Granulocyte Transfusions in Children Undergoing Hematopoietic Stem Cell Transplantation

Abstract

Introduction Neutropenia, often encountered in patients undergoing hematopoietic stem cell transplantation (HSCT) increases the risk of bacterial and/or fungal infections. Granulocyte transfusions (GT) have been indicated for neutropenic patients with severe infections that are often refractory to antimicrobial therapy. There is paucity of pediatric studies on the use of GT in children, leading to reluctance in using GT even when severe documented infections are present. This retrospective study was done on all patients who received at least a single GT at our institution until 2021 to study the indications, dosage, safety, and tolerability of GT. As mandated by the nursing policy all but one patient received their infusion(s) in the pediatric intensive care unit (PICU) for concern of possible reaction or decompensation following GT. Results Thirteen patients who underwent 16 transplants (hematological malignancies = 11, immune dysregulation = 1, severe aplastic anemia = 1) and received GT during their stay for transplant. All patients had prolonged neutropenia and were given 1- to 69 GT (median = 5) for fungal or bacterial infections (n = 5 each), fungal and bacterial infection (n=1) and perianal cellulitis (n =2). The dose of GT for each patient ranged from 145-470 mL per infusion. GT were given no more than once a day, and varied with 3, 5, 1, 1, 2 and 1 patients getting 1, 5, 8, 11, 13 and 69 days of granulocytes. The patient who got 69 GT, got them over 4 separate time periods during his prolonged stay in hospital for graft failure after first and second transplants. Nine patients received premedication with acetaminophen, diphenhydramine, and/or hydrocortisone. None of the patients had any major transfusion reaction or hemodynamic instability during or after the GT. The primary indication for which GT were given, improved in 8/13 (61.5%) of the patients, with partial response in an additional patient, and no response in the remaining 4 patients. At the time of this study, 3/13 patients were alive and the cause of death of the remaining 10 patients was relapse (n=2), primary or secondary graft failure (n=3), VOD (n=2), steroid refractory acute GvHD (n=1), and disseminated fungal disease (n=2). Of the 3 patients still living, all are in remission with 2 having chronic GVHD. Conclusion In our study, GT were well tolerated without any reported significant side effects and after our study, all GT were allowed to be given on the regular floor avoiding the need for transfer to PICU. While GT appear to be safe, those who received infusions for localized infections in the setting of neutropenia had better outcomes compared to those who received infusions for disseminated or systemic disease. A small sample size and retrospective study are the major limitations of our study. We propose that in children undergoing HSCT, in the setting of prolonged neutropenia of any cause, GT can be helpful in ameliorating infectious complications like perianal cellulitis/fistulas, and bacterial or fungal blood stream infections. A larger prospective study is needed to address the effects of GT on overall survival.