Use Of Granulocyte Transfusions Research Articles

Granulocyte Transfusion Therapy as a Bridge to Hematopoietic Stem Cell Transplant in a Child with Aplastic Anemia and Refractory Perirectal Abscess

Granulocyte Transfusion Therapy as a Bridge to Hematopoietic Stem Cell Transplant in a Child with Aplastic Anemia and Refractory Perirectal Abscess

Successful Use of Granulocyte Transfusion Therapy As a Bridge to Hematopoietic Stem Cell Transplant in a Child with Aplastic Anemia and Refractory Perirectal Abscess

Background: Idiopathic aplastic anemia (IAA) is a rare, life-threatening acquired form of bone marrow failure characterized by multilineage cytopenias and hypocellular bone marrow. Profound neutropenia associated with very severe aplastic anemia (vsAA) is an important risk factor for development of life-threatening fungal and bacterial infections. Perirectal cellulitis and perianal abscess are one such infection and are associated with high rates of morbidity. The ability to eradicate infections in IAA is limited by the lack of imminent neutrophil recovery prior to treatment with either immune suppressive therapy (IST) or hematopoietic stem cell transplant (HSCT). We describe the successful use of granulocyte transfusion to treat antibiotic refractory proctitis with perianal abscess in a profoundly neutropenic child with vsAA. Case: A 7yoF presented with fever and pancytopenia in the setting of Human Metapneumovirus and Parainfluenza. Bone marrow biopsy showed hypocellularity (60-70%) with granulocytic and megakaryocytic hypoplasia, favoring viral suppression. Ultimately, she progressed to transfusion dependence. Repeat bone marrow aspirate and biopsy ultimately revealed bone marrow aplasia, DEB chromosomes, telomere lengths, and PNH clones were negative, confirming the diagnosis of vsAA. She was subsequently admitted for febrile neutropenia (F&N) and was found to have mild respiratory COVID-19, but began to complain of rectal pain that was initially attributed to her history of constipation. She defervesced on IV antibiotics (abx) and was discharged home with negative cultures. Within a week she represented with hematochezia and F&N and was found to have proctitis with perianal fistula on MRI (figure 1); GI PCR panel was + Enteroaggregative E. coli, no resistant organisms were identified. She clinically improved and discharged on IV piperacillin-tazobactam (pip-tazo). Despite 2 weeks of IV abx, she developed new fever and imaging confirmed persistent proctitis with peri-rectal abscess. As she had limited response to abx alone we trialed a short course of granulocytes with improvement in anorectal inflammation by CT. She was discharged with a plan to continue IV pip-tazo until achieving radiographic cure; however, interval imaging after an additional 2 weeks of abx showed rebound of her proctitis and she was again admitted with F&N and rising inflammatory markers. Her failure to eradicate her peri-rectal infection despite prolonged antibiotics (>4weeks), along with her previous response to a short course of granulocyte transfusion prompted us to prescribe a prolonged 10-day course of granulocytes with continued antibiosis. Her post-granulocyte CT showed resolution of her perirectal abscess and proctitis (figure 2). With resolution of her infection, she was able to proceed to HSCT which she completed without recurrence of her anorectal infection. Discussion: Conventional granulocyte transfusions are considered when patients have severe neutropenia (<500/uL), bacterial or fungal infection refractory to antimicrobials, and reasonable expectation of neutrophil recovery, but evidence for efficacy is limited. In our case, there was no expectation of imminent bone marrow recovery and our patient's infection limited her ability to proceed to IST or HSCT for treatment of her vsAA. Thus, in conjunction with infectious disease and transfusion medicine, and given her known response to granulocytes, we successfully re-attempted a prolonged, but limited, 10-day course of granulocyte transfusions and were able to eradicate a case of antibiotic-refractory proctitis with peri-anal fistula. We suggest an expanded application for the use of granulocytes in profoundly neutropenic patients without imminent recovery for severe, anti-microbial refractory infection. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Use of Granulocyte Transfusions in Two National Cohorts and Association between Transfusion Dose and Patient Outcomes: The Best Collaborative Study

