Donor Umbilical Cord Blood Research Articles

Reticular dysgenesis: international survey on clinical presentation, transplantation, and outcome

AbstractReticular dysgenesis (RD) is a rare congenital disorder defined clinically by the combination of severe combined immunodeficiency (SCID), agranulocytosis, and sensorineural deafness. Mutations in the gene encoding adenylate kinase 2 were identified to cause the disorder. Hematopoietic stem cell transplantation (HSCT) is the only option to cure this otherwise fatal disease. Retrospective data on clinical presentation, genetics, and outcome of HSCT were collected from centers in Europe, Asia, and North America for a total of 32 patients born between 1982 and 2011. Age at presentation was <4 weeks in 30 of 32 patients (94%). Grafts originated from mismatched family donors in 17 patients (55%), from matched family donors in 6 patients (19%), and from unrelated marrow or umbilical cord blood donors in 8 patients (26%). Thirteen patients received secondary or tertiary transplants. After transplantation, 21 of 31 patients were reported alive at a mean follow-up of 7.9 years (range: 0.6-23.6 years). All patients who died beyond 6 months after HSCT had persistent or recurrent agranulocytosis due to failure of donor myeloid engraftment. In the absence of conditioning, HSCT was ineffective to overcome agranulocytosis, and inclusion of myeloablative components in the conditioning regimens was required to achieve stable lymphomyeloid engraftment. In comparison with other SCID entities, considerable differences were noted regarding age at presentation, onset, and type of infectious complications, as well as the requirement of conditioning prior to HSCT. Although long-term survival is possible in the presence of mixed chimerism, high-level donor myeloid engraftment should be targeted to avoid posttransplant neutropenia.

Dose Escalation of Total Marrow Irradiation in High-Risk Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation

Patients with refractory leukemia or minimal residual disease (MRD) at transplantation are at increased risk of relapse. Augmentation of irradiation, especially to sites of disease (ie, bone marrow) is one potential strategy for overcoming this risk. We studied the feasibility of radiation dose escalation in high-risk patients using total marrow irradiation (TMI) in a phase I dose-escalation trial. Four pediatric and 8 adult patients received conditioning with cyclophosphamide and fludarabine in conjunction with image-guided radiation to the bone marrow at 15 Gy and 18 Gy (in 3-Gy fractions), while maintaining the total body irradiation (TBI) dose to the vital organs (lungs, hearts, eyes, liver, and kidneys) at <13.2 Gy. The biologically effective dose of TMI delivered to the bone marrow was increased by 62% at 15 Gy and by 96% at 18 Gy compared with standard TBI. Although excessive dose-limiting toxicity, defined by graft failure or excessive specific organ toxicity, was not encountered, 3 of 6 patients experienced treatment-related mortality at 18 Gy. Thus, we halted enrollment at this dose level and treated an additional 4 patients at 15 Gy. The 1- year overall survival was 42% (95% confidence interval [CI], 15%-67%) and disease-free survival was 22% (95% CI, 4%-49%). The rate of relapse was 36% (95% CI, 10%-62%), and nonrelapse mortality was 42% (95% CI, 14%-70%). This study shows that TMI dose escalation to 15 Gy is feasible with acceptable toxicity in pediatric and adult patients with high-risk leukemia undergoing umbilical cord blood and sibling donor transplantation.

Awareness of cord blood collection and the impact on banking

Umbilical cord blood (UCB) is an important source of hematopoietic stem cells for transplantation especially in minority populations with limited chances of finding a histocompatible volunteer donor in the registry. UCB has the advantages of early availability, successful outcomes despite some histocompatibility mismatch, and low incidence of chronic graft-versus-host disease. Public cord blood banks that disseminate UCB products for transplant depend on voluntary donation at participating hospitals and obstetrical providers for collection. Using survey questionnaires, we evaluated attitudes toward UCB donation, the frequency of donation, and provider opinions on UCB collection in the greater St. Louis metropolitan area that caters to minority ethnicities in significant numbers. Our data suggest that nervousness and lack of information regarding the donation and utility of the product were ubiquitous reasons for not donating. Additionally, irrespective of age or level of education, women relied on healthcare providers for information regarding UCB donation. Providers reported primarily time constraints to discussing UCB donation at prenatal visits (54%). Of the interviewees, 62% donated UCB. Fallout due to refusal or preferring private banking was miniscule. These results suggest that dedicated personnel focused on disseminating information, obtaining consent, and collecting the UCB product at major hospitals can enrich cord blood banks especially with minority cords. Sustained and focused efforts could improve upon a relatively high wastage rate and ensure a robust supply of UCB products at local public banks.

MDS disease characteristics, not donor source, predict hematopoietic stem cell transplant outcomes.

Myelodysplastic syndrome (MDS) is a heterogeneous group of hematological malignancies with considerably variable prognoses and curable only with hematopoietic cell transplantation (HCT). Few studies comparing MDS HCT outcomes between sibling and umbilical cord blood (UCB) donors exist. Using the University of Minnesota Blood and Marrow Transplant (BMT) database, we retrospectively analyzed HCT outcomes among 89 MDS patients undergoing either sibling or double UCB HCT in 2000–2013. We observed similar survival, relapse and non-relapse mortality between sibling and UCB donor sources. Relapse was increased in those with monosomal karyotype (P=0.04) and with reduced intensity conditioning (P<0.01). In summary, our data highlight similar MDS HCT outcomes regardless of donor source and support the use of UCB as an alternative donor when a sibling is unavailable.

