Red cells from Cord Blood - a new product for the Blood Bank??

1. Red cells from Cord Blood-a new product for the Blood Bank?? Elisabeth Semple, PhD Scientific Director Cells for Life Cord Blood Institute Toronto

2. Learning objectives: • Understand the difference between cord blood and adult blood • Understand the benefits and risks with using red cells from cord blood

3. 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

4. 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

5. Embryonic vs umbilical vs bone marrow?? Stemness = the ability of unspecialized cells to renew themselves as unspecialized cells but still retain the ability to specialize. 5

6. 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? Data from NYBC

7. Clinical trials underway: Juvenile diabetes (autologous) Repair of heart valves (auto) Cerebral Palsy (auto) Spinal cord injury (auto/allo) Research is underway for other diseases and conditions Alzheimer’s Disease Liver Disease Muscular Dystrophy Parkinson’s Disease Future Potential of UCB Stem Cells • Celebral Palsy • Dr 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 Type I Diabetes: Infused within the first year after diagnosis. Decreased need of insulin Protective mechanism?? (Haller et al, Exp Hematol 2008)

8. Today’s topic: Cord blood (whole blood or red cells) as a blood component for transfusion?

9. 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: To collect the maximum volume of anticoagulated umbilical cord blood by aseptic technique 10

11. Can we predict the volume?? Bigger is better! Big Baby  Big placenta  Large volume cord blood  Higher number of cells!! Ballen et al, Bone Marrow Transplant 2001, Donaldson et al, Br J Haematol 1999

13. Vaginal delivery – C-section 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

15. 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? 15

16. 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

17. Whole blood or RBC? • 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??

18. Storage of RBC from CB? Most studies expire CB RBC after 14-21 days. Widing et al. Transfusion 2007;47:1481-7 Brune et al. Transfusion 2007;47:2271-5

19. 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

20. Autologous use 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 syndrome Disorders of pulmonary adaption + Infection, apnea bradycardia syndrome, anemia CB was collected and centrifuged to remove the plasma/CPD SAGM was added

21. Autologous use Eichler et al. Transfusion 2000;40:1111-7 Results: Collected volume: 56 ±33 ml RBC volume (after processing): 29 (range: 6-87ml) Bacterial contamination: 9% of units Storage time: max 14 days CB – K+: 23 mmol/L, Hs: 0.9% RBC: K+: 15 mmol/L, Hs: 0.1% 21/47 infants got transfused total: 4 autologous and 62 allogeneic the most immature (and smallest) needed most transfusions most transfusions >14 days after birth. No baby only got autologous blood Cost: approx 11 times higher then standard blood

22. 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.”

23. 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 RBC Only 6 got just autologous RBC

24. 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 typing Stored 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.”

25. 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 collected Only 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 transfused from infants with low transfusion need Could replace allogeneic blood for 27% of infants needing transfusion

26. 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

27. Allogeneic use Bhattacharya 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???

28. 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 disease Still high bacterial contamination

29. Clinical benefits with using RBC from CB?? • HbF • High affinity for O2 • Autologous use • Will it reduce donor exposure?? • In-utero transfusion

30. Risks • Bacterial contamination • 5-10% in clinical studies

31. Conclusions • A lot of work for little benefit… • Malaria endemic countries?? • Use the cord blood to obtain the stem cells

32. Red cells from Cord Blood-a new product for the Blood Bank??Questions?? Elisabeth Semple, PhD Scientific Director Cells for Life Cord Blood Institute Toronto

33. Happy Holidays!