Granulocytes for transfusion (GTX) continue to be administered, mostly to treat refractory infection 1. Single center series continue to be reported, but evidence of GTX effectiveness remains uncertain. Recent attempts at randomized trials of GTX have not been completed to target although the largest trial, RING 2, identified potentially promising results in a sub-group analysis by dose.GTX can be produced by apheresis (from ‘stimulated’ donors), aGTX, or as a component pooled from whole blood (WB) donations. Logistic difficulties arise with aGTX, including recruitment of suitable donors willing to undergo cell mobilization and collection. In England GTX are now only supplied as pooled (10 WB donations/pool, mean volume single pooled unit 207 ml, mean granulocyte yield/unit 0.9 x10 10, typical adult dose 2 pools, available 6 days per week). In France, production moved from aGTX to pooled in 2020 (20 WB donations/pool, mean volume single pooled component 428 ml, mean granulocyte yield/unit 1.8 x10 10, typical adult dose 1 pool, available 6 days per week). There have been no recent published national data on the clinical use of pooled granulocytes, or comparisons between large datasets.The aim of this study was to 1) describe the use of GTX, including pooled granulocytes, in two national cohorts of recipients; 2) estimate the effect of dose on patient mortality using statistical methods which could be applied to a larger dataset in the future.A pre-piloted data collection form (DCF) was used to collect prospective audit data on all GTX given to patients in participating hospitals in England from March 2017 -Sept 2020 in England. The PROspective Granulocyte usage and outcomEs Survey (ProGrES) was deemed a national registry/audit with no individual patient consent required for anonymized data. Information on patient characteristics and outcomes was collected at the time of the request for GTX, following completion of GTX and at 28 days and 6 months follow up. DCFs were adapted for international use, and French data were collected from Jan 2018 to Dec 2020.Descriptive analyses were performed to summarize GTX dose, patient characteristics, and outcomes. Using the English data, we investigated the association between GTX dose and mortality within 28 days of final GTX using logistic regression models with and without adjustment for possible confounders (age, infection source, use of renal therapy) and using the target trial framework. Ethical approval was obtained from London School of Hygiene and Tropical Medicine for analysis of English data.Results are presented on 224 (England, pooled) and 139 (France) patients who received GTX. In France, 95 and 44 patients received aGTX and pooled GTX, respectively. Table 1 shows patient features and outcomes. The most frequent underlying diagnosis was acute myeloid leukemia in all groups, and the most common indication was treatment of refractory infection. Median number of transfusions was similar in all groups (5.0, 5.3, 6.0). The mean dose/kg/transfusion was highest in the aGTX group (0.55 x10 9/kg), followed by French pooled (0.40) and English pooled (0.2). Death within 28 days of last GTX varied from 20.2% (French apheresis) to 32.5% (French pooled).Additional analyses were performed on the English data; for death within 28 days, a 0.1 x10 9 increase in GTX dose was associated with a 22% reduction (95% CI -45% to +0%) in odds of death within 28 days of referral; odds ratio 0.78 (95% CI 0.57 to 1.00). After adjustment for potential confounders, the odds ratio was attenuated to 0.92 (95% CI 0.67, 1.23).In summary, GTX continue to be requested by clinicians in patients with poor outcomes, despite an uncertain evidence-base. Regression analysis found dose was associated with lower odds of 28-day mortality. This was not significant after confounder adjustment, but this proof-of-principle analysis was limited by the sample size. A potential dose effect was also seen in the RING study. Our analysis using a target trial approach provides an approach for estimating GTX effectiveness in a larger cohort, which is required given the well-recognized challenges of undertaking randomized trials. The analysis provides a range of sample size calculations for testing an association between dose and outcomes for a defined effect size in a larger international cohort, supported by the BEST Collaborative 3.

Use of granulocyte transfusion in early period in life-threatening infections of pediatric hematology and oncology patients: A single-center experience

Despite all the developments in medicine, infections continue to be one of the most important causes of mortality in pediatric hematology and oncology patients. The more severe the degree of neutropenia develops after intensive chemotherapy in cancer patients, and the longer the neutropenia duration, the higher the risk of infection. Granulocyte transfusion (GT) is used as supportive therapy in cases where the bone marrow needs time to recover in invasive bacterial or fungal infections along with severe neutropenia. The patients who had granulocyte transfusions in our clinic between June 2019 and June 2020 were reviewed retrospectively. A total of 15 units of granulocyte concentrate were used in 11 febrile neutropenia attacks of 9 patients. The demographic characteristics of the patients and features belonging to the period of GT were recorded. In our study, the clinical response rate after GT was 90.9 %, while the hematological response rate was 40 %. Most of the patients were treated succesfully, the mortality rate was 9%. We think that the most critical factor for success with GTs is determining the neutropenic patient in particular with a combination of high-risk malignancy and acute life-threatening infection for using GT. Also, early use of GT in those patients who do not recover despite appropriate antimicrobial and supportive treatment may contribute to improvement of the clinical conditon in a shorter period of time and reduction of repeated GTs.

