Safety and survival outcomes for bloodless transplantation in patients with myeloma

Increased blood transfusion after outpatient autologous transplantation with reduced intensity conditioning for hematological malignancies predicts worse outcomes

Transfusion has a recognized immunomodulatory effect, and its role on the outcomes after an ambulatory autologous hematopoietic stem cell transplantation (auto-HSCT) following reduced intensity conditioning (RIC) has not been documented. A study to assess factors associated with the number of packed red blood cells (PRBCs) and platelet units transfused and their impact on survival rates of auto-HSCT recipients after RIC was conducted between 2013 and 2019. Transfusions were recorded from days 0 to 100. Of the 130 patients studied, seventy (53.9%) required transfusion support. The median number of PRBC transfused was 2 (range 1-20), and for platelets, it was also 2 units (range 1-19). Infused CD34 + cells/kg, pre-transplant CMV status, and relapse/progression were significantly associated with the number of PRBC units transfused and sex, infused CD34 + cells/kg, and pre-transplant CMV status with the number of platelet units transfused. In multivariate analysis, a high/very high Disease Risk Index (P = .001) (P = .001) and transfusion of ≥ 5 total blood products (P = .001) (P = .010) were associated with decreased disease-free and overall survival. Two-year cumulative incidence of relapse was 50% for transfused patients vs. 34% for those not transfused (P = .009). These data suggest that the transfusion burden and its interplay with other patient and transplant-related factors could be associated with inferior auto-HSCT outcomes.

Safety of bloodless autologous stem cell transplantation in Jehovah's Witness patients

Due to the curative potential and improvement in progression-free survival (PFS), high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is considered the standard of care for several hematologic malignancies, such as multiple myeloma, and lymphomas. ASCT typically involves support with blood product transfusion. Thus, difficulties arise when Jehovah’s Witness patients refuse blood transfusions. In order to demonstrate the safety of performing “bloodless” ASCT (BL-ASCT), we performed a retrospective analysis of 66 Jehovah's Witnesses patients who underwent BL-ASCT and 1114 non-Jehovah’s Witness patients who underwent transfusion-supported ASCT (TF-ASCT) at Cedars-Sinai Medical Center between January 2000 and September 2018. Survival was compared between the two groups. Transplant-related complications, mortality, engraftment time, length of hospital stay, and number of ICU transfers were characterized for the BL-ASCT group. One year survival was found to be 87.9% for both groups (P = 0.92). In the BL-ASCT group, there was one death prior to the 30 days post transplant due to CNS hemorrhage, and one death prior to 100 days due to sepsis. Based on our data, BL-ASCT can be safely performed with appropriate supportive measures, and we encourage community oncologists to promptly refer JW patients for transplant evaluation when ASCT is indicated.

A Review of Growth Factor Support in Bloodless Autologous Hematopoietic Stem Cell Transplant

Bloodless autologous hematopoietic cell transplantation is associated with risks of severe bleeding and profound anemia. RBC or platelet transfusions are often used to prevent these hematologic complications. However, in patients such as Jehovah's Witnesses who refuse major blood components, the lack of transfusion support is not an absolute contraindication to an autologous hematopoietic cell transplant. Pennsylvania Hospital performed the world's first bloodless hematopoietic cell transplant more than 15 years ago and has gradually improved its technique with a sizable patient population. Erythropoiesis-stimulating agents were successfully employed as part of their pretransplant regimen to prevent severe anemia. Thrombopoietin agonists' potential role in bloodless transplant is also currently being explored. Although there is limited literature, available reports in combination with physiologic reasoning may support the use of these growth factors to promote transplant success. These agents offer potential benefit and may be of utility in minimizing complications of a bloodless transplant. In this review, we summarize the available literature and offer insight into how we may incorporate growth factors to allow bloodless autologous hematopoietic cell transplantation to be an available option to patients who may otherwise be denied.