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Double unrelated cord blood transplant (dUCBT) has been used to circumvent cell dose limitation of single UCBT; however, few data are available describing outcomes, infectious disease, and immune recovery. We analyzed 35 consecutive dUCBT recipients with high-risk malignant disorders (n=21) and bone marrow failure syndromes (n=14). Median follow-up was 32 months. Conditioning regimen was myeloablative in 14 and reduced intensity in 21 patients. Median infused nucleated cell dose was 4 × 10(7) /kg. Median time to absolute neutrophil count >0.5 × 10(9) /L was 25 days. Cumulative incidence (CI) of acute grade II-IV graft-versus-host disease was 47%. Estimated overall survival at 2 years was 48%. CI of first viral infections at 1 year was 92%. We observed 49 viral infections in 30 patients, 34 bacterial infections in 19 patients, and 16 fungal or parasitic infections in 12 patients. Lymphocyte subset analyses were performed at 3, 6, 9, and >12 months after dUCBT. Decreased T-cell and B-cell counts with expansion of natural killer cells were observed until 9 months post transplantation. Recovery of thymopoiesis measured by T-cell receptor excision circles was impaired until 9 months after dUCBT, when the appearance of new thymic precursors was observed. Delayed immune recovery and high incidence of infectious complications were observed after dUCBT in patients with high-risk hematological diseases.

BACKGROUND: In allogeneic bone marrow transplantation (BMT), a higher nucleated and CD34+ cell dose has been reported to improve various outcomes. Other cell types, such as lymphocyte subsets, also influenced BMT results. While nucleated red blood cells (NRBCs) represent a subset of bone marrow (BM) cell subpopulation, the question of their quantification in BM grafts and the impact of BM processing on their recovery has not been addressed. STUDY DESIGN AND METHODS: In a prospective study on 77 BM products, NRBCs were enumerated by flow cytometry and the recovery analyzed after manipulation. Because NRBCs could compromise white blood cell count, the impact of NRBC count on CD34+ cell percentage and total nucleated cell (TNC) dose were also determined. RESULTS: The mean percentage of NRBCs in BM grafts was 21.6 percent (range, 7.8%-40.9%). Mean NRBC recoveries after BM concentration or RBC depletion were 98.4 and 28.7 percent, respectively, close to those obtained for TNC cells (88.6 and 31.3%, respectively). When corrected with NRBC count, the mean percentages of corrected CD34+ cell and TNC dose were significantly modified when compared with uncorrected values, whatever the type of BM manipulation. CONCLUSION: Our data show that NRBC quantification might be of importance to improve quality control of BM products and to evaluate the influence of NRBCs cell dose on outcomes after BMT.

The incidence and potential clinical consequences of bacterial contamination of autologous and allogeneic BM products remains open to question. We report our experience of bacterial contamination of BM grafts and adverse events that occurred after transplantation.From January 2003 to February 2006, 257 BM harvests were processed and infused at our institution. Analysis of microbial contamination incidence before and after processing, sensitivity spectra of isolated bacteria and adverse events after graft infusion were analyzed.Nineteen of 257 BM (7.4%) were contaminated. Coagulase-negative Staphylococcus (n=9) and Propionibacterium acnes (n=6) were the most frequently isolated microorganisms. Two of nine coagulase-negative staphylococci were found to be resistant to erythromycin and two of six P. acnes to fosfomycin and gentamycin. The frequency and severity of immediate adverse events reported in patients receiving a contaminated graft were similar to those observed in patients receiving a non-contaminated product. No major adverse sequelae occurred after infusion of contaminated grafts. Finally, none of the patients transplanted with a contaminated graft developed bacteriemia that could have been related to the isolated microorganism.Microbial contamination of BM progenitor cell grafts does not induce severe clinical complications or infectious diseases after infusion. The vast majority of isolated pathogens were skin contaminants.

BACKGROUND: Red cell (RBC) depletion is needed to bypass ABO mismatch in allogeneic bone marrow transplantation (BMT). Technical and clinical data obtained after bone marrow (BM) processing with a continuous-flow cell separator (Cobe Spectra, Gambro BCT) are reported. STUDY DESIGN AND METHODS: RBC depletion and recovery of nucleated cells, CD3+ cells, CD34+ cells, and colony-forming unit–granulocyte-macrophage were calculated. Bacteriologic contaminations, side effects of graft infusion, and hematopoietic recovery were analyzed. RESULTS: A total of 114 BM samples were processed. The mean volume collected was 1099 mL (range, 390-2450 mL). Initial and residual mean RBCs volumes were 309.9 and 4.0 mL corresponding to a depletion of 98.6 ± 0.78 percent. Before processing, the mean numbers of nucleated cells, granulocytes, CD3+ cells, CD34+ cells, and CFU-GM were 20.28 × 109, 12.79 × 109, 1.96 × 109, 356.7 × 106, and 195.6 × 105, respectively. The mean corresponding recoveries after processing were 33.66, 48.98, 82.02, 82.2, and 93.9 percent. Limited side effects were observed in 14 patients without correlation with residual RBCs volume. All but two patients engrafted. CONCLUSION: BM processing with the Cobe Spectra cell separator provides high rates of RBC depletion without significant side effects after BMT.