The burden of invasive infections in neutropenic patients: incidence, outcomes, and use of granulocyte transfusions.

BACKGROUNDPatients with prolonged neutropenia caused by chemotherapy or underlying marrow disorders are at risk of invasive bacterial and fungal infections. New treatment options alongside targeted antimicrobial therapy that might improve outcomes include granulocyte transfusions (GTX). To inform the research agenda, a prospective observational cohort study was performed in the Netherlands and United Kingdom. The aim was to describe the incidence, characteristics, and outcomes of patients developing invasive infections and assess patients fulfilling criteria for GTX.STUDY DESIGN AND METHODSAll patients receiving myeloablative chemotherapy and anticipated to develop 7 or more days of neutropenia (<0.5 × 109/L) were eligible and followed for the development of invasive infections according to a defined algorithm and mortality up to 100 days. Secondary outcomes were types of infection and eligibility for GTX.RESULTSA total of 471 patients enrolled at six hematology‐oncology departments were followed for 569 neutropenic episodes. Overall, 32.5% of patients developed invasive infections during their first episode. Significant baseline risk factors for developing infections were high comorbidity scores (WHO performance status ≥ 2, hazard ratio [HR], 2.6 [1.7‐3.9]; and hematopoietic cell transplantation‐comorbidity index score ≥ 2 HR 1.3 [0.9‐1.8]). Infections were bacterial (59.4%) and fungal (22.3%). Despite 34 patients (6.3% of all episodes) appearing to meet criteria to receive GTX, only nine patients received granulocytes. The HR for death was 5.8 (2.5‐13.0) for patients with invasive infections.CONCLUSIONThis study documents that invasive infections are associated with significant mortality. There is a need for new strategies to prevent and treat infections, which may include better understanding of use GTX.

Granulocyte transfusions collected after steroid priming for severe infections during neutropenia: A single center experience.

There is no universally accepted opinion on the use of granulocyte transfusions collected using apheresis (GTA) in neutropenic patients and severe infection. The efficacy and safety of GTAs transfused at a single center over 10 years were analyzed retrospectively. GTAs were harvested from voluntary unrelated donors after priming with methylprednisolone using continuous apheresis and hydroxyethylstarch as sedimentation agent. 41 patients with neutropenia and hematologic malignancy (15 females and 26 males aged 22-69 (median 45.5)) were given a median 3.5 GTAs per patient (range: 1-17) containing a median 1.39×1010 granulocyte/GTA (range: 0.65-2.81). The indications for GTA use were soft tissue inflammation, sepsis, and pneumonia in 30, 22, and 14 cases, respectively. After GTA complete(30 patients: 73.2%) or partial (6 patients: 14.6%) healing of the infection was achieved. The success rate was 91.7% in soft tissue infections, 66.7% in invasive fungal infections, and 68% in sepsis. Septic shock (documented in 12 cases) was associated with a poor response (P<0.03; Chi-square test). Clinical worsening was observed in six cases (14.6%); four patients died. No significant short-term side effects of GTA treatment were recorded. In our study GTAs collected after steroid priming and used for the treatment of infection during severe neutropenia have shown comparable efficacy with several previously reported trials. However retrospective fashion of our study and inhomogeneous group of patients do not allow any firm conclusions. Prospective studies (including patients' registries) are needed for the better clarification of the role and the dose of GTAs necessary for the successful infection management during neutropenia.

Use of granulocyte transfusions among haematology units in England and North Wales.

