Repeated Autologous Umbilical Cord Blood Infusions are Feasible and had No Acute Safety Issues in Young Babies with Congenital Hydrocephalus

Abstract

Babies with congenital hydrocephalus often experience developmental disabilities due to brain injury associated with prolonged increased pressure on the developing brain parenchyma. Umbilical cord blood (CB) infusion has favorable effects in animal models of brain hypoxia and stroke and is being investigated in clinical trials of brain injury in both children and adults. We sought to establish the safety and feasibility of repeated intravenous infusions of autologous CB in young babies with congenital hydrocephalus.
Infants with severe congenital hydrocephalus and an available qualified autologous CB unit traveled to Duke for evaluation and CB infusion. When possible, the CB unit was utilized for multiple infusions. Patient and CB data were obtained at the time of infusion and analyzed retrospectively.
From October 2006 to August 2014, 76 patients with congenital hydrocephalus received 143 autologous CB infusions. Most babies received repeated doses, for a total of two (n=45), three (n=18), or four (n=4) infusions. There were no infusion-related adverse events. As expected, all babies experienced developmental delays.
Cryopreserved CB products may be effectively manipulated to provide multiple CB doses. Repeated intravenous infusion of autologous CB is safe and feasible in young babies with congenital hydrocephalus.Pediatric Research (2015); doi:10.1038/pr.2015.161.

Full text

Copyright © 2015 International Pediatric Research Foundation, Inc.
Articles
Clinical Investigation
nature publishing group
BACKGROUND: Babies with congenital hydrocephalus often
experience developmental disabilities due to brain injury asso-
ciated with prolonged increased pressure on the developing
brain parenchyma. Umbilical cord blood (CB) infusion has
favorable effects in animal models of brain hypoxia and stroke
and is being investigated in clinical trials of brain injury in both
children and adults. We sought to establish the safety and fea-
sibility of repeated intravenous infusions of autologous CB in
young babies with congenital hydrocephalus.
METHODS: Infants with severe congenital hydrocephalus and
an available qualified autologous CB unit traveled to Duke for
evaluation and CB infusion. When possible, the CB unit was uti-
lized for multiple infusions. Patient and CB data were obtained
at the time of infusion and analyzed retrospectively.
RESULTS: From October 2006 to August 2014, 76 patients
with congenital hydrocephalus received 143 autologous CB
infusions. Most babies received repeated doses, for a total of
two (n = 45), three (n = 18), or four (n = 4) infusions. There were
no infusion-related adverse events. As expected, all babies
experienced developmental delays.
CONCLUSION: Cryopreserved CB products may be effectively
manipulated to provide multiple CB doses. Repeated intrave-
nous infusion of autologous CB is safe and feasible in young
babies with congenital hydrocephalus.
H
ydrocephalus results from an excessive accumulation of
cerebral spinal uid (CSF) within the ventricular system
of the brain resulting in a progressive increase in ventricular
volume and intracranial pressure. It may be caused by a block-
age within the ventricular system, overproduction of cerebral
spinal uid, or decreased absorption of cerebral spinal uid.
e incidence of congenital hydrocephalus has been esti-
mated as 0.3 to 1.5 per 1,000 live births (1,2). Congenital
hydrocephalus may occur in isolation or as a result of neural
dysgenesis, such as spina bida or a Dandy Walker malforma-
tion. ough many patients with congenital hydrocephalus are
suspected to have a genetic cause, a causal mutation is identied
in only a small portion of patients, most commonly X-linked
hydrocephalus due to a mutation in L1CAM (3). Various other
chromosomal abnormalities have been described in babies
with hydrocephalus with additional associated somatic defects.
Such genetic cases can usually be identied before or at birth.
Most cases of congenital hydrocephalus are diagnosed
inutero on routine prenatal, screening ultrasonography when
macrocephaly and/or ventriculomegaly are seen. Typically
signs of hydrocephalus are rst recognized between 15–10 wk
of gestation. Options at the time of an in utero diagnosis of
severe hydrocephalus are currently limited to termination of
the pregnancy or expectant management. Fetal shunt place-
ment has been attempted, but technical issues with the shunt
and mixed patient outcomes resulted in a moratorium on fetal
percutaneous shunting in the United States since 1985 (4,5).
