Preterm delivery is a global health problem. The rate of preterm birth ranges from 5% to 18% of babies born across 184 countries. An estimated 15 million babies are born preterm every year [
Human umbilical cord blood cells (UCBC) are abundant in stem cells. These primitive cells can home into damaged tissues, produce anti-inflammatory and immune-modulatory factors by paracrine effects, and differentiate into tissue cells [
Recently, delayed cord clamping in premature neonates have been reported to improve neonatal mortality and morbidity. The American College of Obstetricians and Gynecologists now recommends a delay in umbilical cord clamping in preterm infants for at least 30–60 seconds after birth [
Based on these evidence, we hypothesized that autologous cord blood infusion was safe for preterm infants. We report the outcomes of the infusion of autologous, volume- and RBC-reduced, noncryopreserved cord blood cell to 15 premature neonates.
This study was a phase I, open-label, single-arm, single-center trial to evaluate the safety of autologous, volume- and red blood cell- (RBC-) reduced, noncryopreserved umbilical cord blood cells (UCBC) (5 × 107cells/kg) infusion for preterm infants <37 weeks gestational age.
We initiated this pilot study in December 2009. Inborn infants admitted to the Neonatal Intensive Care Unit (NICU) of Guangdong Women and Children’s Hospital were eligible if they were (1) preterm: <37 weeks gestation, (2) without congenital abnormalities, (3) without maternal chorioamnionitis, (4) had available UCB, and (5) the mother was negative for hepatitis B (HBsAg and/or HBeAg) and C virus (anti-HCV), syphilis, HIV (anti-HIV-1 and -2) and IgM against Cytomegalovirus, rubella, toxoplasma, and herpes simplex virus. The study protocol was approved by the ethics committee of Guangdong Women and Children’s Hospital. All patients in the study were given an intensive care therapy in accordance with the departmental guidelines which included therapies including positive pressure mechanical ventilation, noninvasive respiratory support, oxygen therapy, and exogenous surfactant (Curosurf, Chiesi, Parma, Italy) replacement. Chest radiographs were performed at admission and 8 hours after CBT on the first day of life in all surviving patients. Blood gas was monitored every 24 hours until weaning from ventilation. All clinical diagnoses were defined according to a standard reference [
Guangdong Cord Blood and Stem Cell Bank is a public provincial blood bank affiliated to the Guangdong Women and Children’s Hospital, which collects cord blood of every delivery in this hospital. Therefore, the cord blood of all the subjects had been routinely collected during the delivery. The procedure of cord blood collection and transfusion was performed in accordance with the cord blood bank guidance [
Shortly, before, during, and until 24 hours after transfusion, heart rate, systolic, diastolic, and mean arterial blood pressure and arterial blood oxygen saturation level were monitored in peripheral blood continually and documented. Moreover, laboratory investigations in peripheral blood were monitored and kept stable during the whole treatment period, detailed in Table
