The expanding role of the clinical haematologist in the new world of advanced therapy medicinal products

Advanced therapy medicinal products (ATMP s) represent the current pinnacle of ‘patient‐specific medicines’ and will change the nature of medicine in the near future. They fall into three categories; somatic cell‐therapy products, gene therapy products and cells or tissues for regenerative medicine, which are termed ‘tissue engineered’ products. The term also incorporates ‘combination products’ where a human cell or tissue is combined with a medical device. Plainly, many of these new medicines share similarities with conventional haematological stem cell transplant products and donor lymphocyte infusions as well as solid organ grafts and yet ATMP s are regulated as medicines and their development has remained predominantly in academic settings and within specialist centres. However, with the advent of commercialisation of dendritic cell vaccines, chimeric antigen receptor (CAR )‐T cells and genetically modified autologous haematopoietic stem cells to cure single gene‐defects in β‐thalassaemia and haemophilia, the widespread availability of these therapies needs to be accommodated. Uniquely to ATMP s, the patient or an allogeneic donor is regularly part of the manufacturing process. All of the examples given above require procurement of blood, bone marrow or an apheresate from a patient as a starting material for manufacture. This can only occur in a clinical facility licensed for the procurement of human cells for therapeutic use and this is likely to fall to haematology departments, either as stem cell transplant programmes or as blood transfusion departments, to provide under a contract with the company that will manufacture and supply the final medicine. The resource implications associated with this can impact on all haematology departments, not just stem cell transplant units, and should not be under‐estimated.     

The future of academic haematology

Recent advances in the basic medical sciences, particularly cell biology and genomics, have great promise for the future development of all aspects of haematological practice. They will also impinge on the hitherto neglected fields of haematology, including haematology involving the care of the rapidly increasing number of elderly patients and the complex problems of haematological practice in the developing countries. To obtain the maximum benefit from these new developments it will be necessary to review the patterns of training of haematologists of the future at every level. In short, it will be important to try to design and develop various career pathways for training haematologists including those who wish to work full time in basic research, combine research with clinical practice, or commit all their time to clinical work and teaching.     

How I manage haematology patients with septic shock

Patients with a variety of haematological conditions are at risk of infection and its most serious complication: septic shock. Mortality for septic shock remains high and especially so in patients with haematological malignancy and following bone marrow transplantation. However, advances in the treatment of severe sepsis have improved mortality rates even though evidence for the management of severe sepsis in haematology patients is limited. Wherever possible this review will concentrate on evidence directly applicable to haematology patients but inevitably will have to extrapolate evidence from other patient groups. The Surviving Sepsis Guidelines 2008 provide information on best practice in the management of patients with severe sepsis and septic shock and are broadly applicable though not specific to haematology patients. This review summarizes a practical approach to the management of severe sepsis in haematology patients and highlights areas of research which may bring new treatments in the future. The review is limited to the management and initial resuscitation of septic shock in adult haematology patients and will not address the detailed intensive care management of these patients or the management of severe sepsis in children.     

Training future haematologists,a privilege or a burden? “A trainer's view”

Recent decades have seen the emergence of new problems in haematology training, relating particularly to an expanding curriculum, less time available for training, staff shortages and the increasing separation of clinical haematology from its laboratory base. We have sought to identify the problems and propose possible solutions.     

Rule based processing of the CD4000, CD3200 and CD Sapphire analyser output using the Cerner Discern Expert Module

The latest version of our Laboratory Information System haematology laboratory expert system that handles the output of Abbott Cell-Dyn Sapphires, CD4000s and a CD3200 full blood count analyser in three high-volume haematology laboratories is described. The three hospital laboratories use Cerner Millennium Version 2007.02 software and the expert system uses Cerner Millennium Discern Expert rules and some small Cerner Command Language in-house programs. The entire expert system is totally integrated with the area-wide database and has been built and maintained by haematology staff members, as has the haematology database. Using patient demographic data, analyser numeric results, analyser error and morphology flags and previous results for the patient, this expert system decides whether to validate the main full blood count indices and white cell differential, or if the analyser results warrant further operator intervention/investigation before verifying, whether a blood film is required for microscopic review and if abnormal results require phoning to the staff treating the patient. The principles of this expert system can be generalized to different haematology analysers and haematology laboratories that have different workflows and different software.     

