Granulocyte Transfusions Research Articles

Empiric therapy of febrile granulocytopenic patients

Antibiotic therapy in granulocytopenic cancer patients, the risk factors predisposing these patients to infection, and the signs, symptoms and types of infections occurring in these patients are reviewed. The four most commonly isolated organism at most cancer treatment centers are Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa and Staphylococcus aureus. Early antimicrobial therapy with broad-spectrum antibiotics before culture results are known produces cure rates of approximately 70%, regardless of the combination used. The most important predictor of response to any antibacterial regimen is a rise in the absolute granulocyte count. The current recommended fever regimen would be carbenicillin (or ticarcillin) with an aminoglycoside. The choice of an aminoglycoside depends on the prevailing organism sensitivities at a particular institution; in many cases, gentamicin sulfate is suitable. Addition of a cephalosporin to the two-drug regimen offers little increase in cure rates, except whem aminoglycoside-resistant Enterobacteriaceae are prevalent. Because of nephrotoxicity produced with combinations of cephalothin sodium and the aminoglycosides, cefazolin sodium would be the current cephalosporin of choice. An alternate third drug to be considered is co-trimoxazole, a broad-spectrum antimicrobial not yet commercially available in parenteral form. In the absence of a clinical response to appropriate antimicrobial therapy in documented infections, granulocyte transfusions may be indicated.

Lack of Predictive Value of Antileukocyte Antibody Screening in Granulocyte Transfusion Therapy

To clarify the relationship between recipient presensitization and response to granulocyte (PMN) transfusion, we tested 187 non-HL-A matched donor-recipient pairs for the presence of antileukocyte antibody using granulocytotoxicity (G), lymphocytotoxicity (L), microleukoagglutination (M), and capillary leukoagglutination (C) assays. PMN increments per 10(11) transfused PMNs per square meter of body surface area, ascertained one hour following termination of transfusion, and the occurrence of nonhemolytic transfusion reactions, were correlated with the assay results. Although circulating anti-donor-leukocyte antibody was detected in 52 per cent of recipients, there was no statistically significant relationship between the presence of these antibodies and either PMN recovery or incidence of transfusion reaction. We conclude that the prospective use of these assays is of little value in predicting the recipient's response to PMN transfusion.

Leukapheresis and Granulocyte Transfusion

Granulocyte transfusion is becoming widely used in the treatment of infections in granulocytopenic patients. Several techniques are available for granulocyte collection. Some involve centrifugation of the whole blood and one removes granulocytes from whole blood by reversible adhesion to nylon fibers. The risks to the donor from leukapheresis do not appear to be greater than from whole blood donation. Granulocytes collected by centrifuge techniques function normally in vitro and have normal intravascular recovery and disappearance following transfusion. Granulocytes collected by filtration leukapheresis function almost normally in vitro but have a reduced intravascular recovery and abnormal kinetics as they leave the circulation. The role of leukocyte typing and compatibility testing for granulocyte transfusion is controversial. When the recipient has circulating antibody against donor leukocytes, transfused leukocytes do not circulate or migrate to sites of infection but are sequestered in the liver and spleen. Clinical studies have not defined whether patients benefit equally well clinically from transfusion of compatible or incompatible granulocytes. Initial reports of clinical trials of granulocyte transfusion were promising. However, similar patients who did not receive granulocytes were not studied. Most subsequent controlled trials showed a clear benefit from granulocyte transfusion while others did not. Differences in antibiotic therapy, chemotherapy, use of laminar flow rooms, and grouping of patients make it difficult to compare these clinical trials. Some, but not all, infected granulocytopenic patients benefit from transfusion. Granulocyte transfusions improve survival of granulocytopenic patients with gram negative sepsis and prolonged bone marrow aplasia. Studies are now attempting to identify other patients who should receive granulocytes, the optimum dose and schedule of transfusions, the optimum time to begin transfusion, and the value, if any, of prophylactic transfusions.