Clinical findings previous and post infusion.
Serial number | Blood routine | Blood gas | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
HB | HCT | WBC | PLT | pH | PO2 | PCO2 | Fio2 | |||||||||||||
Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post-12 h | Post-24 h | Pre | Post-12 h | Post-24 h | Pre | Post-12 h | Post-24 h | Pre | Post-12 h | Post-24 h | |
1 | 177 | 144 | 50 | 37.3 | 10.8 | 9.2 | 304 | 335 | 7.34 | 7.27 | 7.45 | 9.3 | 8.9 | 8.9 | 4.8 | 7 | 3.2 | 0.3 | 0.21 | 0.21 |
2 | 167 | 137 | 49 | 37.4 | 10.9 | 10.2 | 284 | 243 | 7.26 | 7.4 | 7.37 | 6.7 | 12.7 | 6.4 | 6.8 | 3.7 | 4.6 | 0.4 | 0.25 | 0.21 |
3 | 135 | 132 | 37 | 15.3 | 14.9 | 13.2 | 252 | 248 | 7.25 | 7.2 | 7.33 | 4.64 | 5.07 | 9.9 | 7.25 | 8.02 | 4.26 | 0.35 | 0.25 | 0.21 |
4 | 145 | 144 | 39 | 39.9 | 8.8 | 10.1 | 405 | 336 | 7.25 | 7.28 | 7.39 | 6.5 | 9.1 | 6.1 | 7.6 | 6.6 | 4.4 | 0.35 | 0.21 | 0.21 |
5 | 171 | 180 | 50 | 50.6 | 9.6 | 17.9 | 265 | 161 | 7.42 | 7.39 | 7.34 | 3.9 | 4.5 | 6.4 | 3.7 | 3.9 | 5.1 | 0.55 | 0.3 | 0.23 |
6 | 120 | 116 | 35 | 34 | 14 | 13.5 | 320 | 256 | 7.34 | 7.36 | 7.49 | 8.3 | 6.6 | 5.6 | 5.9 | 4.8 | 3.2 | 0.45 | 0.21 | 0.21 |
7 | 148 | 139 | 44 | 39.1 | 35 | 14.2 | 274 | 446 | 7.3 | 7.34 | 7.37 | 11.6 | 11.3 | 6.95 | 5.1 | 4.28 | 4.34 | 0.35 | 0.21 | 0.21 |
8 | 212 | 203 | 60.5 | 54.3 | 13.7 | 14 | 413 | 420 | 7.42 | 7.28 | 7.45 | 10.48 | 10.25 | 8.31 | 4.78 | 4.82 | 3.62 | 0.25 | 0.21 | 0.21 |
9 | 149 | 136 | 43.7 | 42.1 | 9.62 | 10.3 | 338 | 340 | 7.28 | 7.42 | 7.43 | 9.77 | 8.23 | 7.14 | 7.82 | 4.5 | 4.23 | 0.25 | 0.21 | 0.21 |
10 | 166 | 158 | 47.6 | 46.7 | 12.3 | 16.3 | 271 | 189 | 7.32 | 7.3 | 7.3 | 9.84 | 10.2 | 8.13 | 6.66 | 5.45 | 6.03 | 0.5 | 0.4 | 0.35 |
11 | 164 | 109 | 49 | 31.8 | 14.4 | 9.4 | 229 | 154 | 7.34 | 7.35 | 7.36 | 6.4 | 5.3 | 5 | 5.2 | 4.9 | 4.5 | 0.5 | 0.3 | 0.21 |
12 | 169 | 136 | 49 | 41.9 | 7.1 | 17 | 296 | 318 | 7.32 | 7.5 | 7.37 | 9 | 14 | 7.6 | 4.7 | 2.5 | 3.4 | 0.25 | 0.21 | 0.21 |
13 | 159 | 105 | 46 | 31.2 | 12.9 | 10.6 | 329 | 465 | 7.28 | 7.5 | 7.48 | 8.3 | 6.2 | 8 | 7.6 | 3 | 4.1 | 0.3 | 0.21 | 0.21 |
14 | 142 | 136 | 46 | 42 | 11.8 | 9.6 | 235 | 245 | 7.39 | 7.4 | 7.58 | 10.06 | 9.82 | 6.17 | 5.3 | 4.82 | 2.92 | 0.25 | 0.21 | 0.21 |
15 | 136 | 122 | 48 | 46.3 | 11.3 | 9.3 | 236 | 240 | 7.32 | 7.36 | 7.4 | 11.1 | 10.95 | 10.32 | 6.47 | 5.37 | 4.83 | 0.45 | 0.25 | 0.21 |
Mean | 157 | 139 | 46.3 | 39.3 | 13.1 | 12.3 | 296.7 | 293.1 | 7.32 | 7.36 | 7.40 | 8.39 | 8.87 | 7.39 | 5.98 | 4.91 | 4.18 | 0.37 | 0.24 | 0.22 |
SD | 22.04 | 25.5 | 6.18 | 9.30 | 6.4 | 3.03 | 56.70 | 97.88 | 0.06 | 0.08 | 0.07 | 2.31 | 2.86 | 1.54 | 1.28 | 1.5 | 0.82 | 0.10 | 0.05 | 0.034 |
From January 1, 2009, till June 5, 2016, fifteen infants were enrolled for the treatment, gestational age ranged from 28 2/7 to 34 1/7 (31.2 ± 1.62) weeks and birth weight ranged from 1200 to 2220 (1582.7 ± 252.8) grams; 12/15 (80%) were delivered by cesarean section. All 15 patients who received the cord blood infusion survived. The duration of hospitalization ranged from 4 to 65 (30 ± 23.6) days. Details were shown in Table
