脐带血移植的应用进展及脐带血库建设

脐带血(umbilical cord blood)作为公认的造血干细胞重要来源之一,已经被广泛地用于治疗儿童和成人的良恶性血液系统疾病以及中枢神经系统疾病、实体瘤、缺血性下肢血管病和组织再生等。相对于骨髓移植和外周血来源的造血干细胞移植,脐带血移植(UCBT)在细胞收集使用、干细胞增殖能力以及移植物抗宿主反应等方面都具有明显的优势。目前的数据显示,因为HLA配型等原因而无法进行骨髓移植的患者应该尽早进行UCBT。此外,UCBT的增多促进了脐带血库的快速建设。本文针对UCBT和脐带血库的最新进展进行了综述。     

Abnormalities of blood coagulation at high altitude

Immediately on arrival of man at 3,600 m altitude there was a tendency towards hypercoagulation with increase in the platelet count, factor X, factor XII, thrombotest activity and thrombin clotting time with compensatory increase in fibrinolysis and reduction in factor VIII. During continuous stay there was a regression of the hypercoagulation state with reduction in platelet count, platelet factor 3, clot retraction, factor X, factor XII, thrombotest activity and persistence of increased fibrinolytic activity. The main difference in the hypercoagulation state in high-altitude pulmonary oedema and the corresponding highaltitude controls was the absence of a compensatory increase in fibrinolysis and increase in factor VIII. The main difference in the hypercoagulation state in highaltitude pulmonary hypertension and the corresponding high-altitude controls was an increase in platelet adhesiveness, platelet factor 3, factor V and factor VIII. The outstanding difference between high-altitude pulmonary oedema and highaltitude pulmonary hypertension was in the fibrinolytic activity and thrombin clotting time which were reduced in pulmonary oedema but were increased in pulmonary hypertension.

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Zusammenfassung Unmittelbar nach der Ankunft von Männern in 3.600 m Höhe zeigte sich eine Hyperkoagulation mit Anstieg der Plättchenzahl, Faktor X und Faktor XII, Thrombotest-Aktivität und Thrombin-Gerinnungszeit mit kompensatorischem Anstieg der Fibrinolyse und Verminderung von Faktor VIII. Bei längerem Aufenthalt ging der Hyperkoagulationszustand zurück mit verminderter Plättchenzahl, Plättchenfaktor 3, Thrombusretraktion, Faktor X, Faktor XII, Thrombotest-Aktivität und Verbleiben oder Anstieg der fibrinolytischen Aktivität. Der Hauptunterschied in der Hyperkoagulationsphase von Personen mit Lungenoedem und Gesunden in der Höhe war das Fehlen eines kompensatorischen Anstieges der Fibrinolyse und Faktor VIII. Der Hauptunterschied in der Hyperkoagulationsphase von Personen mit pulmonalem Hochdruck und Gesunden in der Höhe war ein Anstieg der Klebrigkeit der Plättchen, Plättchenfaktor 3, Faktor V und Faktor VIII. Die fibrinolytische Aktivität und die Thrombin-Gerinnungszeit waren bei Lungenoedem vermindert und bei pulmonalem Hochdruck erhöht.

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Resume A l'arrivée à 3.600 m d'altitude, on constate chez des sujets d'expérience une hypercoagulation accompagnée d'une hausse du nombre de plaquettes, du facteur X et du facteur XII, de l'activité du thrombotest et du temps de réaction de la thrombine. En compensation, on note une hausse de la fibrinolyse et une baisse du facteur VIII. Un séjour prolongé en altitude a pour conséquence une normalisation des réactions sanguines. Dans la phase d'hypercoagulation, la principale différence observée entre les personnes souffrant d'oedème pulmonaire et les personnes en bonne santé a été que, chez les premières, on n'a pas constaté de hausse compensatoire de la fibrinolyse ni de baisse du facteur VIII. Dans cette même phase, les personnes souffrant d'hypertension pulmonaires se distinguent des gens en bonne santé par le fait que les plaquettes collent entre elles et par une augmentation du facteur de plaques 3, du facteur V et du facteur VIII. L'activité fibrinolytique et le temps de coagulation de la thrombine sont diminués par l'oedème et augmentés par l'hypertension pulmonaire.

