Banking on baby: all about umbilical cord blood stem cell transplants

Over the summer, my then-pregnant friend asked for my opinion about umbilical cord blood banking, naturally sending me into a world of fascinating biology, cutting edge medicine and some ethical quandaries.

If you can afford the $1000-2000 processing fee and at least $100 a year to store the blood, banking seems like a no-brainer. “You never know,” rings in the backs of many expecting parents’ minds as the one-time opportunity approaches. But there is more to consider than price. The biology behind the technique and the currently available applications of frozen cord blood may influence one’s decision about whether to bank, and also how and where to do it.

Cord blood contains a high frequency of hematopoietic stem cells, which can differentiate into any kind of blood cell. They can mature into megakaryocytes that make platelets, red blood cells, or immune cells like B cells or eosinophils. We all carry these stem cells throughout our lives, mainly in our bone marrow, and they produce cells that periodically replace blood cell populations.

Blood cells arising from hematopoietic stem cells. (Wikimedia commons, based on original by A. Rad)

Cancers rising from white blood cells (like lymphoma or leukemia) and genetic defects interfering with the production of any kind of blood cell can conceivably be addressed by resetting the whole system with a bone marrow (or stem cell) transplant.  Transplants using donated bone marrow have been used to do just this for about 50 years. In the late 1980s, it became clear that cord blood stem cells could do the same with some distinct advantages.

For one thing, collecting cord blood is much less difficult and invasive compared to harvesting bone marrow. Bone marrow donation involves anesthesia and a very large needle stuck directly into the bone. Stem or progenitor cells can also be separated from adult blood through a process called apheresis, but it is no cakewalk, especially compared to harvesting cord blood, which simply involves injecting a needle into the cord after it’s been cut.

Donor matching is also more flexible for cord blood. To avoid graft rejection, stem cell (and all organ) donors and recipients are matched for proteins expressed on the surface of immune cells. If they don’t match, the T cells in the donated transplant may attack the tissues of the recipient. T cells found in cord blood respond with less gusto and there are higher frequencies of T cell subsets that control the immune response called T regulatory cells. This means there’s a lower chance of the donor immune system harming the recipient.

Given these advantages, is banking worthwhile? It depends on what you hope to get out of it. When you think about storing a baby’s cord blood, you may think it’s for the sake of that particular child. The truth is, the stem cells in that kid’s blood are more likely to be useful for someone else. That was the case of the first ever cord blood transplant performed in 1988. A five year-old boy with a rare genetic disease called Fanconi Anemia received cord blood cells from his newborn sister. At the time, the boy’s white blood cell counts were dropping because inherited defects in a DNA repair pathway made it impossible for his bone marrow to produce healthy blood cells quickly enough. His own cord blood, of course, would have been useless because the same genetic defect would manifest again. Today, that patient is a grown man, but he has a female blood and immune system thanks to his sister.

Cases covered in the news about cancer patients cured because of cord blood transplants are usually about patients who received donated cord blood from public banks. In fact, their own stem cells would not have worked. In such cases, the transplant is an imperfect match on purpose so that the new immune system will attack cancer cells that the old immune system was blind to. This is typically done for blood cancers like leukemia. A transplant of a close or perfect match is desirable for patients whose bone marrow is depleted as a side effect of chemotherapy and/or irradiation for other types of cancer. However, stem cells for this kind of transplant can also be harvested from one’s own bone marrow or blood before beginning treatment.

photo credit: Banc de Sang i Teixits via photopin

Even if the chances of using one’s own cord blood are remote, it may be desirable to store it in case a family member could use it. There are a couple of caveats to consider, however, before committing to private banking. First, it’s been estimated that at least 70% of adult recipients need two units of cord blood to successfully reinstate a new blood and immune systems That means it’s likely that even if you do save your baby’s cord blood, it may not be enough if he or she needs it as an adult. This may change in the future; a study published last week in Science found that a drug compound called UM171 kept human cord blood stem cells “immature” while allowing them to expand. There are also several clinical trials underway that will test whether expanding cord blood progenitors through other means can reduce the number of units needed and increase transplant success.

The second caveat is a little bit more about logistics and politics than science. Right now, only 10% of collected cord blood meets the standards required for transplantation. These standards included how many cells are present, how many cells survived and whether the blood was collected, shipped and frozen properly. (For an interesting glimpse at what could go wrong, check out this Wall Street Journal article).  And the way cord blood units are handled and stored is only regulated by the Food and Drug Administration if they are stored in public banks. That is not to say that there are no good and reputable private banks. It is, however, important to recognize that private banking requires lots of research and care when choosing a company.