Late Adherent Subpopulation in Umbilical Cord Blood Has the Same Characteristics and Hematopoiesis-Supporting Capacity As Mesenchymal Stromal/Stem Cells

Mesenchymal stromal/stem cells (MSCs) are a major source of cell for cell therapy. MSCs derived from bone marrow (BMMSCs) have been mostly used in clinical applications. BMMSCs can be easily isolated as a cell population that adheres to plastic culture dishes within 1 week of culture. A recent report has demonstrated that cells that remain in suspension and fail to form adherent colonies contain a fraction of late adherent cells that resembles BMMSCs (Biomed Res Int, 2013; 2013: 790842). Umbilical cord blood (UCB) is as accessible as bone marrow for the isolation of MSCs. In this study, we identified a late adherent subpopulation in UCB and determined its hematopoiesis-supporting activity.Forty-five UCB units, which were not matched to the eligibility criterion defined in the Japan UCB donation program, were collected after delivery of placenta. Written informed consent was obtained before delivery from all pregnant women who participated in the study. The study protocol was approved by the ethics committee of the Kyoto University Graduate School of Medicine.Mononuclear cells were isolated from UCB by the density gradient centrifugation method with (n = 19) and without (n = 18) subsequent separation of CD34 negative cells using anti-CD34 immunomagnetic microbeads (Miltenyi Biotec, Bergisch Gladbach, Germany). Nucleated cells were separated by the hydroxyethyl starch sedimentation method from the other eight UCB units. The cells were then seeded into a culture flask and cultured in alpha minimal essential medium supplemented with 15% FBS (Culture 1; C1). After 1 week of culture, non-adherent cells in C1 supernatant were collected and re-seeded into a new flask (C2). The attached cells in C1 were cultured until adherent colonies emerged, after which they were detached using trypsin/EDTA and twice passaged to obtain a sufficient number of cells (C1 cells). In the same way, after 1 week of culture, non-adherent cells in C2 supernatant were collected and re-seeded into a new flask (C3). The attached cells in C2 were cultured to obtain C2 cells. Afterwards, re-seeding and culture (C4, C5c) were repeated until no new colonies were formed. Collected cells were cryopreserved and thawed when required in experiments. BMMSCs were isolated from human bone marrow cells purchased from AllCells (Emeryville, CA).C1 cells, the so-called UCBMSCs, were successfully isolated from 18 units (40 %). Adherent cells isolated from C2 and later were defined as elate adherent cellsf and, were obtained from 9 units: these cells were referred to as C2 cells (from 9 units), C3 cells (from 9 units), C4 cells (from 6 units) and C5 cells (from 2 units). The interval from seeding to the first colony formation in C1 was shorter in these 9 units than that in the other 9 units that contained only C1 cells: 10.8 } 1.4 vs 15.9 } 4.5 days, p < 0.01. The volume of the former 9 units tended to be large compared to the latter 9 units: 49.6 } 10.5 vs 33.7 } 21.0 mL, p = 0.07. These findings indicated that UCB containing late adherent cells was suitable for a cell source of MSCs. Next, we examined whether these late adherent cells (C2 and C3 cells) had properties consistent with those of MSCs. Both C2 and C3 cells showed spindle-shaped fibroblast-like morphology and the same immunophenotype as C1 cells: positive for CD73, CD90 and CD105, and negative for CD34, CD45 and HLA-DR. They had osteogenic, adipogenic and chondrogenic differentiation potentials in vitro. These findings are the minimal criteria for MSCs (Cytotherapy, 2006; 8:315). Finally, we evaluated the hematopoiesis-supporting activity of these cells in vitro and in vivo. CD45-positive hematopoietic cells were expanded when co-cultured of CD34-positive hematopoietic progenitor cells (6 ~ 102 cells) with C2 or C3 cells (2 ~ 104 cells) in vitro as much as when co-cultured with C1 cells (Figure A). In vivo analysis was conducted by using subcutaneous transplantation of MSCs on NOD/SCID mice (Int J Hematol, 2015; 102: 218). C2 cells induced trabecular bone formation and bone marrow hematopoiesis as well as C1 cells, however, C3 cells did not induce hematopoiesis (Figure B).In conclusion, we demonstrated that UCB contains a late adherent cell subpopulation with the same characteristics and hematopoiesis-supporting activity as those of UCBMSCs isolated using the conventional method. The continuance of cell culture without discarding suspension cells could improve the efficiency of isolation of MSCs from UCB. [Display omitted] DisclosuresHirai:Kyowa Hakko Kirin: Research Funding; Novartis Pharma: Research Funding. Maekawa:Bristol-Myers K.K.: Research Funding.

