods and an upgrade and realignment of banking resources and operations. Significant improvements have already been proposed to support the clinical perspective including definition of the cellular threshold for engraftment, development of transplantation methods for adult patients, engraftment acceleration with single cell expansion and homing technologies, personalised protocols to improve efficacy, use of adoptive cell therapy to mitigate delayed immune reconstitution, and further enhancement of the graft-versus-leukaemia effect using advanced therapies. The role of CB banks in improving transplantation results are also critical by optimizing the collection, processing, storage and characterization of CB units, and improving reproducibility, efficiency and cost of banking. But future developments beyond transplantation are needed. This implies the extension from transplantation banks to banks that support cell therapy, regenerative medicine and specialized transfusion medicine. This new "CB banking 2.0" concept will require promotion of international scientific and technical collaborations between bank specialists, clinical investigators and transplant physicians.

Recomendaciones para la realización de intervenciones pulmonares durante la pandemia COVID-19 / Recommendations for performing interventions during the COVID-19 pandemic

Coronavirus infection (SARS-CoV-2), is a pandemic disease declared by the World Health Organization (WHO). This disease reports a high risk of contagion, especially by the transmission of aerosols in health care workers. In this scenario, aerosol exposure is increased in various procedures related to the airway, lungs, and pleural space. For this reason, it is important to have recommendations that reduce the risk of exposure and infection with COVID-19. In this document, a team of international specialists in interventional pulmonology elaborated a series of recommendations, based on the available evidence to define the risk stratification, diagnostic methods and technical considerations on procedures such as bronchoscopy, tracheostomy, and pleural procedures among others. As well as the precautions to reduce the risk of contagion when carrying out pulmonary interventions.

[Recommendations for performing interventions during the COVID-19 pandemic]. / Recomendaciones para la realización de intervenciones pulmonares durante la pandemia COVID-19.

Coronavirus infection (SARS-CoV-2), is a pandemic disease declared by the World Health Organization (WHO). This disease reports a high risk of contagion, especially by the transmission of aerosols in health care workers. In this scenario, aerosol exposure is increased in various procedures related to the airway, lungs, and pleural space. For this reason, it is important to have recommendations that reduce the risk of exposure and infection with COVID-19. In this document, a team of international specialists in interventional pulmonology elaborated a series of recommendations, based on the available evidence to define the risk stratification, diagnostic methods and technical considerations on procedures such as bronchoscopy, tracheostomy, and pleural procedures among others. As well as the precautions to reduce the risk of contagion when carrying out pulmonary interventions.

Impact of delayed umbilical cord clamping on public cord blood donations: can we help future patients and benefit infant donors?

BACKGROUND: Cord blood (CB) is a widely accepted stem cell source and its clinical utilization depends, to a great extent, on its cell content. Birth-to-clamping (BTC) time of umbilical cord determines placental transfusion to the newborn, and the remaining blood that can be collected and banked. The 2017 Committee Opinion of the American College of Obstetrics and Gynecologists (ACOG) recommends a delay of "at least 30-60 seconds" before clamping the cord for all newborns to ensure adequate iron stores. The impact of delayed cord clamping (DCC) on public CB banking can be substantial. STUDY DESIGN AND METHODS: Cord blood units (CBUs) collected from 1210 mothers at one hospital were evaluated for total nucleated cells (TNCs) and weight/volume based on time to clamping. Bank staff recorded BTC time in seconds as reported by obstetricians; collections were performed ex utero. Immediate clamping was defined as BTC of less than 30 seconds, whereas DCC was defined as BTC of 30 seconds or more. RESULTS: Cord clamping was immediate in 903 (75%) and delayed in 307 (25%) deliveries. Successful recovery (% clinical CBUs) decreased 10-fold with DCC of more than 60 seconds (22% vs. 2.4%, p < 0.001). CBUs collected after DCC of more than 60 seconds had significantly lower TNC counts than those after DCC of less than 60 seconds (p < 0.0001). Furthermore, 38% to 46% of CBUs after DCC of more than 60 seconds had volume of less than 40 mL. CONCLUSION: Our study indicates that DCC of 30 to 60 seconds has a small negative impact on collection of high-TNC-count CBUs. However, increasing BTC to more than 60 seconds decreases significantly both TNC content and volume, reducing drastically the chances of obtaining clinically useful CBUs.