Objectives Platelet products have been proposed as adjuvant therapy for wound healing. We undertook this study to determine the healing effect of topically applied frozen autologous platelets (FAP) on chronic venous ulcers, compared with effect of placebo, and whether use of topical FAP modifies local expression of vascular endothelial growth factor (VEGF), keratinocyte growth factor (KGF), interleukin 8 (IL-8), and tissue inhibitor of metalloproteinase-1 (TIMP-1) in wound fluid. Methods This randomized, placebo-controlled, double-blind trial was carried out in institutional practice, with ambulatory patients with proved chronic venous leg ulcers. In all patients, whole venous blood was drawn for preparation of FAP. FAP or normal saline solution was applied three times per week for up to 12 weeks, together with hydrocolloids and standardized compression bandages. Leg ulcer surface was assessed with numerical pictures. IL-8, VEGF, KGF, and TIMP-1 levels were determined (enzyme-linked immunosorbent assay) in wound fluid after each 4 weeks of treatment. Results Fifteen patients were randomized into two groups with comparable leg ulcer characteristics. Mean percent reduction in ulcer area was 26.2% in the FAP group versus 15.2% in the placebo group ( P = .94). One ulcer in each group was completely healed at study end. Levels of TIMP-1 increased significantly during FAP treatment. IL-8 concentration was significantly lower in wound fluid of healing ulcers than in the fluid of nonhealing ulcers, in both FAP and placebo groups. Growth factor levels were not modified with FAP treatment. Conclusion Topical autologous platelets have no significant adjuvant effect on healing of chronic venous leg ulcers and increased wound fluid TIMP-1 concentration. Ulcer healing is associated with a decrease in wound fluid IL-8.

Allogeneic transplantation is the only curative treatment for Fanconi anaemia (FA) patients who develop myeloid malignancies. Dose-intensive preparative regimens, to decrease disease recurrence, lead to unacceptable transplant-related toxicity in FA. We report the outcome of three FA patients with such malignancies who underwent transplantation with reduced-intensity preparative regimens. This approach was well tolerated, even as second transplantations, and resulted in complete leukaemic remissions. However, the graft-versus-leukaemia effect was associated with fatal graft-versus-host disease. Even after transplantation, myeloid malignancies remain associated with a poor outcome in FA, and this argues in favour of early intervention when suitable donors are available.

In order to study the influence of bone marrow CD34(+) cell dose on the outcome of allogeneic bone marrow transplantation (BMT), we analysed the results of BMT from HLA-identical siblings donors in 50 patients with chronic myeloid leukaemia (CML). The median numbers of nucleated cells (NC) and CD34(+) cells infused were 2.18 x 10(8)/kg (0.05-4.14 x 10(8)/kg) and 3.12 x 10(6)/kg (0.35-8.52 x 10(6)/kg), respectively. All patients engrafted. In univariate analysis, there was no correlation between the number of CD34(+) cells infused and the time to neutrophil recovery (P = 0.17). The Kaplan-Meier estimate of grade II-IV acute graft-versus-host disease (GVHD) at day 100 was 53 +/- 14% and 2-year survival was 46 +/- 15%. A number of CD34(+) cells infused greater than the median was the main factor increasing survival (P = 0.0006) and decreasing 100 day transplant-related mortality (P = 0.009). Patient-, disease- and transplant-related characteristics were not statistically different among patients receiving more or less than the median number of CD34(+) cells. The rate of infectious deaths was significantly higher in patients receiving less than 3.12 x 10(6) CD34/kg (48% vs 16%, P = 0.01). In a multivariable analysis, two factors associated with increased risk of death were advanced disease status at transplant (HR: 2.5 (95% CI: 1.09-5.75), P = 0.03) and a lower number of marrow CD34(+) cells infused/kg (HR: 4.55 (95% CI: 1.87-10.90), P = 0.0008).

Summary: Glanzmann’s thrombasthenia is an autosomal recessive disorder characterized by a lack of platelet aggregation due to the absence of platelet glycoprotein IIb and IIIa. Usually, the disease leads to mild hemorrhage but sometimes bleeding is severe enough to be life-threatening. We report the case of a 16-year-old girl, presenting with very severe type 1 Glanzmann’s thrombasthenia, successfully treated with an HLA-identical sibling bone marrow transplant (BMT). We also update the clinical and laboratory data of her brother, who had received a BMT 16 years ago for the same disease. In the light of these two cases and two others published in the literature, we discuss the indications for BMT from HLAidentical sibling donors in Glanzmann’s thrombasthenia. Alloimmunization against the missing platelet GPIIb/IIIa complex and severity of bleeding episodes may constitute sufficient criteria for allogeneic BMT after careful assessment of the risk-benefit of such a procedure, although this remains exceptional in this disease. Bone Marrow Transplantation (2000) 25, 327‐ 330.

