Granulocyte Transfusion Therapy Research Articles

Impact of the mobilization regimen and the harvesting technique on the granulocyte yield in healthy donors for granulocyte transfusion therapy

Granulocyte mobilization and harvesting, the two major phases of granulocyte collection, have not been standardized. The data on 123 granulocyte collections were retrospectively investigated for the effect of the mobilization regimen and the harvesting technique. After a single subcutaneous dose (600 µg) of granulocyte-colony-stimulating factor (G-CSF) with (n = 68) or without (n = 40) 8 mg of orally administered dexamethasone, 108 granulocyte donors underwent granulocyte collections. Moreover, 15 peripheral blood stem cell (PBSC) donors who had received 400 µg/m2 or 10 µg/kg G-CSF for 5 days underwent granulocyte collections on the day after the last PBSC collections (PBSC-GTX donors). Granulocyte harvesting was performed by leukapheresis with (n = 108) or without (n = 15) using high-molecular-weight hydroxyethyl starch (HES). Granulocyte donors who received mobilization with G-CSF plus dexamethasone produced significantly higher granulocyte yields than those who received G-CSF alone (7.2 × 10(10) ± 2.0 × 10(10) vs. 5.7 × 10(10) ± 1.7 × 10(10) , p = 0.006). PBSC-GTX donors produced a remarkably high granulocyte yield (9.7 × 10(10) ± 2.3 × 10(10) ). The use of HES was associated with better granulocyte collection efficiency (42 ± 7.8% vs. 10 ± 9.1%, p < 0.0001). G-CSF plus dexamethasone produces higher granulocyte yields than G-CSF alone. Granulocyte collection from PBSC donors appears to be a rational strategy, since it produces high granulocyte yields when the related patients are at a high risk for infection and reduces difficulties in finding granulocyte donors. HES should be used in apheresis procedures.

Pretreatment with phosphatase and tensin homolog deleted on chromosome 10 (PTEN) inhibitor SF1670 augments the efficacy of granulocyte transfusion in a clinically relevant mouse model

AbstractThe clinical outcome of granulocyte transfusion therapy is often hampered by short ex vivo shelf life, inefficiency of recruitment to sites of inflammation, and poor pathogen-killing capability of transplanted neutrophils. Here, using a recently developed mouse granulocyte transfusion model, we revealed that the efficacy of granulocyte transfusion can be significantly increased by elevating intracellular phosphatidylinositol (3,4,5)-trisphosphate signaling with a specific phosphatase and tensin homolog deleted on chromosome 10 (PTEN) inhibitor SF1670. Neutrophils treated with SF1670 were much sensitive to chemoattractant stimulation. Neutrophil functions, such as phagocytosis, oxidative burst, polarization, and chemotaxis, were augmented after SF1670 treatment. The recruitment of SF1670-pretreated transfused neutrophils to the inflamed peritoneal cavity and lungs was significantly elevated. In addition, transfusion with SF1670-treated neutrophils led to augmented bacteria-killing capability (decreased bacterial burden) in neutropenic recipient mice in both peritonitis and bacterial pneumonia. Consequently, this alleviated the severity of and decreased the mortality of neutropenia-related pneumonia. Together, these observations demonstrate that the innate immune responses can be enhanced and the severity of neutropenia-related infection can be alleviated by augmenting phosphatidylinositol (3,4,5)-trisphosphate in transfused neutrophils with PTEN inhibitor SF1670, providing a therapeutic strategy for improving the efficacy of granulocyte transfusion.

Granulocyte transfusion therapy: randomization after all?

Granulocyte transfusions were first used to treat infections in neutropenic patients in the early 1960s. The first donors were patients with chronic myeloid leukemia. Forty years later the value of these transfusions remains unclear. In this perspective article Drs. Drewniak and Kuijpers discuss the relevant data. See related paper on page 1661.