Cytomegalovirus viral load in cord blood and impact of congenital infection on markers of hematopoietic progenitor cell potency.

BACKGROUND: The low incidence of cytomegalovirus (CMV) infection in neonates decreases the risk of viral transmission with cord blood transplantation. Cord blood donors are screened by testing the maternal sample for total antibodies to CMV. Some cord blood banks also screen cord blood for CMV-DNA. The aim of this study was to develop and validate a multiplex real-time polymerase chain reaction assay to measure CMV viral load in cord blood from asymptomatic infants with congenital CMV infection and to assess the impact of CMV infection on cord blood hematopoietic progenitor cell concentrations and colony-forming unit functionality. STUDY DESIGN AND METHODS: CMV infection was evaluated in two groups of cord blood donors: 1) 30,308 neonates prospectively screened by saliva culture, including 41 positive cases (0.14%), all from mothers with total antibodies to CMV; and 2) 4712 newborns from mothers with total antibodies to CMV who were screened retrospectively by polymerase chain reaction, including 18 positive cases (0.38%). All 59 infants with CMV were asymptomatic at birth. RESULTS: Among the 59 positive cases, the average CMV viral load in cord blood was 20.6 × 104 viral copies (vc)/mL; seven of 59 mothers (12%) had CMV-DNA detected, however, with no association to their newborns' CMV viral load. Levels of colony-forming units, CD34+ /CD45+ cells, and total nucleated cells measured in a cohort of CMV-positive cord blood samples were higher than those in the matched control group. CONCLUSION: We developed and validated a multiplex real-time polymerase chain reaction assay to detect CMV-DNA in cord blood. In our study, maternal total antibodies to CMV or CMV-DNA at birth were poor predictors of infection in cord blood donors. Furthermore, our results suggest that CMV congenital infection impacts CD34+ /CD45+ cells and some hematopoietic progenitor cells toward higher proliferation.

Banking or Bankrupting: Strategies for Sustaining the Economic Future of Public Cord Blood Banks.

BACKGROUND: Cord blood is an important source of stem cells. However, nearly 90% of public cord blood banks have declared that they are struggling to maintain their financial sustainability and avoid bankruptcy. The objective of this study is to evaluate how characteristics of cord blood units influence their utilization, then use this information to model the economic viability and therapeutic value of different banking strategies. METHODS: Retrospective analysis of cord blood data registered between January 1st, 2009 and December 31st, 2011 in Bone Marrow Donor Worldwide. Data were collected from four public banks in France, Germany and the USA. Samples were eligible for inclusion in the analysis if data on cord blood and maternal HLA typing and biological characteristics after processing were available (total nucleated and CD34+ cell counts). 9,396 banked cord blood units were analyzed, of which 5,815 were Caucasian in origin. A multivariate logistic regression model assessed the influence of three parameters on the CBU utilization rate: ethnic background, total nucleated and CD34+ cell counts. From this model, we elaborated a Utilization Score reflecting the probability of transplantation for each cord blood unit. We stratified three Utilization Score thresholds representing four different banking strategies, from the least selective (scenario A) to the most selective (scenario D). We measured the cost-effectiveness ratio for each strategy by comparing performance in terms of number of transplanted cord blood units and level of financial deficit. RESULTS: When comparing inputs and outputs over three years, Scenario A represented the most extreme case as it delivered the highest therapeutic value for patients (284 CBUs transplanted) along with the highest financial deficit (USD 5.89 million). We found that scenario C resulted in 219 CBUs transplanted with a limited deficit (USD 0.98 million) that charities and public health could realistically finance over the long term. We also found that using a pre-freezing level of 18 x 10(8) TNC would be the most cost-effective strategy for a public bank. CONCLUSION: Our study shows that a swift transition from strategy A to C can play a vital role in preventing public cord blood banks worldwide from collapsing.

