Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Umbilical cord blood graft engineering: challenges and opportunities

Abstract

We are entering a very exciting era in umbilical cord blood transplantation (UCBT), where many of the associated formidable challenges may become treatable by ex vivo graft manipulation and/or adoptive immunotherapy utilizing specific cellular products. We envisage the use of double UCBT rather than single UCBT for most patients; this allows for greater ability to treat larger patients as well as to manipulate the graft. Ex vivo expansion and/or fucosylation of one cord will achieve more rapid engraftment, minimize the period of neutropenia and also give certainty that the other cord will provide long-term engraftment/immune reconstitution. The non-expanded (and future dominant) cord could be chosen for characteristics such as better HLA matching to minimize GvHD, or larger cell counts to enable part of the unit to be utilized for the development of specific cellular therapies such as the production of virus-specificT-cells or chimeric-antigen receptor T-cells which are reviewed in this study.

Main

Umbilical cord blood transplantation (UCBT) was first utilized to treat a 5-year-old child with severe aplastic anemia because of Fanconi Anemia in 1988, who had a UCBT from an HLA-identical sibling.1 In the pediatric setting, UCBT, when compared with matched-unrelated donor (MUD) bone marrow (BM) or mobilized PBSC transplantation, is associated with delayed engraftment, less acute and chronic GvHD and overall similar relapse rate and survival.2

Initial results in adults were poor, with 40% mortality at day 100 (D100).3 However, these have improved with better patient and cord selection and supportive care.4 Adult patients treated for AML or ALL have lower relapse rates with UCBT compared with other stem cell sources, but higher treatment-related mortality (TRM) and overall similar survival.5

Only ~30% of patients who require allogeneic stem cell transplantation (alloSCT) will have a matched sibling donor. Many patients without a matched sibling will have an adult MUD, but this is often not the case in patients from ethnic minorities.6 There is a lower incidence of acute GvHD (aGVHD) and chronic GvHD (cGvHD)after UCBT relative to transplant from an adult donor for a given degree of HLA mismatch;7 this has substantially increased the number of patients potentially able to undergo alloSCT as patients undergoing 4–6/6 matched UCBT have a lower incidence of aGvHD than an 8/8-matched sibling or adult MUD transplant and a lower incidence of cGvHD than an 8/8-matched MUD, but not sibling donor.8 The development of reduced-intensity conditioning (RIC) regimens has also extended eligibility to older patients who could not tolerate myeloablative conditioning.9

Challenges associated with UCBT

Despite the advantages of UCBT and the advances in management of patients undergoing the procedure, substantial challenges remain.

Delayed engraftment, failed engraftment and unit selection

The low numbers of hematopoietic progenitors present within a cord blood (CB) unit leads to slower engraftment than with other stem cell transplant sources and a higher risk of failed engraftment.5 Overall rates of engraftment in adults are ~80–90%.7, 10, 11, 12, 13, 14 In contrast, failure to engraft is rare in patients receiving alloSCT from an adult MUD with myeloablative conditioning (<1%) when 6/6 matched at class-I HLA alleles. However, failed engraftment does increase to 21% in the presence of a single class-I HLA antigen mismatch or multiple class-I allele/antigen mismatches.15

Improving engraftment rates: cord selection

Cell dose is the most important determinant of successful UCBT in adults.10, 11, 13, 16 UCBT with a single cord (sUCBT) containing <2.5 × 107/kg total nucleated cells is associated with poor engraftment, high TRM and poor survival.16 Double UCBT (dUCBT) compared with sUCBT may allow this cell-dose threshold to be reached for adult patients.5 dUCBT, relative to sUCBT, is associated with lower relapse rates and improved leukemia-free survival in patients with acute leukemia transplanted in CR1, at a cost of higher rates of grade II–IV, but not grade III–IV, GvHD, with no difference in TRM.17 Other factors contributing to risk of graft rejection include the presence of donor-specific anti-HLA antibodies, which have been associated with both failed engraftment and higher TRM.18 Recipient antibodies against mismatched donor HLA-DP have also been shown in 10/10 matched MUD alloSCT to be associated with a higher incidence of graft failure and mortality.19 Risk of rejection also increases with increasing numbers of mismatches at HLA-A, -B, -C and -DR loci.20

Patients receiving dUCBT often have a period of transient mixed chimerism and almost universally have eventual dominance of one cord and disappearance of the other.9, 21, 22 This is owing to CD8+ T-cell-mediated immunologic rejection of one cord unit by the other.23 No factors have been identified to predict which unit will become dominant.24

Improving rapidity of engraftment: novel strategies

Neutrophil engraftment in UCBT is delayed relative to PBSC or BM, occurring between 20–30 days when patients receive myeloablative conditioning.25 It depends strongly on cell dose.10, 11, 13, 26, 27, 28 RIC accelerates neutrophil recovery and is associated with a more rapid quantitative and qualitative T-cell recovery. However, whether this translates into improved outcomes is unclear.29

Recently, there has been considerable interest in the development of techniques for the manipulation of CB ex vivo to accelerate engraftment. These have focused on either expanding the number of progenitor cells within the unit or on modifications to stem cells to improve homing to marrow niches.

Culture of CB cells with mesenchymal stromal cells enhances the expansion of primitive and mature hematopoietic progenitor cells (HPCs).30 de Lima et al.31 demonstrated a significantly reduced time to neutrophil (15 vs 24 days) and platelet (42 vs 49 days) engraftment in patients receiving dUCBT where one cord was cultured ex vivo with mesenchymal stromal cells relative to historical control patients receiving unmanipulated dUCBT. Chimerism results showed, however, that long-term reconstitution of hematopoiesis was almost entirely derived from the unmanipulated CB unit. This suggests that the culture process expands committed myeloid and megakaryocytic progenitors in the graft capable of rapid engraftment at the expense of depleting the graft of cells capable of producing long-term marrow repopulation. In clinical use, certainty surrounding which CB unit will eventually provide long-term hematopoietic and immunological reconstitution will potentially be useful, as the unit with less ideal HLA matching could be used for expansion. Long-term engraftment by the better-matched cord could potentially reduce the risk of aGvHD and cGvHD. Alternatively, if there were no specific immunologic advantages to one cord over another, one cord could be utilized for cellular therapy procedures such as generation of viral-specific T-cells (see below); these could then be expected to persist long-term in the absence of competition from the other CB unit, which would be expanded ex vivo to provide rapid hematopoietic recovery.

An alternative strategy for ex vivo expansion of HPCs utilizes culture in the presence of NOTCH ligand. NOTCH is expressed in CD34+ HPCs32 and retroviral transduction of a constitutively expressed form immortalizes HPCs.33 Incubation of CB progenitors with NOTCH-ligand produced a 100-fold increase in CD34 numbers and enhanced repopulating ability in an immunodeficient mouse model.34, 35. Preliminary results in a phase-I human study have shown more rapid neutrophil engraftment (16 vs 24 days in a similarly and simultaneously treated cohort). Similarly to the results using mesenchymal stromal cell-mediated ex vivo expansion, the expanded cord did not contribute to CD3+ engraftment or long-term hematopoiesis.36

Another potential strategy to achieve more rapid engraftment is to improve homing of HPCs to the recipient’s marrow. Fucosylation of selectin ligands on HPCs is critical for the rolling of HPCs on P- and E-selectins expressed by hematopoietic microvascular endothelium37, 38, 39, which is the initial step of homing to the marrow. Fucosylated HPCs are responsible for engraftment in the NOD scid gamma mouse model40 and PBSC and BM HPCs have >2 × the level of fucosylation of UCB HPCs. Levels of fucosylation can be increased by incubation with α1–3 fucosyltransferase (FT)-VI.38, 40, 42 Robinson et al.41 showed that fucosylation of CB HPCs can be increased from a baseline of ~15% to >95% with a 30-min incubation with FT-VI at room temperature and that only the fucosylated fraction of CD34+ HPCs contributes to engraftment in NOD scid gamma mice. In addition, appearance of human CD45+ cells in the peripheral blood of NOD scid gamma mice was more rapid in mice receiving fucosylated grafts than those receiving untreated grafts and both myeloid and B-lymphoid engraftment in marrow and spleen were threefold greater than in recipients of unfucosylated grafts. Preliminary results of a phase-I study have shown encouraging results with a median time to neutrophil and platelet engraftment of 14 and 33 days, respectively.43 Patients received dUCBT and the cord with a smaller number of total nucleated cells was utilized for the fucosylation procedure. It is unclear from these preliminary results what the effects on long-term hematopoiesis and immune reconstitution will be. However, theoretically, this process could be simply combined with one of the two ex vivo expansion methods described above and this may result in even more rapid engraftment. Cutler et al.44 used an alternative strategy involving the brief ex vivo incubation of one of two CB units with dimethyl prostaglandin E2. Dimethyl prostaglandin E2 has pleotropic effects on HPCs, upregulating genes involved in stem cell homing, proliferation and survival.45, 46 Long-term engraftment occurred from the manipulated unit in 10 of 12 cases, but numbers of patients treated are too small to draw strong conclusions from this observation.44

GvHD

Grade II–IV and III–IV aGvHD occur in ~30–50% and 10–20% of UCBT recipients, respectively.7, 10, 11, 12, 13, 26, 28, 47, 48 Despite the lower incidence of aGvHD relative to adult donor transplants and the lower incidence of cGvHD relative to all but fully matched sibling transplants, GvHD remains a major cause of morbidity and mortality post UCBT.