Hematopoietic progenitor cells are present in umbilical cord blood; placental blood (PB) previously considered as waste product now constitutes an alternative source of hematopoietic stem cells for bone marrow reconstitution. This has promoted the establishment of cord blood banks for use in unrelated transplants. The banking of PB offers many advantages: the donors do not require anesthesia, stored PB can be a valuable source of stem cells for patients from ethnic minorities underrepresented in volunteer registers, and stored PB can be made available much faster than bone marrow from unrelated donors. Preliminary clinical experience suggests that, due to the immunological immaturity of PB cells, graft versus host disease might be lower than when using bone marrow from adult donors and HLA restrictions might be less stringent. If the number of nucleated cells in PB often appears low for patients weighing more than 40 kg, clinical data suggest that the number of stem cells may be sufficient for adult transplantation. The number of cord blood banks throughout the world is increasing rapidly. In the USA and Europe, more than 10,500 PB units are stored and available for transplantation. In the next 5 years, a total of 50,000 PB will be reached which may be sufficient to provide for the majority of candidates for unrelated BM transplantation. The practices of umbilical cord blood collection, mother selection, infectious disease screening, cell manipulation and storage must be standardized. Some accreditation process should be mandatory for assessing operating procedures and the quality assurance programs of the banks, and for allowing the international exchange of placental blood between transplant centers.

Umbilical cord blood collected and cryopreserved at birth contains enough hematopoietic progenitor stem cells for engraftment. HLA identical sibling cord blood transplantation has been performed for the first time in a child with Fanconi's anemia. This child is alive 3 years later with a complete donor type bone marrow. Since this first attempt, several other patients with other diseases have been transplanted successfully. Cord blood banking is a safe and easy procedure. Due to the high proliferative capacity of neonatal hematopoietic progenitors and to the relative immunological functional immaturity of neonatal lymphocytes, cord blood cells could be used for matched unrelated or partially mismatched transplants.

Major ABO incompatibility between donor and recipient is not considered a barrier to successful allogeneic hematopoietic stem cell transplantation (HSCT), even if it can be associated with several immunohematologic complications. Nevertheless, conflicting data still exist as to its influence on graft-versus-host disease (GVHD) incidence, relapse rate, and survival. To further investigate the relevance of ABO major mismatch on transplantation outcome, we retrospectively analyzed results from 414 patients with major or major/minor ABO-mismatched bone marrow (BM), peripheral blood (PB), and cord blood (CB) allogeneic HSCT. Transplantation outcome was assessed by comparison with results from a 395-patient ABO-compatible population with similar characteristics. Median time to red cell transfusion independence was significantly longer in ABO-incompatible BM recipients (median time, 63 days vs 41 days; P =.001), with faster disappearance of antidonor IgM hemagglutinins in unrelated recipients (median time, 36 days vs 44 days; P = .03) and in patients with gradeor =II acute GVHD (aGVHD) (median time, 35 days vs 59 days ; P = .001). In PB stem cell (PBSC) and CB transplantation, erythroid reconstitution was not significantly delayed, regardless of donor type or presence of aGVHD. A slight correlation between ABO incompatibility and GVHD incidence was found in PBSC recipients when considering gradeor =II aGVHD incidence (63% in ABO-matched HSCT vs 83% in ABO-mismatched HSCT; P = .055), but this was not confirmed in multivariate analysis. In patients with acute leukemia, multivariate analysis revealed an association between major ABO mismatch and decreased relapse rate with borderline statistical significance (hazard ratio, 0.65; P = .04). Major ABO incompatibility mainly, if not exclusively, affects red blood cell engraftment after BM transplantation. Somewhat surprisingly, the graft-versus-plasma cell effect seems to be confined to this stem cell source.

Since 1980, 107 consecutive patients (pts) underwent bone marrow transplantation (BMT) for nonconstitutional severe aplastic anemia (SAA) at our institution. All received conditioning with Cytoxan (150 mg/kg) and thoraco-abdominal irradiation (6 Gy) from an HLA-identical sibling donor. Mean age was 19 years (5 to 46 years). Forty-nine pts had less than 0.2 x 10(9)/L PMN and 53 failed to respond to previous immunosuppressive therapy before BMT. Graft-versus-host disease (GVHD) prophylaxis consisted of methotrexate (22 pts), cyclosporine (52 pts), or both (33 pts). With a median follow-up of 45 months (12 to 120 months), overall actuarial survival was 68% (confidence interval 95%:9.7). Of 16 factors tested, five were shown to adversely influence survival by multivariate analysis: grade greater than or equal to 2 acute GVHD (relative risk [RR]: 5.5), prior immunosuppressive therapy (RR: 3.5), female as donor (RR: 2.4), nonidiopathic SAA (RR: 2), and more than 0.2 x 10(9)/L PMN AA (RR: 2). Because acute GVHD was the most potent factor for survival, we analysed risk factors for acute GVHD. By multivariate analysis, 2 of 14 factors tested were independent: male as recipient (RR: 3) and previous alloimmunization of the donor (RR: 4.3). On long-term follow-up, chronic GVHD was observed in 49 pts of 89 surviving more than 100 days (55%). Multivariate analysis showed that infection before transplant (RR: 1.3) and previous history of acute GVHD (RR: 1.8) were associated with an increased risk of chronic GVHD.