Current standard management of a baby with severe con-
genital hydrocephalus involves aggressive monitoring of the
third trimester of pregnancy and delivery when fetal lung
maturity is achieved. Ventriculoperitoneal shunt placement
is performed shortly aer birth to divert the ow of CSF and
decrease the intracranial pressure. In the modern era, shunt
placement is associated with very low postoperative mortality,
although there is still a moderate risk of infection in the neo-
natal period. A newer procedure called an endoscopic third
ventriculostomy along with choroid plexus coagulation is now
being performed in hopes of avoiding a shunt, although a
shunt is still most common to manage severe hydrocephalus in
the neonatal period. Survivors face the sequelae of both shunt
complications and brain injury resulting from the prolonged
hydrocephalic state in utero including motor decits (50–60%),
auditory and visual decits (25–60%), seizures (20–50%), and
impaired intelligence (50–70%) (6–13). Additional comorbidi-
ties may be present if a genetic syndrome is diagnosed post-
natally or if other anatomical abnormalities are present on
imaging, such as agenesis of the corpus callosum, colpcephaly,
holoprosencephaly, or Dandy Walker malformation.
Umbilical cord blood (CB) has been shown to lessen the clin-
ical and radiographic impact of hypoxic brain injury and stroke
Received 11 March 2015; accepted 29 May 2015; advance online publication 7 October 2015. doi:10.1038/pr.2015.161
1
Robertson Clinical and Translational Cell Therapy Program, Duke University, Durham, North Carolina;
2
Department of Neurosurgery, Stanford University, Stanford, California.
Correspondence: Jessica M. Sun (jessica.sun@duke.edu)
Repeated autologous umbilical cord blood infusions are
feasible and had no acute safety issues in young babies
withcongenital hydrocephalus
JessicaM.Sun
1
, GeraldA.Grant
2
, ColleenMcLaughlin
1
, JuneAllison
1
, AnneFitzgerald
1
, BarbaraWaters-Pick
1
and
JoanneKurtzberg
1
Pediatr Res
00
00
2015
Pediatric Research
10.1038/pr.2015.161
7October2015
00
00
11March2015
29May2015
Copyright © 2015 International Pediatric Research Foundation, Inc.
CB infusion in babies with hydrocephalus
Sun et al.
Clinical Investigation
Articles
Pediatric RESEARCH 1

Copyright © 2015 International Pediatric Research Foundation, Inc.
Articles
Sun et al.
in animal models (14–18). In particular, Ballabh and colleagues
have developed a model of intraventricular hemorrhage in rab-
bit pups that is followed by the development of hydrocephalus
and subsequent white matter demyelination (19). In this model,
intraventricular administration of human CB cells 24 and 72 h
aer injury failed to prevent the hydrocephalus, but did reduce
subsequent demyelination (Ballabh, personal communication,
2014). CB has also been shown to engra and dierentiate in
the brain, facilitating neural cell repair, in animal models and
human patients with inborn errors of metabolism undergo-
ing allogeneic, unrelated donor CB transplantation (20,21).
Intravenous infusion of autologous CB is currently under inves-
tigation for the treatment of acquired brain injuries including
hypoxic ischemic encephalopathy (22), cerebral palsy (23), and
spinal cord injury. A small safety trial testing CB-derived mes-
enchymal stem cells (MSCs) delivered directly into the airways
of premature babies at risk for bronchopulmonary dysplasia has
also been reported (24).
We have previously reported the safety of intravenous
autologous CB infusion in 184 children with brain injury. e
median age of infusion in that series was 2 y, and most children
received a single infusion (23). Building on this experience,
we hypothesized that autologous CB infusion might facilitate
repair of the brain subjected to the pressure injury caused by
severe congenital hydrocephalus. Prenatal diagnosis of these
infants and delivery by planned C-section allowed for optimi-
zation of CB collection and banking at birth. e small size of
the baby relative to the number of cells harvested in a typical
CB collection allowed for planning of administration of more
than one dose of CB during the rst 1–2 y of life. e purpose
of this investigation was to determine the safety and feasibil-
ity of repeated doses of autologous CB given intravenously to
very young infants with brain injury due to severe congenital
hydrocephalus.