The level of CD4+, CD25+ and FOXP3+ regulatory T-cells (Tregs) correlates inversely with aGvHD and cGvHD.49, 50, 51, 52 Although overall Treg numbers and function are preserved, in patients developing aGvHD, there is a marked depletion of naive Tregs which occurs as an early event in aGvHD.53 In cGHVD, there is impaired thymic generation of naive Tregs (CD45RA+) and increased apoptosis of proliferating memory/effector Tregs (CD45RA−).

Treg differentiation and function remains stable even in highly inflammatory conditions,54 which suggests they may be useful as adoptive immunotherapy in aGvHD and cGHVD. However, their in vivo survival in this setting remains to be determined.55 Ex vivo expansion of UCB-derived Tregs may be more attractive than PB-derived Tregs, as the T-cell repertoire is less complex and predominantly naïve, with a well-defined Treg subset present in relatively higher numbers than in PB.56, 57 After flow cytometry-based sorting of CD4+/CD25+ T-cells, UCB-derived Tregs can be expanded ~100-fold using CD3/28-coated microbeads and IL-2. These cells express FOXP3 and maintain potent suppressor function.58, 59 Expansion using IL-15 may be superior. 60, 61 Several murine xenogenic GvHD models have shown that infusion of human UCB-derived Tregs conferred protection from aGvHD and improved survival.62, 63

Although there is concern that Treg infusion post-transplant may potentially impair immune reconstitution, Tregs may suppress alloreactive T-cells, whereas actually facilitating functional immune reconstitution through inhibition of GvHD-induced thymic and secondary lymphoid microenvironmental damage.64, 65, 66, 67 Immune function is preserved in murine models of Treg infusion, suggesting that the suppression of GvHD is relatively specific.68

Another theoretical concern with adoptive transfer of Tregs is the potential for impairment of GVL effect with increased risk of disease relapse.69 Data from mouse models is somewhat contradictory; tumor regression after IL-2-diphtheria toxin-mediated Treg depletion was seen in one model suggesting that Tregs may adversely affect disease-control.70 In contrast, simultaneous adoptive transfer of Tregs and unselected donor T-cells in mismatched mouse transplant models showed protection from GvHD without impairing tumor control.71, 72 It has been suggested that this apparent specificity of Tregs for alloreactive T-cells rather than tumor-reactive T-cells may relate to a different mechanism for the development of GvHD and GVL effect. GvHD may predominantly occur owing to alloantigen-driven expansion of alloreactive T-cells, whereas GVL effect may rely predominantly on activation of alloreactive T-cells.72 Thus, the adoptive transfer of Tregs post-transplant may allow specific inhibition of GvHD, without impairing immune reconstitution and GVL effect.

A preliminary human study has shown post-transplant adoptive transfer of Tregs to be safe, with a reduction in risk of grade II–IV aGvHD relative to historical controls and similar disease-free survival.73 There did not appear to be an excess risk of disease relapse or infection in these patients.

Infection

There is delayed neutrophil recovery after UCBT relative to BMT or PBSCT and an increased infection risk which persists beyond the period of neutropenia, with ongoing risk of bacterial, viral74 and fungal infection.75

There are both qualitative and quantitative differences in lymphocyte recovery post-UCBT, with delayed recovery of lymphocyte numbers, particularly naive T-cells, which are present in small numbers until 9–12 months. Fungal infections (particularly invasive aspergillosis) are common, especially prior to D100, but also post-D100.75 Viral infections, especially CMV, adenovirus (ADV), respiratory syncytial virus, varicella-zoster virus, Epstein-Barr virus (EBV)-driven post-transplant lymphoproliferative disease and human herpes virus 6 are seen both pre- and post-D100 and represent a major challenge.75 Patients transplanted with RIC have more rapid reconstitution of T-cell repertoire complexity than after myeloablative conditioning,76 higher T-cell numbers and complexity at different time points and higher numbers of naive T-cells at 12 months after transplantation. In contrast, patients treated with ATG as part of RIC have a delayed T-cell recovery owing to in vivo T-cell depletion of the graft and a substantially higher risk of EBV reactivation and post-transplant lymphoproliferative disease.77

Treatment for viral infection is challenging. Up to one in three deaths after alloSCT may relate to viral infection.78 Pharmacotherapy, where available, is expensive, toxic and often ineffective.79, 80, 81 Consequently, adoptive immunotherapy for treatment and prevention of viral reactivation/infection post-allograft is attractive.

In the adult donor setting, virus-specific T-cells (VSTs) can be generated from the donor, either by culture with modified APCs82, 83, 84, 85, 86, 87 or peptide multimers.88, 89 Rapid isolation strategies such as ‘gamma catch’ can be utilized when VSTs occur at high frequency in the donor’s blood. This strategy has been successfully used in patients with CMV disease or viremia, with a response rate of 83%,90 EBV, with a response rate of 50–70%91, 92 and ADV, with responses in 5 of 6 patients in a small study.93

Adoptive transfer of VSTs from an adult stem cell donor is effective as prophylaxis and treatment for treatment-refractory EBV, CMV and ADV infections.83, 84 However, there are considerable barriers to successful use of adoptive immunotherapy with VSTs post-UCBT; specifically, there are small numbers of T-cells available for manipulation and their phenotype is naïve.85, 86, 87, 94, 95 Hanley et al. have shown that multi-VSTs against EBV, CMV and ADV can be generated from naïve cord blood cells using a complex method of transducing EBV-LCLs transduced with CMVpp65 via an adenoviral vector and these are highly active against virus, despite recognition of non-canonical CMV and EBV epitopes. These VSTs generated from UCB have been shown to be efficacious for treatment of viral infection post-allograft.96 Ex vivo priming of T-cells requires culture with an APC and the addition of IL-7, IL-12 and IL-15. These cytokines decrease antigen concentration threshold, direct T-cells toward a central memory phenotype and influence TH1 and T-cytotoxic type 1 cell differentiation. This process is currently slow and laborious, which will limit its use for urgent treatment, but may allow prophylactic use. Studies to shorten the procedure are in progress and will likely broaden the use of this approach in the sUCBT and dUCBT settings.

3rd party, banked VSTs from adult donors could be used to treat viral reactivation in UCBT patients.97 Suitable lines are available in approximately 90% of patients, can be rapidly identified and made available and induce high response rates in refractory CMV, ADV and Epstein-Barr virus-driven post-transplant lymphoproliferative disease. Despite the theoretical risk of inducing GvHD due to HLA mismatch, no severe cases of de novo acute GvHD were seen.98 Persistence of these cells may be limited in comparison to infusion of VSTs from an HLA-matched stem cell donor owing to the possibility of immunologic rejection.87 Although unclear from existing data, response to subsequent infusions from the same donor may potentially be inhibited because of an anamnestic immune response.

Five VSTs (EBV, CMV, ADV, BK and human herpes virus 6) can now be produced from adult donors after culture with a peptide mix containing immunodominant antigens of the five viruses.99 This method will hopefully be adapted for generation of VSTs from naive, CB units in the future.

Preventing relapse

Leukemia relapse is the second most-common cause of mortality post-UCBT.26, 28 Disease-free survival is improved and relapse rates are lower after dUCBT for leukemia compared with sUCBT in adults.100 Potential methods of enhancing the GVL effect include the modification of T-cells with chimeric-antigen receptors (CARs) targeting a tumor-associated antigen and adoptive transfer of NK cells.

CAR-modified T-cells

Autologous CARs have been used with great success in CD19-positive malignancies in the setting of refractory disease.101, 102, 103, 104, 105 Limited experience exists with infusion of CAR-T-cells post allograft. A pilot study of peri-transplant infusion of allogeneic VSTs modified to express a CAR targeting CD19 has shown these to be safe in small numbers of treated patients.106 The study was not powered to assess the efficacy of this approach. Theoretically, the modification of VSTs with a CAR will enhance CAR T-cell persistence owing to stimulation of the cells via the native TCR by virus, whereas the CAR will direct tumor-specific cytotoxicity. This bi-specific approach using virus and CD19+ tumor-specific CTLs is being translated to the UCBT setting.107 The MD Anderson investigators have used the sleeping beauty transposase/transposon system to electroporate a CD19 construct into the UCB of four patients who received those cells following UCBT.108 The CB-CD19-CAR+ T-cells were well tolerated and accrual to the study continues. Kochenderfer et al.109 have also recently demonstrated the feasibility and effectiveness of utilizing donor-derived T-cells for the generation of a CAR T-cell, with a patient with CLL achieving a CR after infusion of donor-derived T-cells transduced with an anti-CD19/28 CAR. These methods are being adapted by several groups for use in the UCBT setting.