Beneficial Effect of Granulocyte Transfusions in Patients with Defects in Granulocyte Function and Severe Infections

A 3-year-old boy (patient A) with a congenital and a 24-year-old man (patient B) with an acquired granulocyte function defect received supportive granulocyte transfusions for the management of severe infections. The boy had suffered from recurrent infections since bith. His granulocytes showed in vitro almost no chemotactic responsiveness, an impaired phagocytosis and reduced intracellular killing of Candida albicans. Family studies suggested that it was an inherited autosomal recessive defect. The child developed a Pseudomonas pneumonia at the age of 3 years, which did not respond to antibiotic therapy. Granulocyte transfusions were then started and soon after the fever and pneumonia disappeared. Patient B showed the haematological signs of a preleukaemic state. He had 3 recurrent episodes of furunculosis which led each time to cellulitis and septic temperatures accompanied by symptoms of an enterocolitis. Tests of granulocyte function in vitro showed reduced intracellular killing of Staphylococcus aureus. Granulocyte transfusions were started, since no clinical improvement could be attained by antibiotics. With transfusion therapy, fever, cellulitis and enterocolitis disappeared each time.

HLA-antigen matched platelet and granulocyte transfusions for patients with leukaemia and aplastic anaemia

About 1500 blood donors in Perth have been typed for HLA-A and -B antigens and donate platelets and white cells when required for transfusion to patients with leukaemia or aplastic anaemia if suitable HLA-compatible related donors are not available. Selection of HLA-matched donors is achieved by an on-line computer search, using matching criteria based on those developed by Duquesnoy, Aster and their colleagues at the Milwaukee Blood Center for platelet transfusions. Cells are collected using an Haemonetics 30 cell separator. ACD solution B (USP) is the preferred anticoagulant, and dextran 150 is added for granulocyte collection to enhance red cell sedimentation. To date HLA-matched cell concentrates have been provided for 38 patients, of whom 15 received only platelets, 4 only granulocytes and 19 have had both. In only one case have major difficulties been encountered with reactions to transfusion associated with immunization to many HLA-antigens. Good HLA matches (no incompatible antigens) have been achieved for 23% of 334 transfusions given, acceptable matches (only one incompatible) for 46% and poor matches (two or more incompatible) for the remainder. Platelet concentrates have been effective in controlling bleeding in most cases. In a few instances febrile reactions have occured, usually to platelets with one or more incompatible HLA antigens, which were then less effective than better matched cells given to the same patient. Effects of granulocyte transfusions have been difficult to assess, on account of variations in the number of cells given and in other measures taken to treat the patient's infections. For example, one hospital regularly uses ‘life island’ isolation for these patients, but the others do not have this facility. A clinical impression that granulocyte transfusions have been of value in control of systemic infections has been confirmed by study of a larger number of patients. About 1500 blood donors in Perth have been typed for HLA-A and -B antigens and donate platelets and white cells when required for transfusion to patients with leukaemia or aplastic anaemia if suitable HLA-compatible related donors are not available. Selection of HLA-matched donors is achieved by an on-line computer search, using matching criteria based on those developed by Duquesnoy, Aster and their colleagues at the Milwaukee Blood Center for platelet transfusions. Cells are collected using an Haemonetics 30 cell separator. ACD solution B (USP) is the preferred anticoagulant, and dextran 150 is added for granulocyte collection to enhance red cell sedimentation. To date HLA-matched cell concentrates have been provided for 38 patients, of whom 15 received only platelets, 4 only granulocytes and 19 have had both. In only one case have major difficulties been encountered with reactions to transfusion associated with immunization to many HLA-antigens. Good HLA matches (no incompatible antigens) have been achieved for 23% of 334 transfusions given, acceptable matches (only one incompatible) for 46% and poor matches (two or more incompatible) for the remainder. Platelet concentrates have been effective in controlling bleeding in most cases. In a few instances febrile reactions have occured, usually to platelets with one or more incompatible HLA antigens, which were then less effective than better matched cells given to the same patient. Effects of granulocyte transfusions have been difficult to assess, on account of variations in the number of cells given and in other measures taken to treat the patient's infections. For example, one hospital regularly uses ‘life island’ isolation for these patients, but the others do not have this facility. A clinical impression that granulocyte transfusions have been of value in control of systemic infections has been confirmed by study of a larger number of patients.