     

Accuracy of handheld blood glucose meters at high altitude

Background

Due to increasing numbers of people with diabetes taking part in extreme sports (e.g., high-altitude trekking), reliable handheld blood glucose meters (BGMs) are necessary. Accurate blood glucose measurement under extreme conditions is paramount for safe recreation at altitude. Prior studies reported bias in blood glucose measurements using different BGMs at high altitude. We hypothesized that glucose-oxidase based BGMs are more influenced by the lower atmospheric oxygen pressure at altitude than glucose dehydrogenase based BGMs.

Methodology/Principal Findings

Glucose measurements at simulated altitude of nine BGMs (six glucose dehydrogenase and three glucose oxidase BGMs) were compared to glucose measurement on a similar BGM at sea level and to a laboratory glucose reference method. Venous blood samples of four different glucose levels were used. Moreover, two glucose oxidase and two glucose dehydrogenase based BGMs were evaluated at different altitudes on Mount Kilimanjaro. Accuracy criteria were set at a bias <15% from reference glucose (when >6.5 mmol/L) and <1 mmol/L from reference glucose (when <6.5 mmol/L). No significant difference was observed between measurements at simulated altitude and sea level for either glucose oxidase based BGMs or glucose dehydrogenase based BGMs as a group phenomenon. Two GDH based BGMs did not meet set performance criteria. Most BGMs are generally overestimating true glucose concentration at high altitude.

Conclusion

At simulated high altitude all tested BGMs, including glucose oxidase based BGMs, did not show influence of low atmospheric oxygen pressure. All BGMs, except for two GDH based BGMs, performed within predefined criteria. At true high altitude one GDH based BGM had best precision and accuracy.     

Effect of adaptation to high altitude on components of blood and urine of lowlanders compared with high altitude natives

Some of the blood and urinary constituents, oral glucose tolerance and urea clearance were determined in lowlanders at sea level (200 m) and at an altitude of 4, 000 m after their stay of two years. These data were compared with those of natives of high altitude area. The concentration of proteins, cholesterol, creatinephosphokinase and aspartate aminotransferase in blood among lowlanders after 2 year acclimatization were similar to that observed among highlanders. The urinary excretion of creatine and creatinine was of similar magnitude in highlanders and in acclimatized lowlanders but that of 17-keto and 17-hydroxysteroids was higher among highlanders. High altitude acclimatization among lowlanders facilitated appearance of a sharp peak in oral glucose tolerance curves and a decreased fasting blood glucose values. It also induced a restriction in renal filtration as indicated by a depressed urea clearance among lowlanders.     

Contact phase of blood coagulation is not activated in edema of high altitude

To examine whether bradykinin generated by the activation of the contact phase of blood coagulation is involved in the pathogenesis of edema occurring after acute exposure to high altitude, 15 mountaineers were examined at 490 m and 1, 3, and 5 days after arrival at 4,559 m. The clotting activity levels of factor XII, factor XI, plasma prekallikrein, and high-molecular-weight kininogen (HMWK) were measured, and plasma kallikrein-induced proteolytic cleavage of HMWK was assessed by ligand blotting by use of radiolabeled factor XI. After an ascent on foot from 1,170 to 4,559 m in 3 days, three subjects developed high-altitude pulmonary edema, and four subjects presented facial edema. There was no evidence for activation of the contact system in any subject as demonstrated by the lack of proteolytic cleavage of HMWK at high altitude. The absence of contact system activation was further supported by stable plasma levels of the individual factors of contact activation. Therefore, we conclude that bradykinin generated by plasma kallikrein-induced cleavage of HMWK is not involved in the pathogenesis of edema due to acute exposure to high altitude.     