Adoptive transfer of NK cells to enhance anti-tumor effect

NK cells can kill cancer cells independently of antigen recognition and are thus attractive for use in adoptive immunotherapy. Allografts containing higher numbers of NK cells have been associated both with reduced disease relapse and lower rates of GvHD.110 Adoptive transfer of NK cells has previously been limited by the small numbers of circulating NK cells (5–15% of the total lymphocytes) and consequently low numbers obtained in an apheresis procedure.111

Methods of NK expansion include:

  1. 1

    Overnight culture with IL-2 or IL-15, combined with CD3 depletion of T-cells and infusion the following day.112

  2. 2

    Longer-term culture in IL-2 and IL-15-supplemented media can expand NK cells 60–80 fold in 2 weeks. Nicotinamide increases in vivo survival and cytotoxic activity.113

  3. 3

    Culture with irradiated EBV-LCLs as feeder cells results in expansion 800–1000 fold within 2 weeks. These cells show upregulation of natural cytotoxicity and activating receptors, greater IFN-γ secretion and greater cytotoxicity against K562 and other tumor cell lines compared with resting or overnight IL-2-activated NK cells.114 The irradiated, gene-modified CML cell line K562 can be used as a feeder cell for ex vivo NK cell proliferation and these cells can be genetically modified to express a range of surface proteins to enhance NK cell expansion and function, for example IL-15 and 4-1BB ligand, CD64 (FCγRI), CD84 (B7-2), CD137L, truncated CD19 and membrane-bound IL-2.115,116,117,118,119,120,121

NK cells can be generated from HSCs, including CB122 and show similar phenotype and activity against leukemic targets to peripheral blood-derived NK cells.123 These can be generated using aAPCs derived from K562 cell lines116, 120 or in feeder cell-free conditions.122 Achieving large-cell production in GMP compliant conditions may be easier with a feeder cell-free system.122

Potential limitations of NK cell adoptive transfer include:

  1. 1

    Rapid development of exhaustion after adoptive transfer despite initial high degree of activity.124

  2. 2

    Lymphoyte contamination of the graft. T-cell contamination should be limited to <1–5 × 105/kg,125, 126 especially in the context of HLA-mismatched allogeneic stem cell transplantation, to minimize the risk of GvHD. This can be achieved by CD3 depletion.112 Addition of CD56+ selection reduces B-cell contamination to <1%, which also minimizes passenger B lymphocyte-mediated complications such as EBV-driven post-transplant lymphoproliferative disease and acute hemolytic anemia, the latter a risk if minor ABO incompatibility is present.127 Two-step NK cell enrichment achieves 99% NK cell purity.128

  3. 3

    Extensive ex vivo expansion may reduce in vivo proliferative potential and long-term viability after adoptive transfer.120

  4. 4

    Defects in homing. K562-expanded NK cells show potential defects in CCR7-mediated homing to lymph nodes.129 Modification of K562 feeder cells to transfer CCR7 to NK cells via trogocytosis transiently increases NK cell CCR7 expression and improves homing to LNs of athymic mice.130 Culture with irradiated EBV LCL reduces CD62L-mediated homing to marrow and secondary lymphoid tissues, which can be improved by adding nicotinamide to the culture.113

  5. 5

    Cytokine dependence. A rapid decline in NK cell function occurs when IL-2 is removed from medium.41 In vivo dependence on IL-2 for persistence is greater with ex vivo expanded cells than fresh, activated cells.131 In vivo use of IL-2 (which can expand NK cell numbers) can lead to severe toxicity and also to Treg expansion which limits NK cell activation.132 In contrast, IL-15/IL-15Rα complexes promote NK cell activation and enhanced function without the detrimental effects of IL-2.133, 134 Whether in vivo use of Il-15/IL-15Rα will rescue NK cells from this phenomenon is not known.

NK cell genes

KiRs (killer-Ig-like receptors) are divided into inhibitory and activating subtypes. Inhibitory subtypes bind to HLA-Bw4, HLA-C1 and HLA-C2 group ligands, although many ligands for activating KiRs are unknown.131 KiRs are inherited as haplotypes (KIR-A and KIR-B). KIR-A haplotypes, found in 1:3 adult Caucasians, have one activating receptor, whereas the KIR-B haplotypes have2. Transplantation in AML from a KIR-B haplotype donor is associated with lower relapse rates and better survival.135 Specific donor KIR genes and HLA types are associated with lower rates of relapse in patients receiving 10/10 or 9/10 HLA-matched-unrelated donor allografts. In particular, donor positivity for the KIR2DS1 activating KIR results in a lower risk of relapse and improved survival owing to increased NK cell-mediated GVL effect. However, this beneficial effect is lost in donors who are homozygous for HLA-C2 as high levels of HLA-C2, which is recognized by KIR2DS1, result in NK cell tolerization. The lowest relapse rates were seen in recipients of a transplant from an HLA-C mismatched donor who was positive for HLA-C1 and KIR2DS1.136 Recipients who are HLA-C2/C2 homozygous are also at higher risk of relapse, but their relapse risk is lower when receiving an HLA-C mismatched transplant from a KIR2DS1 positive donor.136 These observations raise the prospect that, in the setting of AML, if ex vivo NK cell expansion from cord blood is performed, selection of cord units with specific KIR and HLA-C genotypes may be beneficial. Whether the addition of immunomodulatory drugs such as lenalidomide or checkpoint inhibitors such as PD1-antibodies will further enhance NK cell anti-tumor function will be an important future question.

Summary: potential future directions

Given the array of potential cellular therapies that can now be generated from a cord unit, and the limited number of cells available, we are faced with the prospect of having to choose which of these is the most important in an individual patient. For example, a patient deemed to be at high risk of relapse may have part of a cord utilized for NK cell expansion, whereas a patient at high risk for infection could be given prophylactic VSTs post transplantation. This limitation could potentially be overcome by the use of ‘third party’ cellular therapy products for certain applications. For example, third party VSTs could be used when required to treat refractory viral infections rather than infusing CB-derived VSTs prophylactically. This would allow generation of Tregs to minimize GvHD and/or NK cells to maximize anti-tumor effect from the non-expanded cord unit. This cord could be chosen based on its HLA-C/KIR genotype to maximize NK-cell-mediated anti-tumor effect. Another potential avenue to explore in the future would be the use of a third cord to manufacture Tregs and NK cells for adoptive therapy. Alternatively, if two cords are to be used, the first could be split in two, using 50–60% for ex vivo expansion/fucosylation to provide rapid engraftment and the remainder for the generation of Tregs and NK cells to be infused peri-transplant. The other cord, which will provide long-term engraftment, if of sufficient size, could have 20% utilized for the generation of VSTs ±CARs, whereas the remainder is infused unmanipulated to provide long-term hematopoiesis and immune reconstitution.

Clearly, these are exciting times in the field and systematic investigation will be required to determine how best to utilize available resources to maximize the anti-tumor effect and minimize the AE associated with UCBT.

References

  1. 1

    Gluckman E, Broxmeyer HA, Auerbach AD, Friedman HS, Douglas GW, Devergie A 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.

    CAS  Article  Google Scholar 

  2. 2

    Rocha V, Cornish J, Sievers EL, Filipovich A, Locatelli F, Peters C et al. Comparison of outcomes of unrelated bone marrow and umbilical cord blood transplants in children with acute leukemia. Blood 2001; 97: 2962–2971.

    CAS  PubMed  PubMed Central  Google Scholar 

  3. 3

    Laughlin MJ, Barker J, Bambach B, Koc ON, Rizzieri DA, Wagner JE et al. Hematopoietic engraftment and survival in adult recipients of umbilical-cord blood from unrelated donors. N Engl J Med 2001; 344: 1815–1822.

    CAS  Article  Google Scholar 

  4. 4

    Ballen KK, Gluckman E, Broxmeyer HE . Umbilical cord blood transplantation: the first 25 years and beyond. Blood 2013; 122: 491–498.

    CAS  PubMed  PubMed Central  Google Scholar 

  5. 5

    Brunstein CG, Gutman JA, Weisdorf DJ, Woolfrey AE, Defor TE, Gooley TA et al. Allogeneic hematopoietic cell transplantation for hematologic malignancy: relative risks and benefits of double umbilical cord blood. Blood 2010; 116: 4693–4699.