I mentioned that the chances of performing a cord blood transplant on the original donor are not very high given the current uses of cord blood stem cells—mainly to replace blood stem cells in the bone marrow. That is not the whole story though. There are clinical trials going on to test the therapeutic effects of cord blood stem cells for things like cerebral palsy, type I diabetes and even hearing loss. These studies are based on observations suggesting stem cells found in cord blood can reduce brain damage after injury, but it’s not yet clear how. There are also other kinds of stem cells in cord blood that can differentiate into cells other than blood cells (pancreatic cells for example). There may still be a lot of untapped potential for cord blood. For many parents, that is enough reason to put their kids’ blood “on ice” and wait it out.

Sources:

Metheny L., Caimi P. & de Lima M. (2013). Cord Blood Transplantation: Can We Make it Better?, Frontiers in oncology, PMID: http://www.ncbi.nlm.nih.gov/pubmed/24062989

Gluckman E., Arleen D. Auerbach, Henry S. Friedman, Gordon W. Douglas, Agnès Devergie, Hélène Esperou, Dominique Thierry, Gérard Socie, Pierre Lehn & Scott Cooper & (1989). Hematopoietic Reconstitution in a Patient with Fanconi’s Anemia by Means of Umbilical-Cord Blood from an HLA-Identical Sibling, New England Journal of Medicine, 321 (17) 1174-1178. DOI: http://dx.doi.org/10.1056/nejm198910263211707

Wagner J.E. Should double cord blood transplants be the preferred choice when a sibling donor is unavailable?, Best practice & research. Clinical haematology, PMID: http://www.ncbi.nlm.nih.gov/pubmed/19959107

Fares I., Chagraoui J., Gareau Y., Gingras S., Ruel R., Mayotte N., Csaszar E., Knapp D.J.H.F., Miller P. & Ngom M. & Cord blood expansion. Pyrimidoindole derivatives are agonists of human hematopoietic stem cell self-renewal., Science (New York, N.Y.), PMID: http://www.ncbi.nlm.nih.gov/pubmed/25237102

Petrini C. (2014). Umbilical cord blood banking: from personal donation to international public registries to global bioeconomy., Journal of blood medicine, PMID: http://www.ncbi.nlm.nih.gov/pubmed/24971040

Training the immune system to kill cancer

Have you ever heard the term “cancer vaccine?”  Are there really vaccines to prevent cancer, and do they really work? The truth is, it’s kind of a misnomer. The vaccine against herpes papilloma virus (HPV) is often called a cancer vaccine, but it’s actually a vaccine to prevent an infection that can lead to cancer.  In other cases, the term “cancer vaccine” describes a treatment that trains immune cells to attack cancer cells.  There is one FDA-approved vaccine treatment for prostate cancer, but there are ongoing clinical trials for many other types of cancers. 

One recent clinical trial for patients with glioblastoma found that a cancer vaccine approach significantly extended the patients’ lives. Glioblastoma is the most common and most aggressive type of tumor that originates in the brain, and the average survival after treatment is about a year. This vaccine approach tested at Cedars-Sinai Medical Center in LA was so significant is because it gave half of the patients about five years.  The results of the study were reported at a meeting, but the details of the trial and initial findings were published in January.

Researchers collected large numbers of white blood cells (immune cells) from the volunteers through a process called leukapheresis, which separates immune cells and returns red blood cells and other blood components back to the donor.  They were after a rare cell type called monocytes that can morph into different cell types depending on their environment. Monocytes originally come from the bone marrow and remain round and smooth as they roll through the blood. Given the right signals, they can leave the blood for other tissues and change into macrophages or dendritic cells, both rugged spindly cells that poke out tiny arms to sense their environment.  

If you put white blood cells in a culture dish, as the scientists at Cedars-Sinai did,  the monocytes will stick to the bottom of the dish in just a couple of hours. Then you can wash away all of the other cells and keep just the monocytes. After about a week, they will morph on their own into macrophages—cells that eat up pathogens or other dead cells.  But if you add a couple of signaling proteins called cytokines, the monocytes will become dendritic cells.

Dendritic cells also eat up foreign material, but they are somewhat more refined at it. They break down everything that they eat and then present little pieces of it to educate other immune cells about what is going on in the body. T cells are their main pupils, and have receptors that sense what the dendritic cells are displaying.  Then both types of cells can make proteins to attack the foreign material (bacteria, cancer cells, infected cells) and signal other cells to start a cascading immune response.