APGAR | RDS grade | PS | Respiratory support | Complications | Duration of hospitalization (D) | Prognosis | |||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Sex | GA (weeks) | BW (g) | Delivery mode | 1 minute | 5 minute | Times | Duration of mechanical ventilation (D) | Duration of oxygen therapy (D) | Reintubation | Time return to BW (D) | BPD | VAP | IVH | ROP | LOS | NEC | |||||
1 | M | 30 + 5 | 1630 | CS | 9 | 9 | 3 | Y | 1 | 5 | 5 | N | 20 | Nil | Nil | Nil | Nil | Nil | Nil | 18 | Cured |
2 | M | 30 + 5 | 1510 | CS | 5 | 9 | 4 | Y | 1 | 3 | 9 | N | 21 | Nil | Nil | Nil | Nil | Nil | Nil | 53 | Cured |
3 | M | 33 | 1630 | VD | 8 | 6 | 3 | Y | 1 | 4 | 11 | N | 36 | Nil | Nil | Nil | Nil | Nil | Nil | 46 | Cured |
4 | M | 31 + 2 | 1510 | VD | 9 | 10 | 2 | Y | 1 | 2.5 | 3 | N | 20 | Nil | Y | Nil | Nil | Y | Nil | 65 | Cured |
5 | F | 28 + 2 | 1400 | CS | 9 | 10 | 3 | Y | 1 | 4 | 9 | Y | 32 | Nil | Y | Nil | Nil | Nil | Nil | 30 | Cured |
6 | M | 30 + 1 | 1600 | CS | 8 | 10 | 4 | Y | 1 | 2.5 | 4 | N | 26 | Nil | Y | Nil | Nil | Nil | Nil | 4 | Cured |
7 | M | 29 + 1 | 1450 | CS | 9 | 10 | 2 | Y | 1 | 7 | 8 | N | 28 | Nil | Nil | Nil | Nil | Nil | Nil | 10 | Cured |
8 | M | 31 + 5 | 1700 | CS | 8 | 9 | 1 | Y | 1 | 2 | 2 | N | 14 | Nil | Nil | Nil | Nil | Nil | Nil | 47 | Cured |
9 | M | 32 + 5 | 1940 | CS | 9 | 10 | 2 | Y | 1 | 3 | 3 | N | 13 | Nil | Nil | Nil | Nil | Nil | Nil | 24 | Cured |
10 | M | 29 + 6 | 1400 | CS | 10 | 10 | 1 | N | 0 | 0 | 3 | N | 14 | Nil | Y | Nil | Nil | Nil | Nil | 82 | Cured |
11 | M | 32 + 5 | 1660 | CS | 9 | 10 | 3 | Y | 1 | 5.5 | 9 | N | 12 | Nil | Nil | Nil | Nil | Nil | Nil | 23 | Cured |
12 | M | 31 | 1240 | VD | 9 | 9 | 2 | Y | 1 | 4 | 5 | N | 14 | Nil | Y | Y | Nil | Nil | Nil | 20 | Cured |
13 | M | 30 | 1600 | CS | 9 | 10 | 3 | Y | 1 | 3 | 4.5 | N | 12 | Nil | Nil | Nil | Nil | Nil | Nil | 19 | Cured |
14 | F | 32 + 2 | 1450 | CS | 9 | 10 | 2 | N | 0 | 1.5 | 2.5 | N | 16 | Nil | Nil | Nil | Nil | Nil | Nil | 5 | Cured |
15 | F | 34 + 1 | 2220 | VD | 9 | 10 | 3 | N | 0 | 1 | 2 | N | 14 | Nil | Nil | Nil | Nil | Nil | Nil | 4 | Cured |
MEAN ± SD | 3.2 ± 1.8 | 5.3 ± 3.0 | 30 ± 23.6 |
Cord blood volume collected ranged from 27 to 76 ml, mean (47.13 ± 19.10) ml; volume postprocessing ranged from 16 to 30 ml, mean (22.67 ± 4.05) ml; cells collected ranged from 0.97 to 8.11 (×108), mean (3.10 ± 2.17 × 108); cells postprocessing ranged from 0.86 to 7.83 (×108), mean (2.67 ± 2.00 × 108); cells concentration postprocessing ranged from 5.85 to 40.8 × 106/ml, mean (13.10 ± 10.35 × 106/ml); CFU-GM ranged from 0.72 to 11.27 (×105), mean (3.72 ± 3.25 × 105); amount of CD34+ cells in units varied widely, ranged from 0.1 to 16.22 × 106, mean (22.67 ± 4.05) ml; and viability of postprocessing units was high, ranged from 99.5 to 100%, mean (99.7 ± 0.17%). Details are shown in Table
No | Volume collected | Volume postprocessing | Cells collected (108) | Cells postprocessing (108) | Cell concentration postprocessing |