Granulocyte transfusion therapy in abdominal organ transplant recipients

Patients with neutropenia are at increased risk for infections. Granulocyte transfusions (GT) have had mixed success in treatment of neutropenic infections in adult patients with hematologic malignancy. This study examined the outcomes of GT therapy in neutropenic solid organ transplant recipients, a novel population for this therapy. We performed a retrospective examination of the transfusion and medical records of all 14 solid organ-transplant recipients without hematologic malignancy who experienced neutropenia and received GT therapy from 2004 to 2006. Twelve patients received GT therapy for an active infection and two patients for infection prophylaxis. The mean absolute neutrophil count (ANC) one day increment per GT in these patients was 526/microl (median 215/microl). The mean ANC one day increment per dose of 10(10) granulocytes was 246/microl (median 86/microl). Of the 12 infected patients, four patients (33%) showed a clinical response to GT with improvement or resolution of the infection, 7 (58%) patients had no clinical response and one additional patient had a clinical response to a course of GT but died during a second GT course. Neither patient receiving GT for prophylaxis developed an infection. We observed temporal increases in ANC to levels above 1,000/microl in 15/18 (83.3%) courses of GT. We observed a clinical response to infection in 5/12 (42%) patients, the remaining infected patients had no clinical response. Our results suggest that GT therapy in neutropenic solid organ transplant recipients can boost peripheral blood neutrophil counts. Additional studies are needed to document an independent clinical benefit for GT in this patient population.

Granulocyte transfusion therapy: a new era?

Granulocyte transfusion therapy is not a new idea; since the 1930’s hematologists have tried to find ways to collect and transfuse enough granulocytes to prevent and treat infections in severely neutropenic patients. It has been a long road with periods of excitement and disappointment. Without question, the availability of the myeloid growth factors, particularly granulocyte colony-stimulating factor (G-CSF), and new antibiotics and antifungal agents have improved supportive care. Nevertheless, severe neutropenia remains an important and serious complication of cancer chemotherapy and hematopoietic stem cell transplantation, and the mortality rate is still about ten percent for patients admitted to U S hospital with febrile neutropenia. (1) With prolonged neutropenia, fungal infections are still the most difficult clinical problem. The strongest predictor of recovery from invasive fungal infections in this setting is recovery of neutrophil production by the marrow and an adequate number of blood and tissue neutrophils. (2) Neutrophil transfusion therapy represents a possible way to bridge the gap between marrow suppression and neutrophil recovery. In the early 1990’s it was established that G-CSF is a powerful mobilizer of granulocytes from the marrow to the blood in normal donors for transfusion to severely neutropenic patients. (3) A study by Bensinger, et. al. then established that large numbers of neutrophils can be harvested by centrifuge leukapheresis from normal donors treated with a single dose of G-CSF. (4) When these cells were transfused to neutropenic recipients, they circulated normally and the effect of the transfusion lasted for at least 24 hours. Subsequent studies established that addition of dexamethasone to G-CSF enhanced the harvest almost two-fold, permitting the collection of approximately 8 × 1010 neutrophils, sufficient cells to raise the circulating count of a severely neutropenic patients to a normal level. (5) Further trials then showed that these cells also could migrate to a site of inflammation and had normal functional characteristics. (6) This was the start of a new era for neutrophil transfusion therapy. Since these original trials, several studies have suggested that granulocyte transfusion from G-CSF/dexamethasone stimulated donors are effective for the treatment of infections in severely neutropenic patients, but there is not yet any definitive proof of clinical benefit. (7) Now for the first time, a phase III randomized controlled clinical trial is underway to evaluate the effectiveness of transfusing large numbers of G-CSF/dexamethasone mobilized granulocytes under sponsorship of the National Heart, Lung and Blood Institute, NIH, conducted by the Transfusion Medicine/Hemostasis Clinical Trials Network. The study will evaluate neutropenic patients who have undergone dose-intensive chemotherapy or hematopoietic stem cell transplantation within the last 60 days who have proven or probable infections. The objective is to evaluate the benefit of treating patients with G-CSF/dexamethasone mobilized granulocyte transfusion as an adjunct to organism-directed antimicrobial therapy. The control group will receive standard care with organism-directed antimicrobial therapy alone. Subjects in the granulocyte arm will receive daily transfusions for up to 42 days and all enrolled subjects will be followed for up to three months to evaluate survival benefits. The primary end point is a composite one: survival and a microbial response, both evaluated at 42 days after randomization. One of the most important aspects of this study is the use of community donors. This part of the study plan is based upon observations in preliminary trials that allo-immunization occur slowly if at all in this patient population, permitting many days of transfusion of cells from a general donor population. Many other aspects of the trial, for example, the cytomegalovirus status of the donor and the recipient, collection techniques, storage duration of the granulocytes, need for irradiation of the cells to be transfused, timing of granulocyte transfusions in relationship to antimicrobial therapy and other factors have been worked out through careful studies over the last several years. This trial will also reinvestigate many of these factors and provide valuable information on contemporary patterns of infection in severely neutropenic patients, particularly on the diagnosis, treatment and outcomes for high risk fungal infections in this setting. The study, called the RING (Resolving Infections in Neutropenia with Granulocytes) study, opened mid-year 2008 and aims to enroll 236 subjects (118 in each arm), based upon estimates of the effectiveness of current treatment and risk of mortality in this population. The Transfusion Medicine/Hemostasis Clinical Trials Network is interested in adding out-of-network participating centers and investigators. Interested parties should contact Dr. Thomas Price (gro.cbsp@ecirpht) or Julie Miller (moc.ecneicsiren@relliMJ) at the New England Research Institue (the study’s data coordinating center).