Our bodies use this process to fight infection and to prevent cancers from developing. But once a tumor is formed, tumor cells are very effective at re-educating T cells and other immune cells.  Tumor cells can make proteins that lull and calm immune cells so that they can’t respond or don’t recognize the tumor cells as foreign. Technically, cancer cells aren’t foreign, but mutated and rebellious.  Proteins displayed on cancer cells can be distorted or can be made in excess, distinguishing them from normal cells.

By Simon Caulton. This file is licensed under the Creative Commons Attribution-Share Alike 3.0 Unported license.

The idea behind cancer vaccines is to prepare dendritic cells outside of the body and put them back in where they can push immune system toward actively attacking tumors. The researchers at Cedars-Sinai coaxed monocytes into becoming active dendritic cells in culture. Then they gave the cells peptides, or pieces of proteins, that resembled the ones made in high abundance on glioblastoma cells.  Years of research went into simply identifying exactly which proteins were overproduced by these cancer cells and which would best activate the dendritic cells.  This study used six peptides to activate and train the dendritic cells.  Then the cells were sent back into the patients near their lymph nodes, which are full of T cells awaiting instructions.

Variations on this method are being tested for breast cancer, melanoma, leukemia and many other cancers. The outcomes will depend on which peptides are used, which peptides are made by each person’s tumor, how well one’s cells grow in culture and respond to activation and other variables. It’s a simple idea—to use the body’s own defenses to fight cancer—but there is a lot more to learn about this fascinating and promising treatment.

Sources:

The National Cancer Institute 

Vaccine promises longer survival for brain tumor patients, Belinda Weber Medical News Today, Nov 2013

Phase I trial of a multi-epitope-pulsed dendritic cell vaccine for patients with newly diagnosed glioblastoma, Phuphanich S, Wheeler CJ, et al. Cancer Immunol Immunother. Jan 2013

I missed antibiotic resistance awareness week!

Last week, Europe, Australia and the U.S. all launched their 5th Antibiotic Awareness Weeks, spreading the word about bacterial resistance to antibiotics. I heard of the event during a conversation about the death of a New Zealand man who had been infected with pan-antibiotic resistant bacteria.  According to reports, the infection was not the cause of his death, but it made news because his doctors found that no known antibiotic could stop his infection.

On her blog, Superbug, writer Maryn McKenna closely follows the growing issue of antibiotic resistance. She also recently wrote a report about what the world might look like without any working antibiotics. Recall any time you’ve taken antibiotics for an ear infection or after a root canal or a simple surgery. Those simple infections and procedures could become a lot more dangerous without the ability to kill off bacteria.  After all, the first test case for penicillin was a gardener who was dying of an infection caused by a small cut from a thorn.

A very well illustrated CDC report estimated that 2 million people are infected with antibiotic resistant bacteria in the U.S. each year.  In an effort to bring some organization to the overwhelming issue, the report ranked 18 resistant organisms as “urgent,” “concerning” or “serious” threats.

What does resistance mean exactly? And what does this have to do with immunology?

Our immune systems have a variety of techniques to address bacterial infections. We have cells called phagocytes that eat bacteria and digest them, we have specialized T cells, natural killer cells and neutrophils that secrete molecules and proteins that damage bacteria or kill infected cells. Proteins in our blood (complement proteins) stick to bacterial cell surfaces and then build upon each other like blocks until they make what’s called an “attack complex” that drills a hole in the bacterial cell membrane. 

{Did you know we need free radicals to fight infections and kill cancer cells?  Phagocytes use them to kill the bacteria that they engulf.  Many people think of free radicals as “bad” molecules and take antioxidants hoping to prevent cancer, but free radicals are one way our bodies destroy rebellious cancer cells. In fact, many cancer treatments activate free radicals to target cancer cells and patients receiving these treatments are instructed to avoid antioxidant supplements.}

If a species of bacteria is good at avoiding one tactic, there are plenty of others, and a healthy immune system will usually contain an infection and eliminate it. If someone has an unhealthy immune system (immunocompromised) or the inflammation from the immune response starts to damage tissue, antibiotics are a great way give the immune cells a fighting chance and spare the infected person.

Unlike the immune system, an antibiotic is just one compound with one tactic or mechanism. So it’s possible for just one mutation to give a bacterium resistance to that one compound’s tactic. If a drug targets a protein needed for bacterial cell membrane construction, the bacteria may alter the protein, change its construction method or make a different protein that pumps the drug out of the cell.

DNA mutations are common at the rate that bacteria divide.  Staphylococcus aureus, for example, can divide every half hour. I grow S. aureus in the lab, and when I put an amount that could fit on a pen point into a tube of special broth at 37° C (the same temperature as the human body), the next day I end up with enough bacteria to fill about a quarter of a teaspoon.

