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

Granulocyte Transfusion: Clinical Updates and a Practical Approach to Transfusion

Neutrophils are an integral component of the innate immune system and key regulators of cell-mediated defense against bacterial and fungal pathogens. The potential of granulocyte transfusions has been investigated to temporarily replenish innate immune function to prevent and/or treat infections in patients with severe neutropenia or neutrophil dysfunction. However, evidence has been largely theoretical, experimental, and/or inconclusive. Clinical efficacy has yet to be confirmed by large-scale randomized controlled clinical trials. Performing such trials has been hampered by low granulocyte collection yield and poor patient accrual. We provide a practical summary of the current literature surrounding the practice of granulocyte transfusion.

Granulocyte transfusions in the management of invasive fungal infections

Granulocyte transfusions have a long history of being used in patients with neutropenia or neutrophil dysfunction to prevent and treat invasive fungal infections. However, there are limited and conflicting data concerning its clinical effectiveness, considerable variations in current granulocyte transfusion practices, and uncertainties about its benefit as an adjunct to modern antifungal therapy. In this review, we provide an overview on granulocyte transfusions and summarize the evidence on their role in the prevention and treatment of invasive fungal infections.

Bacterial Sepsis in the Newborn Infant: Developmental Deficiencies in Neutrophils and the Role of Neutrophil Transfusion

Bacterial sepsis is an important cause of morbidity and mortality in newborns. Group B streptococci and Es cherichia coli are the primary causative organisms. New and theoretically more effective antibiotics have not im proved survival. Because the neonate has defects in the immune response, new forms of therapy may be able to improve outcome by correcting or circumventing those deficiencies. The neutrophil has a substantial role in antibacterial defense, yet neonatal neutrophil function is limited by impaired chemotaxis, phagocytosis, and in tracellular killing. The supply of neonatal neutrophils is restricted by a small neutrophil reserve, a delay in mobilization of neutrophils from the bone marrow re serve after bacterial invasion, a small granulocytopoietic progenitor cell reserve, and a limited ability to acceler ate proliferation of progenitor cells during bacterial in fection. Recent studies of neutrophil transfusions in in fected neonates suggest a beneficial effect at least in certain situations. Exchange transfusion with fresh whole blood may be an alternative to transfusion with neutro phils obtained by apheresis. The ultimate role of neutro phil transfusions as an adjunct therapy for neonatal sep sis remains to be determined.

Granulocyte transfusions in neutropaenic children: a systematic review of the literature

BACKGROUND

Granulocyte transfusions (GTX) have been used for decades in paediatric neutropaenic patients, but uncertainty remains regarding their effectiveness. We reviewed all the paediatric data available on GTX, to gain a insight in to the indications for use, favourable effects and side effects in patients and donors.

METHODS

A comprehensive search was done in MEDLINE, EMBASE, LILACS and CENTRAL (1966 until 2006). All studies including children (1-18 years) who received GTX were included.

RESULTS

A total of 66 observational studies were included:Seven using prophylactic and 59 therapeutic GTX. Of the therapeutic studies 55 reported a proven sepsis caused by Gram-negative bacteria (34%) or fungal disease (48%) as the indication for GTX. Concerning effectiveness 70% survival was reported, but no controlled studies were identified. Side effects were mentioned in 27 studies including mild respiratory symptoms, allergic reactions and infection related complications (CMV). Side effects in the donor were mainly flu-like illness.

DISCUSSION

In this first review covering 30 years of experience on the use of GTX in children, we found no randomised evidence showing a positive benefit risk ratio. The available case reports and cohort studies alert us as to the potential benefits and harms of the use of GTX in neutropaenic children and provides the basis for a well designed trial in children.