Granulocyte transfusions in infected neutropenic children with malignancies

Thirty-six febrile neutropenic episodes were treated by granulocyte transfusions in 33 children. Septicemia and mucous membrane ulcerations were most commonly associated with the fever. Infection cleared in 81% of the episodes, eight per cent ended in death from bacterial infections, 11% from nonbacterial infections or hemorrhage. The median number of polymorphonuclear leukocytes given was 1.1 X 10(10)/m2/transfusion. Two to twenty-eight (median 8.5) transfusions were given over 3--34 days (median 10.5). The source of cells (parental or random) and the method of collection did not seem to affect the outcome. None of the 23 patients whose marrow recovered during the transfusions died of bacterial infections. Infection cleared even without marrow recovery in 62% of the patients, but then only 25% lived for more than two months after clearing of sepsis. In a subgroup of patients with nonlymphoblastic leukemia on the same chemotherapy and antibiotic treatment protocol, 8/11 (73%) survived bacteremia when white cell support was available; only 2/11 (18%) of a historical control group survived when such support was not available. Granulocyte support appears to be a valuable tool in helping neutropenic patients overcome their infections or, at the very least, helping them survive long enough for normal marrow recovery to occur.

Infectious Complications of Human Bone Marrow Transplantation

Infections are an almost inevitable complication of human bone marrow transplantation and account for the majority of deaths in transplant recipients. Even prior to the initiation of the transplantation procedure, patients may present with infections complicating previously unsuccessful chemotherapy for hematological malignancy or aplastic anemia. Nevertheless, these pre-transplantation infections should not exclude the possibility of bone marrow transplantation if they can be successfully controlled with specific antimicrobial therapy and necessary adjunctive measures. The immediate post-transplantation period prior to engraftment is characterized by severe marrow aplasia that results from high-dose chemotherapy and total-body irradiation. Infections are primarily septicemias and localized processes caused by bacteria and fungi and their incidence increases as the intensity of immunosuppression is escalated. The high mortality associated with bacterial septicemia makes early, empirical antibacterial therapy mandatory. However, the reduction in mortality from bacterial infection resulting from such an aggressive approach may be offset by a higher mortality from invasive fungal infection, especially in patients with prior fungal colonization and undergoing prolonged conditioning therapy. Thus, until more specific and sensitive tests for the diagnosis of invasive fungal infection become available, empirical intravenous amphotericin should be considered in patients who are persistently febrile and deteriorate clinically in the face of appropriate antibacterial therapy. Interstitial pneumonia associated with severe GVHD is the major infectious complication after successful marrow engraftment and is the most significant barrier to long-term survival. Trimethoprim-sulfamethoxazole is effective prophylaxis against interstitial pneumonia due to Pneumocystis carinii, but one half of the patients still develop a pneumonitis either associated with CMV or of unknown etiology. Mortality from interstitial pneumonia is related to prior radiation therapy while survival is associated with a four-fold rise in CMV CF antibody titer. The latter observation supports the need to investigate passive immunization with CMV antibody as a means of preventing some interstitial pneumonias. Despite the progress made in many areas of human bone marrow transplantation, the majority of graft recipients still die of infectious complications. Thus, new approaches to the management of infections in transplant recipients are urgently needed. Better-tolerated oral nonabsorbable antibiotics, laminar-air-flow rooms, granulocyte transfusions, and chemotherapy and immunotherapy for CMV are among the prophylactic and therapeutic measures that must be critically evaluated in well-controlled, prospective studies. Continued assessment of the infectious complications of bone marrow transplantation is a critical aspect of any ongoing transplant program, not just a research goal...

The Effect of Granulocyte Transfusions on Septicemia in Patient with Acute Leukemia

The Effect of Granulocyte Transfusions on Septicemia in Patient with Acute Leukemia

Erythro-myeloid aplasia following D-penicillamine treatment in primary biliary cirrhosis

Summary A woman with primary biliary cirrhosis and a high liver copper concentration was treated with D-penicillamine as a participant in a controlled trial of the drug. After 14 weeks she developed a Pseudomonas septicaemia and was found to have erythro-myeloid aplasia. Similar, but not identical blood dyscrasias have previously been reported as complications of D-penicillamine therapy. She survived after treatment with antibiotics and granulocyte transfusions, and bone marrow function returned to normal.

Supportive granulocyte transfusion in the infected severely neutropenic patient.

The patterns and types of infection in 93 infectious episodes in 76 patients who received supportive granulocyte transfusions are presented. In this population of infected patients 86 per cent had debilitating malignancies, 88 per cent of the infectious episodes were associated with severe (less than 100/microleters) neutropenia and septicemia was documented in 56 per cent. The overall four-week survival was 71 per cent. Patients with localized infection did extremely well. Pediatric patients also responded well to the transfusion dose and schedule. Older patients (greater than 60) and patients over the age of 17 with diffuse infection did not do as well. Delay in the initiation of granulocyte transfusions after a diagnosis of serious infection was a significant factor in the group which died less than four weeks after the initial WBC transfusion. Donor reactions in nylon filtration leukapheresis and problems associated with administration of nylon filter cells are presented and discussed.