RESULTS
Patients
Between October 2006 and August 2014, 76 patients with con-
genital hydrocephalus were treated with 143 autologous CB
infusions. e most common etiology for hydrocephalus was
aqueductal stenosis (46%). Four patients were subsequently
diagnosed with genetic conditions: one each with Aicardi syn-
drome, Walker Warburg syndrome, and a partial duplication
and interstitial deletion of chromosome 6, and one patient
with both a partial deletion of chromosome 10 and a partial
duplication of the X chromosome. See Table 1 for patient
characteristics.
CB Units (CBUs)
CBUs were collected at the time of delivery by the mother’s
obstetrical provider or, when available, trained collectors from
the Carolinas Cord Blood Bank, a public CB bank housed at
Duke University. Fiy-six (74%) units were stored as directed
donors. Of these, nine patients were born and had CBUs collected
at Duke and 47 (84%) were collected remotely via a kit program
and then shipped to the Duke Stem Cell Lab for processing and
storage. e remaining 20 (26%) CBUs were stored at six dier-
ent private CB banks (four US, two international). For units in
which it was recorded (n = 68), the median collection volume
of CB was 55 ml (range 5–180 ml). When these units were iden-
tied as potential candidates for infusion, low resolution HLA
typing was performed on both a test sample of the CBU and
the patient for identity conrmation. Almost all CBUs (n = 73,
96%) were stored in two-compartment bags. When possible,
only one compartment or a portion of one compartment was
utilized for infusion to provide an adequate cell dose, allowing
the remainder to be stored for later infusions. e median prec-
ryopreservation total nucleated cell count (TNCC) of the CBUs
was 4.81 × 10
8
(range 0.15–18.6 × 10
8
), median viability 97%
(range 71–100%). Despite negative precryopreservation sterility
cultures, ve CBUs had positive post-thaw cultures (coagulase
negative Staphlococcus (4), Streptococcus viridans (1)). One of
the positive cultures was on a third infusion from a CBU from
which prior post-thaw cultures on the rst and second infu-
sions were negative. Since these culture results were not avail-
able until 24–72 h aer the infusions, no patients were treated
with antibiotics. At the time the positive culture was reported, a
sta member communicated with the patient’s parents to deter-
mine whether there was any concern for post infusion infection.
No patient had concerning symptomatology and no antibiotic
treatment was initiated. ere were no clinical infections docu-
mented in any patient.
When the TNCC allowed, a portion of the CBU was utilized
for infusion. If a CBU was stored in a bag with an 80/20 con-
guration, the 20% compartment was generally used for the
rst infusion. If the 80% compartment contained an TNCC of
>5 × 10
7
/kg at the time of the second infusion, then only a por-
tion of the cells in the 80% compartment were used and the
remaining thawed cells were refrozen in an 80/20 bag for future
dosing. In this study, 19 infusions were performed using cells
that had been previously thawed and refrozen. e median
post-thaw recovery of TNCC of the initial thaws of these prod-
ucts was 66% (range 41–78%). When these units were refrozen
and subsequently rethawed, the median post-thaw recovery of
TNCC was 74% (range 50–109%) of the refrozen cells and 47%
(range 21–72%) of the initial TNCC. As many of these CBUs
Table 1. Patient characteristics
(n = 76)
Age at first infusion
Median
2 mo
Range
6 d to 4.5 y
Gender (N, %)
Male
39 (51%)
Female
37 (49%)
Diagnosis (N, %)
Aqueductal stenosis
35 (46%)
Stroke/hemorrhage
10 (13%)
Other (Dandy-Walker variant, Chiari II without spina
bifida, etc)
31 (41%)
2
Pediatric RESEARCH

Copyright © 2015 International Pediatric Research Foundation, Inc.