Granulocyte transfusions--a review for the intensive care physician

In order to achieve the maximum therapeutic benefit in the treatment of malignancies, doses of chemotherapeutic agents are pushed to the point of severe marrow toxicity. This aggressive therapy can lead to iatrogenic complications including haemorrhage and sepsis due to the depletion of platelets and granulocytes. Prior to the advent of platelet transfusions, haemorrhage was the leading cause of death in these patients. Advances in blood banking and the availability of platelet transfusions have markedly decreased the incidence of fatal haemorrhage. As a result, infection has become the leading cause of death in patients with marrow failure. Although the risk of infection in patients with neutropenia has been well documented, the role of granulocyte transfusions in the treatment and prevention of these infections remains controversial. This paper will attempt to review the currently available literature regarding granulocyte procurement techniques and the efficacy of granulocyte transfusions.

Transplacentally transferred dermatoses

Transplacentally transferred dermatoses (TTDs) are cutaneous diseases that are transmitted from mother to fetus through the placental circulation. The uniqueness of the maternal-placental-fetal interaction provides many helpful opportunities to enhance our understanding of the pathogenesis and course of these diseases.

Graft versus host disease following transfusion of normal blood products to patients with malignancies

A patient undergoing treatment with cytotoxic chemotherapy for Hodgkin's disease developed graft versus host disease (GVHD) following a transfusion of packed red cells. This is the 28th reported patient with a malignancy who did not have a bone marrow transplant and developed GVHD after transfusion of normal blood or blood products. All patients had received cytotoxic chemotherapy prior to acquiring GVHD. The underlying malignancies included lymphoma, acute leukemia, neuroblastoma, rhabdomyosarcoma, and glioblastoma. Twenty-three of the 28 patients died of GVHD. The incidence of transfusion-related GVHD in this patient population is low but the illness is often fatal as treatment is largely ineffective. Transfusion-related GVHD can be prevented by irradiating all blood products with 1500 rad prior to administration.

Rationale and recommendations for the irradiation of blood products

Blood products are often irradiated to prevent proliferation of lymphocytes which could cause graft-vs.-host disease in immunocompromised recipients. The effects of irradiation on the function of blood components is discussed. It is concluded that 1500 rad is sufficient to prevent lymphocyte proliferation and production of graft-vs.-host disease in vivo, although 10 to 20% of lymphocytes are still capable of proliferation in vitro after 1500 rad. Neutrophils and erythrocytes are extremely radioresistant and their function is unaffected by 1500 rad. There is limited data to suggest that platelet yields may be slightly reduced following irradiation. Guidelines for the use of irradiated blood products are suggested.

Transfusion of circulating stem cells

Bone marrow collected from all species including man contains specific cells, putative pluripotential stem cells, capable of reestablishing hemopoiesis in a syngeneic or genetically identical member of the same species which has been treated with whole body irradiation. The question of whether similar pluripotential stem cells are present in the circulation in all animals is not yet resolved. In mice, reconstitution of hemopoiesis can be achieved by transfusion of peripheral blood cells only. The same result can be obtained in dogs and probably in baboons. In dogs, experiments with fresh and cryopreserved blood mononuclear cells have confirmed a dose-response relationship--below a certain number of mononuclear cells failure of hemopoietic reconstitution can be predicted. In man, isolated anecdotal case reports suggest that pluripotential stem cells in the circulation may or may not be valuable in repopulating a bone marrow defective as a result of primary disease or following chemotherapy. Indirect evidence from in vitro culture of circulating myeloid progenitor cells suggests but does not prove that pluripotential stem cells circulate in normal man. Pluripotential stem cell numbers are probably greatly increased in the circulation in patients with chronic granulocytic leukemia: such cells can be collected, cryopreserved, and used at a later date as "bone marrow autografts". Whether circulating stem cells can be collected and used in an analogous manner for patients with other leukemias or other neoplasms is not yet established.

Human posttransfusion graft-versus-host disease

Graft-versus-host disease (GVDH) follows blood product transfusions in patients with deficient cell-mediated immunity. The rate of mortality in this adverse effect of blood transfusions is between 90 and 100%. The historical; clinical and pathologic; and mechanism of acute and chronic GVHD are presented. The patients at risk, the clinical and pathologic features of posttransfusion GVDH have been presented in hopes that, with increased awareness of this usually fatal complication, clinicians and transfusion therapists may more intelligently advise and select patients who may need lymphocyte-poor or irradiated blood products and may recognize the syndrome earlier.