Effects of high altitude exposure on components of blood and urine in mountaineers

Physiological correlations with impaired or umimpaired performance at high altitude were sought among 24 blood and urine parameters measured in 50 mountaineers and 21 observers before (preclimb) and after (postclimb) expeditions on Mt. McKinley. Values and per cent changes were compared for five degrees of impairment at high altitude. Average preclimb values were all near established normal levels and no correlations with subsequent involvement at high altitude were found. Postclimb samples contained more Hb, PCV, urea, LDH, and HBD and less bilirubin (P < 0.05). But no association was found between degrees of altitude impairment and preclimb/postclimb changes in any of the 24 blood and urine parameters. Additional results from samples collected at 4300 m showed "weaker" mountaineers excreted 1/4 as much Na in urine and had 50% more serum FFA concentration than stronger mountaineers.

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Zusammenfassung Bei 50 Bergsteigern und 21 Beobachtern wurden vor und nach einer Expedition zum Mt. McKinley (Alaska) für 24 Parameter im Blut und Harn die Beziehungen zur Abschwächung der Leistung in grosser Höhe untersucht. Zum Vergleich wurden 5 Grade von unbeeinflusster bis schwerer Schädigung in der Höhe verwendet. Die mittleren Werte vor dem Aufstieg lagen alle im Bereich der Normbreite. Beziehungen zu nachfolgenden Komplikationen in der Höhe bestanden nicht. Nach dem Aufstieg waren Hgb, Hämatokrit, Harnstoff, LDH, Hydroxybutyric Dehydrogenase erhöht und Bilirubin erniedrigt (P < 0, 05). Es liess sich jedoch für keinen Parameter eine Beziehung zwischen dem Ausmass der Höhenschädigung und den Veränderungen vor und nach dem Aufstieg nachweisen. Zusätzliche Ergebnisse von Proben, die in 4300 m Höhe gesammelt wurden, ergaben, dass schwache Bergsteiger ein Viertel soviel Na im Harn ausschieden und 50% mehr freie Fettsäuren im Blut aufwiesen als starke Bergsteiger.

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Resume On a mesuré 24 paramètre du sang et de l'urine de 50 alpinistes et 21 observateurs avant et après l'ascension du Mont McKinley (Canada). On a établi ensuite la corrélation physiologique existant entre ces paramètres et une diminution éventuelle des performances. Les valeurs absolues et le taux de modification ont été comparés à 5 degrés de diminution des capacités physiques à haute altitude. Les valeurs moyennes des analyses faites avant l'ascension ont toutes été voisines du niveau normal et on n'a pas constaté de corrélation avec les performances individuelles subséquentes. Les échantillons recueillis après l'ascension contenaient davantage de Hb, PCV, urée, LDH, et HBD, mais moins de bilirubine (P < 0, 05). On n'a cependant trouvé aucune relation entre le degré de diminution des performances et les modifications d'aucun des 24 paramètres retenus du sang ou de l'urine avant et après l'ascension. Des échantillons prélevés à 4300 m d'altitude ont montré que les alpinistes peu aguerris ne sécrétaient que le 1/4 du Na par l'urine, mais avaient 50% d'acides gras libres de plus dans le sang que les montagnards les plus résistants.

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Work supported by Themis Contract No DADA 17-68-C-8018     

Seasonal changes of blood values in Rufous-collared sparrows from high and low altitude

Haematocrit, red blood cell (RBC) count, haemoglobin (Hb) concentration, and plasma solids concentration, were measured in populations ofZonotrichia capensis captured during different seasons of the year at altitudes ranging from sea level up to 3500 m. Winter blood values of birds from high and low altitude proved not to be significantly different. Similar results were obtained during summertime, with the exception of cell Hb content and concentration, which were about 10% higher in low-altitude birds. Seasonal changes in RBC size and number appear to be better correlated with the prevailing summer and winter conditions than with the particular altitudinal distribution of the examined populations.     

