Granulocyte Transfusions Research Articles

Functional State of Steroid- versus G-CSF-Mobilized Granulocytes: Considerations about the Storage of Granulocyte Concentrates for Neutropenic Patients

Background: High yields of granulocytes mobilized with G-CSF sparked new enthusiasm for transfusion in patients with severe neutropenia. The in vitro and in vivo function of granulocytes prior to and following storage was investigated. Material and Methods: Granulocyte concentrates collected from 10 donors receiving prednisone or G-CSF before leukapheresis were evaluated over 48 h of storage for differential blood count, pH, electrolytes, viability, phagocytosis, oxidative burst, and secretion of IL-1β, IL-6, IL-8 and TNFα. The follow-up of 5 transfused patients was monitored by blood counts, Creactive protein, and clinical outcome. Results: Compared to fresh granulocyte concentrates, no major changes in viability, phagocytosis, oxidative burst, and cytokine profile were seen in granulocytes stored overnight. In contrast, significant differences were observed after 48 h of storage. Steroid- and G-CSF-mobilized granulocytes showed no major differences in the first 24 h, except for changes in pH and IL-8 secretion. Transfusions of G-CSF-mobilized granulocytes stored overnight were well tolerated without additional adverse effects. Conclusion: G-CSF increased the yield of leukocytes 3.5-fold without enhancing side effects after granulocyte transfusions. The in vitro and in vivo function of G-CSF-mobilized granulocytes remained stable during storage for 24 h. Thus, the therapeutic use of G-CSF-mobilized granulocyte concentrates is facilitated by the possibility of overnight storage.

Molecular nature of antigens implicated in immune neutropenias.

Granulocyte (neutrophil) antibodies can cause autoimmune neutropenia, drug-induced neutropenia, immune neutropenia after bone marrow transplantation, neonatal immune neutropenia, refractoriness to granulocyte transfusions as well as febrile and pulmonary transfusion reactions. In the last decade, considerable progress has been made in the characterization of the implicated antigens. In 1998, the Granulocyte Antigen Working Party of the ISBT introduced a new nomenclature for human neutrophil alloantigens (HNA), which is based on the antigens' glycoprotein location. In the HNA nomenclature the immunogenic (glyco-) proteins are indicated by arabic numbers followed by a letter of the alphabet which identify the (glyco-) proteins' polymorphisms, i.e. the specific antigens. Currently, seven HNA antigens are assigned to five systems. The HNA-1a, HNA-lb and HNA-1c antigens, the former NA1, NA2, and SH antigens, have been identified as polymorphic forms of the neutrophil Fc gamma receptor IIIb (CD16b) encoded by three alleles. Recently, we could elucidate the primary structure of the HNA-2a antigen, the former NB1. We could identify the HNA-2a-bearing glycoprotein as a novel member of the Ly-6/uPAR superfamily which has been clustered meanwhile as CD177. The HNA-3a antigen, the former 5b, is located on a 70-95 kDa glycoprotein. However, its molecular basis is still unknown. Finally, the HNA-4a and HNA-5a antigens, the former MART and OND, were found to be caused by single nucleotide mutations in the alphaM (CD11b) and alphaL (CD11a) subunits of the leucocyte adhesion molecules (beta2 integrins). The glycoproteins CD11b, CD16b, and CD177 have been found to be also frequent targets of autoantibodies - approximately 30% of neutrophil autoantibodies are directed against CD16b. Characterization of granulocyte antigens have expanded our diagnostic tools by the introduction of genotyping techniques and immunoassays for antibody identification. In addition, it allowed new insights in the pathophysiology of immune neutropenias and transfusion reactions. Ongoing studies will further improve the prevention and management of granulocyte antibody-mediated diseases.

Prophylaxis and treatment of patients with aspergillosis: an overview, including the Royal Melbourne Hospital experience.

Patients receiving allogeneic bone marrow transplants are at risk of developing Aspergillus infections. The pre-transplant risk factors for the development of invasive disease include prolonged neutropenia, colonization with Aspergillus sp. or a prior history of fungal infection. Post-transplant risk factors include severe graft-versus-host disease with concomitant high-dose corticosteroid therapy, and colonization with Aspergillus sp. The antifungal prophylaxis of selected high-risk pre-transplant patients at the Royal Melbourne Hospital includes granulocyte transfusions and AmBisome. In high-risk patients post-engraftment, prophylaxis consists of oral itraconazole, or if it cannot be tolerated, AmBisome. Antifungal prophylaxis is discontinued upon resolution of neutropenia, when prednisolone dose falls below 10 mg/day or when Aspergillus colonization disappears. Following this regimen, there has been only one death due to fungal infection in over 80 consecutive allograft patients. This patient was infected with an amphotericin B-resistant organism.