Graft-versus-host reaction in 3 adult leukaemia patients after transfusion of blood cell products

We describe 3 cases of acute graft-versus-host (GVH) disease in patients with acute myeloid leukaemia following transfusions taken from non-HLA-identical healthy donors. The leucocyte transfusions were given because of severe bone marrow aplasia and granulocytopenia following leukaemia induction treatment. The first patient had an acute GVH reaction with an erythrodermia-like skin reaction all over and associated with severe abdominal cramping, enlarged liver and pathological liver function tests. The second patient had a relatively mild skin reaction and enlarged liver. Both died of severe pulmonary infection. The third patient also had a mild skin reaction and enlarged liver. He died of pulmonary embolism. The diagnosis of GVH of the latter 2 cases was made on skin biopsy. The autopsy samples revealed in all cases a heavy lymphocytic infiltration of the kidneys and liver portal area. Until more precise guidelines can be established, irradiation of blood cell products given to patients with neutropenia due to leukaemia induction treatment should be considered.

Autologous cryopreserved platelets and prophylaxis of bleeding in autologous bone marrow transplantation

Autologous platelets were harvested and cryopreserved in eight consecutive patients elected for ablative chemotherapy and autologous bone marrow transplantation (ABMT) for solid malignancy. There was a 19% loss in platelet count after the freeze thaw and wash procedure; with an in vitro functional loss of 40-60%. No correlation could be found for individual platelet transfusions between in vitro functional tests and in vivo recovery. Six consecutive patients received a total of 16 autologous platelet transfusions in the aplastic phase of ABMT. No bleeding was observed during the study period and there was no CMV infection in the recipients. While improvement in freezing and subsequent handling is desirable, autologous cryopreserved platelets can safely be used for the prophylaxis of bleeding during aplasia in patients treated with ABMT.

The MHC in human bone marrow allotransplantation

In this chapter, we have considered the theoretical and practical background of bone marrow transplantation. The immune response and its regulation by genes within the major histocompatibility complex, particularly of the I region of the mouse and of the HLA-D/DR region in man, is of central importance in both graft acceptance (rejection) and graft-versus-host disease. Methods which are available for typing alleles at the HLA-A, -C, -B, -DR and complotype (BF, C2, C4A, C4B) loci, have been considered in detail. The extent to which recombination affects specific alleles on haplotypes within families is discussed, as is the occurrence of linkage disequilibrium and extended haplotypes in populations of unrelated individuals. Because the HLA-DR and complotype region in man is thought to be critical for the success of bone marrow transplantation, methods for typing of HLA-D by both the HTC and PLT approaches have been examined. Although HLA-D/DR assignments are easily made in normal subjects, they are ambiguous in about 50 per cent of candidates for bone marrow transplantation, including, particularly, patients with aplastic anaemia, leukaemia, and severe combined immunodeficiency. In this setting, it is particularly important to obtain additional information by modification of HLA-D typing procedures and through complotype and GLO allele determinations in all family members. Finally, we can hope that there will be an increased possibility of using non-family donors through methods for removing cytotoxic T cells from donor marrow and through the identification, in the general population, of individuals who are genotypically similar or identical to the recipient. In this regard, the recognition that some 30 per cent of chromosome 6 in caucasians (50 per cent of individuals) bear extended haplotypes, which include a relatively fixed set of alleles particularly in the HLA-B, -DR, complotype and GLO regions, offers considerable promise.

