Cord blood banking in London: the first 1000 collections

Bone Marrow Transplantation, (1999) 24, 139 145 1999 Stockton Press All rights reserved 0268 3369/99 $12.00 http://www.stockton-press.co.uk/bmt in London: the first 1000 collections S Armitage, R Warwick, D Fehily, C Navarrete and M Contreras National Blood Service London and SE Zone, North London Centre, UK Summary: The London Cord Blood Bank was established with the aim of collecting, processing and storing 10 000 unrelated stem cell donations for the significant number of children in the UK requiring transplantation, for whom a matched unrelated bone marrow donor cannot be found. Collection is performed at two hospitals by dedicated cord blood bank staff after delivery of the placenta. Mothers are interviewed regarding medical, ethnic and behavioural history by nurse counsellors and sign a detailed consent form. Donations are returned to the bank for processing. Volume reduction is undertaken by a simple, closed, semi-automated blood processing system, with excellent recovery of progenitor cells. Units are cryopreserved and stored in the vapour phase of liquid nitrogen. Blood samples from mothers and cord blood donations are tested for the UK mandatory red cell and microbiology markers for blood donors. Donations are typed for HLA-A, B and DR at medium resolution (antigen split) level using sequencespecific oligonucleotide probing and sequence-specific priming techniques. The selection of collection hospitals on the basis of ethnic mix has proven effective, with 41.5% of donations derived from non-european caucasoid donors. Bacterial contamination of collections has been dramatically reduced by implementation of improved umbilical cord decontamination protocols. Keywords: cord blood; cord blood banking; stem cells; progenitor cells Cord blood (CB) is rich in haematopoietic progenitor cells and can be used as an alternative to bone marrow (BM) for transplantation. The collection of CB poses no risk to the donor, in contrast to BM harvesting which requires general anaesthesia. To facilitate the provision of CB units for transplantation, cord blood banks (CBB) have been developed worldwide. 1 4 CBB utilise a waste product that is abundantly available from a diverse ethnic mix and there is a huge potential donor base, with about 600000 births per year in the United Kingdom. Successful haematopoietic and immunological engraftment can occur when CB is the source of stem cells, even when there is one or more HLA antigen disparity between donor and recipient. 5 10 As a consequence, much smaller CB registries, compared with Correspondence: Dr S Armitage, London Cord Blood Bank, Deansbrook Road, Edgware, Middx HA8 9BG, UK Received 4 December 1998; accepted 16 February 1999 bone marrow donor registries of hundreds of thousands, can provide adequate matches for large numbers of potential recipients. Tracking back to the donor at the time of final selection of the CB unit for transplantation is not required, therefore the time taken to identify a matched unit will be weeks rather than the months typically required to identify an unrelated BM donor. An additional advantage of CB is the low viral carriage rate of neonatal/fetal blood compared to adult blood. 7 Prompted by the unavailability of suitable BM donors for a significant number of children requiring transplantation in England, the National Blood Service (NBS) founded the London Cord Blood Bank (LCBB). The bank aims to collect, process and store 10 000 CB donations. Its geographical location allows it to concentrate recruitment efforts in those ethnic groups that are not adequately represented in BM donor panels. The LCBB operates within the highly regulated environment of a Medicines Control Agency (MCA) licensed blood centre. The framework of good manufacturing practice (GMP) and good laboratory practice (GLP) ensures that donations are reliably traced from donor to recipient. Microbiology and bacteriology testing is to blood service standards 11 and processing facilities and protocols comply with pharmaceutical guidelines. An experienced counselling service is available, as required, for mothers found to be positive for microbiological agents. CB banking, therefore, runs as a Total Quality System, in parallel with routine blood banking. Cord blood collection Hospital sites CB collection is established at two hospitals selected on the basis of number of obstetric deliveries, the enthusiasm of staff and patient ethnic mix. Permission for the collection of CB, consent and screening of the mother was sought from hospital Research Ethics Committees. Links were forged with obstetric, paediatric and haematology consultants. A close working relationship was established between a LCBB nurse counsellor, based at each hospital, and the midwifery staff. The aims and expectations of the LCBB were initially explained, with the nurse counsellors providing continual education and update through meetings and presentations to hospital and community professional groups. The LCBB employs dedicated collection staff to work within the labour ward, covering 24 h a day, 5 days a week. During the antenatal period, mothers receive an infor-