To establish the current use of granulocyte transfusions in haematology patients and explore interest in further research. Granulocytes may be used for the treatment of severe infection in neutropenic patients or for primary or secondary prophylaxis. Clinical utility of granulocyte transfusions is unclear, and recent studies have demonstrated equivocal outcomes. Pooled granulocytes are the main granulocyte product used in England and Wales, but there are no data on the patterns of use and little consensus on accepted indications. A survey was distributed to UK hospitals delivering intensive chemotherapy. Clinical scenarios were posed, with further questions on clinician experience of using granulocytes, availability of the product, barriers to use and interest in further research. The response rate was 57%; 34·9% of all responses were from allogeneic stem cell transplant centres. Paediatric centres comprised 9·5% respondents, and 19% centres had access to apheresis granulocytes. Of respondents, 58·7% had used granulocytes in the last 3 years, 89·2% of whom used granulocytes to treat refractory infection. There was little consensus on use of granulocytes in the given clinical scenarios even when patients clearly met national guideline criteria. Paediatric centres were overall more likely to recommend granulocyte use. The most frequently identified barrier to use of granulocytes was lack of evidence of effect. Of the respondents, 75% indicated a willingness to participate in further research. There remains a lack of consistency about use of granulocytes, which is unsurprising given the lack of clinical data to support their efficacy. We did, however, demonstrate a willingness to participate in further research.

Changing Trends in the Use of Granulocyte Transfusions in Neutropenic Children with Sepsis in India.

We present our data on granulocyte transfusions in children undergoing treatment for cancer and HSCT at our centre and their changing indications. In this retrospective observational analysis of children who received granulocytes from 2007 to 2015, we divided children receiving granulocytes into two groups-the first from January 2007 till December 2013 and the second from January 2014 till December 2015. This division is based on the change in our policy to use granulocytes within 48h of septicemia as the incidence of drug resistant bacterial strains had increased at our centre. Data on 72 children with febrile neutropenia treated with 230 granulocyte infusions was analyzed. From 2007 to 2013 (n=48/72), 27/48 (56%) had culture proven sepsis of which 14 (51%) were carbapenem resistant gram negative bacilli. 11 of the 27 children survived the crisis (41%). We then changed our policy to transfuse granulocytes early during sepsis. From 2014 to 2015 (n=24/72) 22 patients had culture proven sepsis (91%) of which 20 had carbapenem resistant gram negative bacilli. 12/22 (54%) with culture proven sepsis survived the episode. The survival rate improved from 41% in first group to 54% after early intervention with granulocytes (P value 0.0347). Despite the increased incidence of resistant bacteria during the period of 2014-2015, early use of granulocytes improved survival rate from 41 to 54%. This intervention cannot be taken in isolation and needs to be offered early in parallel with appropriate antibiotics.

Granulocyte transfusions in fulminant invasive fungal sinusitis

PurposeFulminant invasive fungal sinusitis (IFS) is an aggressive disease seen in patients who are severely neutropenic. The use of granulocyte transfusions to address neutropenia-associated IFS has been described for almost 2 decades. The objectives are to provide our experience using granulocyte transfusions in patients with IFS and to provide a current review of the literature. Materials and methodsA retrospective chart review was performed at the Medical College of Wisconsin to identify patients who received granulocyte transfusions for IFS. Data collected included age, original diagnosis, IFS pathogen, dates, transfusion number, reason for discontinuation, additional therapies, last known follow-up, and status at last known follow-up. A Medline search and manual review of citations within bibliographies was also performed. ResultsA total of 20 patients received granulocyte transfusions at the Medical College of Wisconsin between October 2003 and June 2009; 3 of these patients received granulocyte transfusions for fulminant IFS. A total of 22 reported cases of IFS treated with granulocyte transfusions exist in the current literature. ConclusionsAlthough limitations to the use of granulocyte transfusions exist, they still represent a viable treatment option in individuals who fail to respond to more conventional therapies.

Granulocyte transfusions

Neutrophils play an essential role in the defense of the body against bacterial and fungal infections. Disorders of their number or function significantly increase the risk of life-threatening infection. In spite of the development of growth factors, new broad spectrum antibiotics and antifungal drugs against nearly all known pathogens, severe neutropenia associated with bacterial or invasive fungal infections remains a major cause of morbidity and mortality in patients undergoing aggressive cancer chemotherapy or hematopoietic stem cell transplantation. Lately, an interest about granulocyte transfusions was renewed, what is a logical approach in the management of patients with prolonged 'reversible' severe neutropenia and severe infection, which is not controlled with appropriate antimicrobial and supportive treatment, including recombinant hematopoietic growth factors. It was a consequence of advances in the field of apheresis science, use of sedimenting agents and especially advances in mobilization of granulocytes to the peripheral blood. It became now possible to collect large numbers of neutrophils. Therefore, the clinical use of granulocyte transfusions, as a potential life saving treatment option in patients with severe neutropenia and uncontrolled infection in spite of appropriate antimicrobial therapy should be considered, with regard to possible benefits and risks (Ref. 74).