Successful Engraftment of Donor Umbilical Cord Blood (UCB) Cells after Co-Transplantation of Nicord® (Ex Vivo Expanded UCB Progenitor Cells with Nicotinamide) and a Second Unmanipulated Cord Blood Unit after Myeloablative Chemotherapy in Pediatric Patients with Severe Sickle Cell Disease

Background: Patients with severe sickle cell disease (SCD) experience organ damage, poor quality of life, and are at high risk of premature mortality. To date, allogeneic hematopoietic stem cell transplant remains the only available curative therapy for SCD. However, patients with SCD have difficulties finding matched related or unrelated donors for transplantation. UCB could be an alternative graft option for most of the SCD patients but, to date, results with unrelated UCB have not been satisfactory for these hard to engraft patients. NiCord is an ex vivo expanded product manufactured from an entire UCB unit which has been shown to produce rapid and sustained engraftment in combination with a second unmanipulated CB unit or as a standalone graft in adult patients with high-risk hematologic malignancies. We hypothesized that the combination of NiCord with an unmanipulated UCB unit might overcome the engraftment barriers which have limited the success of UCBT in patients with SCD. This strategy is currently evaluated for safety and efficacy in a phase I/II multi-center study in pediatric patients with SCD undergoing myeloablative conditioning therapy. Here we report the results of the first 8 patients in the study.Methods: Patients with SCD and high risk features were eligible if they were between 2 and 45 years of age and if they had adequate performance status and organ function, 2 suitable unrelated UCB units that minimally matched the patient at 4/6 HLA alleles, and if they did not have a fully HLA matched related or unrelated adult donor. The NiCord graft, manufactured by the study sponsor, consisted of a CD133+ expanded cell fraction and an uncultured CD133- T-cell containing fraction. All patients received hydroxyurea beginning on day -35. Patients were subsequently prepared for transplantation with myeloablative chemotherapy: Busulfan/Cyclophosphamide and Anti Thymocyte Globulin (ATG). After the first 3 patients an adverse effect of ATG on the expanded graft was suspected and ATG was replaced by Fludarabine for the subsequent 5 patients. On day 0, the unmanipulated CB unit and NiCord graft were infused. Engraftment, GVHD incidence, treatment related mortality and survival were assessed by conventional parameters.Results: Eight patients, at a median age of 12 years (range 3-16 years) and a median weight of 41 kg (range 17-67 kg) were transplanted. HLA matching between patients and NiCord units was 4/6 (n=7) and 5/6 (n=1); and that between patients and unmanipulated units was 4/6 (n=5) and 5/6 (n=3). Median CD34+ cell dose infused in the NiCord graft was 107 x 105/kg. All 8 transplanted patients initially engrafted neutrophils at a median of 7 days (range 6-20 days) with the NiCord graft. One patient experienced secondary graft failure and died after a second transplant. Ultimately, long term engraftment was derived from NiCord in 2 patients, from the unmanipulated unit in 4 patients and mixed donor chimerism is still sustained in one patient. Patients were hospitalized for initial transplant for a median of 55 days (range 43-100 days). The 7 patients with sustained full donor cell engraftment are currently alive at a median follow-up of 33 months (range 3-45 months), transfusion free and without sickle cell related symptoms. Engraftment and clinical outcomes of the 8 patients are shown in Table 1.Conclusions: NiCord appears to overcome the engraftment barriers of UCB in patients with SCD. Remarkably, sustained donor cell engraftment was obtained in 7/8 patients, despite 4/6 matched UCB units and 5 patients without ATG. NiCord has the potential to increase access to transplantation for patients with SCD by enabling the successful use of unrelated UCB donors. Further optimization of this approach with strategies to further decrease GVHD is warranted. [Display omitted] DisclosuresMartin:Novartis: Other: Support of clinical trials; Jazz Pharmaceuticals: Other: One time discussion panel. Galamidi:Gamida Cell Ltd.: Employment. Peleg:Gamida Cell Ltd.: Employment. Goshen:Gamida Cell Ltd.: Employment. Schwarzbach:Gamida Cell Ltd.: Employment. Snyder:Gamida Cell Ltd.: Employment. Peled:Gamida Cell Ltd.: Employment.

Predictors of high-quality cord blood units.

Analysis of umbilical cord blood (UCB) transplants shows a correlation between engraftment and total number of infused cells. Thus, it is worth evaluating what maternal and neonatal characteristics and collection techniques may affect the quality of UCB units. A cross-sectional study was performed with 7897 donors sequentially selected in three health care institutions in Brazil from October 2004 to March 2012, in which both quantitative and qualitative approaches were applied. All donors were considered suitable for cord blood collection. The maternal and neonatal characteristics and techniques of collection that influenced the total number of nucleated cells (TNCs; p < 0.001) were type of delivery, newborn weight and sex, and institution of UCB collection. The TNC count was associated with gestational age (p = 0.008), type of delivery (p < 0.001), newborn sex (p < 0.001), newborn weight (p < 0.001), and UCB collection technique (p = 0.003). Center B presented the largest number of nucleated cells in its results (p < 0.001), followed by Center A (p = 0.001). Other characteristics, such as maternal age, were analyzed but were not relevant for the nucleated cell number. This study provides elements for a model that allows an efficient selection of UCB donors, prioritizing candidates who have a better chance to lead to an optimized use of cord blood cells units.

Health care professionals' knowledge, attitudes and practices relating to umbilical cord blood banking and donation: an integrative review.

BackgroundCollection and storage of an infant’s cord blood at birth is an option available to many new parents. Antenatal health care providers have an important role in providing non-biased and evidence based information to expectant parents about cord blood and tissue banking options. The aim of this paper was to identify and review studies of health care professionals’ knowledge, attitudes and practices concerning cord blood banking and the sources by which healthcare professionals obtained their information on this topic.MethodsAn integrative review was conducted using several electronic databases to identify papers on health care professionals’ knowledge, attitudes and practices pertaining to cord blood banking. The CASP tool was used to determine validity and quality of the studies included in the review.ResultsThe search of the international literature identified nine papers which met review inclusion criteria. The literature review identified that there was little focus placed on antenatal health care professionals’ knowledge of cord blood banking options despite these health care professionals being identified by expectant parents as their preferred, key source of information.ConclusionLimited high quality studies have investigated what health care professionals know and communicate to expectant parents regarding cord blood banking. Further research should focus on understanding the knowledge, attitudes and practices of healthcare professionals and how they communicate with expectant parents about this issue. In addition, how this knowledge influences professional practice around birth is also important, as this may positively or negatively impact the information that is provided to expectant parents.