Summary Patients with bone marrow failure syndromes (BMFS) who reject a first allogeneic transplant or fail immunosuppressive therapy (IST) have an especially grim prognosis. We report 14 patients (eight adults, six children) transplanted with double cord blood transplantation (dUCBT) for BMFS. Neutrophil recovery was observed in eight patients, with full donor chimerism of one unit, and acute GVHD in 10. With a median follow-up of 23 months, the estimated 2 years overall survival was 80 ± 17% and 33 ± 16% for patients with acquired and inherited BMFS, respectively. Transplantation of two partially HLA-matched UCB thus enables salvage treatment of high-risk patients with BMFS.

Prostaglandin E1 (PGE1) was used to prevent veno-occlusive disease (VOD) of the liver after allogeneic bone marrow transplantation (BMT) for leukaemia. It was given in continuous i.v. infusion from day--8 to day 30 after BMT at a dose of 0.3 micrograms/kg/h. The patients were studied according to the risk factors for VOD: diagnosis, intensification of the conditioning and previous liver abnormalities. The diagnosis of VOD was made on at least two of the following factors: weight gain, hepatomegaly, jaundice, ascitis, pain of the right upper quadrant, increased platelet consumption. 109 patients were studied, 50 were treated by PGE1 and 59 did not receive it. The actuarial incidence of VOD was 12.2% in the PGE1 group and 25.5% in the non PGE1 group (P = 0.05). In acute leukaemia, the incidence was 39.1% in the non-treated group and 12.8% in the PGE1 treated group (P = 0.02). Patients with previous hepatitis had an incidence of 62.5% in the non treated group and 15.5% in the treated group (P = 0.05). A positive cytomegalovirus (CMV) serology seemed to increase the risk of VOD: the incidence of VOD was 31.4% in non-treated patients and 22% in PGE1 treated patients. The multivariate analysis of the risk factors for VOD shows that unfavourable factors were: recipient positive CMV serology (P = 0.06), hepatic disease prior to transplant (P = 0.02) and the absence of PGE1 treatment (P = 0.02). This study suggests that prophylactic PGE1 treatment may decrease the incidence of VOD in patients treated for leukaemia by allogeneic bone marrow transplantation.

Graft failure (GF) can be a fatal complication following haematopoietic stem cell transplantation (HSCT). We report four patients who developed early GF after unrelated HSCT and who subsequently received a double unrelated cord blood transplant (dUCBT) after reduced-intensity conditioning, at a median 15 d after the decision to perform a second transplant. Neutrophil recovery was observed in all four patients between day +15 and +31 with full donor chimaerism of one unit. Acute GVHD grades II-IV was observed in three patients. Three are alive, between 12 and 25 months after dUCBT. In conclusion, dUCBT is a promising procedure to treat early GF.

We recently reported an increased incidence of cirrhosis in hepatitis C virus (HCV)-infected stem cell transplant (SCT) recipients. Here, we describe our experience in the treatment of these patients, which has been, to date, poorly reported in the literature. Among 99 HCV-infected HCT recipients, 36 had HCV-related liver lesions on biopsy requiring therapy. Owing to HCV treatment contraindications, only 61% of patients (22/36) could be treated. In all, 12 patients received more than one course of anti-HCV treatment if they had HCV RNA still detectable after the first course of treatment and no treatment contraindications. Combined therapy (pegylated interferon (IFN): n=9, or standard IFN: n=9, in combination with ribavirin) led to sustained virological response in 4/18 (20%) patients as compared to 2/20 (10%) in patients who received IFN alone. Hematological toxicity was more frequent with combined therapy. While anemia responded to erythropoietin and/or dose modification, thrombocytopenia usually led to treatment interruption (n=3). This study thus highlights the efficacy of combined therapy and emphasizes the fact that the undue safety concerns are not a problem when treating this particular population.

From January 1978 to December 2001, 133 patients with severe aplastic anemia (SAA) underwent non-T cell-depleted allogeneic bone marrow transplantation from an HLA-identical sibling donor, at the Hospital Saint Louis using either the combination of cyclophosphamide (Cy) and thoracoabdominal irradiation (TAI; n = 100) or Cy and antithymocyte globulin (ATG; n = 33), as a conditioning regimen. With 13.6 years of follow-up, the 10-year survival estimate was 64%. Four factors were associated with lower survival: older age, use of Cy-TAI, any form of treatment prior to transplantation (either androgens or immunosuppressive therapy, [IST]), and grade II to IV acute graft-versus-host disease (GvHD). TAI was the sole factor associated with the occurrence of acute GvHD. The risk of cancers (15-year cumulative incidence, 10.9%) was associated with older age and with the use of cyclosporine as IST before transplantation. Cumulative incidences and risk factors of nonmalignant late effect including avascular osteonecrosis and late bacterial, viral, and fungal infection were also analyzed. Improved results using Cy-ATG as conditioning can lead to more than 90% chance of cure in patients with SAA. Even if, in our experience, the role of Cy-ATG versus that of Cy-TAI remained inextricably related to the year of transplantation, the major detrimental role of the GvHD disease in the long-term outcome and its relation to TAI supports avoidance of irradiation in the conditioning regimen. Furthermore, avoidance of any IST before transplantation in patients with a sibling donor is a prerequisite for attaining such excellent results.