CFU-GM/105 | CD34+/106 | Viability | Infused NC |
Infused age (H) | Infused volume | Pathogen detection |
---|---|---|---|---|---|---|---|---|---|---|---|---|
1 | 34 | 22 | 1.82 | 1.46 | 6.65 | 1.84 | 1.1 | 100 | 4.48 | 5 | 11 | Negative |
2 | 35 | 20 | 1.6 | 1.32 | 5.82 | 1.98 | 0.7 | 99.5 | 5 | 6 | 13 | Negative |
3 | 61 | 24 | 2.44 | 1.67 | 6.95 | 2.3 | 1.14 | 99.8 | 5 | 7 | 12 | Negative |
4 | 33 | 16 | 0.97 | 0.86 | 5.4 | 0.72 | 0.31 | 99.8 | 5 | 4 | 14 | Negative |
5 | 36 | 22 | 1.43 | 1.21 | 5.5 | 1.57 | 0.59 | 99.8 | 5 | 9 | 13 | Negative |
6 | 28 | 16 | 1.43 | 1.23 | 7.7 | 1.53 | 0.9 | 99.5 | 5 | 4.5 | 11 | Negative |
7 | 55 | 28 | 5.81 | 5.43 | 26.3 | 11.27 | 5.69 | 99.8 | 5 | 6 | 3 | Negative |
8 | 65 | 20 | 2.99 | 2.37 | 11.85 | 1.66 | 1.66 | 99.9 | 5 | 7 | 8 | Negative |
9 | 81 | 20 | 6.14 | 4.33 | 21.65 | 9.96 | 3.9 | 99.9 | 5 | 8 | 5 | Negative |
10 | 27 | 28 | 2.21 | 1.97 | 7.05 | 3.35 | 0.55 | 99.8 | 5 | 8 | 28 | Negative |
11 | 46 | 24 | 2.96 | 2.65 | 13.6 | 3.32 | 1.01 | 99.5 | 5 | 7 | 6 | Negative |
12 | 37 | 24 | 1.51 | 1.4 | 5.85 | 1.04 | 0.08 | 99.9 | 5 | 9 | 12 | Negative |
13 | 24 | 22 | 1.72 | 1.58 | 8.53 | 2.82 | 1.1 | 99.8 | 5 | 6 | 9 | Negative |
14 | 69 | 24 | 8.11 | 7.83 | 40.8 | 6.08 | 16.22 | 99.8 | 5 | 7 | 2 | Negative |
15 | 76 | 30 | 5.3 | 4.7 | 22.8 | 6.39 | 1 | 99.5 | 5 | 8 | 7 | Negative |
Mean | 47.13 | 22.67 | 3.10 | 2.67 | 13.10 | 3.72 | 2.40 | 99.7 | 4.97 | 6.77 | 10.27 | |
SD | 19.10 | 4.05 | 2.17 | 2.00 | 10.35 | 3.25 | 4.10 | 0.17 | 0.13 | 1.52 | 6.18 |
Infused NC ranged from 4.48 to 5.0 × 107/kg, mean (4.97 ± 0.13 × 106/ml); time between collection (birth) and initiation of infusion ranged from 4.5 to 9 hours after birth, mean (6.77 ± 1.52 h); infused volume ranged from 2 to 28 ml, mean (10.27 ± 6.18 ml); pathogen detection (including bacteria culture, fungus culture, human immunodeficiency virus, hepatitis B virus, hepatitis C virus, Cytomegalovirus, and Treponema Pallidum) results were all negative.
The patient’s vital signs and laboratory investigations were monitored during the whole treatment period, details were shown in Table
The fifteen patients who received infusions all survived.
Three patients had birth asphyxia, among them one suffered from IVH. None of the patients developed abnormal clinical features of central nervous system disorders such as convulsions, apnea, or dysphagia.
12/15 (80%) presented with tachypnea and grunting soon after birth. The infants were diagnosed with RDS, 2/15 (13.3%) cases were grade I, 5/15 (33.3%) cases were grade II, 6/15 (40%) cases were grade III, and 2/15 (13.3%) cases were grade IV; and 12/15 (80%) received one dose PS replacement and 8/15 (53.3%) received intubation-surfactant replacement extubation–nasal continuous positive airway pressure (INSURE) therapy; however, one patient needed reintubation. 4/15 (26.7%) received mechanical ventilation; the median duration was 3.2 ± 1.8 days. The duration of oxygen therapy was (5.3 ± 3.0) days. No patient suffered from BPD, and chest radiographs showed improvement.
