Introduction

Since the first umbilical cord blood transplantation in 1988 for Fanconi’s anemia (1), umbilical cord blood has become a safe and dependable alternative donor graft source for use in allogeneic hematopoietic cell transplantation. Approximately 10% of alternative donor grafts for adult hematopoietic cell transplants are umbilical cord blood.(2)

Umbilical cord blood has many advantages including rapid availability, less graft-versus-host disease, low CMV transmission, and tolerance to human leukocyte antigen (HLA) disparities. Umbilical cord blood cells can restore hematopoiesis after conditioning regimens for malignant as well as non-malignant disorders. Moreover, umbilical cord blood contains non-hematopoietic stem and progenitor cells that are capable of differentiating into a variety of different cell types and tissue lineages.(3) This plasticity allows umbilical cord blood to be used for novel regenerative medicine research for a wide variety of indications such as neurodegenerative diseases, cerebral palsy, diabetes and its complications, and congenital heart conditions. With increased usage of umbilical cord blood for allogeneic hematopoietic cell transplantation and regenerative medicine, both public and private cord blood banks provide options for the storage of umbilical cord blood for use in the general population (public banks) or for family-directed donation (private banks).

Transplantation

The most common use of umbilical cord blood is as a graft source after conditioning chemotherapy for allogeneic hematopoietic cell transplant restoring hematopoiesis (Table 1). A majority of umbilical cord blood used for the hematopoietic cell transplant indication is donated anonymously through a public bank or, less often, privately through a directed family donation. Even though the HLA matching is less stringent with umbilical cord blood than adult matched unrelated donors, the risk of graft-versus-host disease is less. However, the risk of engraftment failure due to low cell dose is greater using umbilical cord blood. Ongoing research is evaluating ways to improve engraftment in patients receiving umbilical cord blood transplant such as ex-vivo expansion strategies, accessory cell populations, improved cord blood homing, and ex-vivo expression/engineering of cord blood immune cells (Table 2).

Regenerative Medicine

Umbilical cord blood-based therapies are now being used increasingly for novel applications in non-hematopoietic diseases as a form of cellular regenerative therapy or immune modulation (Table 3). These indications use autologous banking and are still considered investigational and should only be performed on a clinical trial. Families who are interested in participating in a clinical trial should visit https://clinicaltrials.gov.

Role of Private Cord Blood Banks

Most of the umbilical cord blood units used for hematopoietic cell transplantation in children and adults are obtained through public umbilical cord blood banks. Rarely do recipients of umbilical cord blood transplants have family members who have donated umbilical cord blood to a private bank. In a review performed by the Center for International Blood and Marrow Transplant Research (CIBMTR), a total of 244 patients received directed-family umbilical cord blood transplants from 73 centers in a 12-year time frame from 2000 to 2012.(9) These transplants were performed most commonly for acute leukemia (37%), hemoglobinopathies (29%), Fanconi’s anemia (7%), and immune or metabolic disorders (18%). More than 500 patients transplanted with related umbilical cord blood units have been reported to the Eurocord registry with a 4-year overall survival of 91% for patients with nonmalignant diseases and 56% for patients with malignant diseases.(10) Main hematologic indications for treatment in children were leukemia, hemoglobinopathies or inherited hematologic, immunological or metabolic disorders (Table 4).

Conclusion

Umbilical cord blood can reconstitute hematopoiesis after conditioning chemotherapy for malignant and non-malignant disorders. The availability of umbilical cord blood through public and private banks allows patients who would not otherwise have a graft source proceed to a potentially life-saving hematopoietic cell transplant. Since umbilical cord blood can regenerate tissue and modulate the immune system, umbilical cord blood has the potential to be used in the treatment of many other non-hematologic conditions.

Diseases Treated by Umbilical Cord Blood Transplantation Using

Either Sibling or Unrelated Donors

 Malignant Diseases Non-Malignant Diseases
 Acute Lymphoblastic Leukemia (ALL) Fanconi Anemia
 Acute Myeloblastic Leukemia (AML) Idiopathic Aplastic Anemia
 Juvenile Chronic Myelogenous Leukemia (JMML) Thalassemia
 Chronic Lymphocytic Leukemia (CLL) Sickle Cell Anemia
 Chronic Myelogenous Leukemia (CML) Amegakaryocytic Thrombocytopenia
 Non-Hodgkin Lymphoma (NHL) Kostman Syndrome
 Hodgkin Lymphoma (HL) Blackfan-Diamond Syndrome
 Neuroblastoma Dyskeratosis Congenita
 Myelodysplastic Syndrome Severe Combined Immunodeficiency
 Myelofibrosis X-linked Lymphoproliferative Syndrome
 Multiple myeloma Wiskott-Aldrich Syndrome
 Solid Tumors Krabbe’s Disease
 Hurler Syndrome
 Sanfilippo Syndrome
 Hunter Syndrome
 Gunther Disease
 Osteopetrosis
 Globoid Cell Leukodystrophy
 Metachomatic Leukodystrophy
 Adrenoleukodsytrophy
 Tay-Sachs Disease
 Lesch-Nyhan Syndrome
 Sandhoff Disease
Other rare metabolic and primary immunodeficiency diseases