To assess whether Fanconi anemia (FA) patients might be at risk for acute graft-versus-host disease (AGvHD) despite using low-intensity conditionings, we retrospectively analyzed the incidence of AGvHD and its impact on outcome in 37 FA patients and 73 patients with acquired aplastic anemia (AAA) that received transplants at Saint Louis Hospital from HLA-genotypic identical siblings with similar conditionings (thoraco-abdominal irradiation plus cyclophosphamide 20 [FA] or 150 mg/kg [AAA]). Despite being younger, FA patients had an increased risk of grades II to IV AGvHD (relative risk [RR], 2.00; P = .021), especially in younger patients (RR, 7.93; P = .014). The risks of requiring systemic corticosteroids to treat AGvHD and experiencing cortico-resistant AGvHD were significantly increased in FA patients. Although non-FA and FA patients had similar 10-year outcomes, acute and chronic GvHD had a biphasic effect on FA patient outcome with an additional cluster of lethal events starting by 5 years after transplantation. This late survival fall, restricted to FA patients, was closely related to head and neck carcinomas (15-year incidence: 53%). FA patients represent a group at risk regarding AGvHD when using irradiation-based conditionings. The impact of AGvHD on survival may not be limited to the early posttransplantation period and may be a major risk factor for head and neck carcinomas and late mortality in FA patients.

To study the prevalence and clinical features of hepatitis G virus (HGV)/GB virus C (GBV-C) infection in bone marrow transplantation (BMT), we examined frozen serum samples from 95 bone marrow allograft patients for HGV/GBV-C RNA by RT-PCR. Twenty-eight out of 95 (29.5%) were positive and 14 of the HGV+ patients were already positive before transplantation. The mean numbers of blood donors to whom the HGV and HGV+ populations were exposed before BMT were not significantly different (Kruskal-Wallis test, P = 0.08, NS) but did reveal that the HGV+ population had been transfused more often. Moreover, all but one of the patients who were HGV+ before graft, had had hematological diseases which needed heavy transfusion protocols suggesting, a role of blood products in HGV transmission. Fifty out of the 95 patients received Gammagard intravenous immunoglobulin (i.v.IG) batches suspected of having transmitted HCV. However, no significant difference appeared between these recipients and those receiving other i.v.IG. Despite their immunodeficiency, no clinical or biological evidence of liver disease potentially linked to HGV infection has as yet been observed. The clinical outcome, in terms of acute GVHD, chronic GVHD or veno-occlusive disease was similar in HGV+ and HGV- recipients suggesting the absence of adverse effects of HGV infection on the early outcome of allogenic BMT. Long-term evolution remains to be prospectively studied.

CMV infection is the major infectious complication following bone marrow transplantation. It is most often related to reactivation of latent infection in patients who were CMV seropositive before BMT. The incidence and severity have recently been modified by the use of preventive and curative treatments. Prevention of CMV infection with the transfusion of seronegative blood products is useful only when donor and recipient are seronegative. High-dose acyclovir has been shown effective in one randomized study. A multicenter study is currently being performed in Europe to confirm this result. Intravenous gammaglobulins seemed to lower the number of patients who incur interstitial pneumonitis but not the incidence of viremia. They also decreased the incidence of gram-negative sepsis and severe GVH and improved survival. The treatment is based on the use of gancyclovir. Several studies show that gancyclovir is more effective in asymptomatic patients with viral isolation from blood or bronchoalveolar lavage. The addition to gancyclovir of high-dose gammaglobulin improves survival in symptomatic patients with interstitial pneumonitis. This progress in the prevention and treatment of CMV infection has improved the overall results of allogeneic bone marrow transplantation.

Newborn blood contains a large number of hematopoietic stem/progenitor cells. In human ontogeny, hematopoiesis occurs first in the yolk sac, later in the fetal liver, and then in the bone marrow [26]. The volume of bone marrow in newborns is, in fact, so large that it is nearly equal to the marrow space occupied by hematopoietic cells in adults. The spleen, lymph nodes, and even kidneys may contain too few developing hematopoietic stem cells. During fetal life and at birth, communication of hematopoietic sites through the blood is very active and immature precursors of blood cells and their progenitors are present in peripheral blood. Transplantation of fetal liver cells has been used with limited success because of the limited number of cells infused, the HLA disparity between donor and recipient, and the occurrence of graft vs host disease (GVHD) when the fetus was older than 21 weeks [10]. Peripheral blood stem cells have been used for autologous transplantation in various malignancies, but the concentration of progenitor stem cells is so low that collection of an appropriate number requires multiple leukophereses, utilization of the rebound observed during recovery after chemotherapy, and stimulation by growth factors [30, 31]. The utilization of human cord blood for hematopoietic reconstitution was suggested by E. Boyse, who showed that lethally irradiated mice could be reconstituted with neonatal mouse blood. This led to a cooperative international study to evaluate human cord blood as an alternative source of hematopoietic stem cells for transplantation in humans.