    CAS  PubMed  PubMed Central  Google Scholar 

  6. 6

    Henslee-Downey PJ, Abhyankar SH, Parrish RS, Pati AR, Godder KT, Neglia WJ et al. Use of partially mismatched related donors extends access to allogeneic marrow transplant. Blood 1997; 89: 3864–3872.

    CAS  Google Scholar 

  7. 7

    Rocha V, Wagner JE Jr, Sobocinski KA, Klein JP, Zhang MJ, Horowitz MM et al. Graft-versus-host disease in children who have received a cord-blood or bone marrow transplant from an HLA-identical sibling. Eurocord and International Bone Marrow Transplant Registry Working Committee on Alternative Donor and Stem Cell Sources. N Engl J Med 2000; 342: 1846–1854.

    CAS  PubMed  PubMed Central  Google Scholar 

  8. 8

    Eapen M, Rocha V, Sanz G, Scaradavou A, Zhang MJ, Arcese W et al. Effect of graft source on unrelated donor haemopoietic stem-cell transplantation in adults with acute leukaemia: a retrospective analysis. Lancet Oncol 2010; 11: 653–660.

    PubMed  PubMed Central  Google Scholar 

  9. 9

    Brunstein CG, Barker JN, Weisdorf DJ, DeFor TE, Miller JS, Blazar BR et al. Umbilical cord blood transplantation after nonmyeloablative conditioning: impact on transplantation outcomes in 110 adults with hematologic disease. Blood 2007; 110: 3064–3070.

    CAS  Article  Google Scholar 

  10. 10

    Gluckman E, Rocha V, Boyer-Chammard A, Locatelli F, Arcese W, Pasquini R et al. Outcome of cord-blood transplantation from related and unrelated donors. Eurocord Transplant Group and the European Blood and Marrow Transplantation Group. N Engl J Med 1997; 337: 373–381.

    CAS  PubMed  PubMed Central  Google Scholar 

  11. 11

    Rubinstein P, Carrier C, Scaradavou A, Kurtzberg J, Adamson J, Migliaccio AR et al. Outcomes among 562 recipients of placental-blood transplants from unrelated donors. N Engl J Med 1998; 339: 1565–1577.

    CAS  Article  Google Scholar 

  12. 12

    Eapen M, Rubinstein P, Zhang MJ, Stevens C, Kurtzberg J, Scaradavou A et al. Outcomes of transplantation of unrelated donor umbilical cord blood and bone marrow in children with acute leukaemia: a comparison study. Lancet 2007; 369: 1947–1954.

    Article  Google Scholar 

  13. 13

    Wagner JE, Barker JN, DeFor TE, Baker KS, Blazar BR, Eide C et al. Transplantation of unrelated donor umbilical cord blood in 102 patients with malignant and nonmalignant diseases: influence of CD34 cell dose and HLA disparity on treatment-related mortality and survival. Blood 2002; 100: 1611–1618.

    CAS  PubMed  PubMed Central  Google Scholar 

  14. 14

    Verneris MR, Brunstein CG, Barker J, MacMillan ML, DeFor T, McKenna DH et al. Relapse risk after umbilical cord blood transplantation: enhanced graft-versus-leukemia effect in recipients of 2 units. Blood 2009; 114: 4293–4299.

    CAS  PubMed  PubMed Central  Google Scholar 

  15. 15

    Petersdorf EW, Hansen JA, Martin PJ, Woolfrey A, Malkki M, Gooley T et al. Major-histocompatibility-complex class I alleles and antigens in hematopoietic-cell transplantation. N Engl J Med 2001; 345: 1794–1800.

    CAS  PubMed  PubMed Central  Google Scholar 

  16. 16

    Rocha V, Gluckman E, Eurocord-Netcord r, European B, Marrow Transplant g. Improving outcomes of cord blood transplantation: HLA matching, cell dose and other graft- and transplantation-related factors. Br J Haematol 2009; 147: 262–274.

    CAS  Google Scholar 

  17. 17

    MacMillan ML, Weisdorf DJ, Brunstein CG, Cao Q, DeFor TE, Verneris MR et al. Acute graft-versus-host disease after unrelated donor umbilical cord blood transplantation: analysis of risk factors. Blood 2009; 113: 2410–2415.

    CAS  PubMed  PubMed Central  Google Scholar 

  18. 18

    Ruggeri A, Rocha V, Masson E, Labopin M, Cunha R, Absi L et al. Impact of donor-specific anti-HLA antibodies on graft failure and survival after reduced intensity conditioning-unrelated cord blood transplantation: a Eurocord, Societe Francophone d'Histocompatibilite et d'Immunogenetique (SFHI) and Societe Francaise de Greffe de Moelle et de Therapie Cellulaire (SFGM-TC) analysis. Haematologica 2013; 98: 1154–1160.

    PubMed  PubMed Central  Google Scholar 

  19. 19

    Spellman S, Bray R, Rosen-Bronson S, Haagenson M, Klein J, Flesch S et al. The detection of donor-directed, HLA-specific alloantibodies in recipients of unrelated hematopoietic cell transplantation is predictive of graft failure. Blood 2010; 115: 2704–2708.

    CAS  PubMed  PubMed Central  Google Scholar 

  20. 20

    Stevens CE, Carrier C, Carpenter C, Sung D, Scaradavou A . HLA mismatch direction in cord blood transplantation: impact on outcome and implications for cord blood unit selection. Blood 2011; 118: 3969–3978.

    CAS  PubMed  PubMed Central  Google Scholar 

  21. 21

    Barker JN, Weisdorf DJ, DeFor TE, Blazar BR, McGlave PB, Miller JS et al. Transplantation of 2 partially HLA-matched umbilical cord blood units to enhance engraftment in adults with hematologic malignancy. Blood 2005; 105: 1343–1347.

    CAS  PubMed  PubMed Central  Google Scholar 

  22. 22

    Ballen KK, Spitzer TR, Yeap BY, McAfee S, Dey BR, Attar E et al. Double unrelated reduced-intensity umbilical cord blood transplantation in adults. Biol Blood Marrow Transplant 2007; 13: 82–89.

    CAS  PubMed  PubMed Central  Google Scholar 

  23. 23

    Gutman JA, Turtle CJ, Manley TJ, Heimfeld S, Bernstein ID, Riddell SR et al. Single-unit dominance after double-unit umbilical cord blood transplantation coincides with a specific CD8+ T-cell response against the nonengrafted unit. Blood 2010; 115: 757–765.

    CAS  PubMed  PubMed Central  Google Scholar 

  24. 24

    Majhail NS, Brunstein CG, Wagner JE . Double umbilical cord blood transplantation. Curr Opin Immunol 2006; 18: 571–575.

    CAS  Google Scholar 

  25. 25

    Smith AR, Wagner JE . Alternative haematopoietic stem cell sources for transplantation: place of umbilical cord blood. Br J Haematol 2009; 147: 246–261.

    PubMed  PubMed Central  Google Scholar 

  26. 26

    Laughlin MJ, Eapen M, Rubinstein P, Wagner JE, Zhang MJ, Champlin RE et al. Outcomes after transplantation of cord blood or bone marrow from unrelated donors in adults with leukemia. N Engl J Med 2004; 351: 2265–2275.

    CAS  PubMed  PubMed Central  Google Scholar 

  27. 27

    Locatelli F, Rocha V, Reed W, Bernaudin F, Ertem M, Grafakos S et al. Related umbilical cord blood transplantation in patients with thalassemia and sickle cell disease. Blood 2003; 101: 2137–2143.

    CAS  PubMed  PubMed Central  Google Scholar 

  28. 28

    Rocha V, Labopin M, Sanz G, Arcese W, Schwerdtfeger R, Bosi A et al. Transplants of umbilical-cord blood or bone marrow from unrelated donors in adults with acute leukemia. N Engl J Med 2004; 351: 2276–2285.

    CAS  PubMed  PubMed Central  Google Scholar 

  29. 29

    Chao NJ, Liu CX, Rooney B, Chen BJ, Long GD, Vredenburgh JJ et al. Nonmyeloablative regimen preserves ‘niches’ allowing for peripheral expansion of donor T-cells. Biol Blood Marrow Transplant 2002; 8: 249–256.

    PubMed  Google Scholar 

  30. 30

    Robinson SN, Ng J, Niu T, Yang H, McMannis JD, Karandish S et al. Superior ex vivo cord blood expansion following co-culture with bone marrow-derived mesenchymal stem cells. Bone Marrow Transplant 2006; 37: 359–366.

    CAS  PubMed  PubMed Central  Google Scholar 

  31. 31

    de Lima M, McNiece I, Robinson SN, Munsell M, Eapen M, Horowitz M et al. Cord-blood engraftment with ex vivo mesenchymal-cell coculture. N Engl J Med 2012; 367: 2305–2315.