Life for bacteria is tougher inside a human body since they are always being attacked by the immune system. But say the bacteria get the upper hand inside an infected person, we’ll call her Amy. Amy goes to the doctor and gets an antibiotic prescription, perhaps methicillin or vancomycin—enough pills to take one a day for 7 days. When she starts taking them many bacteria will die or stop dividing and her immune cells will be able to make headway against the infection.  S. aureus can accumulate hundreds of mutations a day and even though most of the mutants will die, there will likely be individual bacterium inside of Amy with mutations that make them resistant to the drug she is taking. Those resistant mutants have an advantage over the other bacteria and will take over as all of their siblings get killed off by the drug.

Imagine the image shown on a kitchen cleaner commercial as it touts “kills 99.9% of germs.” On one side of the screen the “before” shot shows lots of wiggly cartoon “germs” and on the other side, after the cleaner is used, there are one or two wiggly little guys left.  By “99.9%,” the commercial means that their product kills most known household species of bacteria, but if those were all the same species infecting a person and the cleaner was an antibiotic drug, those two little guys left behind would multiply with a vengeance and birth a resistant strain.  There is a potential for that to happen every time a person takes antibiotics.

Ideally, even if mutations do arise, the antibiotics slow down the bacteria enough to let the immune system completely eradicate the infection (including the resistant mutants).  But say Amy takes her prescription for 4 days and feels like she’s back to normal so she decides not to finish the whole 7 day course. By this time, she may be harboring resistant mutants and when she stops taking the drug, her immune system will suddenly have a lot more to deal with, and the mutants may expand.  When she feels sick again a day or two later and starts to take the antibiotics again, they may not work at all since the resistant mutants have outgrown the other bacteria. She may end up having to get a different antibiotic injected into her bloodstream in the hospital and while she’s there, she may spread the resistant bacteria to other patients.

That’s the story of one mutation giving rise to a bacterial strain resistant against one drug.  The man who passed away in New Zealand was infected with a strain of Klebsiella pneumonia that was resistant against every drug. How did that happen?

The short answer is we don’t know the history of every resistant strain. One interesting example that scientists are following is vancomycin-resistant S. aureus (VRSA). VRSA has been isolated about a dozen times from individual patients.  Most of them were diabetic patients with methicillin-resistant S. aureus (MRSA) infections that coincided with the presence of vancomycin-resistant Enterococcus sp. (VRE).  It’s thought that the VRE transferred its genes for vancomycin resistance to the MRSA, resulting in a strain of S. aureus that is resistant to both methicillin and vancomycin.  This sort of gene transfer can happen inside an infected person or out in the environment.

Scientists are also monitoring how the use of antibiotics in agriculture and aquaculture may promote development of antibiotic resistance.  According to a 2010 review, less than half of all antibiotics are used to treat human infections. Most farm animals are constantly on antibiotics and are known to harbor resistant strains of bacteria, making foodborne illness a potential route to spread resistant bacteria or genes to humans.  To microbiologists, chronic use of antibiotics in agriculture is an obvious route to resistance, but it’s difficult to track exactly where resistant strains originate, so the issue is still controversial.  A study published a few days ago found that MRSA infection rates were statistically correlated with how close Pennsylvania residents lived to livestock feedlots or to fields where swine manure was used as fertilizer.

There is a large gap in our knowledge about the link between antibiotics and agriculture, but it is an active area of research.  Whether you buy antibiotic-free meat or whether you cover your house with Lysol, the one non-controversial and vital thing we can all do is always complete the full course of an antibiotic prescription.

Sources

NZs first ‘superbug’ victim? Siouxsi Wiles Nov 2013

The real story behind penicillin. Howard Markel, MD Sept 2013

Antibiotic resistance threats in the United States. The CDC, November 2013

Antibiotic resistance, mutation rates and MRSA. Pray, L. Nature Education, 2008

The emergence of vancomycin-intermediate and vancomycin-resistant Staphylococcus aureus. Appelbaum, P. Clin Micr and Inf Jan 2006

The Origin and Evolution of Antibiotic Resistance. Davies, J. and Davies, D. Microbiol Mol Biol Rev Sept 2010

A call for antibiotics alternatives research. Stanton, T. Trends in Microbiology March 2013

MRSA: Farming up trouble. Mole, B.  Nature July 2013

High-density livestock operations, crop field application of manure, and risk of community-associated methicillin-resistant Staphylococcus aureus infection in Pennsylvania. Casey, JA et. al. JAMA Intern Med Nov 2013