Umbilical cord blood transplantation (UCBT) is a valid option to treat haematological disease when an HLA-matched donor is lacking. Advantages of UCB include the absence of risk for the donors, and its prompt availability when an unrelated donor needs urgently. The naivety of the UCB, allows UCBT recipients to a decreased risk of graft versus host disease (GvHD). Due to the low cell dose contained in a UCB unit, double UCBT (dUCBT) is used for adult patients. UCBT may be associated with an increased risk of graft failure with delayed immune recovery and infections. We report a phase II study on 35 dUCBT from 2004 to 2007. Twenty one patients had high risk malignant disorders (ALL=6, AML=6, MDS=4, CML=3, Hodgkin disease= 2) and 14 high risk of rejection (Fanconi Anemia=8, SAA=4, PNH=1 and congenital dyskeratosis= 1). Among all patients, 9 had undergone previous non-engrafted transplants (previous source: UCB and BM in 5 and 4 cases respectively). Median age was 19 years (6–55). CMV serology was negative for 14 patients. Median follow-up was 21 months (4–42 months). Half of patients received myeloablative conditioning, reduced intensity regimen was performed mostly for second transplant. ATG was used in 22 patients. Most of patients received at least 1 or 2-HLA antigen and/or allelic mismatched unit. aGVHD prophylaxis consisted in cyclosporine+steroids in 21 patients and associated with mycophenolate in 14. Median infused cell doses were 4×10/7 NC/Kg (1.8–9.7) and 3×10/5 CD34+cells/Kg (0.5–7.46). Twenty four patients (69%) engrafted with a median time of 25 days (11–42), 11 subjects had primary graft failure. Among the patients who did not engrafted, 5 patients died early due to rejection, 2 had autologous reconstitution and 1 patient relapsed. The remaining 3 patients underwent a second dUCBT. Median time to platelet recovery >20 ×10/9 cells/L was 103 days (36–180). Before day 100 chimerism data were evaluable in 29 patients. A single UCB unit predominated in 18 patients with full donor chimerism. In 6 patients a combination of both UCB units was detected and 5 patients had persistent host hematopoiesis. In eight out of 15 patients, the predominant UCB unit was the first infused. After day 100, 16 out of 19 evaluable patients had a complete donor chimerism with only one unit contributing to hematopoiesis and 3 showed both CB units engraftment. No patients had secondary graft failure. aGVHD developed in 18 patients (grade III–IV, n=6) and cGVHD in 15 out of 26 patients at risk. During the first 100 days 19 CMV reactivations were observed, 4 disseminated HSV, 1 HHV6-related meningoencephalitis, 4 EBV infections, 4 VRS infections, 3 adenovirus diseases, 5 bacterial infections, 2 probable toxoplasmosis. Twelve patients had a probable or proved IFI. After day 100 we observed 9 CMV reactivations, 3 HSV, 1 EBV-PTLD and 2 fungal infections. Lymphocyte subset phenotype analyses were performed in the patients with donor cells engraftment at 3, 6, 9, 12 months after dUCBT. Median numbers of lymphocytes were 400 mm3 at 3 months (n=19); 430 at 6 months (n=18), 710 at 9 months (n=11), 630 at 12 months (n=12), 860 at 15 months (n=7). Median numbers of CD3/CD4 at 3, 6, 9, 12 and 15 months were: 46, 55, 130, 80, 180 mm3, respectively; of NK cells 220, 230, 250, 190, 190 mm3 and of B cells were 1, 10, 70, 80, 240 mm3, respectively. Naive cells (CD45RA+CCR7+), early or central memory cells (CD45RA+CCR7+), effector memory cells (CD45RA+CCR7+), and late effector memory cells (CD45RA+CCR7+) were analysed. Over a period of 9 months after transplant a high proportion of central and effector memory T cells and a paucity of naïve cells were detected. Naïve cells increased consistently during the follow up period, reaching a trend towards normalization at 15 months, compared with the normal value. At 1 year overall survival was 57±8%. Relapse occurred in 5/35 patients and was cause of death in 3. TRM at 100 days was 29±7%. Seventeen patients died. Infection was a major cause of death in 6 subjects. Five of 9 patients have been rescued of previous non-engraftment and are alive and well (10–41 months). In conclusion, dUCBT is an option to treat patients with high risk diseases lacking a suitable HLA matched donor. In this high risk population immune recovery and consequently infections are major complications after dUCBT. Modifications in the conditioning regimen and GVHD prophylaxis, better surveillance and treatment of infections after dUCBT may improve outcomes.