Granulocyte transfusion: a review

Neutrophils are the body's main defence against invasion by bacteria and fungi and, below a level of 1 x 10(9)/l, there is a direct relationship between their circulating number and the risk of systemic infection. Despite advances in supportive care, such as improved broad-spectrum antibiotics and the haemopoietic growth factors, neutropenia following myelosuppressive chemotherapy for malignant disease remains the most important cause of treatment-related morbidity and mortality and its most important dose-limiting toxicity. Although there is clear theoretical, experimental and anecdotal clinical evidence supporting the use of transfused granulocytes to prevent and treat infection in neutropenia, early attempts at exploiting this clinically were unsuccessful, mainly because of difficulties in collecting a sufficient number of cells. Improvements in the technology of collection, including the use of red cell sedimenting agents, glucocorticoids and, more recently, granulocyte-colony-stimulating factor, now allow granulocyte doses within the therapeutic range to be routinely collected. Preliminary evidence suggests clinical efficacy. However, well-designed trials with clinically relevant end-points will be required before granulocyte transfusion can become part of routine clinical practice.

Severe persistent neuropsychiatric toxicity after a human leucocyte antigen‐non‐identical peripheral blood stem cell transplantation (total body irradiation, etoposide, thiotepa) and interleukin 2‐based experimental therapy for poor prognosis relapse acute lymphoblastic leukaemia

Severe persistent neuropsychiatric toxicity after a human leucocyte antigen‐non‐identical peripheral blood stem cell transplantation (total body irradiation, etoposide, thiotepa) and interleukin 2‐based experimental therapy for poor prognosis relapse acute lymphoblastic leukaemia

Use of blood and blood components and derivatives in newborn infants

OBJECTIVE: To describe the current rationale for the transfusion of blood, blood components, and plasma derivatives in term and preterm infants. SOURCES: Selection of relevant medical articles published within the last ten years. SUMMARY OF THE FINDINGS: Peculiar characteristics and special care concerning exchange transfusion, transfusion of red blood cells, platelets, granulocytes, and fresh frozen plasma were described. The recommendations for the use of hematopoietic growth factors, and plasma derivatives such as fibronectin, immunoglobulins, and albumin were also evaluated. CONCLUSIONS: The authors comment on the recommendations and contraindication of blood transfusions, and warn against the limitations and hazards involved.

Granulocyte Transfusion in the Management of Fulminant Invasive Fungal Rhinosinusitis

Usually, fulminant, invasive fungal rhinosinusitis is observed in the immunocompromised patient and is associated with significant morbidty, and mortality. A high index of suspicion and early diagnosis is imperative for optimizing outcome. Mainstays of treatment include antifungal agents and radical resection of necrotic tissue. Reversal of the underlying medical condition, when possible, is a critical part of the management. In the neutropenic population, granulocyte transfusion may represent an adjunct to current therapy. We provide the first report of a case of invasive fungal rhinosinusitis in which this intervention was used.

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.

Older patients with high-risk fungal infections can be successfully allografted using non-myeloablative conditioning in combination with intensified supportive care regimens.

Leukaemic patients with advanced disease and severe fungal infections as well as older patients with substantial co-morbidity are usually excluded from conventional allotransplantation because of increased morbidity and mortality. We approached allogeneic transplantation in four patients with a median age of 62 years (one chronic myeloid leukaemia in blast crisis, one high-risk acute myeloid leukaemia (AML) in first complete remission (CR1), one AML in 2nd relapse, one AML in CR2 with pre-existing fungal lung infections (two aspergillus, two mucor) and additional co-morbidity (diabetes n = 2, aortic aneurysm n = 1, arterial sclerosis n = 2) by combining non-myeloablative conditioning with an intensified supportive care regimen, including amphotericin B and 4-12 (median 9) prophylactic granulocyte transfusions from granulocyte colony-stimulating factor (G-CSF)-stimulated volunteer donors. G-CSF was also given to patients until neutrophil recovery. All four patients recovered to a neutrophil count of 0.5 x 109/l after a median of 11.5 d (range 11-13 d). Prophylactic granulocyte transfusions also reduced the need for platelet transfusions and minimized mucositis. All patients were discharged at a median of 25 d (range 18-59 d) and are alive and well after a median follow-up of > 390 d (range 336-417 d) without evidence of leukaemia. Regression of the fungal lesions was documented in three patients, with a slight progression detected by computerized tomography scan of the chest in one patient. We conclude that pulmonary fungal infections are not a contraindication for allogeneic stem cell transplantation, if non-myeloablative conditioning regimens are used in combination with granulocyte transfusions, intravenous amphotericin B and G-CSF.

