Correspondence
Cord-Blood Transplants
N Engl J Med 1999; 340:1287-1288April 22, 1999
- Article
To the Editor:
In the excellent paper by Rubinstein et al. (Nov. 26 issue)1 on cord-blood transplants, the number of nucleated cord-blood cells that were transfused per kilogram of the recipient's weight emerged as the main influence on engraftment. The serologic status of the recipient with respect to cytomegalovirus was irrelevant to engraftment and survival.
We have recently evaluated the results of 133 cord-blood transplantations listed in the Eurocord Registry up to April 1998. We found that the dose of nucleated cord-blood cells (measured before the blood was frozen) ranged from 9.7 million to 552 million per kilogram (median, 43.5 million per kilogram). Rates of engraftment were 80 to 90 percent for all patients taken together and for all subgroups of patients analyzed, except those over 15 years of age (failure rate, 32 percent; 8 of 25 patients) and those who were over 15 years of age and who had received less than 37 million nucleated cord-blood cells per kilogram (failure rate, 47 percent; 7 of 15 patients). Substantial delays in the time to engraftment occurred only in patients who were over 15 years of age and in those who received less than 37 million nucleated cord-blood cells per kilogram.
These data are in agreement with the conclusions drawn by Rubinstein et al. that the dose of nucleated cord-blood cells before freezing is a major factor in engraftment, the first goal of successful cord-blood transplantation. Therefore, to improve the outcome of cord-blood transplantation for adults, blood banks should concentrate on collecting large units of cord blood. The time to and probability of engraftment may not be significantly improved by in vitro expansion, as suggested by experiments in a murine model,2 and nothing is known about its eventual effect on post-engraftment events, as noted by Rubinstein et al.
2 ReferencesManuel N. Fernández, M.D., Ph.D.
Isabel Millán, Ph.D.
Universidad Autónoma de Madrid, 28035 Madrid, SpainEliane Gluckman, M.D., Ph.D.
Hôpital Saint-Louis, 75475 Paris CEDEX 10, France1
Rubinstein P ,Carrier C ,Scaradavou A , et al. Outcome among 562 recipients of placental-blood transplants from unrelated donors. N Engl J Med 1998;339:1565-1577
Full Text | Web of Science | Medline2
Guenechea G ,Segovia JC ,Albella B , et al. Delayed engraftment of nonobese diabetic/severe combined immunodeficient mice transplanted with ex vivo-expanded human CD34(+) cord blood cells. Blood 1999;93:1097-1105
Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: Dr. Fernández and colleagues correctly note the association between the dose of cells in placental-blood transplants and engraftment indexes, especially, as we reported, the time to engraftment. It is noteworthy, however, that very few adults in our series received doses of ≥50 million white cells per kilogram, and we could detect no association between overall survival and the dose of cells that was independent of the age of patients in multivariate analyses. Thus, as is the case with ex vivo cell expansion, the overall benefit of administering larger doses of cells in placental-blood transplantations in adult patients remains speculative.
Nevertheless, we believe that larger patients may benefit from receiving as many cells as possible. Enlarging the repositories of placental-blood units available would give larger patients more options. We do not believe, however, that banks should concentrate on collecting larger units if this means discarding smaller ones. Small units may provide perfectly suitable grafts for children. We routinely save all units with a blood volume of at least 40 ml. Among the patients in our study, 25 percent received units of less than 60 ml, or of less than 700 million white cells.
Pablo Rubinstein, M.D.
Cladd E. Stevens, M.D., M.P.H.
New York Blood Center, New York, NY 10021Joanne Kurtzberg, M.D.
Duke University Medical Center, Durham, NC 27710- Citing Articles (8)
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