ABO incompatibility between donor and recipient is not considered a barrier for successful allogeneic hematopoietic stem cell transplantation (HSCT). However, it is well established that major ABO incompatibility is associated with several immunohematological complications such as delayed hemolysis, delayed erythropoiesis, pure red cell aplasia and prolonged transfusion requirements due to the persistent presence of host-derived antibodies. Nevertheless, conflicting data still exist as to its influence on graft-versus-host disease (GvHD) incidence, relapse rate and survival. To further investigate the relevance of ABO major mismatch on transplant outcome, we retrospectively analyzed results from 414 patients with major or major/minor ABO-mismatched related and unrelated allogeneic transplantation performed between 1978 and 2005. Of the 414 patients, 226 (55%) received bone marrow (BM), 138 (33%) peripheral blood stem cells (PBSC) and 49 (12%) cord blood (CB) transplantation. Transplants were performed for both malignant (71%) and non malignant (29%) hematological diseases using myeloablative (81%) and non myeloablative (19%) conditioning regimens. Transplant outcome was assessed by comparison with results from a 395-patient ABO-compatible population with similar characteristics with respect to period of transplant, stem cell source, conditioning regimen, GvHD prophylaxis and donor type. Median time to red cells transfusion independence was significantly longer in ABO-incompatible marrow recipients (median time 63 days vs. 41 days, p=0.001) with faster disappearance of anti-donor IgM hemagglutinins in unrelated recipients (median time 36 days vs. 44 days, p=0.03) and in patients with grade≥2 aGVHD (median time 35 days vs. 59 days, p=0.001). However, erythroid reconstitution was not significantly delayed in PBSC and CB transplantation, whatever donor type or aGVHD occurrence. A strong correlation between ABO incompatibility and GVHD incidence was found in PBSC recipients with a 2.1-fold increased likelihood (1.8–3.1, 95% CI, p=0.01) of developing grade≥2 aGVHD, all patients receiving cyclosporine A-based prophylaxis regimen. An effect of ABO mismatch was also found on relapse rate and overall survival in that population but without reaching statistical significance (35% vs. 41%, p=0.055 and 39 months vs. 34 months, p=0.055). Among CB transplant recipients, we also found an impact of ABO incompatibility on neutrophil engraftment with borderline statistical significance (median time to reach neutrophil count>1000/μL: 29 days vs. 23 days, p=0.05). No effect was seen on platelet recovery, GvHD incidence or relapse rate in this subgroup. When performing multivariate analysis in Cox regression model for effect on relapse rate in the whole population, donor/recipient ABO mismatch and c.GVHD appeared to be the 2 only factors associated with a lower risk of relapse (RR=0.65, 95% CI, p=0.04 and RR=0.55, 95% CI, p=0.035, respectively). Overall, our results confirm the impact of aGVHD and donor type in red blood cells transfusion requirements in bone marrow ABO-mismatched recipients. They also tend to show beneficial impact of ABO incompatibility on relapse rate, especially in PBSCT. Taken together, these data may influence donor choice, i.e.: select ABO-matched donor for bone marrow and cord blood transplants (to favor hematological recovery) and, may be ABO mismatched donor for peripheral blood transplants with the aim to stimulate alloreactivity in patients with hematological malignancy.

The outcome of severe aplastic anemia, refractory to immunosuppressive therapy or observed in case of Fanconi anemia (FA), is usually poor in the absence of Hematopoietic Stem Cell Transplantation (HSCT). Umbilical cord blood is an alternative stem cell source for patients without matched related or unrelated donors. However, single cord blood unit is associated with high transplant related mortality due to the low cell dose infused in previous highly transfused patients. We have driven the hypothesis that double cord blood transplantation (dCBT) could circumvent the cell dose problem. For the purpose of this study, we have studied 13 patients with bone marrow failure syndromes given 2 partially matched dCBT from 2004 to 2007. The diagnoses were FA (n=9), SAA (n=4) and PNH (n=1). Among those patients, 5 (39%) received a dCBT as a rescue of previous rejected transplants (2 SAA and 3 FA). All patients received a fludarabine-based regimen, with TBI (2 Gy) for 4 patients. Cord blood units were a 4/6 or 5/6 HLA A, B and DR match with the patient except one which was 3/6. Graft versus host disease (GVHD) prophylaxis consisted in CSA+MMF. Steroids were given from day 7 to day 14 and stopped in case of no GVHD. Five male (39%) and 8 female (61%) with a median age of 16 years (range 7–31) were treated. The cell doses infused were a median of 5.0 × 107 NC/Kg (4–9) and 5.3 × 105 CD34+ cells/Kg (2–8). Graft rejection was seen in 5 patients (2 previously allotransplanted). Among those patients, one displayed a temporary mixed chimerism before rejection and another presented an autologous reconstitution. Among the remaining 8 patients, the median time to an absolute neutrophils count > 500 was 25 days (range 14–42) and the median time to a platelet count > 20,000 was 39 days. In these last patients, we observed a complete donor chimerism with one cord blood unit during 100 days after dCBT. Acute GVHD grade II–III was scored in 9 patients (69%) (7 grade II, 2 grade III). No patients presented acute GVHD grade IV. Four patients out of 8 developed Chronic GVHD (3 limited and 1 extensive). Four patients died (1 GVHD, 2 fungal infection, 1 thrombotic microangiopathy). With a median follow-up of 13 months (range 1 to 19 months), the overall survival was 55% (±15%) for all patients. The median survival of patients who were transplanted twice was 50% (±25%). In conclusion, dCBT seems to be an option to treat patients with bone marrow failure syndromes and without a suitable compatible HLA donor. Those results need to be established on a large number of patients to warrant the inclusion of dCBT in the treatment strategy of diseases with high risk of rejection.