Outcome with Hyper-CVAD/MTX-Ara-C, a Dose-Intensive Regimen, in Acute Lymphocytic Leukemia and Highly Aggressive Lymphoma in China.

Purpose: The objective of this study was to evaluate the efficacy and potential toxicity of the Hyper-CVAD/MTX-Ara-C regimen,a dose-intensive regimen, in the patients with acute lymphocytic leukemia (ALL) and highly aggressive non-Hodgkin lymphoma (NHL) in China.PATIENTS AND METHODS: Between June 2004 and June 2007, fifty-six patients with ALL or highly aggressive lymphoma were treated with the Hyper-CVAD/MTX-Ara-C regimen at our institution. Median age was 26 years (range 13 to 60 years), and 35 patients (62.50%) were male. All patients were comprised of 32 previously untreated cases and 24 refractory/relapsed ones. Among the 41 patients with ALL, B-cell disease was present in 82.93%, T-cell disease in 17.07%, and Ph-positive ALL was present in 14.63%, refractory/relapsed disease in 43.90%. Among the 15 patients with highly aggressive NHL, lymphoblastic lymphoma was present in 46.67%, Burkitt's lymphoma was in 53.33% and refractory/relapsed disease in 40.00%. CNS involvement was present in 8% at diagnosis. Treatment consisted of four cycles of Hyper-CVAD alternating with four cycles of high-dose methotrexate (MTX) and cytarabine therapy, together with intrathecal CNS prophylaxis and aggressive supportive care with granulocyte colony-stimulating factor (G-CSF), transfusion and antibiotic prophylaxis therapy. Maintenance therapy based on cytogenetics and immunophenotypes in most of patients contained 2-year treatment with mercaptopurine, MTX, vincristine, and prednisone (POMP).RESULTS: The median follow-up time was 7 months (range 1+ to 37+ months). Of the previously untreated 31 patients, twenty-nine patients (93.55%) achieved complete remission (CR) and no patients died during induction therapy. Of the refractory /relapsed 24 patients, fourteen cases (58.33%) achieved CR. Remarkably, the CR rate of the patients with Burkitt's lymphoma was 75.00% (6/8). The median courses finished during the dose-intensive phase were 4 (range 1 to 8), and the median time to delivery of all eight courses was 10 months. The estimated 3-year overall survival (OS) for the untreated and refractory/relapsed patients with ALL was 46.80% and 28.60%, respectively. Meanwhile, the estimated 2-year OS for the aggressive NHL patients was 84.00%. Compared with the patients with ALL who did not receive CR and get less than four courses of this regimen, the patients who did receive CR and get more than four courses of this dose-intensive regimen showed much better OS (p<0.05). The incidence of CNS relapse was low (5%). Myelosuppression-associated complications including documented infections, fever of unknown origin, hemorrhage were the more frequent side effects. Other significant side effects included neurotoxicity, renal and hepatic toxicities, fatigue, mucositis, nausea, vomiting, diarrhea, skin rashes, and G-CSF therapy-associated bone aches.CONCLUSION: The present outcome from our single center in China demonstrated that Hyper-CVAD/MTX-Ara-C, a dose-intensive regimen with much higher CR was superior to our previous regimens, even in patients with highly aggressive lymphoma such as lymphoblastic and Burkitt's lymphoma, and in refractory/relapsed ALL/lymphoma ones. Our study also showed that this regimen was less toxic and well tolerated in most of treated patients in China. Long-term treatment benefits and severe side effects needed further investigation in a well-designed, multiple-center study in China with more eligible patients entering onto the study.

Granulocyte Transfusion: Current Status

Infection associated with therapy-related neutropenia continues to be a major cause of morbidity and mortality. Renewed interest in granulocyte transfusion therapy as treatment for this condition has been generated by the observation that large doses of granulocytes can be obtained from donors who have been stimulated with granulocyte colony-stimulating factor (G-CSF). Granulocytes collected from these donors have been shown to effectively raise the patient's neutrophil count and appear to function normally as judged both by in vitro and in vivo measures. The evidence for clinical efficacy is limited to that of case reports and small series, and the results are not uniform. Randomized controlled clinical trials are needed to determine whether this therapy is useful in either clearing infections or prolonging survival.