Granulocyte transfusions for neonates with confirmed or suspected sepsis and neutropenia

Neonates have immature granulopoiesis, which frequently results in neutropenia after sepsis. Neutropaenic septic neonates have a higher mortality than non-neutropenic septic neonates. Therefore, granulocyte transfusion to septic neutropenic neonates may improve outcomes. The primary objective was to determine the effect of granulocyte or buffy coat transfusions as adjuncts to antibiotics, after confirmed or suspected sepsis in neutropenic neonates, on all-cause mortality during hospital stay and neurological outcome at ≥ year of age. Secondary objectives were to determine the effects of granulocyte transfusions on length of hospital stay in survivors to discharge, adverse effects and immunologic outcomes at ≥ year of age. The Cochrane Central Register of Controlled Trials (The Cochrane Library), MEDLINE, EMBASE and CINAHL, proceedings of the PAS conferences and ongoing trials at clinicaltrials.gov and clinical-trials.com were searched in July 2011. Studies where neutropenic neonates with suspected or confirmed sepsis were randomised or quasi-randomised to granulocyte or buffy coat transfusions at any dose or duration, and reporting any outcome of interest were included. Relative risk (RR) and risk difference (RD) with 95% confidence intervals using the fixed effects model were reported for dichotomous outcomes. Pre-specified subgroup analyses were performed. Four trials were eligible for inclusion. Forty-four infants with sepsis and neutropenia were randomised in three trials to granulocyte transfusions or placebo/no transfusion. In another trial, 35 infants with sepsis and neutropenia on antibiotics were randomised to granulocyte transfusion or IVIG.When granulocyte transfusion was compared with placebo or no transfusion, there was no significant difference in 'all-cause mortality' (three trials; typical RR 0.89, 95% CI 0.43 to 1.86; typical RD -0.05, 95% CI -0.31 to 0.21).When granulocyte transfusion was compared with intravenous immunoglobulin (one trial), there was a reduction in 'all-cause mortality' of borderline statistical significance (RR 0.06, 95% CI 0.00 to 1.04; RD -0.34, 95% CI -0.60 to -0.09; NNT 2.7, 95% CI 1.6 to 9.1).Pulmonary complications were the only adverse effect reported in the trials that used buffy coat transfusions. None of the trials reported on neurological outcome at one year of age or later, length of hospital stay in survivors to discharge or immunological outcome at one year of age or later. Currently, there is inconclusive evidence from randomised controlled trials (RCTs) to support or refute the routine use of granulocyte transfusions in neutropenic, septic neonates. Researchers are encouraged to conduct adequately powered multi-centre trials of granulocyte transfusions in neutropenic septic neonates.

Transfusion strategies in patients undergoing stem-cell transplantation

Hemopoietic stem-cell transplant patients may require intensive blood component support. Complications of transfusions include transmission of viral and bacterial infections, transfusion-associated graft-versus-host disease and transfusion-related acute lung injury. Alloimmunization to red cell antigens may cause difficulties in selecting compatible blood, while alloimmunization to HLA expressed on platelets may cause subsequent platelet transfusion refractoriness. It is essential to define robust transfusion policies and procedures and these should be regularly audited. This article reviews blood component transfusion in the setting of hemopoietic stem-cell transplant and specifically discusses the management of ABO-mismatched transplants, the prevention of cytomegalovirus transmission, the prevention of transfusion-associated graft-versus-host disease and the use of granulocyte transfusions.