Maternal obesity associated with increase in natural killer T cells and CD8+ regulatory T cells in cord blood units.

One of the major limitations of umbilical cord blood (UCB) as hematopoietic stem cell source is its restricted cell number. In mothers who are candidates for stem cell donation, there are variables that affect the quantity and quality of UCB units. The aim of this study was to determine if obstetric, maternal, and fetal factors modify the number of lymphocyte subsets in UCB units. This was a prospective, observational study. In UCB units, the numbers of CD34, NK, NKT, iNKT, Type 1 dendritic cells (DCs), Type 2 DCs, T γδ, T CD4+, T CD8+ lymphocytes, CD4+CD25+FoxP3+, and CD8+CD25+FoxP3+ T regulatory (Treg) cells were quantified by flow cytometry. Fifty-four UCB units were included; the donors' mean weight was 75 kg (range, 52 to 102 kg) and they had a mean body mass index (BMI) of 30 kg/m(2) (range 22 to 40 kg/m(2) ), of which 12 (22%) had a normal BMI, 14 (26%) were overweight, and 28 (52%) were obese. The mean number of CD34+ cells was 4.45 × 10(6) (range, 0.7 × 10(6) to 20.5 × 10(6) ). The number of NKT, CD3+, CD4+, CD8+, and CD8+CD25+FoxP3+ Treg cells was significantly higher in overweight or obese mothers; CD34+ cells were decreased in the same group. The number of iNKT and CD34+ cells was decreased in newborns weighing above the average. Maternal factors such as BMI, and fetal factors such as weight at birth, should be added to the selection criteria of UCB donors.

Loss of T Follicular Helper Cells in the Peripheral Blood of Patients with Chronic Graft-versus-Host Disease

B cell antihost antibody production plays a central role in chronic graft-versus-host disease (cGVHD). T follicular helper (TFH) cells drive B cell responses and are implicated in this process. Given differences in cGVHD incidence between umbilical cord blood (UCB) and adult donor transplant recipients, we evaluated TFH cell reconstitution kinetics to define graft source differences and their potential pathogenic role in cGVHD. Although we observed significantly fewer TFH cells in the blood of UCB recipients (versus matched related donors [MRD]) early after transplantation, by 1 year the numbers of TFH cells were similar. Additionally, at both early (day 60) and late (1 year) time points, TFH cell phenotype was predominantly central memory cells in both cohorts. TFH cells were functional and able to produce multiple cytokines (INF-γ, TNF-α, IL-2, IL-17, and IL-21) after stimulation. In contrast to mouse models, where an enhanced frequency of splenic TFH cells contributes to cGVHD, patients with cGVHD showed significantly depleted circulating TFH cells after both UCB and MRD transplantation. Low numbers of TFH cells early after UCB transplantation could directly contribute to less cGVHD in this cohort. Additionally, systemic therapy (including steroids and calcineurin inhibitors) may contribute to decreases in TFH cells in patients with cGVHD. These data provide further evidence supporting the importance of TFH cells in cGVHD pathogenesis.

Umbilical Cord Blood: A Novel Approach in Regenerative Therapeutics

Umbilical cord blood (UCB) is the most recently identified source of stem cells. The UCB stem cells are capable of giving rise to hematopoietic, epithelial, endothelial, and neural tissues both in vitro and in vivo. They are being increasingly used as an alternative hematopoietic stem cell source for treating many diseases. To date, over 6000 UCB transplant procedures in children and adults have been performed worldwide using UCB donors. It has advantages of easy procurement, no risk to donors, low risk of transmitting infections, immediate availability and immune tolerance allowing successful transplantation despite HLA disparity. This review will focus on the collection techniques, banking systems and various therapeutic potentials of UCB.

Alternative Donors (Umbilical Cord Blood and Haploidentical Donors) for Allogeneic Stem Cell Transplantation in Relapsed / Refractory Hodgkin Lymphoma: A Retrospective Analysis of the EBMT Lymphoma Working Party and the Spanish Group of Stem Cell Transplantation (GETH)