Outcome with Hyper-CVAD/MTX-Ara-C, a Dose-Intensive Regimen, in Acute Lymphocytic Leukemia and Highly Aggressive Lymphoma: A Preliminary Study in a Single Center in China.

BACKGROUND: Although the safety and efficacy of the Hyper-CVAD/MTX-Ara-C regimen in hematologic malignancies has been well established by the large clinical trials developed at the University of Texas M. D. Anderson Cancer Center, the outcome with this regimen in patients in China has not been determined. The objective of this study was to evaluate the efficacy and potential toxicity of this regimen in acute lymphocytic leukemia (ALL) and highly aggressive non-Hodgkin lymphoma (NHL) in a single center in China.PATIENTS AND METHODS: Between September 2004 and July 2006,36 patients with ALL or highly aggressive lymphoma were treated with the Hyper-CVAD/MTX-Ara-C regimen at our institution. Median age was 35 years (range 14 to 60 years), and 23 patients (64%) were male. All patients are comprised of 19 previously untreated cases and 17 refractory/relapsed ones. Among the 28 patients with ALL, B-cell disease was present in 82%, T-cell disease in 18%, and Ph-positive ALL was present in 18%, refractory/relapsed disease in 46%. Among the 8 patients with highly aggressive NHL, lymphoblastic lymphoma was present in 63%, Burkitt's lymphoma was in 37% and refractory/relapsed disease in 50%. CNS involvement was present in 8% at diagnosis. Treatment consisted of four cycles of Hyper-CVAD alternating with four cycles of high-dose methotrexate (MTX) and cytarabine therapy, together with intrathecal CNS prophylaxis and aggressive supportive care with granulocyte colony-stimulating factor, transfusion and antibiotic prophylaxis therapy. Maintenance therapy according to cytogenetics and immunophenotype in partial patients included 2 years of treatment with mercaptopurine, MTX, vincristine, and prednisone (POMP).RESULTS: The median follow-up was 7 months (range 1+ to 23+ months). Of the previously untreated 19 patients, seventeen patients (89.47%) achieved complete remission (CR) and no patients died during induction therapy. Of the refractory/relapsed 17 patients, seven cases (41.48%) achieved CR. Remarkably, the CR rate of the patients with Ph-positive ALL was 60.00%(3/5), and Burkitt's lymphoma 66.67%(2/3). The median finished courses during the dose-intensive phase were 5 (range 1 to 8), and the median time to delivery of all eight courses was 10 months. The estimated 5-year survival and 5-year CR rates were not concluded so far. The incidence of CNS relapse was low (5%). Myelosuppression-associated complications including documented infections, fever of unknown origin, hemorrhage were the more frequent side effects. Other significant side effects included neurotoxicity, renal and hepatic toxicities, fatigue, mucositis, nausea, vomiting, diarrhea, skin rashes, and G-CSF therapy-associated bone aches.CONCLUSION: The preliminary experience from our single center in China demonstrated that Hyper-CVAD/MTX-Ara-C, a dose-intensive regimen with much higher CR is superior to our previous regimens, even in poor-risk Ph-positive ALL, and highly aggressive lymphomas such as lymphoblastic and Burkitt's lymphoma, and refractory/relapsed ALL/lymphoma. Our data also showed that this regimen is less toxic and well tolerated in patients. Due to the aggressive supportive care, the expense with this regimen is more expensive than conventional chemotherapy. Long-term treatment benefits, such as disease-free survival rates and severe side effects need further investigation in a well-designed, multiple-center study in China with more eligible patients entering onto the study.

Therapeutic transfusions of granulocytes collected by simple bag method for children with cancer and neutropenic infections: results of a single‐centre pilot study