Recommendations for a standard UK approach to incorporating umbilical cord blood into clinical transplantation practice: an update on cord blood unit selection,donor selection algorithms and conditioning protocols

Allogeneic haemopoietic stem cell transplantation offers a potentially curative treatment option for a wide range of life‐threatening malignant and non‐malignant disorders of the bone marrow and immune system in patients of all ages. With rapidly emerging advances in the use of alternative donors, such as mismatched unrelated, cord blood and haploidentical donors, it is now possible to find a potential donor for almost all patients in whom an allograft is indicated. Therefore, for any specific patient, the transplant physician may be faced with a myriad of potential choices, including decisions concerning which donor to prioritize where there is more than one, the optimal selection of specific umbilical cord blood units and which conditioning and graft‐versus‐host disease prophylactic schedule to use. Donor choice may be further complicated by other important factors, such as urgency of transplant, the presence of alloantibodies, the disease status (homozygosity or heterozygosity) of sibling donors affected by inherited disorders and the cytomegalovirus serostatus of patient and donor. We report UK consensus guidelines on the selection of umbilical cord blood units, the hierarchy of donor selection and the preferred conditioning regimens for umbilical cord blood transplantation, with a summary of rationale supporting these recommendations.     

Performance evaluation of the Abbott CELL‐DYN Ruby and the Sysmex XT‐2000i haematology analysers

Two mid‐range haematology analysers (Abbott CELL‐DYN Ruby and Sysmex XT‐2000i) were evaluated to determine their analytical performance and workflow efficiency in the haematology laboratory. In total 418 samples were processed for determining equivalence of complete blood count (CBC) measurements, and 100 for reticulocyte comparison. Blood smears served for assessing the agreement of the differential counts. Inter‐instrument agreement for most parameters was good although small numbers of discrepancies were observed. Systematic biases were found for mean cell volume, reticulocytes, platelets and mean platelet volume. CELL‐DYN Ruby WBC differentials were obtained with all samples while the XT‐2000i suppressed differentials partially or completely in 13 samples (3.1%). WBC subpopulation counts were otherwise in good agreement with no major outliers. Following first‐pass CBC/differential analysis, 88 (21%) of XT‐2000i samples required further analyser processing compared to 18 (4.3%) for the CELL‐DYN Ruby. Smear referrals for suspected WBC/nucleated red blood cells and platelet abnormalities were indicated for 106 (25.4%) and 95 (22.7%) of the XT‐2000i and CELL‐DYN Ruby samples respectively. Flagging efficiencies for both analysers were found to be similar. The Sysmex XT‐2000i and Abbott CELL‐DYN Ruby analysers have broadly comparable analytical performance, but the CELL‐DYN Ruby showed superior first‐pass efficiency.     

Allogeneic haemopoietic stem cell transplantation in children: what alternative donor should we choose when no matched sibling is available?

Allogeneic haemopoietic stem cell transplantation has provided curative therapy for life-threatening malignant and non-malignant diseases in children for over 40 years. Only 25% of children in whom an allograft is indicated have the ideal option of a human leucocyte antigen-identical sibling donor. Substantial advances in the use of alternative donors (unrelated volunteer donors, haploidentical family donors and unrelated umbilical cord blood donors) now make it possible for almost all children to benefit from this life-saving treatment. Each donor choice is associated with distinct advantages and disadvantages, which have greater or lesser importance in different diseases. We review the current status of alternative donor transplantation for haematological malignancies, primary immunodeficiencies, inherited metabolic disorders and bone marrow failure syndromes and outline the current UK consensus donor selection algorithms for these disease groups.     

Update on the use of stem cells for cardiac disease

Major advances have recently been made in our understanding of stem cell biology, and in the application of stem cells to treat cardiac disease. Resident cardiac stem cells have now been described and the long-accepted paradigm of the adult mammalian heart as an organ without regenerative capacity has been questioned. Various stem-cell-based approaches for ameliorating cardiac disease have been shown to be beneficial in animal models and are now being trialled in humans, with several phase I clinical studies already completed. Although these clinical studies lacked adequate placebo controls, they have consistently shown promising results. If confirmed by larger phase II/III trials, it is possible that within a few years a powerful new therapeutic option may be available for the burgeoning number of patients suffering from myocardial ischaemia and/or other cardiac disorders.     

Analysis of red blood cell volume distributions using the ICSH reference method: detection of sequential changes in distributions determined by hydrodynamic focusing

Summary Automated haematology analysers determine the volume of red blood cells and provide an erythrocyte volume distribution. For analysis of these distributions, the International Council Tor Standardization in Haematology (ICSH) has recommended methods for fitting a single reference distribution and assessing its goodness of fit (ICSH, 1990). To evaluate the suitability of the ICSH reference method for routine use with haematology analysers, we applied the ICSH method to a reference sample group of 71 healthy individuals and to 618 samples collected from 112 patients. Samples were measured using Sysmex NE-8000 haematology analysers. Each distribution was doubly truncated to eliminate artefactual frequency counts and tested for goodness of fit to a single lognormal distribution (McLaren, Brittenham & Hasselblad, 1986) and mixtures of lognormal distributions (McLaren el al., 1991). Analysis of data from healthy individuals demonstrated the reproducibility of the ICSH reference method. Analysis of data from patients illustrated the ability of the method to detect sequential changes in distributions, providing a useful tool to monitor the effect of therapeutic intervention and blood transfusion.     