The future: are we really being scientific?

Scientific hypotheses abound in the current literature. An explosion in laboratory and molecular assays is providing technology to explore new treatment hypotheses, resolve residual past supportive care (SC) issues and to create innovative trial designs for future transplant/immunotherapy/gene transduction therapies. Systematic reviews of patient treatment to establish `evidence-based' outcomes are emerging as important tools that may challenge the quantity and quality of evidence supporting the treatments given. Given the current intense pressure to reduce costs of medical care, perhaps the question really is “How can we integrate basic-clinical science and technological innovations for cell or plasma molecule collections, ex vivo cell manipulation or graft engineering as well as cytokines for promoting (in vitro or in vivo) proliferation/differentiation of cells or molecules of clinical interest to create substantive SC therapies with measurable outcomes?” Patient needs created indications for SC which throughout the history of apheresis have involved replacement infusions of multiple critical blood factors±removal±exchange of pathologic components, yet objective clinical response to SC is largely limited, to date, to hematopoietic stem cell transplant (HSCT). SC protocols need trial designs that include hypotheses, patient eligibility criteria, treatment procedures, quantitative criteria for response, and biostatistics- variables fundamental to all research protocols. Multi-institutional collaborative trials may also be required to conclude unresolved SC issues of the past – quantitative correlations between post transfusion (Tx) platelet (PLT) counts and hemostasis and the role of granulocyte (PMN) transfusions in disseminated-invasive fungal infections. Automated/quantitative in vitro bleeding time technology may demonstrate post Tx in-vivo hemostasis. Patient data are crucial to demonstrate whether the empirical decision to lower the `trigger point' for PLT transfusion has resulted in a zero hemorrhagic (H+) mortality rate. If fatal thrombocytopenic H+ exists, multivariate analyses to identify risk factors must be done and new replacement strategies implemented. Demonstration of sustained immunologic/infectious benefits of leukoreduced PLT requires long term follow up of patients whose diseases span several years and repetitive PLT Tx support. Polymerase chain reaction-based assays (PCR) are emerging as powerful tools with the potential to (1) detect and define molecular remission/relapse, (2) quantitate the magnitude of residual disease, perhaps identifying a need for multiple HSCT, (3) purge tumor cells from HSC grafts, and (4) identify fungal DNA in disseminated fungal infections in patients who might benefit from PMN Tx. A plethora of monoclonal antibodies and secondary processing for apheresis products are, and will be, available to collect or remove any subset of cells of interest from blood, bone marrow, cord blood to facilitate clinical therapies. SC therapies have been thought of historically as “bridging” therapies until some primary therapy could be administered. It seems clear that infusions of progenitor, immune, or genetically transduced cells will become curative therapy (CT) for some diseases. Documentation of the clinical efficacy of these therapies will require the combined best scientific efforts of an interdisciplinary multiple modality group of investigators.

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.

Serial granulocytapheresisunder daily administration of rHuG-CSF: effects on peripheral blood counts, collection efficiency, and yield.

An option for treatment of severe infections in neutropenic patients is the transfusion of granulocytes from donors stimulated with rHuG-CSF. The schedule of rHuG-CSF-stimulated granulocyte donations and the quality of the components remain controversial. This study was done with the intention of ensuring daily granulocyte support with therapeutic cell numbers, while keeping the patients' allogeneic exposure as low as possible. Granulocyte collection with multiple consecutive leukapheresis procedures under daily rHuG-CSF administration and with hydroxyethyl starch as sedimenting agent were prospectively studied. Complete blood counts of the donors, collection yield, and efficiency were analyzed. Products (n = 259) from 76 donors were examined. The median peripheral blood WBC and neutrophil counts were 28.1 g per L and 24.1 g per L, respectively, and they were significantly higher on Day 5 of collections than on Days 1 to 3. Platelet counts and Hb levels decreased steadily. Collection yields increased over time from 4.9 to 6.7 x 10(10) neutrophils. Side effects of cytokines and aphereses did not exceed World Health Organization grade II status. Repetitive daily rHuG-CSF administration-even under daily leukapheresis procedures-results in a continuing increase in WBC and neutrophil levels and thus leads to increased collection yields. Side effects are tolerable, although Hb and platelet levels should be monitored closely.