140 mation leaflet, printed in various languages (English, Gujarati, Hindi) explaining the project. At delivery, hospital midwives identify those mothers who have not declined donation, passing the placenta to the LCBB collection staff in an adjacent room. Hence, the delivery, in particular the clamping of the cord and the well being of the mother and child, are not influenced in any way by collection of CB, because the delivery staff are not involved in the physical aspects of collection. Analysis of the first 1000 collections reveals that the hospital targeting strategy has achieved its objective of a far broader ethnic mix than that in bone marrow donor registries (Table 1). Collection of cord blood In the CB collection room, the placenta is suspended on an incontinence pad supported by a metal frame and the umbilical cord is stringently cleaned with alcohol and chlorhexidine to minimise bacterial contamination. The umbilical vein is punctured and the blood collected by gravity into cord blood collection bags with two integral needles (Maco Pharma, Hampton upon Thames, UK) containing 21 ml CPD with a capacity for 150 ml of blood. The CB unit is identified with a unique bar-coded number (ISBT code 128) used for testing, processing, storage and issue, which is linked to the mother s unique identification number on the collection record sheet. Data, including weight of placenta, length of cord, gestation, date, time, mode and complications of delivery, are recorded. CB units are stored at 22 2 C and transported to the LCBB twice daily, with the corresponding paperwork. Of the first 1000 collections made, 214 were below the cut-off volume of 40 ml and were used for R&D; 98 did not meet the selection criteria or the mothers did not wish the collection to be banked and 22 were discarded due to operational error. The remaining 666 donations were cryopreserved and stored for possible transplantation. Consent and medical history Careful consideration has been given to the protocol used by the LCBB to obtain consent. Some guidance has been provided by the report published in 1996 on the ethics of tissue transplantation 12 and the Polkinghorne report. 13 The practice of obtaining consent is consistent with this guidance, in that CB is collected as a waste product. However, Table 1 Ethnicity of banked CB Units as compared to the British BM Registry British BM London CB Registry Bank (n = 1400) % (n = 1000) % European caucasoid 98.0 58.5 Indian sub-continent 0.9 20.0 African/Afro-Caribbean 0.7 15.6 Oriental 0.2 4.2 Other 0.2 1.7 no tests are performed until the mother has been fully informed and has given written consent. The consent interview is held on the ward on the day following delivery or later, within 1 month, at the mother s home. Every effort is made to ensure that mothers are informed during their antenatal period that CB collection is routine in participating hospitals. Consent and medical, social and ethnic histories are obtained from the mother, after a successful collection, by an LCBB nurse counsellor during a confidential, face to face interview. If necessary, link workers are used to overcome language barriers. Mothers are asked to read an information sheet before proceeding with the interview. This is more detailed than the information leaflet provided antenatally and explains the importance of lifestyle risks for the carriage of viruses. In signing consent, the mother confirms that she: has read and understood the information sheet about CB banking; has donated CB voluntarily and will not be entitled to any claims on the donation in the future; agrees to the use of her donation for medical research if it cannot be used for clinical purposes; agrees to the removal and storage of placental and associated material at the same time as the CB, to be used for medical or research investigations; grants LCBB access to her and her infant s medical records and relevant medical agencies and health professionals; allows the taking and testing of her blood, to include HIV 1 and 2 screening, and any consequent counselling the LCBB may consider necessary; agrees to the anonymous exchange of CB data and donations