Regenerative medicine for the treatment of heart disease

Heart failure is a major cause of mortality worldwide with a steady increase in prevalence. There is currently no available cure beyond orthotopic heart transplantation, which for a number of reasons is an option only for a small fraction of all patients. Considerable hope has therefore been placed on the possibility of treating a failing heart by replacing lost cardiomyocytes, either through transplantation of various types of stem cells or by boosting endogenous regenerative mechanisms in the heart. Here, we review the current status of stem and progenitor cell‐based therapies for heart disease. We discuss the pros and cons of different stem and progenitor cell types that can be considered for transplantation and describe recent advances in the understanding of how cardiomyocytes normally differentiate and how these cells can be generated from more immature cells ex vivo. Finally, we consider the possibility of activation of endogenous stem and progenitor cells to treat heart failure.     

A European consensus report on blood cell identification: terminology utilized and morphological diagnosis concordance among 28 experts from 17 countries within the European LeukemiaNet network WP10, on behalf of the ELN Morphology Faculty

This paper describes the methodology used to develop a consensual glossary for haematopoietic cells within Diagnostics‐WP10 of European‐LeukemiaNet EU‐project. This highly interactive work was made possible through the use of the net, requiring only a single two‐day meeting of actual confrontation and debate. It resulted in the production of a freely accessible tool that could be useful for training as well as harmonization of morphological reports in onco‐haematology especially, without geographic limitation, not limited to European countries. Moreover, this collective work resulted in the production of a consensus statement, taking into account individual practices, collegial agreement and literature data.     

Induced Pluripotent Stem Cells for the Study of Cardiovascular Disease

Groundbreaking advances in stem cell research have led to techniques for the creation of human cardiomyocytes from cells procured from a variety of sources, including a simple skin biopsy. Since the advent of this technology, most research has focused on utilizing these cells for therapeutic purposes. However, recent studies have demonstrated that stem cell–derived cardiomyocytes generated from patients with inherited cardiovascular disorders recapitulate key phenotypic features of disease in vitro. Furthermore, these cells can be maintained in culture for prolonged periods of time and used for extensive biochemical and physiological analysis. By serving as models of inherited cardiac disorders, these systems have the potential to fundamentally change the manner in which cardiovascular disease is studied and new therapies are developed.     

The role of haploidentical stem cell transplantation in the management of children with haematological disorders

The broader application of stem cell transplantation (SCT) for paediatric diseases has been limited by a lack of human leucocyte antigen (HLA)-matched donors. Virtually all children, however have at least one haploidentical parent who could serve as a donor. Such a donor is immediately available and the considerable costs of additional HLA typing, registry and banking expenditures that are necessary to procure an unrelated donor, could be reduced. Recent technological advances appear to have overcome the historical problems of graft rejection and severe graft versus host disease in the haploidentical setting, and in the latest studies the overall survival for children undergoing haploidentical SCT for leukaemia is now comparable with that following unrelated donor bone marrow or cord blood transplantation. Post-transplant infectious complications and leukaemia relapse remain the most important barriers yet to overcome, and new directions in the use of adoptive cellular immunity appear to be promising in this respect. Haploidentical SCT is now a viable option for those children who do not have an HLA compatible sibling or fully matched unrelated donor. The relative merits of a haploidentical family donor versus mismatched unrelated bone marrow or cord blood donation needs to be assessed in prospective, randomized clinical trials.     

Fate plasticity in the intestine: The devil is in the detail

The intestinal epithelium possesses a remarkable ability for both proliferation and regeneration.The last two decades have generated major advances in our understanding of the stem cell populations responsible for its maintenance during homeostasis and more recently the events that occur during injury induced regeneration.These fundamental discoveries have capitalised on the use of transgenic mouse models and in vivo lineage tracing to make their conclusions.It is evident that maintenance is driven by rapidly proliferating crypt base stem cells,but complexities associated with the technicality of mouse modelling have led to several overlapping populations being held responsible for the same behaviour.Similarly,it has been shown that essentially any population in the intestinal crypt can revert to a stem cell state given the correct stimulus during epithelial regeneration.Whilst these observations are profound it is uncertain how relevant they are to human intestinal homeostasis and pathology.Here,these recent studies are presented,in context with technical considerations of the models used,to argue that their conclusions may indeed not be applicable in understanding“homeostatic regeneration”and experimental suggestions presented for validating their results in human tissue.     