Granulocyte transfusion therapy (GTX) can be effective for life-threatening infections unresponsive to conventional antimicrobial therapies in severely neutropenic children with cancer. We developed a new granulocyte collection method, named the 'bag method', in which apheresis, hydroxyethyl starch (HES) or dexamethasone are not used. We undertook a pilot study to determine the feasibility and the safety of GTX collected by the bag method for children with cancer and life-threatening infections. A total of 25 GTX were administered to 13 patients (median age 3 years, range: 0.3-17; median weight 10.6 kg, range: 4.5-49.8) with neutropenia-related infections. Thirteen blood-relative donors received granulocyte colony-stimulating factor (G-CSF) (5-10 microg/kg), subcutaneously, 14 h before collection. Major end-points were granulocyte yields, post-transfusion absolute neutrophil counts (ANC) in patients, donor and patient safety, and clinical outcome on day 30. The median yield of ANC per 400 ml of processed whole blood was 6.2 x 10(9) (range: 2.5-15.0 x 10(9)). Patients received a mean of 6.4 +/- 0.8 x 10(8) granulocytes per kg of body weight per transfusion. The 1-h and 24-h post-transfusion ANC rose to 607 +/- 124/microl and 704 +/- 300/microl, respectively, from the baseline of 21/microl before the first GTX. Adverse reactions were observed in five of 13 donors (bone pain, headache, vasovagal reaction; all < or = grade 2) and in two of 25 transfusions of 13 patients (transient hypoxia; grade 3). Ten patients had favourable responses, and infection resolved in nine patients. The bag method without apheresis relieves the physical load of donors and enables patients with a low body weight to provide an adequate dose of granulocytes.

Nursing care of the granulocyte donor for pediatric stem cell transplant patients

Infection continues to be the leading cause of morbidity and mortality in patients with severe and sustained neutropenia defined as an Absolute Neutrophil Count of <500/uL. Cesaro et. al (2003) concludes that “granulocyte transfusion therapy is potentially useful when the severity of the infection and the host’s immunodeficiency make any other antimicrobial therapy ineffectual.” The Duke Pediatric Blood and Marrow Transplant program uses granulocyte transfusion therapy for persistently neutropenic patients with severe infections and for patients who must undergo a second bone marrow transplant. Donors are required to go through blood donor questionnaires and blood testing to ensure the safety of both the donor and the recipient per FDA donor regulations effective 5/25/2005. When possible, a CMV negative donor is selected. Once a donor is selected (usually a relative of the patient) a double lumen pheresis catheter is placed for the duration of the donation. The donor is primed with G-CSF 10 mcg/kg twice weekly. Granulocytes are harvested by pheresis 14 to 16 hours post G-CSF dosing, irradiated, divided into 3 doses, and administered IV to the patient daily × 3With 2 pheresis per week, the recipient receives granulocytes 6/7 days. Nurse coordinators and staff nurses on the inpatient transplant unit collaborate to provide the majority of care and education to the granulocyte donors in order to provide consistency of care for families. The transplant patient’s nurse is responsible for monitoring and maintaining the pheresis catheter and for administering G-CSF by injection to the donor. The nurse must also educate the donor about possible side effects of G-CSF therapy and granulocyte donation as well as ways to prevent these side effects. The purpose of this poster will be to (1) educate the learner about the nurse’s responsibility in caring for the granulocyte donor; (2) describe the standard operating procedure for daily care of the pheresis catheter; (3) describe the standards for dosing, frequency, and administration of GCSF; (4) provide education about the possible side effects of granulocyte donation and how they may be prevented; (5) describe the potential emotional implications for the donor. Infection continues to be the leading cause of morbidity and mortality in patients with severe and sustained neutropenia defined as an Absolute Neutrophil Count of <500/uL. Cesaro et. al (2003) concludes that “granulocyte transfusion therapy is potentially useful when the severity of the infection and the host’s immunodeficiency make any other antimicrobial therapy ineffectual.” The Duke Pediatric Blood and Marrow Transplant program uses granulocyte transfusion therapy for persistently neutropenic patients with severe infections and for patients who must undergo a second bone marrow transplant. Donors are required to go through blood donor questionnaires and blood testing to ensure the safety of both the donor and the recipient per FDA donor regulations effective 5/25/2005. When possible, a CMV negative donor is selected. Once a donor is selected (usually a relative of the patient) a double lumen pheresis catheter is placed for the duration of the donation. The donor is primed with G-CSF 10 mcg/kg twice weekly. Granulocytes are harvested by pheresis 14 to 16 hours post G-CSF dosing, irradiated, divided into 3 doses, and administered IV to the patient daily × 3With 2 pheresis per week, the recipient receives granulocytes 6/7 days. Nurse coordinators and staff nurses on the inpatient transplant unit collaborate to provide the majority of care and education to the granulocyte donors in order to provide consistency of care for families. The transplant patient’s nurse is responsible for monitoring and maintaining the pheresis catheter and for administering G-CSF by injection to the donor. The nurse must also educate the donor about possible side effects of G-CSF therapy and granulocyte donation as well as ways to prevent these side effects. The purpose of this poster will be to (1) educate the learner about the nurse’s responsibility in caring for the granulocyte donor; (2) describe the standard operating procedure for daily care of the pheresis catheter; (3) describe the standards for dosing, frequency, and administration of GCSF; (4) provide education about the possible side effects of granulocyte donation and how they may be prevented; (5) describe the potential emotional implications for the donor.