Cytomegalovirus pneumonia in adults with leukemia: an emerging problem.

Cytomegalovirus (CMV) pneumonia is reportedly unusual among adults with leukemia who have not undergone transplantation. To assess the frequency of CMV pneumonia and its outcome during the present time, we reviewed the experience of 2136 hospitalized adults with leukemia. Sixty-one patients (2.9%) had CMV pneumonia diagnosed. The frequency doubled from 1.4% in 1992--1994 to 2.8% in 1995--1997 (P<.05). Fifty-four patients (89%) had received treatment with an immunosuppressive chemotherapeutic regimen that contained fludarabine (n=37), high-dose cytoxan (n=17), or both (n=10), and 15 patients (25%) had received granulocyte transfusions that were stimulated with hematopoietic growth factors from unscreened donors. The overall CMV pneumonia--associated mortality rate was 57%. Among autopsied patients who had leukemia, the frequency of CMV pneumonia increased from 0%, 2.3%, and 0% in 1992, 1993, and 1994, respectively, to 4.6%, 6.5%, and 16% in 1995, 1996, and 1997, respectively (P<.05). CMV has emerged as an important cause of life-threatening pneumonia in adults with leukemia who have received potent immunosuppressive therapies and stimulated granulocyte transfusions from unscreened donors.

Intravenous Rh immune globulin prevents alloimmunization in D– granulocyte recipients but obscures the detection of an alloanti-K

Abstract Rh immune globulin (RhIG) has been used to prevent alloimmunization in D– recipients of apheresis platelet transfusions from D+ donors that may contain up to 5 mL of D+ red blood cells (RBCs). Granulocyte concentrates contain approximately 30 mL of RBCs and it has been necessary to give D– recipients granulocyte transfusions from D+ donors. Intravenous RhIG has not yet been demonstrated to be effective in preventing D alloimmunization with granulocyte transfusions. Four D– recipients received multiple D+ granulocyte transfusions from D+ donors and multiple injections of intravenous RhIG at a standard dose of 600 μg for each D+ transfusion. Two D– males with chronic granulomatous disease were given 32 and 13 daily granulocyte transfusions, 18 and 2 of which, respectively, were D+. After the first dose of intravenous RhIG, both patients exhibited circulating anti-D that was undetectable 3 to 4 years later. Two patients with severe aplastic anemia were given 5 and 14 granulocyte transfusions, 4 and 7 of which, respectively, were D+. Both patients died before the effectiveness of RhIG could be assessed. In one of these patients the indirect and direct antiglobulin tests became positive after the first dose of intravenous RhIG, which required that subsequent granulocyte transfusions from D+ donors be crossmatched by immediate spin (IS) testing only. A delayed hemolytic reaction attributed to alloanti-K occurred after granulocytes from a K+ donor were given to this patient. These results suggest that intravenous RhIG can be used to prevent alloimmunization to D in D– patients receiving large quantities of RBCs from D+ granulocyte transfusions. However, anti-D and other passive antibodies from RhIG prohibit the use of the antiglobulin crossmatch with antigenpositive granulocyte donor samples. It may be important to frequently collect new samples to screen for newly formed alloantibodies when IS crossmatches are used in place of the antiglobulin crossmatch. Immunohematology 2001; 17:37–41.

Diagnosis and treatment of invasive pulmonary aspergillosis in neutropenic patients.

Invasive pulmonary aspergillosis is a major cause of morbidity and mortality in neutropenic patients. Microbiological and serological tests are of limited value. The diagnosis should be considered in neutropenic patients with fever not responding to antibiotics, and typical findings on thoracic computed tomography scan. Whenever possible, diagnosis should be confirmed by tissue examination. Newer techniques, such as polymerase chain reaction may change the current diagnostic approach. Therapeutic strategies consist of prophylaxis in risk groups and the early application of antifungal agents in suspected or probable disease. Amphotericin B as desoxycholate or lipid formulation is the current standard medication in invasive infection, although it has major side effects. Its role is challenged by the new azole derivates, such as itraconazole and voriconazole, and the new echinocandins. Additional therapies with cytokines, such as granulocyte macrophage colony stimulating factor and interferon-gamma, and with granulocyte transfusions are under evaluation. In selected cases lung resection is of proven diagnostic and therapeutic value. This paper analyses the current understanding of the pathogenesis and epidemiology of invasive aspergillosis and reviews the actual diagnostic and therapeutic strategies for invasive pulmonary aspergillosis in neutropenic patients.