Translational research of adult stem cell therapy

Congestive heart failure (CHF) secondary to chronic coronary artery disease is a major cause of morbidity and mortality world-wide. Its prevalence is increasing despite advances in medical and device therapies. Cell based therapies generating new cardiomyocytes and vessels have emerged as a promising treatment to reverse functional deterioration and prevent the progression to CHF. Functional efficacy of progenitor cells isolated from the bone marrow and the heart have been evaluated in preclinical large animal models. Furthermore, several clinical trials using autologous and allogeneic stem cells and progenitor cells have demonstrated their safety in humans yet their clinical relevance is inconclusive. This review will discuss the clinical therapeutic applications of three specific adult stem cells that have shown particularly promising regenerative effects in preclinical studies, bone marrow derived mesenchymal stem cell, heart derived cardiosphere-derived cell and cardiac stem cell. We will also discuss future therapeutic approaches.     

New advances in the management of cytomegalovirus in allogeneic haemopoietic stem cell transplantation

Cytomegalovirus (CMV) viraemia continues to be a frequent complication in the post‐haemopoietic stem cell transplantation period despite a low incidence of CMV end‐organ disease. Several significant advances in the understanding and management of CMV infection have occurred in the last few years including improved diagnostics, monitoring of CMV immunity, availability of novel anti‐CMV drugs, and emerging use of immunotherapies including CMV‐specific T‐cell infusions. In addition to reviewing these advances we also explore some of the more practical prescribing issues of the older and newer CMV drugs including cost, toxicity and drug interactions to help clinicians navigate this new era of CMV management.     

Laboratory evaluation of the Sysmex SE‐9500 automated haematology analyser

The Sysmex SE‐9c500 is a new, fully automated haematology analyser, providing a complete blood count (CBC), including a five‐part differential count (DC), with flagging of morphological abnormalities. The SE‐9500 was evaluated according to guidelines published by the International Committee for Standardisation in Haematology (ICSH). The results demonstrated minimal carryover (< 0.01%) and excellent linearity for WBC, RBC, HGB and platelet (PLT) (r > 0.995). Samples were stable with regard to CBC parameters after storage for up to 48 h at room temperature (RT) and 4 °C. Imprecision was generally acceptable for all CBC parameters (CV < 5%). Correlation between the SE‐9500 and reference methods was excellent (r > 0.97) for all the major CBC parameters (WBC, RBC, HGB, PLT). There was minimal interference for WBC, RBC, HGB and PLT at high concentrations of bilirubin (BIL=224 μmol/l) or triglyceride (TG=7.78 mmol/l). SE‐9500 reference values for CBC parameters are presented. Our results indicate that the SE‐9500 is an excellent tool for routine haematological examination.     

Indirect evidence that maternal microchimerism in cord blood mediates a graft-versus-leukemia effect in cord blood transplantation

During pregnancy women can develop B- and T-cell immunity against the inherited paternal antigens (IPAs) of the fetus, such as HLA, peptides of minor histocompatibilty antigens, and possibly onco-fetal antigens. The biological and pathological role of these pregnancy-induced immunological events is only understood in part. However, anti-IPA immunity in the mother persists for many decades after delivery and may reduce relapse in offspring with leukemia after HLA-haploidentical transplantation of maternal hematopoietic stem cells (HSC). We hypothesized that maternal anti-IPA immune elements cross the placenta and might confer a potent graft-versus-leukemia effect when cord blood (CB) is used in unrelated HSC transplantation. In a retrospective study of single-unit CB recipients with all grafts provided by the New York Blood Center, we show that patients with acute myeloid or lymphoblastic leukemia (n = 845) who shared one or more HLA-A, -B, or -DRB1 antigens with their CB donor's IPAs had a significant decrease in leukemic relapse posttransplantation [hazard ratio (HR) = 0.38, P < 0.001] compared with those that did not. Remarkably, relapse reduction in patients receiving CB with one HLA mismatch (HR = 0.15, P < 0.001) was not associated with an increased risk of severe acute graft-versus-host disease (HR = 1.43, P = 0.730). Our findings may explain the unexpected low relapse rate after CB transplantation, open new avenues in the study of leukemic relapse after HSC transplantation (possibly of malignancies in general), and have practical implications for CB unit selection.