CB infusion in babies with hydrocephalus
Articles
were retrieved from private CB banks, they were not tested
for CD34 content and colony forming units (CFUs) prior to
cryopreservation, making it impossible to compare recovery
aer the initial thaw. Aer refreezing, the median recovery of
CFUs was 64% (range 12 – >100%) and median recovery of
CD34+ cells was 52% (range 0 – >100%) compared to CFUs
and CD34+ cells obtained at the time of the initial thaw.
Infusions
e median age at the time of the rst infusion was 2 mo (range
6 d to 4.5 y). Most babies received repeated doses, for a total
of two (n = 45), three (n = 18), or four (n = 4) infusions, as per
the timeline in Figure 1. Median cell doses per infusion were
TNC 1.9 × 10
7
/kg (range 0.1–13.3 × 10
7
/kg) and CD34 dose
0.5 × 10
5
/kg (range 0–6.4 × 10
5
/kg); cell doses are listed by infu-
sion number in Table 2. All babies were premedicated before
each infusion with a single dose of diphenhydramine (0.5 mg/
kg IV), acetaminophen (10 mg/kg PO), and methylpredniso-
lone (0.5 mg/kg IV). e infusions were well tolerated, with no
acute or long-term adverse reactions noted.
Patient Follow-Up After CB Infusion
e overall survival of the patients in this study was 97% with
a median follow-up of 1.1 y (range 0.1–7.5 y). Two patients
died from issues unrelated to the CB infusion; one 4 mo aer
infusion due to complications from a surgical craniosynasto-
sis repair, and one who died in his sleep 2 mo aer infusion.
As expected, all infants had motor delays in the rst year of
life due to increased head size relative to the baby’s height and
weight. At the time of last follow-up, 42% of patients had been
diagnosed with seizures and 52% of patients had persistent
vision and/or hearing impairments.
DISCUSSION
In this report, we describe our initial clinical experience giv-
ing multiple intravenous autologous CB infusions in a hetero-
geneous group of infants with congenital hydrocephalus. As
this was a phase I, rst-in-man, proof-of-concept safety study,
there was no control group. Since ecacy of cell therapy for
congenital hydrocephalus is unknown, safety was of utmost
importance. We therefore chose to use banked CB, a cell ther-
apy product that has already had a favorable safety prole in the
clinic. In addition, given the very young age of these patients,
we felt strongly that an autologous product would pose the low-
est risk. Furthermore, theoretical concerns have been raised
about inducing aberrant immune tolerance to donor antigens
(HLA or other) if young babies are exposed to third party cells
during the early phases of immune ontogeny. Dimethyl sulfox-
ide and dextran are utilized during cryopreservation of CB, and
dextran and human serum albumin are utilized during thawing
and washing. us, the babies in this series were exposed to
residual amounts of these excipients with each infusion. Prior
to this study, only a few dozen infants <3 mo of age had been
treated with allogeneic, banked CB for correction of genetic dis-
eases, and there was no prior experience giving cryopreserved
and thawed products in single or multiple infusions to neonates
and young infants. In this series, there were no acute or long-
term adverse events related to CB infusion, indicating that the
procedure is safe and feasible in these very young babies.
Due to the young age and small size of the patients, most
(70%) CBUs were large enough to provide more than one
dose of cells and 24% of patients received three or more doses.
e safety and feasibility of multiple CB infusions were also
favorable with no increase in infusion reactions or later toxic-
ities aer subsequent infusions. It was feasible to manipulate
CB products stored in dual compartment bags so that two
to four doses could be administered at distinct and separate
time points, and products that underwent recryopreservation
and thawing demonstrated adequate cell recovery.
As the primary focus of this study was safety and feasibility,
a control group was not included. erefore, a treatment eect
cannot be established. e ecacy of this approach requires addi-
tional investigation and continues to be challenging. Congenital
hydrocephalus is a rare condition, and aected babies may have
other associated abnormalities or genetic syndromes. e causes
of congenital hydrocephalus are heterogeneous and, not surpris-
ingly, aected babies experience a wide variability of outcomes
that are not predictable based on early clinical or radiographic
characteristics. erefore, assessing the ecacy of CB infusion
on the natural history of the disease remains challenging. ere
is also a variable response to shunting in this population both
on imaging and predicting the expansion of the cortical mantle
and correlating this with overall cognitive development.
ere is increasing animal and human data to suggest that
CB may have a role in the treatment of brain injuries. In a
recent phase I trial at Duke University, 23 babies who sustained
hypoxic ischemic encephalopathy at the time of birth were
Figure 1. Timeline of shunt placement and cord blood infusions.