with BM/CB registries and transplant centres in the UK and abroad, in the knowledge that all personal information will remain confidential. Using a standard questionnaire, the detailed medical, social and ethnic history is taken to elicit whether the mother or immediate family have any contraindications to CB donation and to establish ethnic background. The questionnaire seeks personal and family history of genetic disease, malignancy, viral or parasitic infection, autoimmune disease or disease of unknown or degenerative aetiology. Details of race, religion, language, birthplace and parental ancestry are recorded. This interview also allows the opportunity for donor self-exclusion on the basis of lifestyle infectious risks for HIV and hepatitis. Of the first 1000 units collected, 90.2% of mothers approached have granted consent. Full details of the delivery record and any antenatal virology and haemoglobinopathy maternal screening results are obtained by the nurse counsellor from the hospital notes. Processing On arrival at the LCBB, CB units are weighed, recorded on a database and processed, under aseptic conditions, within 24 h of collection. Units with collection volumes

greater than 40 ml are banked, smaller units are discarded or used for research. This practice is based on the data in Table 2 which shows that 79% of units with volumes as low as 40 49 ml contain 4 10 8 nucleated cells, sufficient to transplant children of up to 20 kg body weight with a transplant dose of 2 10 7 total nucleated cells/kg. Although 21% of these units will only contain sufficient cells for children weighing less than 20 kg, a large majority of them are collected from ethnic minority populations, hence the bank s rationale for storing these small units. The mean volume of banked CB is 75 ml (s.d. 23 ml, range 40 179 ml) with 13% of the units being between 40 and 49 ml. Duplicate bar-coded labels are generated for the sample tubes and corresponding paperwork. All labels are computer verified against the original bar-coded donation number of the CB unit. Cryopreservation Initially, the CB units were frozen as whole blood by adding an equal volume of ice-cold 20% dimethylsulphoxide (DMSO) in 10% Dextran 40 (Baxter Healthcare, Newbury, UK). Each CB unit was stored, on average, as three sub-units in Baxter Cryocyte bags with a 250 ml capacity. This was an interim measure until a method of volume reduction had been developed and validated. The units in the Cryocyte bags were put into secondary outer protective bags made of a nylon/polyethylene laminate and placed in aluminium cassettes for immediate freezing in a controlled rate freezing (CRF) machine (Planer Select, Sunbury, UK) at 1 C per minute to 40 C and then to 160 C at5 C per minute. Volume reduction Using the Baxter Optipress II automated blood component separator, the CB unit, after centrifugation at 3300 g for 12 min, is volume reduced by the removal of plasma and red blood cells. 14 The resulting buffy coat is standardised to 25 ml, with a mean volume of 24.1 ml (s.d. 1.8 ml, range 19.5 26.8 ml). The complete process is performed in a closed system with the use of a sterile connecting device (SCD). Cryopreservation is then carried out as for whole blood, but requires only one freezing bag. Hence by reducing the volume to be frozen by two-thirds, this system achieves a significant reduction in storage requirement, and subsequently costs, whilst maintaining the quality and quantity of the progenitor cells. Table 2 Collected volume (ml) Cut off volume for banking CB units % Units 4 10 8 NC 40 49 79 50 59 90 60 69 97 70 79 99 80 89 99 90 179 100 Aim to transplant 2 10 7 nucleated cells (NC) per kg patient s body weight. Mean weight of patient = 20 kg, would require 4 10 8 NC/unit. Quality control Routine monitoring of the processing environment conditions is carried out by settle plates and active air sampling. Processing of units for volume reduction and cryopreservation is monitored by analysis of cell counts before and after volume reduction and printouts from the CRF machines. On a twice monthly basis one CB unit is processed, cryopreserved, stored for a week, thawed and washed as though for transplant, using the New York method, 15 with strategic sampling to monitor contamination of the unit, nucleated cell numbers and functional viability of the product by clonogenic assays (data is summarised in Table 3). CD34 cell analysis of the thawed/washed product was not undertaken due to the inherent problems of these assays with thawed cells, and the lack of information these data provide compared with the colony-forming assays that provide information on the recovery of the