Low Molecular Weight Fraction of Commercial Human Serum Albumin Induces Morphologic and Transcriptional Changes of Bone Marrow-Derived Mesenchymal Stem Cells.

Osteoarthritis (OA) is the most common chronic disease of the joint; however, the therapeutic options for severe OA are limited. The low molecular weight fraction of commercial 5% human serum albumin (LMWF5A) has been shown to have anti-inflammatory properties that are mediated, in part, by a diketopiperazine that is present in the albumin preparation and that was demonstrated to be safe and effective in reducing pain and improving function when administered intra-articularly in a phase III clinical trial. In the present study, bone marrow-derived mesenchymal stem cells (BMMSCs) exposed to LMWF5A exhibited an elongated phenotype with diffuse intracellular F-actin, pronounced migratory leading edges, and filopodia-like projections. In addition, LMWF5A promoted chondrogenic condensation in "micromass" culture, concurrent with the upregulation of collagen 2α1 mRNA. Furthermore, the transcription of the CXCR4-CXCL12 axis was significantly regulated in a manner conducive to migration and homing. Several transcription factors involved in stem cell differentiation were also found to bind oligonucleotide response element probes following exposure to LMWF5A. Finally, a rapid increase in PRAS40 phosphorylation was observed following treatment, potentially resulting in the activation mTORC1. Proteomic analysis of synovial fluid taken from a preliminary set of patients indicated that at 12 weeks following administration of LMWF5A, a microenvironment exists in the knee conducive to stem cell infiltration, self-renewal, and differentiation, in addition to indications of remodeling with a reduction in inflammation. Taken together, these findings imply that LMWF5A treatment may prime stem cells for both mobilization and chondrogenic differentiation, potentially explaining some of the beneficial effects achieved in clinical trials.

How we handled the dextran shortage: an alternative washing or dilution solution for cord blood infusions.

Dextran 40 is the main component of the solution used to wash or dilute thawed cord blood unit (CBU) products for stem cell transplant. Dextran 40 became unavailable in the United States as of April 2014. Like many other cellular therapy laboratories in the United States, we found ourselves with limited dextran 40 inventory, a growing CBU transplant requirement, and no alternative solution. Since there are no published alternative washing solutions for cryopreserved CBU we had to develop and validate a new solution rapidly. We chose to validate hydroxyethyl starch (HES) due to its similar ability to stabilize red blood cells and reduce sudden changes in osmolality that occur during thawing. For the validation we used 3 CBUs and thawed and washed each unit with both dextran 40- and HES-based solutions; thus, each CBU served as its own control. We observed no significant differences between the two wash solutions for all the monitored variables including cell viability, cell recovery, or potency measured by colony-forming cell assay. Based on this initial validation we began using HES-albumin for CBU washing after our supply was exhausted. Our initial experience with the first 16 CBU transplants after validation indicates safe infusion and preliminary cord engraftment.

Noninherited maternal antigens identify acceptable HLA mismatches: benefit to patients and cost-effectiveness for cord blood banks.

Cord blood unit (CBU) transplantations to patients mismatched for only 1 HLA antigen, which is identical to the CBU noninherited maternal antigen (NIMA), are designated as having a 6/6 "virtual" NIMA-matched phenotype and have a prognosis similar to 6/6 inherited HLA-matched CBUs. Such virtual HLA phenotypes of CBUs can be created by replacing the inherited alleles with 1 or more NIMAs. Phenotypes of Dutch patients (n = 2020) were matched against the inherited and virtual HLA phenotypes of the National Cord Blood Program CBU file (with known NIMA, n = 6827). Inherited 6/6 matches were found for 11% of the patients. Including virtual phenotypes resulted in, overall, 19-fold more different phenotypes than were inherited, conferring 6/6 virtual matches for an additional 20% of the patients, whereas another 17% might benefit from CBUs with a 4/6 HLA match and 1 NIMA match (4/6 + 1NIMA or 5/6 virtual match). The elucidation of donors' maternal HLA phenotypes can provide significant numbers of 6/6 and 5/6 virtually matched CBUs to patients and is potentially cost effective.

A perspective on the selection of unrelated donors and cord blood units for transplantation.