Birth
Shunt
placed
First
infusion
Second
infusion
Third
infusion
Fourth
infusion
76N697645184
MedianAge 3 d2 mo 9 mo 14 mo 14 mo
Minimum 0 d6 d2 mo 7 mo 10 mo
Maximum 10 mo 4.5 y 3.6 y 3.2 y 1.9 y
Table 2. Cell doses per infusion
First
(n = 76)
Second
(n = 45)
Third
(n = 18)
Fourth
(n = 4)
Post-thaw total nucleated cell count dose (×10
7
/kg)
Median 1.95 2.08 1.15 0.56
Minimum 0.25 0.25 0.13 0.29
Maximum 13.30 5.68 2.40 3.56
Post-thaw CD34 dose (×10
5
/kg)
Median 0.50 0.70 0.25 0.20
Minimum 0.05 0.04 0.01 0.10
Maximum 6.40 4.90 2.00 0.40
Pediatric RESEARCH 3

Copyright © 2015 International Pediatric Research Foundation, Inc.
Articles
Sun et al.
treated with a standard cooling protocol and also received
intravenous autologous CB infusions (22). CB was processed
and infused fresh, without cryopreservation, in one to four
doses within the rst 72 h of life. Infusions were found to be
safe in these critically ill babies, and babies receiving cells had
increased survival rates to discharge (100 vs. 85%, P = 0.20)
and improved function at 1 y of age (74 vs. 41% with devel-
opment in the normal range, P = 0.05) compared to a con-
comitant group of babies who were treated with cooling but
did not receive cells. A phase II randomized trial is currently
in development.
In older children with cerebral palsy, Korean investigators
compared three groups of children: those who received allo-
geneic CB and erythropoietin, placebo CB and erythropoietin,
and both placebos (25). ey reported greater improvements
in cognitive and select motor functions in children who
received CB and erythropoietin vs. either control group. While
there was no CB-only group for comparison, their ndings are
encouraging and should be replicated. Our group is also cur-
rently conducting a phase II randomized, double-blind, pla-
cebo-controlled, crossover study of intravenous autologous CB
infusion in children ages 1–6 y with cerebral palsy. is study
is expected to conclude in 2015.
e mechanism by which CB cells may potentially improve
the outcome of brain injuries are multiple. In the acute setting,
such as babies with hypoxic ischemic encephalopathy, CB cells
may have the ability to deliver trophic factors that can provide
anti-inammatory and neuroprotective eects and enhance
the survival potential of host cells. In the chronic setting, such
as older children with cerebral palsy, CB cells may be able to
increase the plasticity of the injured brain by enhancing syn-
aptogenesis and angiogenesis, stimulating endogenous repair
mechanisms, and/or inducing migration and proliferation of
endogenous neural stem cells. In these scenarios, long-term
engrament of CB cells should not be required, raising the
possibility of utilizing allogeneic products. It is not yet clear
from either animal models or human studies if an ideal or
maximum therapeutic window for intervention with cell ther-
apy exists aer brain injury. If one does, it is likely to vary by
the type of injury and the age of the patient.
If cell therapies, including CB, are proven to have a role
in the treatment of neurologic injuries, the parameters of
their use will certainly require further renement. Many
issues remain unknown, including ideal cell source, route
of administration, dose and dosing regimen, timing, and
role of immunosuppression. If the intent is to modulate host
repair mechanisms, a multiple dosing regimen could be more
eective than a single dose. Although the optimal cell dose
is unknown, this case series demonstrates that a single CBU
can yield sucient cells for multiple intravenous doses in
young children, and that repeated dosing is safe and feasible
in babies with brain injuries. Data regarding the functional
outcomes of babies with congenital hydrocephalus treated
with CB infusion(s) are being collected under a separate IRB-
approved protocol. Based on the favorable safety prole and
feasibility of CB infusion in this population, a phase II trial
in children with severe hydrocephalus is under development.