functional viability of the product. Quality control of the collection procedure is monitored by bacteriology screening of all CB units. Collections are screened for bacterial and fungal contamination using an automated blood culture system (BacT/Alert, Organon Teknika, Cambridge, UK). Aerobic and anaerobic culture bottles are incubated with 0.5 ml of CB at 37 C for 14 days. All positive cultures are plated on blood agar and any growth is subsequently identified using biochemical tests. The details of any bacterial contamination of a unit will be notified to the Transplant Centre or Registry at first contact, when the unit is selected as a possible match for a patient. At this stage antibiotic sensitivity tests will be performed on a frozen isolate. During the initial 3 months of the collection programme a bacterial contamination rate of up to 28% was observed (Figure 1). Improved procedures and protocols have led to a fall in the rate to 4% at the 1000 collection milestone. Since then, the rate has continued to fall and now runs at less than 1%. Seventy-five per cent of the positive samples could be attributed to skin flora and 10% to vaginal flora; the rest were likely to be of faecal, environmental or oral origin. Specific measures taken to avoid bacterial contami- Table 3 QC data showing recovery of nucleated cells and colonyforming units and the viability of the cells after freezing and thawing Frozen/ Frozen/ Volume reduced/ thawed thawed/ frozen/thawed/ washed washed n 25 10 10 % recovery NCC mean 68.0 75.5 78.6 s.d. 17.1 23.7 20.4 median 67.2 73.5 79.4 % recovery total CFU mean 71.3 93.9 99.7 s.d. 30.9 38.8 35.3 median 60.8 79.2 90.0 % viability mean 70.6 78.9 s.d. 7.7 6.8 median 70.9 79.8 141

142 %Positive 30 25 20 15 10 5 0 Feb 96 Apr 96 Jun 96 Aug 96 Oct 96 Dec 96 Feb 97 Apr 97 Jun 97 Aug 97 Figure 1 The percentage of cord blood collections bacterially contaminated, analysed on a monthly basis. nation of the donations are: to debar collection from mothers that are known to be bacteraemic, to perform the collections under clean conditions and to stringently clean the umbilical cord prior to harvest. The improved cleaning involves a 70% alcohol wash followed with an isopropyl alcohol/chlorhexidine wipe and an iodine swab of the venepuncture site. Storage Following publication of hepatitis B transmission in liquid nitrogen, 16 and new guidelines for the storage of BM and PBPC, 17 procedures have been instituted at the LCBB to double pack and store all units in the vapour phase of nitrogen. An in-house computerised inventory system allows for the location of specific donations to be identified. Each storage dewar has three temperature probes installed that link to a remote central monitoring system which is continuously manned. The storage area is highly ventilated to minimise the potential for oxygen depletion and has constant O 2 monitoring with a visual display at the entrance to the area. The O 2 alarm is also connected to the remote monitoring system. A number of different parallel sample types are archived from each donation and from the mother s blood sample. These samples provide material for confirmatory and further testing at the time of selection for transplantation. This might include new mandatory microbiology tests added since the unit was banked, HLA high resolution typing or tests which are mandatory in countries other than the UK, as well as the use of assays with enhanced detection capability. Testing Microbiology The LCBB microbiology testing strategy has been developed with the expert advice of a specially convened Microbiological Advisory Committee comprised of BM transplanters, microbiologists and NBS staff. The strategy aims at ensuring maximum safety for recipients, while minimising costs and inconvenience to the donor. 18 This Oct 97 Dec 97 Feb 98 Apr 98 approach has resulted in a two-stage testing strategy, with the NBS mandatory microbiology tests undertaken for banking purposes at the time of consent and any additional tests, requested by the transplant clinicians, conducted on a case by case basis at selection for transplantation. Testing for banking Once collection volumes have been confirmed as meeting the minimum requirements of the bank and mothers have given consent for microbiological testing, samples of CB and maternal blood are screened using the same mandatory tests as those applied to blood donors in the UK, ie anti- HIV 1 and 2, anti-hcv, hepatitis B surface antigen and TPHA for syphilis. They are also tested for anti-cmv. In this first cohort, one donation was found to be HBsAg positive and one was anti-hcv positive. There were no anti- HIV or TPHA positive donations