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EDITORIAL
Year : 2023 | Volume
: 14
| Issue : 1 | Page : 1-2
Umbilical cord blood banking: Myth and realities
Aruna Nigam
Department of Obstetrics and Gynaecology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
Correspondence Address:
Prof. Aruna Nigam
Department of Obstetrics and Gynaecology, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi - 110 062
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/injms.injms_143_22
“Yesterday when I was sitting in my antenatal clinic, primigravida at 28 weeks of gestational age with no high-risk factors requested that her husband, an Information Technology professional wants to discuss cord blood storage at the time of delivery. There was no history of genetic disorder in the family but still, he insisted on the same. On further enquiring, he told that two of his colleagues have got it saved as biological insurance for their child and he too wants to give this security to their kid.” This is becoming a common scenario in the obstetrician's clinic when the obstetrician needs to explain the facts of umbilical cord blood (UCB) banking and counsel the couple accordingly.
UCB is blood in the umbilical cord after the delivery of the baby. UCB is known to contain stem cells of clinical importance. These cells can be utilized in the treatment of various genetic, metabolic, hematological, immunological, and oncological disorders. The first UCB transplantation was done successfully in 1988 in a child with Fanconi anemia at the age of 5 years from his identical sibling. Since then, there has been renewed interest in the storage and utilization of cord blood components for a variety of disorders.
UCB is a rich source of hematopoietic stem cells (HSCs) and hematopoietic progenitor cells (HPCs). There are a significantly higher number of repopulating cells and colony-forming cells in UCB than in adult bone marrow and mobilized peripheral blood. These cells have higher reconstitution capacity and possess higher in vitro proliferation and expansion potentials. Besides this, the mesenchymal stromal cells (capable of osteogenic, adipogenic, and chondrogenic lineages) and unrestricted somatic stem cells are also present.
As of now, around 80+ medical diseases can be treated and these belong to mainly hematopoietic disorders and cancers, immune disorders, and a few metabolic disorders. However, as claimed by various blood banks, there is limited evidence of benefit in acute myocardial infarction, stroke, cerebral palsy, spinal cord injury, and muscular dystrophy. Although there are many trials that are ongoing worldwide still, they are at a very primitive stage.[1]
A common phrase written in various bank advertisements is that “banking of baby's cord blood provides you with lifesaving stem cells and offers a lifetime comfort knowing that you can access your baby's preserved stem cells at any time” has lot many caveats.
There are two important points on UCB which need to be understood – which age group is actually benefitted from this and what type of blood banks are needed to provide the best benefit?
A literature search reveals that in hematopoietic transplants in children, a 6/6 matched UCB unit should be considered as the first-line source of HSCs and HPCs if the cell dose is adequate but this does not stand true for adults. UCB has a fixed number of cells and its final count is highly dependent on three Ts (technique, time of collection, and transport to storage site). This number is <30% of the cell number that can be obtained for bone marrow or mobilized peripheral blood collection. Although this number is sufficient for children but for adults, it is a low cell dose/kg body weight and results in delayed engraftment, leading to higher morbidity and mortality after UCB transplantation. That is why 8/8 human leukocyte antigen (HLA)-matched bone marrow still is the “gold standard” for alternative donor hematopoietic transplants. This is also endorsed by the Indian Academy of Pediatrics (IAP).[2]
Opinion of various bodies on autologous blood cell transplantation: It is very important to note here that UCB collected from a neonate or malignancy cannot be used to treat a genetic disease of malignancy in the same individual (autologous blood transfusion) because stored cord blood contains the same genetic variant or premalignant cells that led to the condition being treated; therefore IAP clearly states that cord blood storage is not indicated for autologous blood cells transplantation. The Indian Council of Medical Research also does not support the preservation of cord blood for future self-use and questions ethical and social concerns over it.
The chance estimate that a person will require autologous transfusion is between 1 in 1000 and 1 in 200,000. At present, there is no data on the long-term viability of cord blood cells. Currently, 20 years is a good time provided for storage but again the number of cells depends on 3 Ts and the quantity may not be sufficient for use in older children or adults. A banked cord blood unit (CBU) from a person with no family history of disease treatable by bone marrow transplantation arguably has a very low chance of being used. The chance that a person will contract a disease treatable by their stored cord blood by age 21 years has been estimated to be approximately 0.005% to 0.04%. On the other hand, improvement in the medical treatment of serious diseases may make the need for stem cell transplantation less necessary in the future and result in a reduced probability of using a banked CBU. As a result, it is now impossible to predict the future value of family UCB banking.
Private and Public Blood Banking
Public blood banks are nonprofit banks where there are no charges for storage but when any CBUs are used then the fee is charged. The advantage is that an inventory of CBUs is created with good database which is available for use by anyone nationally or internationally. In addition, more than one unit can be used depending on the HLA matching. Private blood banks are more easily available and currently have aggressive marketing strategies. The storage of CBUs is chargeable to family and is available for use to a family member only. Currently, there are more private blood banks and it is a profitable business whereas there are hardly one or two public blood banks. As per available data, there were 8 lakh units saved in public banks with 4100 unit released per year, whereas in spite of so many numbers of private banks with huge investment, the 40 lakh units saved in private banks has utilization of only 130 units released per year.
In absence of any valid indication, there is a huge ethical issue with cord blood storage, because if one really wants to store cord blood, one cannot practice delayed cord clamping. One should realize that it is not just cord blood, it is the blood of the baby. This extra blood of 80–100 ml is beneficial for all neonates as it helps in preventing anemia, improves iron stores, and enhances fine motor and social domains. Practicing delayed cord clamping facilitates the transfer of immunoglobulins and stem cells, which are essential for tissue and organ repair. Therefore, one should not deprive the infant of these additional stem cells by this most noninvasive method of transplanting stem cells in the baby.
ACOG 2019 has given a position statement on delayed cord clamping and cord blood banking that “In absence of directed donation, benefits to the infant of transfusion of additional blood volume at birth likely exceed the benefits of banking that volume for possible future use. Families who are considering banking of UCB should be counseled accordingly.”[3] Other international bodies such as RCOG, FOGSI, IAP, FIGO, SOGC, and WHO endorse the same.
The cost of storing cord blood for future use ranges from 40,000 to 80,000/rupees/year. In my opinion, whenever there is no indication of its storage, one can suggest to parents better insurance: investment of this money in mutual funds/systematic investment plans from the date of birth of the baby, and this can translate into lakhs and crores of money in 20 years or so, which can help the parents in planning the educational goals or future settlement, and even in fighting diseases.
Therefore, indications of UCB are limited and should be done in families with genetic disorders. UCB collection should not compromise obstetric or neonatal care or alter the routine practice of delayed cord clamping.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
References
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