Successful Granulocyte Transfusions for Cervical Phlegmone after Chemotherapy with Acute Myeloblastic Leukemia

Successful Granulocyte Transfusions for Cervical Phlegmone after Chemotherapy with Acute Myeloblastic Leukemia

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.

Transfusion Therapy: Clinical Principles and Practice.

Medical Writings: Book Notes3 October 2000Transfusion Therapy: Clinical Principles and PracticeJanice P. Dutcher, MDJanice P. Dutcher, MDOur Lady of Mercy Medical Center, New York Medical College, Bronx, New York. (Dutcher)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-133-7-200010030-00032 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Mintz PD, ed. 481 pages. Bethesda, MD: American Assoc of Blood Banks Pr; 1999. $139.00. ISBN 1563950995. Order phone 301-215-6499.Field of medicine: Hematology/oncology and transfusion medicine.Format: Hardcover book.Audience: Hematologists, oncologists, surgeons, obstetricians, and general medicine practitioners.Purpose: To provide a broad view of the clinical practice of transfusion medicine, with emphasis on clinical applications and specific clinical problems.Content: The initial sections discuss cellular blood products and the clinical problems that dictate their use, including red cell transfusion for autoimmune disease and hemoglobinopathy. Platelet and granulocyte transfusion therapy are also covered. A detailed section describes various aspects ... Author, Article, and Disclosure InformationAffiliations: Our Lady of Mercy Medical Center, New York Medical College, Bronx, New York. (Dutcher) PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byHemostatic techniques to reduce blood transfusion after primary TKA: a meta-analysis and systematic review 3 October 2000Volume 133, Issue 7Page: 572KeywordsBlood banksBlood cellsBlood transfusionHematology and oncologyHemostasisPlateletsSoftware toolsSurgeonsTransfusion medicineTransplantation ePublished: 3 October 2000 Issue Published: 3 October 2000 Copyright & PermissionsCopyright © 2000 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...

Antibacterial prophylaxis

Bacterial infections remain an important cause of morbidity and mortality in neutropenic patients. A number of prophylactic strategies have been used in order to reduce the risk of infection during severe granulocytopenia. The measures that have been investigated include isolation of the patient, granulocyte transfusion, active or passive immunisation, acceleration of granulocyte recovery and prophylactic use of antibacterial agents. However, many of these approaches have fallen out of favour, mostly because of concerns about the long lasting efficacy. This paper focuses on the available prophylactic strategies, with emphasis on the use of antibacterial agents.

Consistent Approaches to Procedures and Practices in Neonatal Hematology

Neutropenia is a relatively frequent finding in the neonatal intensive care unit, particularly in very low birth weight neonates during the first week of life.Healthy term and preterm neonates have blood neutrophil counts within the same basic range as adults, but their neutrophil function, and their neutrophil kinetics during infection, differ considerably from those of adults. Neutrophil function of neonates, particularly preterm neonates, is less robust than that of adults and might also contribute to the increase in propensity to infection.In premature infants, early-onset neutropenia is correlated with sepsis, maternal hypertension, intrauterine growth restriction, severe asphyxia, and periventricular haemorrhage, and might be associated with an increase in the incidence of early-onset sepsis, nosocomial infection, and Candida colonisation.Some varieties of neutropenia in the NICU are very common and others are extremely rare. The most common causes of neutropenia in the NICU have an underlying cause that is often evident, and require little diagnostic evaluation. Unlike, persistent neutropenia should prompt evaluation even if it is of moderate severity. The laboratory tests to consider are those that provide a specific diagnosis. The first tests that should be ordered are a blood film, a complete blood count on the mother, and, if her blood neutrophil concentration is normal, maternal neutrophil antigen typing and an anti-neutrophil antibody screen. A bone marrow biopsy can be useful in cases with prolonged, unusual, or refractory neutropenia.Various treatments have been proposed as means of enhancing neutrophil production and function in preterm infants. Both recombinant granulocyte stimulating factor and recombinant granulocyte macrophage-colony-stimulating factor have been tried with variable success. Intravenous immunoglobulin, corticosteroids, granulocyte transfusions, and gamma interferon did not show a clear adequate beneficial role for the therapy of neonatal neutropenia.