and 238 (37%) were CMV antibody positive. CB test results were consistent with maternal results. It is not the policy of the bank to re-sample and re-test the mothers for any of the above markers following a quarantine period. This decision was based on the following arguments, which were thoroughly discussed by the Microbiological Advisory Committee: In other CB banks where such a strategy is employed, the rate of successfully obtaining a second sample is not guaranteed, and as a result the second test cannot be used as a criterion for release of the donation without significant losses or the operation of a double standard. BM donations are not quarantined in this way even when the recipient s condition would make this a feasible option. The transplant clinicians on the committee did not see that such an approach was necessary. The precedent of the first and largest CBB in New York is not to re-call the mothers; it is also not required by the FDA. The funds that could be spent on attempting to collect post quarantine blood samples could alternatively be used to collect larger numbers of donations. Given the current failure to find a matched donor for many patients, allocating resources to increasing collections rather than retesting donors will result in greater benefit for patients. The risk of infection by a seronegative but infectious donor is less than the risk of not having a matched donor and is extremely small compared with transplant related mortality. Current screening tests have shortened considerably the window period of infectivity for viral agents. In addition the possibility of genomic testing at selection shortens this period even further. Positive tests at re-call may represent infection post donation. Testing for transplantation At selection, CB donations where the mothers tested anti- CMV positive will be routinely tested for CMV by nucleic acid testing. The transplanting centres are offered the option

of additional tests, including HIV and HCV by PCR, anti- HTLV I and II, anti-hepatitis B core and Herpes simplex virus. HLA typing Banked CB units are typed for HLA-A, B and DR at medium resolution (antigen split) level using sequence-specific oligonucleotide probing (SSOP) and sequence-specific priming (SSP). CB mononuclear cells (MNC) are separated under sterile conditions using a Ficoll Hypaque gradient and then stored in liquid nitrogen. DNA is extracted from the red cell pellet using a standard salting out technique. 19 Approximately 40 g DNA is obtained from a 5.5 ml red cell pellet. HLA class I typing is carried out by SSOP according to the method of Williams et al, 20 using a panel of biotinylated oligonucleotide probes obtained from the British Society of Histocompatibility and Immunogenetics (BSHI) and from the 13th International Histocompatibility Workshop plus additional locally designed probes. Twenty probes for the HLA-A locus and 32 probes for the HLA-B locus are used. HLA class II typing is performed by reverse dot blot using the INNO-LIPA HLA typing kits (Murex Biotech Ltd, Dartford, UK) as has been previously described. 21 When SSOP typing does not provide a conclusive result due to the combination of certain alleles or apparent homozygosity, CB DNA is tested using sequence-specific priming (SSP). In these cases maternal HLA typing is also carried out. SSP HLA class I typing is performed using a panel of BSHI produced primers plus additional locally designed primers 22 and HLA class II SSP is performed using a commercial kit (Dynal (UK) Ltd, Merseyside, UK). The varied ethnic background of donors is reflected by the HLA profile of the units banked, which shows a higher frequency of certain rare HLA alleles compared with those found in most European caucasoid BM registries. For example, HLA-A23, HLA-B53 and HLA-B72 alleles which are more frequent in Africans and Afro-Caribbean and HLA-A33, HLA-DR10 and HLA-DR1404 alleles which are more frequent in Asians are well represented in the LCBB. Cell counts Full blood counts are performed on all CB collections prior to any processing, to provide information on the health of the newborn donor. The cell counts are repeated after volume reduction, which in addition to indicating the number of nucleated cells in the unit permits continuous quality monitoring of the process. CD34 enumeration is performed on fresh samples from the volume reduced unit, simultaneously labelled with PEconjugated anti-cd34 (anti-hpca-2; Becton Dickinson, Oxford, UK) and FITC-conjugated anti-cd45 (anti-hle- 1; Becton Dickinson) and analysed using a FACSort flow cytometer (Becton Dickinson). 