Introduction: Allogeneic hematopoietic stem cell transplantation (alloHSCT) is currently considered the standard of care for those patients with HL that relapse after autologous HSCT. Several studies have shown that fit patients with chemosensitive disease can benefit from alloHSCT using and identical sibling (SIB) or matched-unrelated (MUD) donors. Recently, encouraging results have been obtained using haploidentical donors (HAPLO) and post-transplantation cyclophosphamide (ptCY) as graft-versus-host disease prophylaxis (GVHD). Because information regarding the results of alloHSCT using alternative donors is still scarce, we aimed to compare outcome of umbilical cord blood (UCB) and HAPLO transplants with conventional SIB and MUD for HL.Patients and methods: Information of patients older than 17y with HL who received an alloHSCT from a SIB, MUD (8/8 antigen matched), UCB or a ptCY-based HAPLO between 2010-2013 was downloaded from the EBMT and GETH databases.Results: 773 patients with HL were identified meeting the inclusion criteria. 339 received a transplant from a SIB donor, 276 from a MUD, 101 from HAPLO, and 47 from UCB. A significant higher number of patients treated with alloHSCT from UCB and HAPLO donors received reduced intensity (RIC) regimens in comparison to SIB and MUD (76% and 88% vs. 69% and 69%, respectively, p=0.001). Bone marrow was more frequently used as source of stem cells in the HAPLO group in relation to SIB and MUD (61% vs 10% and 11%, respectively, p=0.001), Other variables such as sex, age, performance status, chemorefractory disease, and previous autologous SCT were balanced. Median follow-up after alloHSCT for all patients was 12 months (1-60). The 1-year probabilities of overall survival (OS) and progression-free survival (PFS) were 80% and 49% after SIB transplant, 69% and 54% after MUD, 65% and 40% after UCB, and 73% and 56% after HAPLO, respectively. The 1-year probabilities of non-relapse mortality (NRM) and relapse rate (RR) were 12% and 38% after SIB, 21% and 25% after MUD, 20% and 40% after UCB, and 18% and 27% after HAPLO. Multivariate analysis showed that, in comparison with standard SIB alloHSCT, UCB was associated with a trend to a higher NRM (p=0.08) and RR (p=0.06), leading to a significant lower OS and PFS (p=0.009, HR 2.1, 95% CI 1.2-3.6; p=0.02, HR 1.6, 95% CI 1.1-2.3; respectively). NRM was also significantly higher after MUD (p=0.004, HR 1.8, 95% CI 1.2-2.6), but in contrast, RR was lower (p=0.003 HR 0.6, 95%CI 0.5-0.9) with a lower OS (p=0.002, HR 1.6, 95% CI 1.2-2.1) and no significant differences in PFS. No significant differences were observed between HAPLO and SIB in NRM, RR, PFS and OS.Conclusions: This registry study suggests that in adults with advanced HL, the outcome of pt-CY-based HAPLO HSCT may be comparable to that of conventional SIB alloHSCT and MUD across multiple centers and conditioning regimens. These findings need to be corroborated by longer follow-up. [Display omitted] DisclosuresPeggs:Autolus: Consultancy, Equity Ownership; Cellectis: Research Funding. Milpied:Celgene: Honoraria, Research Funding. Afanasiev:CELLTRION, Inc.: Research Funding. Russell:Therakos: Other: shares. Sureda:Takeda: Consultancy, Honoraria, Speakers Bureau.

Evolving Criteria of Donor Selection for Allogeneic Transplant in Acute Myeloid Leukemia

Background. Similar probabilities of survival have been reported for patients transplanted from Matched Unrelated Donor (MUD), Umbilical Cord Blood (UCB) or Haploidentical (Haplo) donors as alternative hematopoietic stem cell sources. However, few studies have compared these results with those obtained in patients transplanted from HLA Id-siblings (Id-sib). Moreover, all reported studies are retrospective and the criteria of donor selection were not predefined. We report the intention to treat (ITT) analysis results on 238 patients with high-risk acute myeloid leukemia (AML) prospectively transplanted according to the policy of the Rome Transplant Network (RTN), a metropolitan transplant program established in Rome in 2006.Patients and Methods. For AML patients eligible to an allogeneic transplant, the RTN policy consists of an algorithm of donor choice based on a hierarchy according to the following criteria: 1) HLA identical sibling; 2) MUD ≥8/10 HLA 3) UCB as single unit selected on the base of cell dose and number of HLA disparities (0-1/6 HLA: TNC ≥2.5x107/kg and CD34 ≥1x105/kg; 2/6 HLA: TNC ≥3.5x107/kg and CD34 ≥2x105/kg); 4) G-CSF primed, unmanipulated bone marrow Haplo donor. Myeloablative (MAC) or reduced intensity (RIC) TBF (Tiothepa, Busulfan, Fludarabine) conditioning regimen was identical for all patients, GVHD prophylaxis was uniform for each categories. of transplantResults. From January 2006 to December 2014, 238(89%) out of 303 adult patients candidates to an allogeneic transplant for high-risk AML were considered eligible. Overall, a donor was available for 205 (86%) of 238 eligible patients. At time of the analysis, 17 of these 205 patients (8%) had lost the transplant eligibility and 4 (2%) were still scheduled for transplant, therefore 184/205 (90%) patients with an available donor were finally transplanted from Id-sib (n=76), MUD (n=38), UCB (n=17) or Haplo (n=53) donors. The 8-yrs overall survival (OS) of the 238 eligible patients from time of HLA typing and of the 184 transplanted patients from time of the graft was 40±4%and 43±4%, respectively. By excluding the low number of UCB recipients (n=17), the OS was particularly dismal for the 34 patients transplanted in advanced disease phase (7±4% at 4 yrs), whereas for the 132 patients transplanted in early (CR1+ CR2) phase the 8-yr OS was 56±5%: 58±7% for 61 HLA Id-sib, 50±8% for 40 Haplo and 63±10% for 27 MUD recipients (P=NS). The OS of patients transplanted in early phase was 63±5% for 97 patients receiving MAC and 33±9% for RIC recipients. For these 97 patients, the survival by type of donor was 62±10% either for 47 Id-sib or 28 Haplo and 70±10% for 22 MUD recipients (P=NS). The results were analyzed by various donor/recipient (D/R) combinations such as age, sex and CMV status. The median donor age was 39 years (range, 18-70) and the median patient age was 43 years (range, 16-59): the 8-yr OS of patients (n=30) with younger D/R combination (D<39y-R<43y) was79±9%, significantly higher than 55±7% observed for the other D/R combinations (P=0.04). The 4 D/R sex combinations were homogeneously distributed among Id-sib, MUD and Haplo recipients: for 51 sex mismatched (DM/RF; DF/RM) patients the 8-yr OS was 73±7%, significantly higher than the 53±8% rate observed for 46 sex matched patients (P=0.03). Finally, the 8-yr OS by D/R CMV status was 68±6% for 74 D/R CMV matched and 46±12% for D/R CMV mismatched patients (P=NS). In multivariate analysis, the factors influencing survival were D/R age (P=0.059), D/R sex (P=0.03) and D/R CMV status (P=0.04). The donor source (Id-sib vs MUD vs Haplo) did not affect survival (P=NS).Conclusions. RTN policy allowed donor identification in 86% of all eligible AML patients and allowed an allogeneic transplant to be carried out in 90% of them with no substantial differences in terms of long-term survival between initially eligible (ITT analysis) and definitively transplanted patients. Only the definition of a specific transplant policy and the ITT analysis allow to evaluate the real impact of a transplant program. As the probability of survival is not substantially different comparing different donor stem cell sources, the final conclusion which can be drawn from our study is that for patients with AML undergoing an allogeneic transplant, the HLA matching is unlikely to remain the first criterion for donor identification. Other factors such as D/R age, sex and CMV status should drive the search for the best donor. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Prospective Study of Peri-Transplant Use of Sorafenib As Remission Maintenance for FLT3-ITD Patients Undergoing Allogeneic Transplantation