Apolipoprotein-specific populations in high density lipoproteins of human cord blood

High density lipoproteins (HDL) in human cord blood have previously been shown to exhibit particle size profiles distinctly different from those of adult HDL. The adult HDL profile is comprised of separate contributions from two major apolipoprotein-specific populations; one population contains both apolipoproteins AI and AII (HDL(AIwAII], while the other has apolipoprotein AI without AII (HDL(AIw/oAII]. The present studies establish that cord blood HDL are also comprised of HDL(AIwAII) and HDL(AIw/oAII) populations whose particle size profiles closely reflect cholesterol and HDL-cholesterol levels in cord blood. Compared with the adult, cord blood HDL(AIwAII) profiles generally show both a greater subspeciation within HDL2a and HDL3b/3c size intervals as well as relative reduction of material in the HDL3a interval. In the cord blood HDL(AIw/oAII) profile, HDL2b(AIw/oAII) particles also show subspeciation with a major component that is consistently larger than that normally observed in the adult (11.2 vs. 10.3 nm). As in the adult, the HDL3a(AIw/oAII) component is present but, unlike the adult, its relative amount is low; hence, its peak is usually not discernable in the cord blood total HDL profile. Our studies show that the larger-sized HDL2b(AIw/oAII) of cord blood are enriched in phospholipid which probably accounts for their increased size. The protein moiety of the larger-sized HDL2b(AIw/oAII) has a molecular weight equivalent to four apolipoprotein AI molecules per particle similar to the normal-sized adult subpopulation. Phospholipid enrichment of cord blood HDL(AIwAII) subpopulations within the HDL2a size interval was not observed. However, the protein moiety of cord blood HDL2a(AIwAII) is unusual in that it exhibits an apolipoprotein AI:AII molar ratio considerably lower (0.8:1 vs. 1.6:1) than that of adult. We suggest that the unique particle size distribution of cord blood total HDL is due in large part to: (a) a specific enrichment of phospholipid in HDL2b(AIw/oAII) species, producing particles larger than normal adult counterparts and (b) an elevated proportion of apoAII carried by the HDL(AIwAII) particles that may influence subspeciation in the HDL3a/b/c size interval.     

Biochemical mechanisms of red blood cell 2,3-diphosphoglycerate increase at high altitude

Red blood cell 2,3 diphosphoglycerate (2,3-DPG) levels increase after ascent to high altitude. Studies were undertaken to identify the biochemical mechanisms responsible for eliciting the 2,3-DPG response in several types of subjects. These included (1) short-term exposure to 3400 m in ten subjects; (2) exposure to 4300 m in an additional ten subjects; (3) studies in 28 high-altitude normal residents of 3100 m; and (4) studies in 28 high-altitude residents with chronic mountain polycythemia. Controls were 41 residents of 240 m. Regression analysis identified the glycolytic variables, termed “key variables,” on which variation in 2,3-DPG levels was dependent (P < .05). Key variables common to the short-term studies were glucose-6-phosphate, phosphoenolpyruvate, and the ratio of the levels of adenosine diphosphate to adenosine triphosphate. The positions of these key variables in the glycolytic pathway and their mean levels suggest erythrocyte hexokinase and pyruvate kinase activation as possible enzymatic mechanisms. Key variables unique to the 3400 m study suggested phosphofructokinase activation also acted to increase 2,3-DPG levels. 2,3-DPG levels in the normal 3100 m residents were not different from low-altitude values, and 2,3-DPG levels in these samples did not appear to be dependent on any of the glycolytic variables examined. Among the high-altitude residents with polycythemia, higher 2,3-DPG levels were dependent on glucose-6-phosphate, fructose diphosphate, dihydroxyacetone phosphate, and the ratio of adenosine diphosphate to adenosine triphosphate levels. The positions of these variables in the glycolytic pathway and their mean levels suggested activation of the hexokinase and phosphofructokinase enzymes.     

Pulmonary hypertention,blood coagulation and aspirin treatment in high altitude exposed cattle

Six calves resident at 400 m altitude were exposed for 2 weeks to a simulated altitude of 4,500 m. This exposure produced the following changes: increases in heart rate (34 b/min), mean pulmonary arterial pressure (8 Torr), erythrocyte number (22%), haemoglobin (32%), haematocrit (34%), blood pH (0.037 units), leucocyte number (21%), blood clotting time (18%), and prothrombin time (7%). Decreases were found in thrombocyte number (8%) and clot retraction (22%). Orally administered acetylsalicylic acid (aspirin) over 14 days (90 mg/(kg.day)) had no effect on these responses to high altitude. The results provide further evidence against the involvement of prostaglandin as mediator in pulmonary hypertension.     