5/15 suffered from ventilation-associated pneumonia (VAP), of which two were cases of Klebsiella pneumonia, one was a case of
No patients suffered from ROP.
No patients suffered from NEC.
10/15 (66.67%) suffered from anemia (≤140 g/l); 2/15 (13.33%) needed RBC transfusion.
In our study, we treated 15 preterm infants with autologous, volume and RBC-reduced cord blood cells. The treatment was started within 8 hours after birth. No adverse effect of cell therapy was noticed. No patient died during treatment. No preterm complications such as BPD, NEC, or ROP were observed. Our study presents preliminary data on the safety of autologous cord blood cell therapy in preterm infants. We postulated that several factors contributed to the safety issue, among them, the most important one was the autologous cell source. Based on the autologous cell source, no GVHD-related complication was observed. Moreover, autologous cell source avoided ethical issues. A second factor that contributed to the safety issue was cord blood minimal-processing procedure. In our study, only density gradient centrifugation was employed to separate nucleated cells. Since our cell infusions were started within 8 hours after birth, no cryopreservation was needed; thus, no chemicals were added into the cord blood cells for cryopreservation. This minimal-processing procedure and immediate transfusion after processing helped to avoid contamination and possible chemical toxicity. It also alleviated decrease of viability which may happen during storage.
In our study, mean (47.13 ± 19.10) ml cord blood with a total TNC of (3.10 ± 2.17) × 108 mononuclear cells was collected before processing. After processing, cord blood volume and TNC were reduced to (22.67 ± 4.05) ml and (2.67 ± 2.00) × 108, respectively, including (22.67 ± 4.05) × 106 CD34+ and (3.72 ± 3.25) × 105colony forming cells (CFU-GM) in a vitality (99.7 ± 0.17%).
Recently, delayed umbilical cord clamping 30–60 seconds after birth in preterms had been recommended by the American College of Obstetricians and Gynecologists and had been reported to reduce preterm-related complications. It is possible that delayed cord clamping increases supply of RBC and valuable stem and progenitor cells (SPC), thus may improve mortality and morbidity in premature neonates [
BPD is the main complication that contributes to morbidity and mortality in extremely premature newborns. It has been reported that among infants born with gestational ages of 22 to 28 weeks, 68% suffered from BPD [
Studies on safety and feasibility of whole autologous cord blood transplant in preterm were also reported [
Regarding the administration route, there were reports on the advantage of damaged site administration when compared to intravenous infusion. However, on the one hand, the potential preterm complications were due to multiorgan damage. To achieve the multiorgan-targeted effect, we used intravenous infusion as the administration route, which may result in cells being trapped in organs such as lung and brain. On the other hand, in the report supported site administration, allogenic-MSC was used in intratracheal administration to treat hyperoxia-induced lung damage; it seemed to attenuate the side effects of rejection.
In our study, we chose the infusion timing to be very soon after birth which is within the first 8 postnatal hours. Although some infants were delivered at midnight, we tried to process as early as within 8 hours after their birth. As it had been reported that it would take more than 1 week for progenitor cells to differentiate into damaged tissue cells, we administered CBC during the first hours after birth, so that it might provide enough time for these cells for differentiation.
In conclusion, we demonstrated autologous, volume- and RBC-reduced, noncryopreserved cord blood cells transfusion soon after birth was safe and feasible in preterm infants. Autologous cord blood infusion avoid GVHD; meanwhile, the reduced volume would protect the fragile cardio-function of the preterm infants. This autologous, volume- and RBC-reduced, method guaranteed the safety of application. In addition, this was an autologous transfusion instead of “cell transplantation therapy”, and therefore it was not regulated by the FDA regulation licensing public cord blood banks distributing unrelated banked cord blood units for allogeneic transplantation in 2012. However, our study was the single-center descriptive study with limited number of preterm infants, further multicenter randomized controlled trials are needed to prove the effectiveness.
The data used to support the findings of this study are available from the corresponding author upon request.
The authors indicated no potential conflicts of interest.
Jie Yang and Zhuxiao Ren has equivalent contribution to the study.
This work was supported by Guangzhou Technology Program (grant numbers 201707010398, 201804010380).