    CAS  PubMed  PubMed Central  Google Scholar 

  32. 32

    Milner LA, Kopan R, Martin DI, Bernstein ID . A human homologue of the Drosophila developmental gene, Notch, is expressed in CD34+ hematopoietic precursors. Blood 1994; 83: 2057–2062.

    CAS  PubMed  Google Scholar 

  33. 33

    Varnum-Finney B, Xu L, Brashem-Stein C, Nourigat C, Flowers D, Bakkour S et al. Pluripotent, cytokine-dependent, hematopoietic stem cells are immortalized by constitutive Notch1 signaling. Nature Med 2000; 6: 1278–1281.

    CAS  PubMed  Google Scholar 

  34. 34

    Delaney C, Varnum-Finney B, Aoyama K, Brashem-Stein C, Bernstein ID . Dose-dependent effects of the Notch ligand Delta1 on ex vivo differentiation and in vivo marrow repopulating ability of cord blood cells. Blood 2005; 106: 2693–2699.

    CAS  PubMed  PubMed Central  Google Scholar 

  35. 35

    Ohishi K, Varnum-Finney B, Bernstein ID . Delta-1 enhances marrow and thymus repopulating ability of human CD34(+)CD38(-) cord blood cells. J Clin Invest 2002; 110: 1165–1174.

    CAS  PubMed  PubMed Central  Google Scholar 

  36. 36

    Delaney C, Heimfeld S, Brashem-Stein C, Voorhies H, Manger RL, Bernstein ID . Notch-mediated expansion of human cord blood progenitor cells capable of rapid myeloid reconstitution. Nature Med 2010; 16: 232–236.

    CAS  PubMed  Google Scholar 

  37. 37

    McEver RP, Moore KL, Cummings RD . Leukocyte trafficking mediated by selectin-carbohydrate interactions. J Biol Chem 1995; 270: 11025–11028.

    CAS  PubMed  Google Scholar 

  38. 38

    Xia L, McDaniel JM, Yago T, Doeden A, McEver RP . Surface fucosylation of human cord blood cells augments binding to P-selectin and E-selectin and enhances engraftment in bone marrow. Blood 2004; 104: 3091–3096.

    CAS  PubMed  Google Scholar 

  39. 39

    Hidalgo A, Frenette PS . Enforced fucosylation of neonatal CD34+ cells generates selectin ligands that enhance the initial interactions with microvessels but not homing to bone marrow. Blood 2005; 105: 567–575.

    CAS  PubMed  Google Scholar 

  40. 40

    Shultz LD, Lyons BL, Burzenski LM, Gott B, Chen X, Chaleff S et al. Human lymphoid and myeloid cell development in NOD/LtSz-scid IL2R gamma null mice engrafted with mobilized human hemopoietic stem cells. J Immunol 2005; 174: 6477–6489.

    CAS  PubMed  PubMed Central  Google Scholar 

  41. 41

    Robinson SN, Simmons PJ, Thomas MW, Brouard N, Javni JA, Trilok S et al. Ex vivo fucosylation improves human cord blood engraftment in NOD-SCID IL-2Rgamma(null) mice. Exp Hematol 2012; 40: 445–456.

    CAS  PubMed  PubMed Central  Google Scholar 

  42. 42

    Kobzdej MM, Leppanen A, Ramachandran V, Cummings RD, McEver RP . Discordant expression of selectin ligands and sialyl Lewis x-related epitopes on murine myeloid cells. Blood 2002; 100: 4485–4494.

    CAS  PubMed  Google Scholar 

  43. 43

    Oran B, Hosing CM, Kebriaei P, Rezvani K, Parmar S, Shah N et al. Ex Vivo fucosylation of cord blood accelerates neutrophil and platelet engraftment. Blood 2013; 122: 691.

    Google Scholar 

  44. 44

    Cutler C, Multani P, Robbins D, Kim HT, Le T, Hoggatt J et al. Prostaglandin-modulated umbilical cord blood hematopoietic stem cell transplantation. Blood 2013; 122: 3074–3081.

    CAS  PubMed  PubMed Central  Google Scholar 

  45. 45

    Goessling W, Allen RS, Guan X, Jin P, Uchida N, Dovey M et al. Prostaglandin E2 enhances human cord blood stem cell xenotransplants and shows long-term safety in preclinical nonhuman primate transplant models. Cell Stem Cell 2011; 8: 445–458.

    CAS  PubMed  PubMed Central  Google Scholar 

  46. 46

    Hoggatt J, Singh P, Sampath J, Pelus LM . Prostaglandin E2 enhances hematopoietic stem cell homing, survival, and proliferation. Blood 2009; 113: 5444–5455.

    CAS  PubMed  PubMed Central  Google Scholar 

  47. 47

    Locatelli F, Rocha V, Chastang C, Arcese W, Michel G, Abecasis M et al. Factors associated with outcome after cord blood transplantation in children with acute leukemia. Eurocord-Cord Blood Transplant Group. Blood 1999; 93: 3662–3671.

    CAS  PubMed  PubMed Central  Google Scholar 

  48. 48

    Kurtzberg J, Laughlin M, Graham ML, Smith C, Olson JF, Halperin EC et al. Placental blood as a source of hematopoietic stem cells for transplantation into unrelated recipients. N Engl J Med 1996; 335: 157–166.

    CAS  PubMed  PubMed Central  Google Scholar 

  49. 49

    Zorn E, Kim HT, Lee SJ, Floyd BH, Litsa D, Arumugarajah S et al. Reduced frequency of FOXP3+ CD4+CD25+ regulatory T cells in patients with chronic graft-versus-host disease. Blood 2005; 106: 2903–2911.

    CAS  PubMed  PubMed Central  Google Scholar 

  50. 50

    Rieger K, Loddenkemper C, Maul J, Fietz T, Wolff D, Terpe H et al. Mucosal FOXP3+ regulatory T cells are numerically deficient in acute and chronic GvHD. Blood 2006; 107: 1717–1723.

    CAS  PubMed  PubMed Central  Google Scholar 

  51. 51

    Rezvani K, Mielke S, Ahmadzadeh M, Kilical Y, Savani BN, Zeilah J et al. High donor FOXP3-positive regulatory T-cell (Treg) content is associated with a low risk of GVHD following HLA-matched allogeneic SCT. Blood 2006; 108: 1291–1297.

    CAS  PubMed  PubMed Central  Google Scholar 

  52. 52

    Miura Y, Thoburn CJ, Bright EC, Phelps ML, Shin T, Matsui EC et al. Association of Foxp3 regulatory gene expression with graft-versus-host disease. Blood 2004; 104: 2187–2193.

    CAS  PubMed  Google Scholar 

  53. 53

    Dong S, Maiella S, Xhaard A, Pang Y, Wenandy L, Larghero J et al. Multiparameter single-cell profiling of human CD4+FOXP3+ regulatory T-cell populations in homeostatic conditions and during graft-versus-host disease. Blood 2013; 122: 1802–1812.

    CAS  PubMed  Google Scholar 

  54. 54

    Rubtsov YP, Niec RE, Josefowicz S, Li L, Darce J, Mathis D et al. Stability of the regulatory T cell lineage in vivo. Science 2010; 329: 1667–1671.

    CAS  PubMed  PubMed Central  Google Scholar 

  55. 55

    Koreth J, Ritz J . Tregs, HSCT, and acute GVHD: up close and personal. Blood 2013; 122: 1690–1691.

    CAS  PubMed  PubMed Central  Google Scholar 

  56. 56

    Wing K, Ekmark A, Karlsson H, Rudin A, Suri-Payer E . Characterization of human CD25+ CD4+ T cells in thymus, cord and adult blood. Immunology 2002; 106: 190–199.

    CAS  PubMed  PubMed Central  Google Scholar 

  57. 57

    Hao L, Gao L, Chen XH, Zou ZM, Zhang X, Kong PY et al. Human umbilical cord blood-derived stromal cells prevent graft-versus-host disease in mice following haplo-identical stem cell transplantation. Cytotherapy 2011; 13: 83–91.

    CAS  PubMed  Google Scholar 

  58. 58

    Bresatz S, Sadlon T, Millard D, Zola H, Barry SC . Isolation, propagation and characterization of cord blood derived CD4+ CD25+ regulatory T cells. J Immunol Methods 2007; 327: 53–62.

    CAS  PubMed  Google Scholar 

  59. 59

    Godfrey WR, Spoden DJ, Ge YG, Baker SR, Liu B, Levine BL et al. Cord blood CD4(+)CD25(+)-derived T regulatory cell lines express FoxP3 protein and manifest potent suppressor function. Blood 2005; 105: 750–758.

    CAS  PubMed  PubMed Central  Google Scholar 

  60. 60

    Lee CC, Lin SJ, Cheng PJ, Kuo ML . The regulatory function of umbilical cord blood CD4(+) CD25(+) T cells stimulated with anti-CD3/anti-CD28 and exogenous interleukin (IL)-2 or IL-15. Pediatr Allergy Immunol 2009; 20: 624–632.