Determinants of blood oxygenation during pregnancy in Andean and European residents of high altitude

High altitude decreases birth weight, but this effect is diminished in long vs. short-resident, high-altitude populations. We asked whether women from long vs. short-resident, high-altitude populations had higher arterial oxygenation levels by comparing 42 Andean and 26 European residents of La Paz, Bolivia (3,600 m), serially during pregnancy (weeks 20, 30, and 36) and again 4 mo postpartum. Pregnancy raised hypoxic ventilatory sensitivity threefold, resting ventilation (.Ve), and arterial O(2) saturation (Sa(O2)) in both groups. Ancestry, as identified using 81 genetic markers, correlated with respiratory pattern, such that greater Andean ancestry was associated with higher respiratory frequency and lower tidal volume. Pregnancy increased total blood and plasma volume approximately 40% in both groups without changing red blood cell mass relative to body weight; hence, hemoglobin fell. The hemoglobin decline was compensated for by the rise in .Ve and Sa(O2) with the result that arterial O2 content (Ca(O2)) was maintained near nonpregnant levels in both groups. Birth weights were similar for all Andean and European babies, but after adjusting for variation in gestational age, maternal height and parity, Andeans weighed 209 g more than Europeans. Babies with heavier birth weights and greater ponderal indices were born to Andean women with higher Ve during pregnancy. We concluded that while maternal .Ve and arterial oxygenation were important, some factor other than higher Ca(O2) was responsible for protecting Andeans from altitude-associated reductions in fetal growth.     

Feasibility of cord blood collection for autologous cell therapy applications in extremely preterm infants

Background aimsUmbilical cord blood (UCB)-derived cells show strong promise as a treatment for neonatal brain injury in pre-clinical models and early-phase clinical trials. Feasibility of UCB collection and autologous administration is reported for term infants, but data are limited for preterm infants. Here the authors assessed the feasibility of UCB-derived cell collection for autologous use in extremely preterm infants born at less than 28 weeks, a population with a high incidence of brain injury and subsequent neurodisability.MethodsIn a prospective study at a tertiary hospital in Melbourne, Australia, UCB was collected from infants born at less than 28 weeks and processed to obtain total nucleated cells (TNCs), CD34+ cells, mononuclear cells and cell viability via fluorescence-activated cell sorting prior to cryopreservation. Feasibility was pre-defined as volume adequate for cryopreservation (>9 mL UCB collected) and >25 × 10⁶ TNCs/kg retrieved.ResultsThirty-eight infants (21 male, 17 female) were included in the study. Twenty-four (63.1%) were delivered via cesarean section, 30 (78.9%) received delayed cord clamping before collection and 11 (28.9%) were a multiple birth. Median (interquartile range [IQR]) gestational age was 26.0 weeks (24.5–27.5) and mean (standard deviation) birth weight was 761.5 g (221.5). Median (IQR) UCB volume collected was 19.1 mL/kg (10.5–23.5), median (IQR) TNC count was 105.2 × 10⁶/kg (57.4–174.4), median (IQR) CD34+ cell count was 1.5 × 10⁶/kg (0.6–2.1) and median (IQR) cell viability pre-cryopreservation was 95% (92.1–96.0). Feasibility of collection volume and cell count suitable for cell cryopreservation was achieved in 27 (71%) and 28 (73.6%) infants, respectively.ConclusionsUCB-derived cell collection adequate for cryopreservation and subsequent autologous reinfusion was achieved in 70% of extremely preterm infants. Extremely preterm UCB demonstrated a higher CD34+:TNC ratio compared with published full-term values. Recruitment to demonstrate safety of UCB cell administration in extremely premature infants is ongoing in the CORD-SAFE study (trial registration no. ACTRN12619001637134).