Modified from Cairo et al, BBMT, 2008

Experimental Approaches of Cord Blood Transplantation

  • Ex-Vivo Expansion Strategies
    • Notch Ligand Delta 1
    • Stem-Regenin I (SRI)
    • Nicotinamide
    • Copper Chelation (TEPA)
    • Accessory Cell Populations
      • Double Umbilical Cord Blood Transplantation
      • Haploidentical Peripheral Blood Stem Cells
      • Ex-Vivo Expanded Mesenchymal Stromal Cells (MSC) Co-culture
      • Human Placental Derived Stem Cells (HPDSCs)
      • Improved Cord Blood Homing
        • Prostaglandin E2 (PG-E2)
        • Inhibition of CD26 Peptidase (Sitagliptin)
        • Ex-vivo Fucosylation of HSC/HPC
        • Intraosseous CB Infusion
        • Ex-Vivo Expression/Engineering of CB Immune Cells
          • Multiviral Cord Blood Cytotoxic T-Lymphocytes (CTLs)
          • CB NK Cells
          • CB T-Regulatory Cells (T-regs)

Modified Cairo et al, BMT, 2016 and Danby and Rocha et al, Frontiers in Immunology, 2014.

Novel Uses of Umbilical Cord Blood Use in Regenerative Medicine

Diseases Being Studied
 Spinal Cord Injury Type I  and Type II Diabetes Mellitus
 Infant Lung Disease Congenital Diaphragmatic Hernia
 Acute Ischemic Stroke Thromboangiitis Obliterans
 Neurodegenerative Disorders Critical Limb Ischemia
 Cerebral Palsy Traumatic Brain Injury
 Autism Spectrum Disorder Congenital Heart Disease
 Preterm Neonatal Complications Hypoplastic Left Heart Syndrome
 Global Developmental Delay Idiopathic Dilated Cardiomyopathy
 Skin—Wound/Burn Liver Cirrhosis
 Epidermolysis Bullosa Viral Hepatitis
 Rheumatoid Arthritis Ulcerative Colitis / Inflammatory Bowel Disease
 Systemic Lupus Erythematosus Duchenne Muscular Dystrophy
 Childhood Hearing Loss Hydrocephalus
 Hypoxic-Ischemic Encephalopathy In-Utero Brain Injury / Stroke
 Sweat Gland Diseases Amyotropic Lateral Sclerosis
 Parkinson’s Disease Glaucoma
 Corneal Epithelial Wounds Diabetic Foot Ulcers

Related Umbilical Cord Blood Transplants Reported to EUROCORD

 Malignant Diseases Non-Malignant Diseases
 Acute Lymphoblastic Leukemia Metabolic Diseases
 Acute Myelogenous Leukemia Fanconi Anemia
 Myelodysplastic Syndrome Thalassemia
 Chronic Myelogenous Leukemia Sickle Cell Disease
 Non-Hodgkin’s Lymphoma Subacute Combined Immunodeficiency
 Hodgkin’s Lymphoma  Other
 Solid Tumors

References

  1. Gluckman E, Broxmeyer HE, Auerbach AD, et al. Hematopoietic reconstitution in a patient with Fanconi’s anemia by means of umbilical-cord blood from an HLA-identical sibling. N Engl J Med. 1989; 321: 1174-1178.
  2. D’Souza A, Fretham C. Current uses and outcomes of hematopoietic stem cell transplantation: CIBMTR Summary Slides, 2017. Available at: http://www.cibmtr.org
  3. Iafolla MAJ, Tay J, Allan DS. Transplantation of umbilical cord blood-derived cells for novel indications in regenerative therapy or immune modulations: A scoping review of clinical studies. Biol Blood Marrow Transplant. 2014; 20: 20-25.
  4. Cairo MS, Rocha V, Gluckman E, et al. Alternative allogeneic donor sources for transplantation for childhood diseases: unrelated cord blood and haploidentical family donors. Biol Blood Marrow Transplant. 2008; 14: 44-53.
  5. Cairo MS, Tarek N, Lee DA, et al. Cellular engineering and therapy in combination with cord blood allografting in pediatric recipients. Bone Marrow Transplant. 2016; 51: 27-33.
  6. Danby R, Rocha V. Improving engraftment and immune reconstitution in umbilical cord blood transplantation. Frontiers Immunol. 2014; 5: 68.
  7. Mazonson P, Kane M, Colberg K, et al. Prevalence of medical conditions potentially amenable to cellular therapy among families privately storing umbilical cord blood. Matern Child Health J. 2016 (online).
  8. https://clinicaltrials.gov
  9. Armson BA, Allan DS, and Casper RF. SOGC Clinical Practice Guideline. Umbilical Cord Blood: Counselling, Collection, and Banking. J Obstet Gynaecol Can. September 2015; 832-844.
  10. Gluckman E, Ruggeri A, Rocha V, et al. for Eurocord, Netcord, World Marrow Donor Association and National Marrow Donor Program. Family-directed umbilical cord blood banking. Haematologica. 2011; 96: 1700-1707.

Article supplied courtesy of Cord Blood Association

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