    PubMed  Google Scholar 

  61. 61

    Asanuma S, Tanaka J, Sugita J, Kosugi M, Shiratori S, Wakasa K et al. Expansion of CD4(+)CD25 (+) regulatory T cells from cord blood CD4(+) cells using the common gamma-chain cytokines (IL-2 and IL-15) and rapamycin. Ann Hematol 2011; 90: 617–624.

    CAS  PubMed  Google Scholar 

  62. 62

    Yang J, Fan H, Hao J, Ren Y, Chen L, Li G et al. Amelioration of acute graft-versus-host disease by adoptive transfer of ex vivo expanded human cord blood CD4+CD25+ forkhead box protein 3+ regulatory T cells is associated with the polarization of Treg/Th17 balance in a mouse model. Transfusion 2012; 52: 1333–1347.

    CAS  PubMed  Google Scholar 

  63. 63

    Parmar S, Liu X, Tung SS, Robinson SN, Rodriguez G, Cooper LJ et al. Third-party umbilical cord blood-derived regulatory T cells prevent xenogenic graft-versus-host disease. Cytotherapy 2014; 16: 90–100.

    CAS  PubMed  Google Scholar 

  64. 64

    Hoffmann P, Ermann J, Edinger M, Fathman CG, Strober S . Donor-type CD4(+)CD25(+) regulatory T cells suppress lethal acute graft-versus-host disease after allogeneic bone marrow transplantation. J Exp Med 2002; 196: 389–399.

    CAS  PubMed  PubMed Central  Google Scholar 

  65. 65

    Nguyen VH, Zeiser R, Dasilva DL, Chang DS, Beilhack A, Contag CH et al. In vivo dynamics of regulatory T-cell trafficking and survival predict effective strategies to control graft-versus-host disease following allogeneic transplantation. Blood 2007; 109: 2649–2656.

    CAS  Google Scholar 

  66. 66

    Nguyen VH, Shashidhar S, Chang DS, Ho L, Kambham N, Bachmann M et al. The impact of regulatory T cells on T-cell immunity following hematopoietic cell transplantation. Blood 2008; 111: 945–953.

    CAS  PubMed  PubMed Central  Google Scholar 

  67. 67

    Taylor PA, Lees CJ, Blazar BR . The infusion of ex vivo activated and expanded CD4(+)CD25(+) immune regulatory cells inhibits graft-versus-host disease lethality. Blood 2002; 99: 3493–3499.

    CAS  PubMed  PubMed Central  Google Scholar 

  68. 68

    Gaidot A, Landau DA, Martin GH, Bonduelle O, Grinberg-Bleyer Y, Matheoud D et al. Immune reconstitution is preserved in hematopoietic stem cell transplantation coadministered with regulatory T cells for GVHD prevention. Blood 2011; 117: 2975–2983.

    CAS  PubMed  Google Scholar 

  69. 69

    Ustun C, Miller JS, Munn DH, Weisdorf DJ, Blazar BR . Regulatory T cells in acute myelogenous leukemia: is it time for immunomodulation? Blood 2011; 118: 5084–5095.

    CAS  PubMed  PubMed Central  Google Scholar 

  70. 70

    Zhou Q, Bucher C, Munger ME, Highfill SL, Tolar J, Munn DH et al. Depletion of endogenous tumor-associated regulatory T cells improves the efficacy of adoptive cytotoxic T-cell immunotherapy in murine acute myeloid leukemia. Blood 2009; 114: 3793–3802.

    CAS  PubMed  PubMed Central  Google Scholar 

  71. 71

    Trenado A, Charlotte F, Fisson S, Yagello M, Klatzmann D, Salomon BL et al. Recipient-type specific CD4+CD25+ regulatory T cells favor immune reconstitution and control graft-versus-host disease while maintaining graft-versus-leukemia. J Clin Invest 2003; 112: 1688–1696.

    CAS  PubMed  PubMed Central  Google Scholar 

  72. 72

    Edinger M, Hoffmann P, Ermann J, Drago K, Fathman CG, Strober S et al. CD4+CD25+ regulatory T cells preserve graft-versus-tumor activity while inhibiting graft-versus-host disease after bone marrow transplantation. Nature Med 2003; 9: 1144–1150.

    CAS  PubMed  Google Scholar 

  73. 73

    Brunstein CG, Miller JS, Cao Q, McKenna DH, Hippen KL, Curtsinger J et al. Infusion of ex vivo expanded T regulatory cells in adults transplanted with umbilical cord blood: safety profile and detection kinetics. Blood 2011; 117: 1061–1070.

    CAS  PubMed  PubMed Central  Google Scholar 

  74. 74

    Saavedra S, Sanz GF, Jarque I, Moscardo F, Jimenez C, Lorenzo I et al. Early infections in adult patients undergoing unrelated donor cord blood transplantation. Bone Marrow Transplant 2002; 30: 937–943.

    CAS  PubMed  PubMed Central  Google Scholar 

  75. 75

    Ruggeri A, Peffault de Latour R, Carmagnat M, Clave E, Douay C, Larghero J et al. Outcomes, infections, and immune reconstitution after double cord blood transplantation in patients with high-risk hematological diseases. Transplant Infect Dis 2011; 13: 456–465.

    CAS  Google Scholar 

  76. 76

    Morecki S, Gelfand Y, Nagler A, Or R, Naparstek E, Varadi G et al. Immune reconstitution following allogeneic stem cell transplantation in recipients conditioned by low intensity vs myeloablative regimen. Bone Marrow Transplant 2001; 28: 243–249.

    CAS  PubMed  PubMed Central  Google Scholar 

  77. 77

    Brunstein CG, Weisdorf DJ, DeFor T, Barker JN, Tolar J, van Burik JA et al. Marked increased risk of Epstein-Barr virus-related complications with the addition of antithymocyte globulin to a nonmyeloablative conditioning prior to unrelated umbilical cord blood transplantation. Blood 2006; 108: 2874–2880.

    CAS  PubMed  PubMed Central  Google Scholar 

  78. 78

    Kennedy-Nasser AA, Bollard CM, Myers GD, Leung KS, Gottschalk S, Zhang Y et al. Comparable outcome of alternative donor and matched sibling donor hematopoietic stem cell transplant for children with acute lymphoblastic leukemia in first or second remission using alemtuzumab in a myeloablative conditioning regimen. Biol Blood Marrow Transplant 2008; 14: 1245–1252.

    CAS  PubMed  Google Scholar 

  79. 79

    Boeckh M, Ljungman P . How we treat cytomegalovirus in hematopoietic cell transplant recipients. Blood 2009; 113: 5711–5719.

    CAS  PubMed  PubMed Central  Google Scholar 

  80. 80

    Heslop HE . How I treat EBV lymphoproliferation. Blood 2009; 114: 4002–4008.

    CAS  PubMed  PubMed Central  Google Scholar 

  81. 81

    Lindemans CA, Leen AM, Boelens JJ . How I treat adenovirus in hematopoietic stem cell transplant recipients. Blood 2010; 116: 5476–5485.

    CAS  PubMed  PubMed Central  Google Scholar 

  82. 82

    Riddell SR, Watanabe KS, Goodrich JM, Li CR, Agha ME, Greenberg PD . Restoration of viral immunity in immunodeficient humans by the adoptive transfer of T cell clones. Science 1992; 257: 238–241.

    CAS  PubMed  PubMed Central  Google Scholar 

  83. 83

    Walter EA, Greenberg PD, Gilbert MJ, Finch RJ, Watanabe KS, Thomas ED et al. Reconstitution of cellular immunity against cytomegalovirus in recipients of allogeneic bone marrow by transfer of T-cell clones from the donor. N Engl J Med 1995; 333: 1038–1044.

    CAS  PubMed  PubMed Central  Google Scholar 

  84. 84

    Peggs KS, Verfuerth S, Pizzey A, Khan N, Guiver M, Moss PA et al. Adoptive cellular therapy for early cytomegalovirus infection after allogeneic stem-cell transplantation with virus-specific T-cell lines. Lancet 2003; 362: 1375–1377.

    PubMed  PubMed Central  Google Scholar 

  85. 85

    Doubrovina E, Oflaz-Sozmen B, Prockop SE, Kernan NA, Abramson S, Teruya-Feldstein J et al. Adoptive immunotherapy with unselected or EBV-specific T cells for biopsy-proven EBV+ lymphomas after allogeneic hematopoietic cell transplantation. Blood 2012; 119: 2644–2656.

    CAS  PubMed  PubMed Central  Google Scholar 

  86. 86

    Heslop HE, Slobod KS, Pule MA, Hale GA, Rousseau A, Smith CA et al. Long-term outcome of EBV-specific T-cell infusions to prevent or treat EBV-related lymphoproliferative disease in transplant recipients. Blood 2010; 115: 925–935.