Chronic Granulomatous Disease: Lessons from a Rare Disorder

Chronic granulomatous disease (CGD) is a rare primary immunodeficiency with X-linked or autosomal recessive inheritance involving defects in genes encoding phox proteins, which are the subunits of the phagocyte NADPH oxidase. This results in failure to produce superoxide anion and downstream antimicrobial oxidant metabolites and to activate antimicrobial proteases. Affected patients are susceptible to severe, life-threatening bacterial and fungal infections and excessive inflammation characterized by granulomatous enteritis resembling Crohn's disease and genitourinary obstruction. Early diagnosis of CGD and rapid treatment of infections are critical. Prophylaxis with antibacterial and mold-active antifungal agents and the administration of interferon-γ has significantly improved the natural history of CGD. Currently, the only cure is allogeneic hematopoietic cell transplant (HCT), although there remains controversy as to which patients with CGD should get a transplant. Allele-based HLA typing of alternative donors, improved supportive care measures, and use of reduced toxicity conditioning have resulted in event-free survival (EFS) of at least 80% even with an unrelated donor and even better when the patient has no active infections/inflammation. Gene correction of CGD would eliminate the risks of graft-versus-host disease (GVHD) and the immunoablative chemotherapy required for allogeneic HCT. Based on gene therapy trials in patients with SCID-X1, ADA-SCID, and the early experience with CGD, it is clear that at least some degree of myeloablation will be necessary for CGD as there is no inherent selective growth advantage for gene-corrected cells. Current efforts for gene therapy focus on use of lentivector constructs, which are thought to be safer from the standpoint of insertional mutagenesis and more efficient in transducing hematopoietic stem cells (HSCs).

Successful Control of Preexistent Active Infection by Granulocyte Transfusions During Conditioning Induced Cytopenia In Patients with Chronic Granulomatous Disease Undergoing Hematopoietic Stem Cell Transplant

AbstractAbstract 1329Chronic granulomatous disease (CGD) is a congenital disorder resulting from decreased or absent oxidase production by neutrophils. As a result, patients with CGD are prone to bacterial and fungal infections and have a shortened life expectancy. Hematopoietic stem cell transplantation (HSCT) can be curative, and patients are increasingly referred for transplant due to an ongoing infection not amenable to cure using standard treatments. The use of granulocyte transfusions has been described in patients undergoing transplant with an underlying infection at the time of conditioning, but reports are limited to single cases. We describe here the effects of granulocyte transfusions in four patients undergoing either an HLA matched sibling or unrelated donor HSCT, using an alemtuzumab containing regimen and sirolimus as GVHD prophylaxis. Age of the patients was 6 to 25 (mean 11.5) yrs, and weight was 15.3 to 54 (mean 27.5) kg. Three of the patients had persistent Aspergillus infection involving the spine, lung, and/or brain despite long term combination antifungal therapy including a triazole, echinocandin and/or amphotericin. The fourth patient had an Actinomyces pneumonia progressive on combination antibacterial treatment. None of the patients had detectable HLA antibodies prior to the transfusions, and none received G-CSF post-transplant. The granulocytes were started on the anticipated day of neutropenia after conditioning and graft infusion and continued until evidence of graft recovery. Volunteer community donors underwent mobilization with dexamethasone 8 mg PO plus G-CSF 480 mcg SC, followed the next day by a 7-liter leukapheresis procedure (Spectra) using Tricitrasol/Hetastarch (Hespan) as the anticoagulant/sedimenting solution. Patients received a mean of 4.5 transfusions each, with three patients receiving biweekly transfusions and one receiving transfusions three times a week. The mean number of granulocytes per component transfused was 6.17 × 10e10 (range 4.0–9.12). This resulted in a mean of 2.78 × 10e9 granulocytes transfused per kg recipient weight (range 0.76–4.48). All patients tolerated the infusions well, without respiratory symptoms. The mean increase in absolute neutrophil count posttransfusion was 1.95 × 10e3/uL (range 0.5–4.61), although the timing of collection of the blood count samples was variable for each transfusion. Using a dihydrorhodamine (DHR) fluorescence based assay we were able to track the presence of oxidase positive cells to help differentiate transfused donor from residual host cells. DHR assays were performed before and after every transfusion in one patient. The number of DHR positive cells prior to infusion was 0–1.4% with a rise to 68.2% 24 hours after transfusion. 24.5% oxidase positive cells were still detectable almost 72 hours after transfusion, just prior to the next transfusion. One product required sedimentation for ABO incompatibility. The mean time to engraftment was 22 days and did not differ in patients with CGD receiving the same transplant regimen with (n=4) or without (n=6) peri-transplant granulocyte transfusions (30 days). Although all four patients had infectious processes not responding to standard antimicrobial therapy prior to transplant, there was no evidence of progressive infection during the period of neutropenia. Imaging studies of the brain, lung and/or spine suggested improvement in the infectious process in all four patients, although the timing of the scans made assessments inconclusive. Our prior experience with granulocyte transfusions in patients with CGD not undergoing transplant is that the cells do not persist in the circulation longer than 24 hours. Higher cell doses per kg in our four patients may have contributed to the sustained detection of transfused circulating cells, particularly as three of the patients weighed less than 21 kg. Peri-transplant immune suppression may also have facilitated the longer circulation time of the cells. We conclude that community-donor granulocyte transfusions are well tolerated in non-alloimmunized CGD patients undergoing HSCT, do not impact engraftment, are logistically feasible, and may provide a therapeutic bridge for patients with an underlying infection during a prescribed period of neutropenia, thus decreasing transplantation risk for such patients. Disclosures:No relevant conflicts of interest to declare.