The possibility to perform double cord blood transplantation (dCBT) has extended its use in adults with high risk hematological disease; however there is no data on immune recovery and report on infections complications. We have performed a phase II study on 16 dCBT from 2004 to 2006. Ten patients had high risk malignant disorders (ALL=1, AML+MDS=6, CML=3) and 6 high risk of rejection (SAA=4, PNH=1 and Fanconi Anemia=1). Among those patients, 4 (25%) received a dBCT as a rescue of previous non-engrafted transplants (2 SAA, 1 AML and 1 CML). Analyses of T, B and NK cells phenotype were performed once a month during the first 3 months and ever two months until 12 months. The median age was 21 years (11–42), the median weight 63 kg (30–90) and the median follow-up was 6 months (3–18). Conditioning regimen varied according to disease (myeloablative) or second transplant (reduced intensity), all but two patients have received ATG. GVHD prophylaxis consisted in CsA + steroids in 12 patients and associated to MMF in 4. Results: 2 patients did not engraft (both with SAA), one patient relapsed 8 days after dCBT, and 12 patients engrafted at a median of 23 days (14–42). Chimerism available in 12 patients before day 100 showed both CB units in 7 patients. After day 100, in 8 evaluable patients, 3 patients had evidence of both CB units engraftement. Acute GVHD was observed in 5 patients (grade II in 4 and grade III in 1) and chronic GVHD in 7 out of 12 at risk. During the first 100 days, 9 CMV reactivations were diagnosed; 4 HSV (resistant to acyclovir); 3 HHV6 infections; 3 EBV reactivations; 2 adenovirus diseases, 4 VRS infections, 2 septicaemias, 3 fungal infections, 1 disseminated toxoplasmosis. After day 100, we observed 4 CMV reactivations, 1 CMV disease, 1 HSV, 1 adenovirus disease and 1 EBV-PTLD. Important lymphopenia was observed in all patients (median of 259mm3 at 3 months (n=14); 389 at 6 months (n=13) and 480 at 12 months (n=8). Median numbers of CD3/CD4 at 3, 6 and 12 months were: 8, 15 and 46 mm3 respectively; of NK cells 203, 249 and 115mm3, and of B cells were 0, 0 and 110 mm3, respectively. At 6 months overall survival was 58±14% and event-free survival was 52±14%. Six patients died: 2 of relapse and 4 from infections. Three out of 4 patients have been rescued of previous non-engraftment and are alive and well (4–18 months). In conclusion, despite the short follow-up dBCT seems to be an option to treat patients with high risk diseases and without a suitable compatible HLA donor. High incidence of infections and delayed immune recovery are major problems after dCBT.

In order to study the association of HLA high resolution typing with outcomes after unrelated bone marrow transplants (UBMT), we have retrospectively analyzed 121 consecutive recipients of unmanipulated UBMT performed in Hôpital Saint-Louis from 1994 to 2002 with a minimum follow-up of 6 months. The median age was 24 years (22 children, 99 adults). Ninety-six patients had malignant disorders (69% leukemias) and 25 had non malignant disorders (bone marrow failure syndromes). High resolution typing was performed in donors and recipients pairs for HLA-A,-B,-C,-DRB1,-DQB1 and-DPB1. According to this typing definition, patients were classified for transplants as 10 out of 10 ( Results: In univariate analysis, we found that patients receiving a graft with less than 10 out of 10 HLA compatibilities (p=0.005) and any disparity in HLA-Class I (p=0.0009) were associated with delayed platelet recovery. Disparities in HLA-B were associated with high incidence of acute GvHD (51% versus 80%, p=0.03) and more importantly, a decreased 180-day transplanted related mortality (TRM) was associated with HLA 12/12 compatibilities instead of HLA 10 out of 10. In fact, TRM was 69% in patients receiving HLA graft In conclusion, decreased TRM and better survival were associated with a compatible unrelated donor using HLA high resolution typing for A, B, C, DRB1, DQB1 and DPB1.

The number of umbilical cord cell transplants is increasing worldwide. The results are comparable to allogeneic bone marrow transplantation in a large variety of hematological diseases that are curable by bone marrow transplantation and, so far, the incidence of graft-versus-host disease has been limited. The advantages of using cord blood are related to the high number of hematopoietic progenitors present in the circulation at birth and to the relative immune immaturity of the newborn. A project is described to establish a European cord blood bank in order to obtain related or unrelated, matched or mismatched hematopoietic stem cells for transplantation to patients without a bone marrow donor.

This paper reviews the experience in the collection of 67 cord blood for use in sibling transplants. Details are given on the mean volumes collected, the numbers of nucleated cells, the CFU-GM and BFU-E obtained, and the incidence of collection failure.