Granulocyte transfusion

Granulocyte transfusions have been used for more than four decades. Several issues have complicated the analysis of previous studies, including the utilization of improved antimicrobials, the effects of recipient alloimmunization and variable cell dose. The use of granulocyte colony-stimulating factor for donor stimulation has revived interest in granulocyte transfusion. The aim of this review is to evaluate the most recent studies in granulocyte transfusion therapy and their clinical applicability. Granulocyte colony-stimulating factor use has increased the granulocyte yield by approximately fourfold. Multiple recent studies have shown that granulocyte transfusions can be helpful in controlling severe infections progressing despite the use of appropriate antibiotics, with a response rate of 40-80% with variability in results depending on patient characteristics. This benefit is limited to a small patient population as the incidence of prolonged reversible neutropenia is relatively small. Severe side effects have been rare in those studies. Granulocyte transfusions are beneficial in neutropenic patients with severe uncontrolled infection. The underlying disease process is the major determinant of outcome in these patients. Because granulocyte transfusions are not commonly used, centers are not currently able to provide transfusions in a timely fashion. Nonalloimmunized patients can receive cells from nonmatched ABO compatible donors, while alloimmunized patients should receive granulocytes from either HLA-matched donors or donors selected by leukoagglutination or lymphocytotoxicity crossmatching. Further studies are needed to clarify the optimal starting time and frequency of transfusions, and the best method for identifying donor-recipient compatibility.

Granulocyte transfusion therapy: it's time for an answer

Granulocyte transfusion therapy: it's time for an answer

Effective storage of granulocytes collected by centrifugation leukapheresis from donors stimulated with granulocyte–colony‐stimulating factor

Donor stimulation with granulocyte-colony-stimulating factor (G-CSF) has increased the number of neutrophils (PMNs) that can be collected for granulocyte transfusion therapy. Clinical utility, however, has been limited by the inability to store functional PMNs ex vivo. This study was conducted to determine whether granulocyte products from G-CSF-stimulated donors could be effectively stored at reduced temperature (22 degrees C vs. 10 degrees C) with maintenance of functional properties in vitro and in vivo. Nine normal subjects received G-CSF (600 microg subcutaneously) 12 hours before centrifugation leukapheresis. Granulocyte products were divided and stored for 24 and 48 hours under four conditions: 1) 22 degrees C; 2) 22 degrees C, with supplemental G-CSF (100 ng/mL); 3) 10 degrees C; and 4) 10 degrees C, with supplemental G-CSF. Functional PMN activity during ex vivo storage was assessed in vitro and in vivo by the skin-window technique for granulocytes stored at 10 degrees C for 24 hours. Surface expression of CD11b/CD18, CD14, CD16, CD32, and CD64 was maintained during 48-hour storage at reduced temperature. Inducible respiratory burst activity, bactericidal activity, and fungicidal activity were preserved during storage for 48-hour storage at 10 degrees C. Proinflammatory cytokine production was decreased in product stored at 10 degrees C. Supplemental G-CSF ex vivo did not substantially improve functional activity during storage. After storage at 10 degrees C for 24 hours, in vitro chemotactic potential was maintained, and transfused granulocytes retained capacity to circulate and migrate appropriately in vivo. Granulocyte product collected by centrifugation leukapheresis from G-CSF-stimulated donors can be effectively stored at subphysiologic temperature for 24 hours with preservation of functional activity. Storage at 10 degrees C appears to be slightly superior to storage at 22 degrees C.

Granulocyte Transfusions in Children With Chronic Granulomatous Disease and Invasive Aspergillosis

The transfusion of granulocytes to restore host defenses in severely granulocytopenic patients or in patients with defective granulocyte functions has been studied for more than 60 years. However, inadequate dosage of cells and inconsistent efficacy has limited the usage of these transfusions. Recently, the use of mobilizing agents such as granulocyte colony stimulating factors and dexamethasone has renewed interest in these treatment modalities. The present study is conducted to determine an appropriate method of enriched granulocyte collection with Fresenius AS.TEC.204 cell separator (Fresenius, Bad Homburg, Germany) and to evaluate the preliminary clinical results of granulocyte transfusion therapy in patients with chronic granulomatous disease and invasive Aspergillosis in parallel with in vitro granulocyte function. Three patients who have been treated for chronic granulomatous disease and invasive Aspergillosis received a total of 20 granulocyte transfusions. To mobilize granulocytes, healthy donors were given 450 microg of granulocyte colony-stimulating factor (G-CSF) subcutaneously and 8 mg of dexamethasone orally approximately 12 h before collection. Five microg/kg/day of G-CSF was also subcutaneously administered prior to granulocyte transfusions. The first patient received 4; the second, 14 and the third, 2 transfusions. The granulocyte count given to these patients ranged between 0.4 and 3.0 x 10(9)/kg. Most transfusions were well tolerated. The nitroblue tetrazolium (NBT) tests that were done 16-24 h after the transfusion showed 14-46% dye reduction. Two of the three patients survived the infection. Granulocyte transfusions from G-CSF and dexamethasone stimulated donors could be a choice of treatment in chronic granulomatous disease patients, especially with disseminated invasive Aspergillosis.