Revisiting the Use of Granulocyte Transfusions in Pediatric Oncology Patients

To describe the clinical course of neutropenic pediatric oncology patients undergoing granulocyte transfusions (GTF). Retrospective chart review including all children receiving GTFs between March, 1998 and June, 2000. Tertiary Children's Hospital and Regional Medical Center. Thirteen pediatric oncology patients (age, 9 mo to 16 y) with neutropenia and proven or suspected serious infection. These 13 patients received a total of 14 courses of GTFs (number of transfusions per course ranged from 1 to 43, median=4.5). Twelve of the patients had documented infections before GTF. Ten of the 14 courses (71%) were followed by survival to hospital discharge. All 5 patients who were intubated before GTF were extubated afterward. Two early deaths occurred due to invasive Aspergillus. No significant differences in monitoring laboratories were found. Ultimately, 8 of 13 (62%) patients in this group died. This case series documents the course of 13 septic neutropenic pediatric oncology patients who underwent a total of 14 GTF courses. GTFs were generally well tolerated with little decline in respiratory status or organ function. Short-term survival in this population was good whereas long-term outcome remains more difficult.

Defining effective therapies in transfusion medicine and hemostasis: new opportunities with the TMH Network

Defining effective therapies in transfusion medicine and hemostasis: new opportunities with the TMH Network

Granulocyte transfusions for neonates with confirmed or suspected sepsis and neutropaenia.

Neonatal sepsis causes significant neonatal mortality and morbidity. Neonates, especially preterm infants, have an immaturity of granulopoeisis and have a limited capacity for progenitor cell proliferation. This results in the frequent occurrence of neutropaenia in septic neonates. Neutropaenic septic neonates have a higher mortality than neonates who are septic but not neutropaenic. Transfusion of granulocytes to septic neutropaenic neonates, therefore, may help reduce mortality and morbidity. The primary objective of this review was to determine the efficacy and safety of granulocyte preparations (granulocyte and buffy coat transfusions) as adjuncts to antibiotics for the treatment of confirmed or suspected sepsis in neonates with neutropaenia in reducing all-cause mortality during hospital stay and adverse neurological outcome at a year of age or later. Secondary objectives were to determine the effects of granulocyte transfusions on length of hospital stay in survivors to discharge, adverse effects (fluid overload, transmission of blood borne infections, pulmonary complications and sensitisation to donor leukocyte antigens) and immunologic outcomes at a year of age or later. Searches for eligible trials were made in September 2002 of the following electronic databases: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2002), MEDLINE, EMBASE, CINAHL. The proceedings of the Pediatric Academic Societies, which were published in the journal, Pediatric Research, were searched from 1987 onwards. The Cambridge Database of Scientific Abstracts (1982 onwards) and Dissertation Abstracts on disc (1960 onwards) were also searched. Communications with prominent authors in the field and additional searches in the reference lists of identified trials were performed Randomised and quasi-randomised studies were included, if the participants were neonates with suspected or confirmed sepsis and neutropaenia who received granulocyte preparations (granulocyte concentrates prepared by leukophoresis or buffy coat transfusions prepared by simple centrifugation of blood) at any dose or duration compared with placebo or no granulocyte transfusion, each as adjuncts to antibiotics or compared to other adjuncts to antibiotics to treat sepsis (e.g. intravenous immunoglobulin). Studies were included if any of the following outcomes were reported: all-cause mortality during hospital stay, neurological outcome at one year of age or later, length of hospital stay in survivors at discharge, adverse effects or immunological outcome at one year or later Trials identified by the search strategy were assessed for eligibility for inclusion in the review. Full text versions of the eligible trials were obtained. Data of interest were extracted on paper forms. Relative risk (RR) and risk difference (RD) with 95% confidence intervals using the fixed effects model were reported for dichotomous outcomes. Pre-specified subgroup analyses were done and reported. Four eligible studies were identified. A total of 44 infants with sepsis and neutropaenia on antibiotics were randomised in three trials to granulocyte transfusions OR placebo/no transfusion. In another trial, 35 infants with sepsis and neutropaenia on antibiotics were randomised to granulocyte transfusion or intravenous immunoglobulin. When granulocyte transfusions were compared with placebo or no transfusion, there was no significant difference in all-cause mortality [typical RR 0.89 (95% CI 0.43, 1.86), typical RD -0.05 (95% CI -0.31, 0.21)]. There was no statistical heterogeneity in the results of the included trials. When granulocyte transfusions were compared with intravenous immunoglobulin, there was a reduction in all-cause mortality of borderline statistical significance [RR 0.06 (95% CI 0.00, 1.04), RD -0.34(95% CI -0.60, -0.09), NNT 2.9 (95% CI 1.7, 11.1)]. Pulmonary complication, seen in four infants (4%), was the only adverse effect reported. This adverse effect was noticed in the two trials which used buffy coat transfusions. None of the trials reported on neurological outcome at one year of age or later, length of hospital stay in survivors to discharge or immunological outcome at one year of age or later. Currently, there is inconclusive evidence from RCTs to support or refute the routine use of granulocyte transfusions in neonates with sepsis and neutropaenia to reduce mortality and morbidity. Researchers can be encouraged to conduct adequately powered multicentre trials of granulocyte transfusions to clarify their role in neonates with sepsis and neutropaenia. Other adjuncts to antibiotics aimed at improving host defence mechanisms such as colony stimulating factors, IVIG and pentoxifylline should also be tested in RCTs.

