Bloodless Autologous Hematopoeitic Stem Cell Transplant: An Alternative for Jehovah's Witnesses and Others Who Prefer to Go Bloodless

Abstract

Topic Significance & Study Purpose/Background/Rationale Every year people are diagnosed with Non-Hodgkin's Lymphoma (NHL) and Multiple Myeloma (MM). As an alternative treatment modality, they may seek to have a Hematopoietic Stem Cell Transplant (HSCT), which usually requires blood product transfusions. This poses a challenge when treating Jehovah's Witnesses, who normally refuse whole blood products based on religious beliefs; however, many will accept minor blood fractions and recombinant products, such as erythropoietin and granulocyte colony stimulating factors (G-CSF). Methods, Intervention, & Analysis In this study, five Jehovah's Witnesses were enrolled in the Bloodless Care Program and went through a series of pretransplant testing. Testing included an echocardiogram, electrocardiogram, and stress test to evaluate possible underlying coronary artery disease and cardiac amyloidosis. Once they qualified for a transplant, a conditioning regimen was determined and they were prepared for apheresis. Before apheresis, the patient must have hemoglobin of 11.0 g/dL and platelet count of 100 K/mm3; if not, erythropoietin and intravenous iron were given to achieve that goal. Patients were then prepped with G-CSF and Plerixafor for stem cell collection. The goal for collection was a minimum of 4 million CD34+ cells per kilogram. Post collection, there was a two week window given prior to admission for the bloodless autologous HSCT. The conditioning regimen varied on their diagnosis. For the four MM patients, the regimen was Melphalan 140mg/m2; for the one NHL patient, the regimen was Carmustine, Etoposide, and Cytoxan (BECy). When the platelet count fell below 30 K/mm3 post-transplant, Amicar was administered. Minimal phlebotomy and pediatric tubes were recommended to reduce iatrogenic anemia. Findings & Interpretation The Average length of stay was 16.7 days. After transplant, the median nadir hemoglobin was 9.15 g/dL, while the platelets were 5.5 K/mm3. One patient was readmitted within 30 days after transplant for fever during engraftment. One patient relapsed and received a second bloodless autologous HSCT 9 months later. There were no mortalities. Discussion & Implications Utilizing minor fractions, blood conservation modalities, and appropriate pre-transplant workup, resulted in safely performing bloodless autologous HSCT for Jehovah's Witness; therefore, proving this can be an alternative treatment for those who prefer to go bloodless.