    CAS  PubMed  PubMed Central  Google Scholar 

  87. 87

    Leen AM, Myers GD, Sili U, Huls MH, Weiss H, Leung KS et al. Monoculture-derived T lymphocytes specific for multiple viruses expand and produce clinically relevant effects in immunocompromised individuals. Nature Med 2006; 12: 1160–1166.

    CAS  PubMed  Google Scholar 

  88. 88

    Cobbold M, Khan N, Pourgheysari B, Tauro S, McDonald D, Osman H et al. Adoptive transfer of cytomegalovirus-specific CTL to stem cell transplant patients after selection by HLA-peptide tetramers. J Exp Med 2005; 202: 379–386.

    CAS  PubMed  PubMed Central  Google Scholar 

  89. 89

    Uhlin M, Okas M, Gertow J, Uzunel M, Brismar TB, Mattsson J . A novel haplo-identical adoptive CTL therapy as a treatment for EBV-associated lymphoma after stem cell transplantation. Cancer Immunol Immunother 2010; 59: 473–477.

    PubMed  Google Scholar 

  90. 90

    Feuchtinger T, Opherk K, Bethge WA, Topp MS, Schuster FR, Weissinger EM et al. Adoptive transfer of pp65-specific T cells for the treatment of chemorefractory cytomegalovirus disease or reactivation after haploidentical and matched unrelated stem cell transplantation. Blood 2010; 116: 4360–4367.

    CAS  PubMed  PubMed Central  Google Scholar 

  91. 91

    Moosmann A, Bigalke I, Tischer J, Schirrmann L, Kasten J, Tippmer S et al. Effective and long-term control of EBV PTLD after transfer of peptide-selected T cells. Blood 2010; 115: 2960–2970.

    CAS  PubMed  Google Scholar 

  92. 92

    Icheva V, Kayser S, Wolff D, Tuve S, Kyzirakos C, Bethge W et al. Adoptive transfer of epstein-barr virus (EBV) nuclear antigen 1-specific t cells as treatment for EBV reactivation and lymphoproliferative disorders after allogeneic stem-cell transplantation. J Clin Oncol 2013; 31: 39–48.

    CAS  PubMed  Google Scholar 

  93. 93

    Feuchtinger T, Matthes-Martin S, Richard C, Lion T, Fuhrer M, Hamprecht K et al. Safe adoptive transfer of virus-specific T-cell immunity for the treatment of systemic adenovirus infection after allogeneic stem cell transplantation. Br J Haematol 2006; 134: 64–76.

    PubMed  PubMed Central  Google Scholar 

  94. 94

    Komanduri KV, St John LS, de Lima M, McMannis J, Rosinski S, McNiece I et al. Delayed immune reconstitution after cord blood transplantation is characterized by impaired thymopoiesis and late memory T-cell skewing. Blood 2007; 110: 4543–4551.

    CAS  PubMed  PubMed Central  Google Scholar 

  95. 95

    Leen AM, Christin A, Myers GD, Liu H, Cruz CR, Hanley PJ et al. Cytotoxic T lymphocyte therapy with donor T cells prevents and treats adenovirus and Epstein-Barr virus infections after haploidentical and matched unrelated stem cell transplantation. Blood 2009; 114: 4283–4292.

    CAS  PubMed  PubMed Central  Google Scholar 

  96. 96

    Leen A, Gee AP, Leung K, Martinez C, Krance RA, Liu H et al. Multi-virus-specific T-cell therapy for patients after hematopoietic stem cell and cord blood transplantation. Blood 2013; 122: 140.

    Google Scholar 

  97. 97

    Leen AM, Bollard CM, Mendizabal AM, Shpall EJ, Szabolcs P, Antin JH et al. Multicenter study of banked third-party virus-specific T cells to treat severe viral infections after hematopoietic stem cell transplantation. Blood 2013; 121: 5113–5123.

    CAS  PubMed  PubMed Central  Google Scholar 

  98. 98

    Melenhorst JJ, Leen AM, Bollard CM, Quigley MF, Price DA, Rooney CM et al. Allogeneic virus-specific T cells with HLA alloreactivity do not produce GVHD in human subjects. Blood 2010; 116: 4700–4702.

    CAS  PubMed  PubMed Central  Google Scholar 

  99. 99

    Katari UL, Gerdemann U, Martinez C, Leung K, Carrum G, Gee AP et al. Safety and clinical efficacy of rapidly-generated virus-specific T cells with activity against Adv, EBV, CMV, HHV6 and BK virus administered after allogeneic hematopoietic stem cell transplant. Blood 2013; 122: 148.

    Google Scholar 

  100. 100

    Versluis J, Labopin M, Niederwieser D, Socie G, Schlenk RF, Milpied N et al. Prediction of non-relapse mortality in recipients of reduced intensity conditioning allo-HSCT with acute myeloid leukemia in first complete remission: integrating the seattle comorbidity index (HCT-CI) and EBMT scoring systems. ASH Annu Meet Abstr 2012; 120: 734.

    Google Scholar 

  101. 101

    Kochenderfer JN, Wilson WH, Janik JE, Dudley ME, Stetler-Stevenson M, Feldman SA et al. Eradication of B-lineage cells and regression of lymphoma in a patient treated with autologous T cells genetically engineered to recognize CD19. Blood 2010; 116: 4099–4102.

    CAS  PubMed  PubMed Central  Google Scholar 

  102. 102

    Brentjens RJ, Riviere I, Park JH, Davila ML, Wang X, Stefanski J et al. Safety and persistence of adoptively transferred autologous CD19-targeted T cells in patients with relapsed or chemotherapy refractory B-cell leukemias. Blood 2011; 118: 4817–4828.

    CAS  PubMed  PubMed Central  Google Scholar 

  103. 103

    Porter DL, Levine BL, Kalos M, Bagg A, June CH . Chimeric antigen receptor-modified T cells in chronic lymphoid leukemia. N Engl J Med 2011; 365: 725–733.

    CAS  PubMed  PubMed Central  Google Scholar 

  104. 104

    Kochenderfer JN, Dudley ME, Feldman SA, Wilson WH, Spaner DE, Maric I et al. B-cell depletion and remissions of malignancy along with cytokine-associated toxicity in a clinical trial of anti-CD19 chimeric-antigen-receptor-transduced T cells. Blood 2012; 119: 2709–2720.

    CAS  PubMed  PubMed Central  Google Scholar 

  105. 105

    Grupp SA, Kalos M, Barrett D, Aplenc R, Porter DL, Rheingold SR et al. Chimeric antigen receptor-modified T cells for acute lymphoid leukemia. N Engl J Med 2013; 368: 1509–1518.

    CAS  PubMed  PubMed Central  Google Scholar 

  106. 106

    Micklethwaite KP, Savoldo B, Ramos CA, Lam S, Ku S, Diouf O et al. Infusion of donor-derived CD19-redirected-virus-specific T cells for b-cell malignancies relapsed after allogeneic stem cell transplant: a phase I study. Blood 2013; 122: 152.

    Google Scholar 

  107. 107

    Micklethwaite KP, Savoldo B, Hanley PJ, Leen AM, Demmler-Harrison GJ, Cooper LJ et al. Derivation of human T lymphocytes from cord blood and peripheral blood with antiviral and antileukemic specificity from a single culture as protection against infection and relapse after stem cell transplantation. Blood 2010; 115: 2695–2703.

    CAS  PubMed  PubMed Central  Google Scholar 

  108. 108

    Kebriaei PHH, Singh H, Olivares S, Figliola M, Kumar PR, Jena B et al. Adoptive immunotherapy following umbilical cord blood transplantation using the sleeping beauty system and artificial antigen presenting cells to generate donor-derived T cells expressing a CD19-specific chimeric antigen receptor. ASH Annu Meet Abstr 2013; 122: 4208.

    Google Scholar 

  109. 109

    Kochenderfer JN, Dudley ME, Carpenter RO, Kassim SH, Rose JJ, Telford WG et al. Donor-derived CD19-targeted T cells cause regression of malignancy persisting after allogeneic hematopoietic stem cell transplantation. Blood 2013; 122: 4129–4139.

    CAS  PubMed  PubMed Central  Google Scholar 

  110. 110

    Ruggeri L, Capanni M, Urbani E, Perruccio K, Shlomchik WD, Tosti A et al. Effectiveness of donor natural killer cell alloreactivity in mismatched hematopoietic transplants. Science 2002; 295: 2097–2100.

    CAS  PubMed  PubMed Central  Google Scholar 

  111. 111

    Childs RW, Berg M . Bringing natural killer cells to the clinic: ex vivo manipulation. Hematology Am Soc Hematol Educ Program 2013; 2013: 234–246.