In that study, diligent genetic screening and review of brain
imaging will be necessary to exclude patients with identiable
genetic conditions and brain malformations. Additional trials
using multiple dosing regimens are also planned for babies
with hypoxic ischemic encephalopathy and children with
cerebral palsy and autism.
METHODS
is analysis is a retrospective data review of patients treated with
intravenous autologous CB infusion for congenital hydrocephalus by
the Duke Pediatric Blood and Marrow Transplant Program. A waiver
of authorization to conduct this study was approved by the Duke
University Medical Center Institutional Review Board. At least one
parent signed routine hospital consent for treatment as well as con-
sent for data to be collected and shared with the National Marrow
Donor Program and Center for International Blood and Marrow
Transplant Research (NMDP/CIBMTR) for entry into the Stem Cell
Transplant Outcomes Database. Charts of children infused from
3/2004 to 8/2014 were reviewed.
Patients
Infants with severe congenital hydrocephalus, diagnosed either before
or aer the child’s birth, were either self-referred or referred by their
treating physicians. Infants were eligible for autologous CB infusion if
their parents elected to bank their CB at birth and if the CB met cer-
tain technical specications enumerated below. Patients with known
genetic diseases, brain malformations, spina bida, ineligible CBUs,
or inability to travel to Duke, were excluded.
Treatment Plan
If referred prenatally, information regarding the patient’s diagnosis
and expected date of delivery was acquired. CB collection was then
arranged through the Stem Cell Lab, a clinical hospital laboratory
at Duke University, via a directed donor kit collection program. If
referred aer birth and if the parents had elected to bank the baby’s
CB with a private CB bank, information regarding the patient’s diag-
nosis, current condition, and CBU characteristics was obtained. In
either case, donor screening labs were obtained on a maternal blood
sample drawn around the time of delivery. Aer the child and their
CBU were deemed eligible, identity and potency of the CB unit were
conrmed. For units banked at private banking facilities, the CBU
was shipped to the Duke Stem Cell Lab in a dry shipper maintain-
ing temperatures <−150 °C, processed on a Sepax 1 to volume reduce
and partially red blood cell and plasma deplete, mixed with dimethyl
sulfoxide/Dextran to a nal concentration of 10% dimethyl sulfox-
ide, cryopreserved by controlled-rate freezing and stored under liq-
uid nitrogen until the time of infusion. Some parents elected to have
their babies born at Duke, so that they were able to have their CB col-
lected and receive neonatal care including their initial neurosurgery
at Duke. All patients not born at Duke traveled with their parent(s) to
Duke for a 3-d visit including: on day 1, a baseline history, physical,
and laboratory evaluation including donor screening labs (if the baby
was >30 d of age); on day 2, infusion of the autologous CB; and on day
3, follow-up by phone to screen for infusion-related toxicities.
CBU Criteria
Cryopreserved CBUs had to meet the following minimum criteria
for infusion as documented by the bank of origin: precryopreser-
vation TNCC documented and >1 × 10
7
cells/kg calculated for the
child’s current body weight, sterility cultures performed and negative,
maternal infectious history screen and infectious disease markers
(minimally HIV 1 and 2, HTLV 1 and 2, Hepatitis B and C, CMV,
West Nile virus, and syphilis) performed and negative. If not stored
by the Duke STCL, in addition to meeting the above specications,
CBU identity was conrmed via HLA typing of both a test sample of
the CBU and peripheral blood of the patient, and a test sample of the
CBU was thawed and tested for viability, CFU, and CD34 to conrm
potency before the baby was scheduled for an infusion.
4 Pediatric RESEARCH

Copyright © 2015 International Pediatric Research Foundation, Inc.