Impact of high‐dose granulocyte transfusions in patients with cancer with candidemia

The efficacy and feasibility of donor granulocyte transfusion therapy (GTX) have changed considerably over the past four decades. The authors sought to determine the impact of high-dose (approximately 5.5 x 10(10) cells) GTX in patients with candidemia. The authors' case-control retrospective analysis comprised 491 consecutive patients treated at The University of Texas M. D. Anderson Cancer Center (Houston,TX) from 1993 to 2000. The cohort included 29 patients with Candida species bloodstream infection who had received GTX and 462 who had not. Both groups were comparable in age, gender, APACHE II score, recent chemotherapy received, broad-spectrum antibiotics, systemic corticosteroids, radiotherapy, intravascular catheter, and concordant antifungal therapy (P > or = 0.1). The patients who received GTX compared with those who did not had a higher incidence of underlying leukemia (86% vs. 29%, P <0.001), persistent neutropenia (59% vs. 18%, P <0.001), non-Candida albicans candidemia (Candida glabrata, 35%; Candida krusei, 31%: 90% vs. 67%, P=0.01), and breakthrough invasive mycosis (62% vs. 23%, P <0.001). Neutropenia was more prolonged in patients who received GTX (28 vs. 10 days, P <0.001). Also, more of the patients who received GTX had received hematopoietic stem cell transplantations (28% vs. 13%, P = 0.03), exposure (within 4 weeks) to antifungals (79% vs. 38%, P <0.001), and stays in critical care units (62% vs. 40%, P=0.02). The overall attributable mortality rate for 25 evaluable recipients of GTX was 48% (n=12), compared with 45% (n=115) of 254 evaluable patients in the control group (P=0.5). Of the 158 patients with leukemia, 25 (16%) had received GTX. In patients with leukemia, more of those who had received GTX experienced disseminated candidiasis (44% vs. 26%; P <0.07) and persistent neutropenia (68% vs. 43%, P <0.02), had candidemia that was more prolonged (> 72 hours, P <0.02), and had more stays in critical care units (68% vs. 44%, P <0.03). On the bases of a reduced multivariate model, a significantly increased risk of death was found for patients with hematopoietic stem cell transplantation (odds ratio [OR]=2.51; 95% confidence interval [95% CI], 0.99-6.31; P <0.05), for patients with persistent neutropenia (OR=4.57; 95% CI, 1.99-10.47; P <0.0003), and for patients with leukemia who also had prolonged candidemia (OR=3.59; 95% CI, 1.61-7.98; P <0.002), disseminated candidiasis (OR=5.19; 95% CI, 2.17-12.42; P <0.0002), or non-C. albicans candidemia (OR=5.02; 95% CI, 1.07-23.64; P <0.04). In patients with leukemia, death was attributable to candidemia in 50% of the GTX recipients, compared with 59% of the non-GTX patients who had received antifungal therapy alone (P=0.4). Despite the presence of multiple predictors of increased mortality, high-dose GTX therapy in these high-risk patients with cancer was associated with better than expected survival rates.

Clinical efficacy of granulocyte transfusion in patients with severe neutropenic infections