Selection of a suitable graft for allogeneic hematopoietic stem cell transplantation involves consideration of both donor and recipient characteristics. Of primary importance is sufficient donor-recipient HLA matching to ensure engraftment and acceptable rates of GVHD. In this Perspective, the National Marrow Donor Program and the Center for International Blood and Marrow Transplant Research provide guidelines, based on large studies correlating graft characteristics with clinical transplantation outcomes, on appropriate typing strategies and matching criteria for unrelated adult donor and cord blood graft selection.

Guidelines for the development and validation of new potency assays for the evaluation of umbilical cord blood.

The following commentary was developed by the National Marrow Donor Program Cord Blood Advisory Group and is intended to provide an overview of umbilical cord blood (UCB) processing, summarize the current state of potency assays used to characterize UCB, and define limitations of the assays and future needs of the cord blood banking and transplant community. The UCB banking industry is eager to participate in the development of standardized assays to uniformly characterize cellular therapy products that are manufactured in a variety of ways. This paper describes the desired qualities of these assays and how the industry proposes to co-operate with developers to bring relevant assays to market. To that end, the National Marrow Donor Program (NMDP) Cord Blood Bank Network is available to serve as a resource for UCB testing material, research and development consulting, and product/assay testing in an accredited UCB manufacturing environment.

Isolation and characterization of mesenchymal stem cells from human umbilical cord blood: reevaluation of critical factors for successful isolation and high ability to proliferate and differentiate to chondrocytes as compared to mesenchymal stem cells from bone marrow and adipose tissue.

Human umbilical cord blood (CB) is a potential source for mesenchymal stem cells (MSC) capable of forming specific tissues, for example, bone, cartilage, or muscle. However, difficulty isolating MSC from CB (CB-MSC) has impeded their clinical application. Using more than 450 CB units donated to two public CB banks, we found that successful cell recovery fits a hyper-exponential function of time since birth with very high fidelity. Additionally, significant improvement in the isolation of CB-MSC was achieved by selecting cord blood units having a volume ≥90 ml and time ≤2 h after donor's birth. This resulted in 90% success in isolation of CB-MSC by density gradient purification and without a requirement for immunoaffinity methods as previously reported. Using MSC isolated from bone marrow (BM-MSC) and adipose tissue (AT-MSC) as reference controls, we observed that CB-MSC exhibited a higher proliferation rate and expanded to the order of the 1 × 10(9) cells required for cell therapies. CB-MSC showed karyotype stability after prolonged expansion. Functionally, CB-MSC could be more readily induced to differentiate into chondrocytes than could BM-MSC and AT-MSC. CB-MSC showed immunosuppressive activity equal to that of BM-MSC and AT-MSC. Collectively, our data indicate that viable CB-MSC could be obtained consistently and that CB should be reconsidered as a practical source of MSC for cell therapy and regenerative medicine using the well established CB banking system.

Infusion of ex vivo expanded T regulatory cells in adults transplanted with umbilical cord blood: safety profile and detection kinetics.

Acute graft-versus-host disease (aGVHD) is associated with high risk of morbidity and mortality and is a common complication after double umbilical cord blood (UCB) transplantation. To reduce these risks, we established a method of CD4(+)CD25(+)FoxP3(+) T regulatory cell (Treg) enrichment from cryopreserved UCB followed by a 18 (+) 1-day expansion culture including anti-CD3/anti-CD28 antibody-coated beads and recombinant human interleukin-2. In a "first-in-human" clinical trial, we evaluated the safety profile of UCB Treg in 23 patients. Patients received a dose of 0.1-30 × 10(5)UCB Treg/kg after double UCB transplantation. The targeted Treg dose was achieved in 74% of cultures, with all products being suppressive in vitro (median 86% suppression at a 1:4 ratio). No infusional toxicities were observed. After infusion, UCB Treg could be detected for 14 days, with the greatest proportion of circulating CD4(+)CD127(-)FoxP3(+) cells observed on day (+)2. Compared with identically treated 108 historical controls without Treg, there was a reduced incidence of grade II-IV aGVHD (43% vs 61%, P = .05) with no deleterious effect on risks of infection, relapse, or early mortality. These results set the stage for a definitive study of UCB Treg to determine its potency in preventing allogeneic aGVHD. This study is registered at http://www.clinicaltrials.gov as NCT00602693.