Granulocyte Transfusions in Infants

To the Editor.— Recently, Ian M. Smith, MD, suggested that granulocyte transfusions might be of value in treating infants with septicemia and leukopenia (239:2599, 1978). Although Dr Smith mentioned that caution should be employed when selecting this form of therapy for infants, he did not cite the published literature related to the use of granulocyte transfusion in children. It is the purpose of this letter to strongly emphasize that there are no published data available to document the efficacy of granulocyte transfusion in the treatment of infected, neutropenic infants and children when compared with antibiotic therapy alone. The results of treating febrile episodes in children with granulocyte transfusion have been reported in two uncontrolled studies. 1,2 A course of four daily granulocyte transfusions has been tentatively accepted by most investigators as a minimum therapeutic trial. The majority of children described in these two studies responded to only one or two

Granulocyte transfusions in infants

Granulocyte transfusions in infants

Granulocyte Transfusions in Infants-Reply

In Reply.— Dr Strauss's letter strengthens and adds to the comment I made in regard to leukocyte transfusions in children. He pointed out that the children responded to only one or two granulocyte transfusions, which may illustrate the relative volume differences in the transfusion and the size of the patient. I would thoroughly agree that this must be regarded as experimental therapy for which informed consent must be obtained. No doubt in the near future there will be control studies available in children. I thank Dr Strauss for his interest in this matter.

Collection of granulocytes for transfusion. The effect of collection methods on cell enzyme release.

When granulocytes are collected by either discontinuous-flow centrifugation or filtration leukapheresis, lysozyme is released. More lysozyme is released during the filtration procedure than during the centrifugation procedure. A small amount of red cell lysis occurs during the centrifugation but not the filtration procedure. A rise in lactate dehydrogenase levels consonant with the amount of hemolysis is observed. These findings suggest that granulocytes collected by either filtration or discontinuous-flow centrifugation undergo degranulation but not lysis sufficient to cause cytoplasmic enzyme release during the donation.

Efficacy of granulocyte transfusions in the control of systemic candidiasis in the leukopenic host

An experimental canine model was designed to evaluate the effect of granulocyte transfusions on systemic infection with Candida albicans in the granulocytopenic host. Each of a pair of dogs was rendered granulocytopenic with a single intravenous (i.v.) dose of cyclophosphamide (50 mg/kg body weight) and challenged with 10(6) Candida albicans organisms administered i.v. when granulocyte counts were less than or equal to 500/mm3. Granulocytes procured by leukofiltration were infused into six experimental dogs 1, 24, 48, and 72 hr after challenge with Candida. An average of 13 +/- 1.3 X 10(9) granulocytes were administered per infusion, producing an average 1-hr increment of 588 +/- 146 granulocytes/mm3 over the pretransfusion granulocyte count. Experimental and control dogs were killed 96 hr after challenge and organs examined grossly and by quantitative culture techniques to measure the extent of infection. All animals receiving granulocyte transfusions had significantly less tissue infection than nontransfused controls (p less than 0.05). It was concluded that granulocyte transfusions are effective in reducing the severity of infection by Candida albicans during periods of leukopenia.

Efficacy of Granulocyte Transfusions in the Control of Systemic Candidiasis in the Leukopenic Host

An experimental canine model was designed to evaluate the effect of granulocyte transfusions on systemic infection with Candida albicans in the granulocytopenic host. Each of a pair of dogs was rendered granulocytopenic with a single intravenous (i.v.) dose of cyclophosphamide (50 mg/kg body weight) and challenged with 10(6) Candida albicans organisms administered i.v. when granulocyte counts were less than or equal to 500/mm3. Granulocytes procured by leukofiltration were infused into six experimental dogs 1, 24, 48, and 72 hr after challenge with Candida. An average of 13 +/- 1.3 X 10(9) granulocytes were administered per infusion, producing an average 1-hr increment of 588 +/- 146 granulocytes/mm3 over the pretransfusion granulocyte count. Experimental and control dogs were killed 96 hr after challenge and organs examined grossly and by quantitative culture techniques to measure the extent of infection. All animals receiving granulocyte transfusions had significantly less tissue infection than nontransfused controls (p less than 0.05). It was concluded that granulocyte transfusions are effective in reducing the severity of infection by Candida albicans during periods of leukopenia.