▪Background: FLT3 ITD mutated acute myeloid leukemia remains a therapeutic challenge with very few patients experiencing prolonged disease free survival after standard therapies. FLT3 inhibitors have thus far demonstrated limited single agent activity in this disease. However, administration of FLT3 inhibitors during a state of minimal residual disease and a reconstituting immune system offers a promise of improved disease control.Methods: We designed a prospective trial for patients FLT3 ITD AML undergoing allogeneic transplant, to evaluate the safety, tolerability and outcome of the FLT3 ITD inhibitor sorafenib administered pre- and post-allogeneic transplant. To be eligible, patients needed to be in remission prior to transplant. At the discretion of the treating physician, sorafenib could be started prior to transplant after confirmation of remission and continued until three days prior to the start of the preparative regimen. Otherwise, all patients were started on sorafenib 200 mg twice a day, no earlier than Day +30 and no later than Day +120 post-transplant, after documented engraftment (Plts >50K, ANC >500). Dosing of sorafenib was based on individual patient tolerance: in tolerant patients sorafenib was escalated to 400 mg twice a day while dose reductions occurred for Grade 3 or 4 toxicities in a stepwise manner (200 mg BID, 200 mg QD, 200 mg QoD) until a tolerable dose was identified.Results: We have accrued to date 28 patients with a median age of 54, with FLT ITD AML undergoing allogeneic transplant who were started on sorafenib in the peri-transplant period (8 pre-transplant). Ten patients underwent myeloablative conditioning and received a transplant from a matched related donor (5), a matched unrelated donor (2) or a haploidentical donor (3). Eighteen patients underwent non-myeloablative conditioning and transplant using either a haploidentical donor (10), a matched sibling donor (4), a matched unrelated donor (3) or an umbilical cord blood donor (1). The median duration of post transplant follow up for active patients is 450 days (range, 107-1192 days). The median duration of sorafenib therapy for all patients is 252 days (range, 52-1081). The tolerability of sorafenib in the peri-transplant period varied among patients: 6 patients tolerated the maximum dose of sorafenib at 400 mg twice a day, 14 patients were maintained on 200 mg twice a day, seven patients were maintained on 200 mg daily and one patient was maintained on 200 mg every other day. Six patients died in the post-transplant period with three deaths due to relapsed leukemia and three from transplant-associated toxicity. No primary or secondary graft failures were observed but 9 patients developed grade 2 or higher GVHD (1-4 weeks after starting sorafenib) requiring escalation of immunosuppression therapy. Overall 5 pts have relapsed so far. Three of these patients were off therapy at the time of relapse. One patient relapsed with FLT3 ITD leukemia 117 days after stopping sorafenib at the 24 month planned stoppage time and is now back in remission after resuming sorafenib.Correlative studies evaluating FLT3 inhibition via a plasma inhibitory activity (PIA) assay showed consistent inhibition of FLT3 at all tolerability-determined dosing levels, suggesting that dosing can be safely adjusted in patients having adverse events without loss of FLT3 inhibition. Consistent with this finding was the fact that the adjusted sorafenib trough concentration exposure accounting for the active metabolite (sorafenib + (14.59*sorafenib N-oxide)) was highly variable (70% CV) and not statistically different across all dosing levels. Exploratory analysis of minimal residual disease monitoring, and of T regulatory cell populations and their relation to GVHD in the pre- and post-treatment peripheral blood, are ongoing.Conclusion: Sorafenib is well tolerated in the post-transplant setting irrespective of the conditioning intensity or the donor source. Our findings indicate that sorafenib dosing should be individualized in the post-transplantation setting according to patient tolerability. This approach results in effective in vivo FLT3 inhibition, and yields encouraging survival results, with 15 of 28 patients currently on therapy without relapse. This data supports the further study of sorafenib in a larger cohort to determine its overall effectiveness in preventing FLT3 ITD AML relapse post allogeneic transplant. [Display omitted] [Display omitted] DisclosuresOff Label Use: Sorafenib for off label usage in Acute Myeloid Leukemia.