Histocompatibility and immunogenetics in cord blood transplantation.

This review of the immunogenetics of cord blood transplantation attempts to highlight the connections between classical studies and conclusions of the tissue transplantation field as a scholarly endeavor, exemplified by the work of Professor Hoecker, with the motivations and some recent and key results of clinical cord blood transplantation. The authors review the evolution of understanding of transplantation biology and find that the results of the application of cord blood stem cells to Transplantation Medicine are consistent with the careful experiments of the pioneers in the field, from the results of tumor and normal tissue transplants, histocompatibility immunogenetics, to cell and molecular biology. Recent results of the National Cord Blood Program of the New York Blood Center describe the functioning in cord blood transplantation of factors, well known in transplantation immunogenetics, like the Fl anti-parent effect and the tolerance-like status of donors produced by non-inherited maternal HLA antigens. Consideration of these factors in donor selection strategies can improve the prognosis of transplantation by characterizing "permissibility" in HLA-incompatible transplantation thereby increasing the probability of survival and reducing the likelihood of leukemic relapse.

Histocompatibility and Immunogenetics in Cord Blood Transplantation

This review of the immunogenetics of cord blood transplantation attempts to highlight the connections between classical studies and conclusions of the tissue transplantation field as a scholarly endeavor, exemplified by the work of Professor Hoecker, with the motivations and some recent and key results of clinical cord blood transplantation. The authors review the evolution of understanding of transplantation biology and find that the results of the application of cord blood stem cells to Transplantation Medicine are consistent with the careful experiments of the pioneers in the field, from the results of tumor and normal tissue transplants, histocompatibility immunogenetics, to cell and molecular biology. Recent results of the National Cord Blood Program of the New York Blood Center describe the functioning in cord blood transplantation of factors, well known in transplantation immunogenetics, like the Fl anti-parent effect and the tolerance-like status of donors produced by non-inherited maternal HLA antigens. Consideration of these factors in donor selection strategies can improve the prognosis of transplantation by characterizing "permissibility" in HLA-incompatible transplantation thereby increasing the probability of survival and reducing the likelihood of leukemic relapse.

Cord blood banking: 'providing cord blood banking for a nation'.

Transplantation of cord blood (CB) is increasingly used as therapy for patients whose own marrow is affected by genetic mutations that prevent the development of normal cells of the blood or immune tissues, or for patients whose marrow has been destroyed in the course of treatment for leukaemia and other malignancies. CB is a rich source of haematopoietic stem cells, can be easily harvested and stored in frozen aliquots in a CB bank. The first public CB bank was established in 1993 allowing unrelated CB transplantation to become an option for patients lacking a suitable adult donor. Today, the results of CB transplantation are comparable to those of bone marrow transplants with several important advantages: the graft is available 'off the shelf', thereby reducing the waiting time, and the requirements of human lecucoyte antigen (HLA) matching are less restrictive than those of adult sources. The reduced requirement for HLA matching allows transplants between incompletely matched donors and recipients, thus reducing the size of the inventory required at the national level. This also mitigates the disadvantage encountered by persons of rare HLA genotypes or those who do not belong to populations of North Western European descent. Finally, national CB programmes can easily make available for research individual surplus units not meeting minimal criteria for clinical use.

Extracellular DNA in cord blood plasma and applications in cord blood banking for sample identification.