Granulocyte transfusions have been advocated for the treatment of severe, progressive infections in neutropenic patients who fail to respond to antimicrobial agents and recombinant hematopoietic growth factors. We conducted the current study to evaluate the safety and efficacy of granulocyte transfusion therapy in patients with neutropenia-related infections. To mobilize granulocytes, healthy normal donors were stimulated with G-CSF 300ug SC dexamethasone 8mg po prior to leukapheresis. Before granulocyte transfusion, recipients were given hydrocortisone and pheniramine. Twenty-nine patients with severe neutropenia-related infections unresponsive to appropriate antimicrobial agents received a total of 36 sessions of granulocyte transfusions (total transfusion number = 148). Among these, 17 sessions were done with preirradiated leukapheresis products. 22 of 36 sessions (61.1%) responded with resolution of neutropenic fever, and side effects, mostly urticaria, were noticed in 13 sessions (36.1%), including 3 cases of peri-transfusion mortality. ANC increment(1495 vs 526), mean duration of antibiotic use (20.8 vs 34.3) and neutropenia (24.0 vs 35.9) were significantly different between responders and non-responders (p = 0.042, 0.058 and 0.043 respectively). Number of transfusion, granulocyte dose, age and irradiation were not significantly different between the 2 groups. We conclude that granulocyte transfusion therapy was useful and safe when the severity of infection and the host’s immunodeficiency make any other antimicrobial treatment ineffectual. TableTreatment OutcomeResponderNon-responderP ValueNo. of session22 (61.1%)14 (38.9%)Mean prior duration ofAntibiotics20.8 ± 12.434.4 ± 26.1P = 0.043Neutropenia24.0 ± 12.435.9 ± 24.2P = 0.058G-CSF11.6 ± 7.918.5 ± 12.9n.s.Irradiation (+/−)12/105/9n.s.No. of transfusion (mean)3.8 ± 1.44.6 ± 6.3n.s.ANC increment (mean)1495 ± 1564526 ± 646P = 0.042Granulocyte dose (1010 cell/kg)5.4 ± 1.66.0 ± 2.9n.s.n.s., not significant.

Clinical applications of granulocyte colony-stimulating factor: an update and summary.

The discovery of granulocyte colony-stimulating factor (G-CSF) and its potential to regulate neutrophil production and function in the inflammatory process has opened an exciting new era for the supportive care of patients with hematological and malignant diseases. Extensive experience has been gained worldwide with G-CSF therapy, and G-CSF is widely employed clinically, primarily because the safety profile appears to be fairly innocuous. A broad consensus has emerged regarding the clinical utility of G-CSF in neutropenic conditions due to chemotherapy. Furthermore, much interest has focused on the use of G-CSF to mobilize CD34+ hematopoietic stem cells from the marrow to the peripheral blood for use in hematopoietic transplantation. The promising results with G-CSF have promoted further studies, e.g., in immunocompetent patients or in granulocyte transfusion therapy. Here, we review the potential clinical role of G-CSF and describe its future perspectives.

Granulocyte transfusion therapy: update on potential clinical applications.

The clinical usefulness of granulocyte transfusions for treatment or prevention of life-threatening bacterial and fungal infections remains controversial. Clinical benefit has long been limited by insufficient donor stimulation regimens and suboptimal leukapheresis techniques. Methodologic progress, in particular mobilization of neutrophils in healthy donors by administration of G-CSF, has significantly enhanced leukapheresis yields. A newly published study indicates that unrelated community donors can be effectively and safely used as an alternative to related family donors. Furthermore, several recent studies suggest that it may be possible to store granulocyte concentrates for 24 to 48 hours with adequate preservation of neutrophil function. This review summarizes the current role of granulocyte transfusion therapy in infectious diseases and highlights important recent advances.

Recent developments in granulocyte transfusion therapy

Neutropenia and its associated bacterial and fungal infections are major limiting factors in the treatment of patients with aggressive chemotherapy regimens and hematopoietic stem cell transplantation. Although transfusion support with functional neutrophils is a logical approach to this clinical problem, such therapy has fallen out of favor over the last 10–15 years, at least in part because clinicians have not found the results impressive. This apparent lack of efficacy has been largely attributed to the relatively low doses of granulocytes obtainable by conventional collection techniques. An additional problem is that granulocytes obtained for transfusion rapidly undergo apoptosis, resulting in an inability to store the cells and limited survival in the recipient.

Current status of granulocyte (neutrophil) transfusion therapy for infectious diseases.

The transfusion of neutrophils, or granulocyte transfusion therapy, has long been considered as a logical approach to the treatment of severe bacterial and fungal infections in patients with prolonged neutropenia or intrinsic defects in neutrophil function. However, despite numerous clinical trials, the efficacy and safety of granulocyte transfusion therapy remain controversial. Efficacy has been compromised largely by the inability to transfuse sufficient quantities of functionally active neutrophils to patients. The recent use of recombinant granulocyte colony-stimulating factor (G-CSF) to mobilize neutrophils in donors before centrifugation leukapheresis has rekindled interest in the potential clinical applications of granulocyte transfusion therapy. This review focuses on the use of G-CSF for donor stimulation and summarizes the current status of granulocyte transfusion therapy for treatment of infectious diseases.