Granulocyte transfusion therapy of experimental Pseudomonas septicemia: study of cell dose and collection technique

To determine the contributions of cell dose and collection technique to the success of granulocyte transfusion therapy, we developed a canine model of granulocytopenia with gram-negative septicemia. Beagles were made granulocytopenic with a single intravenous (i.v.) injection of cyclophosphamide (40 mg/kg); 5 days later, when all animals were granulocytopenic, graded doses of Pseudomonas aeruginosa were injected i.v., followed in 4 hr by antibiotics with or without granulocyte transfusions. Survival of animals not treated with granulocytes was related to the dose of Pseudomonas injected, with 1 × 10 8 bacteria/kg being lethal in greater than 95% of animals. Survival of animals treated with daily granulocyte transfusions after 1 × 10 8 bacteria/kg was critically dependent on the dose of cells transfused and the collection technique employed. When continuous-flow centrifugation was the method employed, none of five animals receiving 1 × 10 8 granulocytes (PMN)/kg daily survived the infectious episode, while four of five receiving 1.5 × 10 8 and five of five receiving 2.0 × 10 8 PMN/kg survived. When cells collected by filtration leukapheresis were used, 2.5 to 3.0 times more PMN were necessary to provide the same protection: none of five survived at 2.0 × 10 8 PMN/kg, one of five survived at 3.0 × 10 8 , three of five survived at 4.0 × 10 8 , and five of five survived at 5.0 × 10 8 PMN/kg. Pretreatment of the recipient of filtration leukapheresis PMN with 25 mg hydrocortisone did not alter the ability of these cells to provide protection. These findings show that the success of PMN transfusion therapy for sepsis is critically dependent on the dose of PMN transfused and the collection technique employed.

Acute leukemia and granulocyte transfusion: Fatal graft-versus-host reaction following transfusion of cells obtained from normal donors

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Recent developments in the supportive therapy of acute myelogenous leukemia.

The prognosis for patients with AML is improving, but mortality due to bleeding and infection remains significant. HLA compatibility has been the cornerstone of matching for prophylactic platelet transfusion; while HLA matched platelets are often of benefit, we have observed that HLA matching does not reliably predict transfusion responses. The platelet migration inhibition assay is, however, consistently predictive. The matching problem may be circumvented by the use of frozen autologous platelets, which circulate and function hemostatically. In the granulocytopenic patient with de novo fever (frequently due to bacterial sepsis), the immediate empiric use of broad spectrum antibiotics is mandatory. If the marrow begins to recover from chemotherapy shortly after the onset of infection, such that the peripheral granulocyte count will approach normal within 10 days, the likelihood of survival from an episode of septicemia after antibiosis now approaches 80%. If the marrow does not recover shortly, however, the likelihood of survival with antibiosis alone is poor. In this setting, survival is improved if patients are given granulocyte transfusions in addition to antibiotics. Patients who receive chemotherapy in a laminar air-flow room (LAFR) experience fewer severe infections than do patients in a conventional ward. However, most patients who are unresponsive to initial chemotherapy remain so in spite of protection from infection. Thus, the available results do not suggest that the LAFR is likely to improve appreciably the rate or duration of remission. Using malignant lymphoma as a model, we have found that cryopreserved autologous marrow infusions can hasten hematopoietic recovery in man after high-dose chemotherapy, and earlier reconstitution may be of clinical benefit to the patient; techniques are at hand that might permit the application of this concept to AML.

Effects of temperature on granulocyte preservation

With the increasing use of granulocyte transfusion it is becoming important to determine if granulocytes can be preserved for a few days. If so, the optimum storage conditions must be identified. We studied the function in vitro of granulocytes collected as they would be for transfusion by continuous-flow centrifuge leukapheresis (CFCL) and filtration leukapheresis (FL). Granulocytes collected by CFCL maintained normal ability to phagocytose and kill bacteria after 48 hr and normal chemotaxis after 24 hr of storage at 20 degrees--24 degrees C. Neither 1 degrees--6 degrees C nor 37 degrees C were as effective in preserving chemotactic response. Agitation of the granulocyte suspension during storage caused reduced bacterial killing and chemotaxis. Granulocytes collected by FL functioned very poorly after 24 hr storage at all temperatures studied. These studies suggest that it may be possible to store CFCL granulocytes at 20 degrees--24 degrees C for 24 hr. FL granulocytes should not be stored at all.