23 The absolute CD34 cell number is calculated on the basis of the total nucleated cells; see Table 4 for the CD34 content of the CB units. Progenitor cell assays are performed using a commercially prepared complete methylcellulose medium, Metho- Cult GF H4434 (StemCell Technologies, Metachem Diagnostics, Northampton, UK), supporting growth of CFU- GM, BFU-E and CFU-GEMM. The first 77 CB units were assessed for their progenitor cell content (Table 4) to confirm that the validation values of units prior to the start of banking still held. Frequencies of the different CFU varied from those seen in bone marrow, particularly for the more immature CFU-GEMM, bone marrow containing 2% and CB 20%. Analysis of the LCBB data demonstrated good correlation between CD34 cell numbers and total progenitor cell numbers of the fresh CB collections, r = 0.91 (Figure 2). Hence, it was deemed unnecessary to perform both CD34 and CFU analysis on each collection. The cloning efficiency, as measured on the fresh units, was 50 60%. This compares with data from other banks 3,24 showing cloning efficiencies of 38 60%. Due to the wide variation and lack of standardisation for both CD34 and CFU assays, comparison between laboratories is not currently valid. At the present time no correlation has been found between these two parameters and engraftment data, probably because of the variability in the techniques used. At the LCBB CD34 cell enumeration is performed on fresh samples, to indicate the presence of progenitor cells, and progenitor cell assays are used to assess the functional viability of thawed units selected for transplant. The CFU assay is also used for routine quality monitoring. Donation clearance No unit is considered cleared for search until the completed file has been reviewed by a LCBB physician; clearance of CB donations is based on information gathered from a number of sources. The bank has established links with the Regional Cytogenetics and Malformation Register and Haemoglobinopathy Screening Service. These units report all infants registered with abnormalities that have been delivered at the LCBB collecting hospitals. The family general practitioner of each donor receives a questionnaire at least 2 months following collection which is returned to the LCBB confirming that mother and baby have been well since the delivery and that the practitioner is not aware, to the best of his/her knowledge, of any relevant hereditary disease in the family. The rate of return of the GP questionnaires is 52%, 23%, 13%, 4% and 6% at 2, 4, 8, 12 and 12 weeks, respectively. No replies were received from 2%. The detailed medical, social and ethnic history of the donor is reviewed by the physician, and followed up by further enquiries as required. Positive microbiology markers are discussed in a counselling review group, which includes experts in transfusion microbiology, donor selection and counselling. Selection and issue Searches All units are searched for 4/6, 5/6 and 6/6 HLA antigen matches at the medium resolution level for HLA-A, B, DR 143

144 Table 4 Volume, nucleated cells and haematopoietic progenitor cells in unrelated CB units Volume CB (ml) NCC a 10 8 /unit MNC b 10 8 /unit CD34 cells 10 6 /unit Total CFU 10 6 /unit n 666 666 666 180 77 mean 75 10.2 4.5 3.1 1.9 s.d. 23 5.7 2.6 3.5 1.8 median 78 8.9 4.0 2.2 1.3 range 41 179 2.5 40.8 1.0 28.3 0.2 28.0 0.2 11.7 a Nucleated cell count (including nucleated red cells). b Mononuclear cell count. Total CFU x 106 12 10 8 6 4 2 0 0 5 10 15 Total CD34+cells x 106 Figure 2 Relationship between the total CD34 + cell numbers and the total progenitor cell numbers of cord blood units; n = 77, r = 0.91. (including B1 and B3, B4 or B5). A preliminary report indicating the degree of HLA compatibility, volume and cell content, as well as bacteriology and transfusion microbiology status, including CMV, of the CB unit is issued to the requesting centre. Upon request, high resolution HLA typing (including HLA-Cw and DQ) is carried out by SSP on the potentially selected unit. Over the period covered in this paper all search requests have been dealt with by the LCBB. When the number of units accrued reached 1000, the CB donations were registered with Netcord 25,26 and Bone Marrow Donors Worldwide (BMDW) via the British Bone Marrow Registry (BBMR). This permits easier management of searches by the transplant centre s search coordinators and at the same time makes the units more accessible. Confirmatory HLA typing Selected units are retyped for HLA and VNTRs prior to provision. DNA is isolated as previously described from a bleed line segment of the frozen unit in order to confirm that the HLA type of the unit is identical to that of the DNA sample used in the original typing and entered on the registry. In addition, a panel of microsatellite probes (VNTRs) is also used to confirm identity of the units and the tested DNA sample, as described. 