CB infusion in babies with hydrocephalus
Articles
CBU Thawing and Infusion Procedure
Cryopreserved CBUs were thawed and washed as described by
Rubinstein et al. (26) and resuspended in dextran
40
+ 5% human
serum albumin solution on the day of infusion. awed CBUs
were tested for enumeration of TNCC, viable CD34
+
cells, CFUs,
cell viability via trypan blue, and sterility cultures. On the day of
infusion, patients were admitted to the Duke Children’s Health
Center Day Hospital and IV access was established via a peripheral
vein. Aer premedication with Tylenol (10 mg/kg PO), Benadryl
(0.5 mg/kg IV), and Solumedrol (0.5 mg/kg IV), patients received
either a portion of or their entire CBU via peripheral IV infusion
over 5–15 min. e volume of the infusion was adjusted postwash
to deliver no more than 1.25 cc/kg over 15 min. Intravenous uids
were administered at 1.5 times maintenance for 2–4 h aer the CB
infusion. Vital signs and pulse oximetry were monitored continu-
ously during the infusion and every 30 min for 1–2 h postinfusion
as medically indicated.
Dosing and Multiple Infusions
e target dose per infusion was 1–5 × 10
7
cells per kilogram of
patient body weight at the time of infusion. Based on the congura-
tion in which each CBU was stored and the number of cells available,
only one compartment of the CBU bag or a portion of one compart-
ment was utilized for infusion to provide an adequate cell dose, and
the remainder was stored under liquid nitrogen for later infusions.
Generally, when the CB unit was stored in a bag with the 80/20 con-
guration, the smaller compartment was utilized for the rst infu-
sion. At the time of the second infusion, the 80% compartment was
thawed and a portion of the thawed product was administered to
deliver a targeted cell dose which was calculated based on the baby’s
weight. e remaining cells were recryopreserved in a new 80/20 bag
to allow for administration of additional 1–3 future doses. e exact
number of doses available depended on the TNCC of the initial col-
lection and the weight of the baby over time. When the CBU cell dose
was sucient for multiple infusions, patients received subsequent
doses at intervals of approximately 2–6 mo as feasible based on their
medical condition and feasibility of travel logistics.
Data Collection and Statistics
Data regarding patients (diagnosis, age, birth history, surgical history,
developmental trajectory, and symptoms at birth and at the time of
infusion), infusions, and autologous CBU characteristics (collection
volume, precryopreservation TNCC, viability, sterility, CD34 and CFU
as well as post-thaw TNCC, CD34 count, viability, sterility cultures,
and post-thaw CFUs) were obtained from both a prospectively main-
tained clinical database and retrospective review of routine medical
records. Descriptive statistics were calculated for CBU parameters.
STATEMENT OF FINANCIAL SUPPORT
This study was supported by The Julian Robertson Foundation, New York
City, NY.
Disclosures: The authors to not have any conicts of interest or nancial ties
to disclose.
REFERENCES
1. GarneE, LoaneM, AddorMC, BoydPA, Barisic I, DolkH. Congenital
hydrocephalus–prevalence, prenatal diagnosis and outcome of pregnancy
in four European regions. Eur J Paediatr Neurol 2010;14:150–5.
2. PerssonEK, HagbergG, UvebrantP. Hydrocephalus prevalence and out-
come in a population-based cohort of children born in 1989-1998. Acta
Paediatr 2005;94:726–32.
3. TullyHM, DobynsWB. Infantile hydrocephalus: a review of epidemiology,
classication and causes. Eur J Med Genet 2014;57:359–68.
4. ClewellWH, JohnsonML, MeierPR, et al. A surgical approach to the treat-
ment of fetal hydrocephalus. N Engl J Med 1982;306:1320–5.
5. ManningFA, HarrisonMR, Rodeck C. Catheter shunts for fetal hydro-
nephrosis and hydrocephalus. Report of the International Fetal Surgery
Registry. N Engl J Med 1986;315:336–40.
6. Hoppe-HirschE, LaroussinieF, BrunetL, et al. Late outcome of the surgi-
cal treatment of hydrocephalus. Childs Nerv Syst 1998;14:97–9.
7. Heinsbergen I, Rotteveel J, Roeleveld N, Grotenhuis A. Outcome in
shunted hydrocephalic children. Eur J Paediatr Neurol 2002;6:99–107.