BACKGROUND: Human cord blood (CB) units donated for transplantation require testing for various markers in blood and plasma aliquots. Although the identity link between the CB unit and the labeled aliquots with the same identifiers can be confirmed by HLA-DNA assays, these methods have not been used for CB plasma. We have previously reported that viral DNA sequences are present in the CB plasma of carrier babies and now hypothesize that human genomic DNA may also be present in CB plasma. STUDY DESIGN AND METHODS: The aim of the study was to determine whether human genomic DNA is also present in CB plasma in quality and quantity able to support human genetic identification by short tandem repeat analysis (STR). RESULTS: The presence of extracellular DNA (EC-DNA) in CB and adult peripheral blood plasma was confirmed by HLA-DR polymerase chain reaction (PCR) and real-time PCR of Alu (SB2) genes. High concentrations were seen in CB plasma (0.131 ng/mL vs. adult 0.005 ng/mL; p < 0.001). EC-DNA increased over time while CB was stored at room temperature; this increase was associated with decreasing cell viability. STR-PCR of EC-DNA showed good signal strength and accurate allele calling so that linkage between the infant donor, the collected CB unit, and CB plasma aliquots could be established. CONCLUSION: This study demonstrates that infant-derived EC-DNA is present in CB plasma and provides a useful tool for the unambiguous confirmation of plasma aliquot identity, as routinely used in CB banking, by the use of a sensitive and highly accurate DNA assay.

Umbilical cord blood regulatory T-cell expansion and functional effects of tumor necrosis factor receptor family members OX40 and 4-1BB expressed on artificial antigen-presenting cells.

Previously, we showed that human umbilical cord blood (UCB) regulatory T cells (Tregs) could be expanded approximately 100-fold using anti-CD3/28 monoclonal antibody (mAb)-coated beads to provide T-cell receptor and costimulatory signals. Because Treg numbers from a single UCB unit are limited, we explored the use of cell-based artificial antigen-presenting cells (aAPCs) preloaded with anti-CD3/28 mAbs to achieve higher levels of Treg expansion. Compared with beads, aAPCs had similar expansion properties while significantly increasing transforming growth factor beta (TGF-beta) secretion and the potency of Treg suppressor function. aAPCs modified to coexpress OX40L or 4-1BBL expanded UCB Tregs to a significantly greater extent than bead- or nonmodified aAPC cultures, reaching mean expansion levels exceeding 1250-fold. Despite the high expansion and in contrast to studies using other Treg sources, neither OX40 nor 4-1BB signaling of UCB Tregs reduced in vitro suppression. UCB Tregs expanded with 4-1BBL expressing aAPCs had decreased levels of proapoptotic bim. UCB Tregs expanded with nonmodified or modified aAPCs versus beads resulted in higher survival associated with increased Treg persistence in a xeno-geneic graft-versus-host disease lethality model. These data offer a novel approach for UCB Treg expansion using aAPCs, including those coexpressing OX40L or 4-1BBL.

Combined neonatal blood transplants in a parent-to-F1 mouse model: improved survival rates and stable long-term engraftment.

The use of cord blood (CB) transplantation for adult patients is limited by the relatively low cell content of a single collection. Two, partially-matched CB grafts could provide optimal cell doses. The interactions among the donor-derived populations have not been fully evaluated. We used our mouse model (Neonatal peripheral blood--NPB--transplants to adult recipients) to evaluate whether grafts from two histocompatibility-disparate donors ("combined" grafts) had higher survival and faster hematopoietic recovery than single donor transplants, each at suboptimal cell dose (leading to survival <60%). Transplants were performed in a parent-to-F1 setting: NPB or bone marrow (BM) cells from the fully mismatched, homozygous parental strains (A/J, B6) were given to myeloablated B6AF1 recipients. Outcomes improved by combining NPB grafts: 48% of A/J graft recipients (1 x 10(6) cells/animal) survived; all animals transplanted with B6 (same cell dose) died. Survival after combined NPB transplants was 75% (P < 0.01) and recipients had accelerated recovery of WBCs and platelets compared to single donor A/J grafts (P < 0.01). No such improvements occurred with suboptimal dose combined BM transplants. Recipients of combined NPB grafts reconstituted with one donor primarily. Chimerism levels remained stable. Successful secondary transplants demonstrated long-term persistence of both NPB grafts. Combined haplo-identical NPB but not BM grafts, each transplanted at suboptimal cell doses, engraft synergistically leading to faster reconstitution. Although the mouse model does not fully represent the complex clinical aspects of human transplantation, our findings support the concept of using two CB grafts for adult patients when a sufficiently large single one is not available.