Similar Survival after Umbilical Cord Blood (UCB) and HLA-Matched Adult Donor Transplantation By Disease Risk Index (DRI) Assignment

DRI incorporates both disease type and status at transplant and was found to be strong independent predictor of survival after allogeneic (allo) hematopoietic cell transplantation (HCT). Using the refined DRI assignment, we compared survival outcomes of UCB transplant (n=548: 314 with 5-6/6 and 231 with 4/6 HLA-matched units) to 8/8 HLA-matched adult donor HCT (n=528: 446 sibling and 82 unrelated; 78 bone marrow [BM] and 450 peripheral blood [PB] grafts) for hematological malignancies from 2000-2013. UCB and adult (BM/PB) groups had similar patient and transplant characteristics except UCB patients were slightly younger (47.5 year vs. 50.5 year; p <0.01), had more comorbid conditions at HCT (37.0% vs. 28.2% HCT-CI ≥3; p =0.03), and were more likely to receive reduced intensity conditioning regimen (67.7% vs. 55.9%; p <0.01). Three DRI groupings were identified: low risk (LR, 83 UCB and 110 BM/PB), intermediate risk (IR, 369 UCB and 329 PB) and high/very high risk (HR, 96 UCB and 89 BM/PB) groups. Adjusted estimates of OS at 2 years were similar with UCB or adult donors for all DRI groups (Figure). Multiple regression analysis compared outcomes of UCB with matched adult donor in each DRI group (Table). After adjusting for age and conditioning, grade III-IV acute GVHD incidence in all DRI groups was similar with both donor types. In contrast, UCB resulted in significantly lower rates of chronic GVHD in all DRI groups. Importantly, donor type was not an independent predictor of either TRM or relapse in any DRI group. In the LR-DRI group DFS was inferior with UCB, but in IR- and HR-DRI donor type had no influence on DFS after adjusting for comorbidities and CMV serostatus. Our data demonstrates that UCB is a valid alternative donor type for alloHCT, particularly those with IR and HR DRI. UCB grafts yield survival similar to matched adult donor alloHCT when DRI is considered. Low chronic GVHD risk makes UCB particularly attractive graft source for older patients.Table 1Adjusted clinical outcomes by graft source based on DRIDRIGroupGraftSourceNaGVHDGrade III-IVcGVHDTRMRelapseDFSOSHR(95%CI)PHR(95%CI)PRR(95%CI)PRR(95%CI)PHR*(95%CI)PHR†(95%CI)PLow riskBM/PB UCB110 831.0 0.68 (0.36-1.26).821.0 0.32 (0.18-0.57)<.011.0 1.47 (0.72-3.00).291.0 1.83 (0.96-3.48).071.0 1.70 (1.06-2.72).031.0 1.34 (0.75-2.41).32Intermediate RiskBM/PB UCB329 3691.0 1.01 (0.73-1.39).961.0 0.50 (0.38-0.67)<.011.0 1.08 (0.76-1.52).661.0 0.95 (0.72-1.26).741.0 0.91 (0.74-1.14).421.0 1.17 (0.91-1.50).23High/very- high riskBM/PB UCB89 961.0 0.75 (0.39-1.45).401.0 0.76 (0.60-0.96).021.0 1.57 (0.85-2.90).151.0 0.68 (0.41-.110).121.0 1.06 (0.73-1.54).761.0 1.36 (0.90-2.06).15HR indicates hazard ratio; RR, relative risk. *Denotes hazard ratio of death/relapse. †Denotes hazard ratio of death. [Display omitted] DisclosuresBachanova:Seattle Genetics Inc.: Consultancy, Research Funding.

The impact of fetal and maternal physiologic factors on umbilical cord blood quality as a source of stem cells in Egyptian population.

Umbilical cord blood (UCB) has rapidly become a clinically useful alternative stem cell source. Many variables have been used to evaluate a UCB unit and predict transplant outcomes. The objective of this study was to measure the expression of hematopoietic stem cells in UCB and its relation to certain maternal and neonatal physiologic factors to establish optimum criteria for UCB donor selection. Two hundred UCB units were collected from normal uncomplicated vaginal and cesarean deliveries. Total volume was noted and immediately assessed for total nucleated cell (TNC) count and CD34+ cell concentration. Assessment of maternal and neonatal variables such as mode of delivery, placental weight, baby's birthweight, and sex was made. The volume of the donations ranged from 42.0 to 126 mL, the TNC count ranged from 5 × 10(9) to 28.7 × 10(9) cells/L, and CD34+ cells ranged from 0.03% to 0.62%. There was a significant positive correlation between cord blood volume and cesarean section (p = 0.01) and placental weight (p = 0.02). There was a significant positive correlation with a p value of less than 0.05 between the number of CD34+ cells and UCB volume and TNC. There was no significant difference between the variables and the TNC count. Our study concludes that cord units collected for banking should be obtained by selecting units of larger volumes, of higher TNCs, from female babies with heavy placenta, and from babies delivered via cesarean section.