    PubMed  Google Scholar 

  112. 112

    Miller JS, Soignier Y, Panoskaltsis-Mortari A, McNearney SA, Yun GH, Fautsch SK et al. Successful adoptive transfer and in vivo expansion of human haploidentical NK cells in patients with cancer. Blood 2005; 105: 3051–3057.

    CAS  Google Scholar 

  113. 113

    Frei GM, Persi N, Lador C, Peled A, Cohen YC, Nagler A et al. Nicotinamide, a form of vitamin B3, promotes expansion of natural killer cells that display increased in vivo survival and cytotoxic activity. ASH Annu Meet Abstr 2011; 118: 4035.

    Google Scholar 

  114. 114

    Berg M, Lundqvist A, Betters D, Childs RW . In vitro expanded NK cells have increased natural cytotoxity receptors, TRAIL and NKG2D expression, and superior tumor cytotoxicity compared to short-term IL-2-activated NK cells. ASH Annu Meet Abstr 2009; 114: 463.

    Google Scholar 

  115. 115

    Zhang H, Cui Y, Voong N, Sabatino M, Stroncek DF, Morisot S et al. Activating signals dominate inhibitory signals in CD137L/IL-15 activated natural killer cells. J Immunother 2011; 34: 187–195.

    CAS  PubMed  PubMed Central  Google Scholar 

  116. 116

    Lapteva N, Durett AG, Sun J, Rollins LA, Huye LL, Fang J et al. Large-scale ex vivo expansion and characterization of natural killer cells for clinical applications. Cytotherapy 2012; 14: 1131–1143.

    CAS  PubMed  PubMed Central  Google Scholar 

  117. 117

    Imai C, Iwamoto S, Campana D . Genetic modification of primary natural killer cells overcomes inhibitory signals and induces specific killing of leukemic cells. Blood 2005; 106: 376–383.

    CAS  PubMed  PubMed Central  Google Scholar 

  118. 118

    Fujisaki H, Kakuda H, Shimasaki N, Imai C, Ma J, Lockey T et al. Expansion of highly cytotoxic human natural killer cells for cancer cell therapy. Cancer Res 2009; 69: 4010–4017.

    CAS  PubMed  PubMed Central  Google Scholar 

  119. 119

    Baird K, Fry TJ, Merchant M, Richards K, Delbrook C, Wayne AS et al. Early clinical experience of aAPC activated NK-DLI following allogeneic PBSCT in pediatric solid tumor patients. ASH Annu Meet Abstr 2012; 120: 3013.

    Google Scholar 

  120. 120

    Denman CJ, Senyukov VV, Somanchi SS, Phatarpekar PV, Kopp LM, Johnson JL et al. Membrane-bound IL-21 promotes sustained ex vivo proliferation of human natural killer cells. PloS One 2012; 7: e30264.

    CAS  PubMed  PubMed Central  Google Scholar 

  121. 121

    Liu Y, Wu HW, Sheard MA, Sposto R, Somanchi SS, Cooper LJ et al. Growth and activation of natural killer cells ex vivo from children with neuroblastoma for adoptive cell therapy. Clin Cancer Res 2013; 19: 2132–2143.

    CAS  PubMed  PubMed Central  Google Scholar 

  122. 122

    Spanholtz J, Preijers F, Tordoir M, Trilsbeek C, Paardekooper J, de Witte T et al. Clinical-grade generation of active NK cells from cord blood hematopoietic progenitor cells for immunotherapy using a closed-system culture process. PloS One 2011; 6: e20740.

    CAS  PubMed  PubMed Central  Google Scholar 

  123. 123

    Xing D, Ramsay AG, Gribben JG, Decker WK, Burks JK, Munsell M et al. Cord blood natural killer cells exhibit impaired lytic immunological synapse formation that is reversed with IL-2 ex vivo expansion. J Immunother 2010; 33: 684–696.

    CAS  PubMed  PubMed Central  Google Scholar 

  124. 124

    Gill S, Vasey AE, De Souza A, Baker J, Smith AT, Kohrt HE et al. Rapid development of exhaustion and down-regulation of eomesodermin limit the antitumor activity of adoptively transferred murine natural killer cells. Blood 2012; 119: 5758–5768.

    CAS  PubMed  PubMed Central  Google Scholar 

  125. 125

    Curti A, Ruggeri L, D'Addio A, Bontadini A, Dan E, Motta MR et al. Successful transfer of alloreactive haploidentical KIR ligand-mismatched natural killer cells after infusion in elderly high risk acute myeloid leukemia patients. Blood 2011; 118: 3273–3279.

    CAS  PubMed  Google Scholar 

  126. 126

    Szmania S, Lapteva N, Garg TK, Lingo JD, Greenway AD, Bost A et al. Expanded natural killer (NK) cells for immunotherapy: fresh and made to order. ASH Annu Meet Abstr 2012; 120: 1912.

    Google Scholar 

  127. 127

    Skeate R, Singh C, Cooley S, Geller M, Northouse J, Welbig J et al. Hemolytic anemia due to passenger lymphocyte syndrome in solid malignancy patients treated with allogeneic natural killer cell products. Transfusion 2013; 53: 419–423.

    CAS  PubMed  Google Scholar 

  128. 128

    Berg M, Lundqvist A, McCoy P Jr, Samsel L, Fan Y, Tawab A et al. Clinical-grade ex vivo-expanded human natural killer cells up-regulate activating receptors and death receptor ligands and have enhanced cytolytic activity against tumor cells. Cytotherapy 2009; 11: 341–355.

    CAS  PubMed  PubMed Central  Google Scholar 

  129. 129

    Somanchi SS, Senyukov VV, Denman CJ, Lee DA . Expansion, purification, and functional assessment of human peripheral blood NK cells. J Vis Exp 2011; 2: 2540.

    Google Scholar 

  130. 130

    Somanchi SS, Somanchi A, Cooper LJ, Lee DA . Engineering lymph node homing of ex vivo-expanded human natural killer cells via trogocytosis of the chemokine receptor CCR7. Blood 2012; 119: 5164–5172.

    CAS  PubMed  PubMed Central  Google Scholar 

  131. 131

    Miller JS . Therapeutic applications: natural killer cells in the clinic. Hematology Am Soc Hematol Educ Program 2013; 2013: 247–253.

    PubMed  Google Scholar 

  132. 132

    Brandenburg S, Takahashi T, de la Rosa M, Janke M, Karsten G, Muzzulini T et al. IL-2 induces in vivo suppression by CD4(+)CD25(+)Foxp3(+) regulatory T cells. Eur J Immunol 2008; 38: 1643–1653.

    CAS  PubMed  Google Scholar 

  133. 133

    Stoklasek TA, Schluns KS, Lefrancois L . Combined IL-15/IL-15Ralpha immunotherapy maximizes IL-15 activity in vivo. J Immunol 2006; 177: 6072–6080.

    CAS  PubMed  PubMed Central  Google Scholar 

  134. 134

    Huntington ND, Legrand N, Alves NL, Jaron B, Weijer K, Plet A et al. IL-15 trans-presentation promotes human NK cell development and differentiation in vivo. J Exp Med 2009; 206: 25–34.

    CAS  PubMed  PubMed Central  Google Scholar 

  135. 135

    Cooley S, Trachtenberg E, Bergemann TL, Saeteurn K, Klein J, Le CT et al. Donors with group B KIR haplotypes improve relapse-free survival after unrelated hematopoietic cell transplantation for acute myelogenous leukemia. Blood 2009; 113: 726–732.

    CAS  PubMed  PubMed Central  Google Scholar 

  136. 136

    Venstrom JM, Pittari G, Gooley TA, Chewning JH, Spellman S, Haagenson M et al. HLA-C-dependent prevention of leukemia relapse by donor activating KIR2DS1. N Engl J Med 2012; 367: 805–816.

    CAS  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to E J Shpall.

Ethics declarations

Competing interests

LC has served as a consultant for Targazyme (formerly American Stem cells), GE Healthcare, Ferring Pharmaceuticals, Fate Therapeutics, Janssen Pharmaceuticals, and Bristol-Myers Squibb. LC owns equity/stock in Targazyme, has received lecture fees from Miltenyi Biotec and served on the Scientific Advisory Board of Cellectis. CMH has received grant support from Celgene. NDS has served on a Celgene Advisory Board and received grant support from Celgene.

Additional information

This article was published as part of a supplement, supported by WIS-CSP Foundation, in collaboration with Gilead, Milteny Biotec, Gamida cell, Adienne Pharma and Biotech, Medac hematology, Kiadis Pharma and Almog Diagnostic.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Thompson, P., Rezvani, K., Hosing, C. et al. Umbilical cord blood graft engineering: challenges and opportunities. Bone Marrow Transplant 50, S55–S62 (2015). https://doi.org/10.1038/bmt.2015.97

Download citation

Further reading

Search

Quick links