8. EricksonK, BaronIS, FantieBD. Neuropsychological functioning in early
hydrocephalus: review from a developmental perspective. Child Neuro-
psychol 2001;7:199–229.
9. DalenK, BruarøyS, Wentzel-LarsenT, LaegreidLM. Intelligence in chil-
dren with hydrocephalus, aged 4-15 years: a population-based, controlled
study. Neuropediatrics 2008;39:146–50.
10. KirkinenP, SerloW, JouppilaP, RyynanenM, MartikainenA. Long-term
outcome of fetal hydrocephaly. J Child Neurol 1996;11:189–92.
11. SatoO, YamguchiT, KittakaM, ToyamaH. Hydrocephalus and epilepsy.
Childs Nerv Syst 2001;17:76–86.
12. Idowu OE, Balogun MM. Visual function in infants with congenital
hydrocephalus with and without myelomeningocoele. Childs Nerv Syst
2014;30:327–30.
13. RicciD, LucianoR, BaranelloG, et al. Visual development in infants with
prenatal post-haemorrhagic ventricular dilatation. Arch Dis Child Fetal
Neonatal Ed 2007;92:F255–8.
14. VendrameM, CassadyJ, NewcombJ, et al. Infusion of human umbilical
cord blood cells in a rat model of stroke dose-dependently rescues behav-
ioral decits and reduces infarct volume. Stroke 2004;35:2390–5.
15. Chen J, Sanberg PR, Li Y, et al. Intravenous administration of human
umbilical cord blood reduces behavioral decits aer stroke in rats. Stroke
2001;32:2682–8.
16. Willing AE, Lixian J, Milliken M, et al. Intravenous versus intrastriatal
cord blood administration in a rodent model of stroke. J Neurosci Res
2003;73:296–307.
17. TaguchiA, SomaT, TanakaH, et al. Administration of CD34+ cells aer
stroke enhances neurogenesis via angiogenesis in a mouse model. J Clin
Invest 2004;114:330–8.
18. MeierC, MiddelanisJ, WasielewskiB, et al. Spastic paresis aer perinatal
brain damage in rats is reduced by human cord blood mononuclear cells.
Pediatr Res 2006;59:244–9.
19. ChuaCO, ChahbouneH, BraunA, et al. Consequences of intraventricular
hemorrhage in a rabbit pup model. Stroke 2009;40:3369–77.
20. Escolar ML, Poe MD, Provenzale JM, et al. Transplantation of umbili-
cal-cord blood in babies with infantile Krabbe’s disease. N Engl J Med
2005;352:2069–81.
21. KurtzbergJ, KosarasB, StephensC, SnyderEY. Umbilical cord blood cells
engra and dierentiate in neural tissues aer human transplantation. Biol
Blood Marrow Transplant 2003;9:128–9.
22. CottenCM, MurthaAP, GoldbergRN, et al. Feasibility of autologous cord
blood cells for infants with hypoxic-ischemic encephalopathy. J Pediatr
2014;164:973–979.e1.
23. SunJ, AllisonJ, McLaughlinC, et al. Dierences in quality between pri-
vately and publicly banked umbilical cord blood units: a pilot study of
autologous cord blood infusion in children with acquired neurologic dis-
orders. Transfusion 2010;50:1980–7.
24. ChangYS, AhnSY, YooHS, et al. Mesenchymal stem cells for broncho-
pulmonary dysplasia: phase 1 dose-escalation clinical trial. J Pediatr
2014;164:966–972.e6.
25. MinK, SongJ, KangJY, et al. Umbilical cord blood therapy potentiated
with erythropoietin for children with cerebral palsy: a double-blind, ran-
domized, placebo-controlled trial. Stem Cells 2013;31:581–91.
26. RubinsteinP, DobrilaL, RoseneldRE, et al. Processing and cryopreserva-
tion of placental/umbilical cord blood for unrelated bone marrow recon-
stitution. Proc Natl Acad Sci USA 1995;92:10119–22.
Pediatric RESEARCH 5