Characterization of copy number variations (CNV) in the NKG2C receptor gene

The cytolytic function of natural killer (NK) cells is controlled by a balance of activatory and inhibitory signals transduced by specific NK-cell receptors. NKG2 family is one of the superfamilies of these receptor genes located on chromosome 12 in the NKC gene complex. NKG2C is expressed as heterodimers with CD94 and they deliver activating signals upon contacting HLA-E via adaptor molecules. NKG2C genes are not only polymorphic and also NKG2C gene deletion was identified. The aim of the study was to develop a genotyping assay for the detection of the wild type and the deletion of the NKG2C gene. Method Copy numbers of the NKG2C genes were genotyped and assessed in 352 subjects by PCR-SSP method using a set of primer pairs described previously (Mararu M & Miyashita R, etc.). Two pairs of primers are used to detect the NKG2C genotypes: one pairs to amplify a 201 bp fragment from NKG2C wild type (wt) carrier; and the second pairs to amplify a 411 bp fragment from NKG2C deletion (del) carrier. A single-tube PCR-SSP genotyping strategy combining the two sets of primers was modified from Moraru M, etc. (Tissue Antigens, 2012). Results The presence or absence of NKG2C gene was determined by the single-tube PCR-SSP assay. Three genotypes were observed in the study subjects: wild type homozygous carrier (wt/wt), wild type and deletion heterozygous carrier (wt/del), and deletion homozygous carrier (del/del). Copy number of NKG2C in 3 International Histocompatibility Workshop (IHW) cells was assessed and confirmed: IHW 9043 as NKG2C wt/wt , IHW 9047 as NKG2C wt/del , and IHW 9044 as NKG2C del/del . Of the 352 subjects, wt/wt genotype accounted for 62.82% ( n = 221), wt/del for 32.88% ( n = 116), and del/del for 4.3% ( n = 15). The allele frequency of NKG2C deletion was 20.74% in this study group. Conclusion Studies have shown that NK cells expressing the activating receptor NKG2C preferentially expand after coculture with cytomegalovirus (CMV) infected fibroblasts and CMV-induced innate memory cells may contribute to malignant disease relapse protection and infectious disease control after transplantation. NKG2C deletion was shown to be a risk factor of HIV infection. Further study of the impact of the NKG2C CNV on outcomes of stem cell transplants with umbilical cord blood, related or unrelated donors would be warranted.

Umbilical cord blood donation: public or private?

Umbilical cord blood (UCB) is a graft source for patients with malignant or genetic diseases who can be cured by allogeneic hematopoietic cell transplantation (HCT), but who do not have an appropriately HLA-matched family or volunteer unrelated adult donor. Starting in the 1990s, unrelated UCB banks were established, accepting donations from term deliveries and storing UCB units for public use. An estimated 730 000 UCB units have been donated and stored to date and ~35 000 UCB transplants have been performed worldwide. Over the past 20 years, private and family banks have grown rapidly, storing ~4 million UCB units for a particular patient or family, usually charging an up-front and yearly storage fee; therefore, these banks are able to be financially sustainable without releasing UCB units. Private banks are not obligated to fulfill the same regulatory requirements of the public banks. The public banks have released ~30 times more UCB units for therapy. Some countries have transitioned to an integrated banking model, a hybrid of public and family banking. Today, pregnant women, their families, obstetrical providers and pediatricians are faced with multiple choices about the disposition of their newborn's cord blood. In this commentary, we review the progress of UCB banking technology; we also analyze the current data on pediatric and adult unrelated UCB, including the recent expansion of interest in transplantation for hemoglobinopathies, and discuss emerging studies on the use of autologous UCB for neurologic diseases and regenerative medicine. We will review worldwide approaches to UCB banking, ethical considerations, criteria for public and family banking, integrated banking ideas and future strategies for UCB banking.

Impact of maternal and neonatal factors on parameters of hematopoietic potential in umbilical cord blood

Objectives:To determine characteristics of laboratory parameters of hematopoietic potential in umbilical cord blood and their association with maternal and neonatal factors.Methods:This prospective analysis was performed on 206 umbilical cord blood donations (50-200 ml) from King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia between January and September 2014. Samples were processed and analyzed for total nucleated cells (TNC’s), cluster designation (CD)45+, CD34+ counts, nucleated red blood cells (NRBCs) count, and viability testing.Results:Most of the study participants (63.6%) were on their first 3 deliveries and from women with age between 17 and 30 years (80.6%). The donated volume was 50.4-192.4 ml, TNCs ranged from 500.2×106 to 9430.3 ×106 cells, and CD34+ cells ranged from 1.25×106 to 12.82×106/unit. The volume was positively affected by bigger birth weight of the baby (p<0.0001), larger placenta (p=0.001), TNCs (p<0.0001), CD34+ (p<0.0001), NRBCs (p<0.0001), and viability (p=0.002). There were no statistically significant differences between baby boys and girls for laboratory variables.Conclusion:In the selection and identification of a possible donor of umbilical cord blood, several maternal and neonatal factors should be considered, as younger maternal age, neonatal birth weight >3300 grams, larger placental size, and first or second-born babies, were shown to be associated with higher TNCs, CD34+, CD45+, NRBCs, and viability.

Who is the best alternative allotransplant donor?

Assuming that most physicians will chose an HLA-identical sibling as the best allotransplant donor, the question arises who is the best alternative donor when an HLA-identical sibling is unavailable? The most commonly used alternative donors are HLA-identical or -mismatched unrelated donors, HLA-matched or -mismatched umbilical cord blood donor or a related, HLA-haplotype-matched related donors. Each alternative donor option has advantages and disadvantages. We discuss selected aspects of these issues based on data from randomized clinical trials and observational databases. However, because there are limited data to address specific clinical settings, quantification of expert opinion is sometimes needed.