27 In the case of a transplant, retrospective high resolution HLA-A, B, C, DR (B1, B3, B4, B5), DQ (A1, B1) and DP (A1, B1) typing of the transplanted CB unit and patient will be carried out in order to assess the role of each HLA locus in the outcome of the transplant. Directed CB donation service The LCBB also offers a service for the collection of CB from siblings for children with leukaemia or other haematological or immunological diseases, who may need a stem cell transplant. Referrals are made to the LCBB physician by the clinician treating the affected child. Written consent is obtained from the obstetrician caring for the pregnant mother and from the mother herself. A 24 h on-call service is provided and a team from the LCBB attends the delivery and performs the collection whilst the placenta is in utero but without early cord clamping. The mandatory microbiology markers are tested for prior to banking. Units are processed without volume reduction and stored for an initial period of 1 year. In addition to the tests performed routinely on the unrelated units, clonogenic assays are performed on all related units. HLA typing is carried out on the patient and parents, if available, as well as on the CB unit. The decision to continue storage is made by the referring clinician. In the past year, three transplants were performed with units from LCBB; all were from HLA-identical siblings. The first patient was 2 years 5 months old at the time of transplant and has thalassaemia major. Although the dose of nucleated cells in the fresh collected unit was 7.56 10 7 /kg, there was no detectable donor haemopoiesis at 5 months post transplant. BM transplantation from the CB donor is under consideration. The second recipient was a 5 year 5 month old boy with Fanconi anaemia transplanted with a nucleated cell dose of 5.21 10 7 /kg. The absolute neutrophil count reached 500 10 9 /l by day 21 and platelets 20 10 9 /l by day 36. The patient was discharged from hospital on day 48 with good engraftment. The third transplant, with a cell dose of 19.44 10 7 /kg, was in a 2 year old child with a primary neutrophil granule deficiency and other congenital abnormalities and a history of recurrent infections from birth. Neutrophils reached 500 10 9 /l by day 21 but the patient was still platelet dependent on discharge, although chimerism studies showed 98% donor type in the neutrophils and 100% in mononuclear cells by FISH. Discussion Since the first CB transplant in 1988, 5 CB has been increasingly used as an alternative source of haematopoietic progenitor cells. 6 10 In order to develop and evaluate these CB

transplant results, the European Blood and Marrow Transplantation Group (EBMT) organised the concerted action Eurocord Group. The LCBB participates in this group, which aims to standardise the methods of collection, testing and cryopreservation of CB; study the properties of the haematopoietic progenitors and gene transfer in CB; study the immune function of CB lymphocytes; exchange sera and cells from donors and recipients of CB transplants; establish a European registry of patients receiving CB transplants and design protocols to compare CB transplants with the alternative conventional blood and marrow haematopoietic stem cell transplants. As a consequence of Eurocord, and with the increasing number of CB banks providing an ever increasing number of units for transplantation, Netcord was conceived. Netcord 25,26 is a CB allocation network linking CB banks. It aims to maximise the availability of CB units from all the participating banks by establishing a CB registry which will link to central marrow donor registries, such as BMDW. Additional objectives are to establish standards for banking, which will enable accreditation and auditing of the member banks. The LCBB is a member of Netcord and is involved in the development of standards for CB banks worldwide, which are essential to ensure the maximum quality of the CB cells for transplant. As CB transplantation develops, its success will depend on the existence of well controlled, safe systems of banking. The LCBB has used the principles, standards and infrastructure of the UK Blood Transfusion Service to ensure that it is prepared for this challenge. References 1 Rubinstein P, Taylor PE, Scaradavou A et al. Unrelated placental blood for bone marrow reconstitution: organisation of the placental blood program. Blood Cells 1994; 20: 587 600. 2 Gluckman E. 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