Granulocyte concentrates: how can we assess their quality?

The use of granulocyte transfusions to treat and prevent life-threatening infection in patients lacking neutrophil numbers or function may become increasingly important in aiding advances in the treatment of haematological malignancies. A critical factor in determining the outcome of granulocyte transfusion is the number of cells transfused, and collection of sufficiently high concentration of cells from donors remains challenging. A number of tests of granulocyte function can be performed in vitro to assess the quality of granulocyte concentrates, which may be useful in helping to optimize granulocyte collection, processing and storage methods. Studies that have examined neutrophil function in granulocyte concentrates to date have tended to focus on the assessment of viability, chemotaxis, phagocytosis and oxidative killing. How useful in vitro tests of neutrophil function are in predicting neutrophil function following granulocyte transfusion remains to be established in conjunction with well-designed clinical trials.

Genetic, biochemical, and clinical features of chronic granulomatous disease.

The reduced nicotinamide dinucleotide phosphate (NADPH) oxidase complex allows phagocytes to rapidly convert O2 to superoxide anion which then generates other antimicrobial reactive oxygen intermediates, such as H2O2, hydroxyl anion, and peroxynitrite anion. Chronic granulomatous disease (CGD) results from a defect in any of the 4 subunits of the NADPH oxidase and is characterized by recurrent life-threatening bacterial and fungal infections and abnormal tissue granuloma formation. Activation of the NADPH oxidase requires translocation of the cytosolic subunits p47phox (phagocyte oxidase), p67phox, and the low molecular weight GT-Pase Rac, to the membrane-bound flavocytochrome, a heterodimer composed of the heavy chain gp91phox and the light chain p22phox. This complex transfers electrons from NADPH on the cytoplasmic side to O2 on the vacuolar or extracellular side, thereby generating superoxide anion. Activation of the NADPH oxidase requires complex rearrangements between the protein subunits, which are in part mediated by noncovalent binding between src-homology 3 domains (SH3 domains) and proline-rich motifs. Outpatient management of CGD patients relies on the use of prophylactic antibiotics and interferon-gamma. When infection is suspected, aggressive effort to obtain culture material is required. Treatment of infections involves prolonged use of systemic antibiotics, surgical debridement when feasible, and, in severe infections, use of granulocyte transfusions. Mouse knockout models of CGD have been created in which to examine aspects of pathophysiology and therapy. Gene therapy and bone marrow transplantation trials in CGD patients are ongoing and show great promise.

Resolution of pulmonary and vertebral aspergillosis in a child with CGD following combined use of granulocyte transfusions and voriconazole

Resolution of pulmonary and vertebral aspergillosis in a child with CGD following combined use of granulocyte transfusions and voriconazole