Transfusion therapy with platelets and leukocytes

Supportive care of the child with leukemia and solid tumors has improved dramatically due to advances in blood component preparation and use. Despite these advances, unsolved questions remain which will require research into better component preparation and randomized clinical trials. The prevention of post-transfusion graft-vs-host disease in the immunocompromised patient will require research into optimum radiation dosages for blood products and the appropriate choice of patients to receive these products. Alloimmunization to platelet concentrates will continue to be a problem as children receive more ablative cancer therapy. The use of leukocyte-poor platelets and allogeneic cryopreserved platelets may aid some of these patients, but the value of these products needs to be proven by more clinical trials. Finally, crossmatching of platelet products may become more readily available and may prove useful for more adequate selection of donors. If bone marrow transplantation becomes a therapeutic modality following remission induction for a large number of leukemic patients, the use of blood products pretransplantation will require intense investigation. Graft rejection in these children may be linked to the kind, number, and cytomegalovirus status of blood products given during their acute leukemic phase. The blood bank provides an important resource for procurement of blood products and for specialized product preparation. In addition, it should serve as a resource for new ideas and experimental blood products for use of the clinician caring for the child with cancer.

Graft-versus-host reaction following blood product transfusion

The observation of graft-versus-host (GVH) reaction after platelet transfusion in a patient with Hodgkin's disease led us to analyze 38 reported cases in the literature, to outline prognostic factors and to characterize patients at risk. Overall mortality was 68 percent. It was higher among children (76 percent) than among adults (62 percent), and among patients with Hodgkin's disease and immune deficiency syndromes (88 percent) than among those with leukemias (23 percent, p less than 0.005). Following blood transfusions from normal donors, mortality was higher (88 percent) than after transfusions from donors with chronic myelocytic leukemia (25 percent, p less than 0.05). Minimal lymphocyte doses necessary to cause GVH reaction are in excess of 10(7)/kg. Adults seem more resistant to homografts than do children, and the host's cellular immune status is of major prognostic importance. Lymphocytes from donors with chronic myelocytic leukemia may be deficient, and after a threshold dose, the number of lymphocytes transfused does not correlate with clinical outcome. Effective prophylactic measures do exist for this complication but satisfactory therapy does not.

High-dose cyclophosphamide chemotherapy for recurrent CNS tumors in children

A Phase Ii chemotherapy trial was conducted in 18 children with recurrent brain tumors, using high doses (80 mg/kg or greater) of intravenous cyclophosphamide cyclophosphamide. All eight patients with medulloblastomas responded; two patients with systemic metastases had complete responses and six others had partial responses. In seven patients with gliomas, there were one complete and four partial responses. In a third group, all three patients with intracranial germ-cell tumors had partial responses. The overall response rate was, therefore, 89% (16 of 18 patients), and the mean duration of response was 7 months (range 2 to 24 or more months). The hematological toxicity was considerable, with two deaths possibly related to chemotherapy: one patient, a recipient of unirradiated packed cells, died from a graft versus host reaction, and the other died from an intracranial hemorrhage during a thrombocytopenic episode. Four patients had prior chemotherapy, and 10 patients had prior neuraxis radiation therapy. These patients tolerated aggressive chemotherapy reasonably well. The results are sufficiently encouraging to justify a Phase III trial in patients with newly diagnosed disease.

A controlled trial of prophylactic granulocyte transfusions during initial induction chemotherapy for acute myelogenous leukemia

To evaluate the role of prophylactic granulocyte transfusions during remission-induction chemotherapy for acute myelogenous leukemia (AML) we randomized 102 infected patients either to receive daily granulocyte transfusions when blood granulocytes fell below 0.5 x 10(9) per liter (54 patients) or not to receive them (48). Although the percentage of patients acquiring any infection was similar in the transfusion and control groups (46 and 42 per cent, respectively), granulocyte transfusions decreased the proportion of patients with bacterial septicemia (9 per cent of those with transfusions vs. 27 per cent of the controls; P = 0.01). Granulocyte transfusions did not reduce the incidence of other infections or improve bone-marrow recovery, remission rate and duration, or survival. Seventy-two per cent of the patients given transfusions had transfusion reactions. Pulmonary infiltrates were more common in the transfusion group than in the control group (57 per cent vs. 27 per cent; P = 0.002). Thirty-five per cent of the patients with pulmonary filtrates died, as compared with 5 per cent of those without filtrates. We conclude that prophylactic granulocyte transfusions should not be used during remission-induction chemotherapy in AML because the risks outweigh the benefits.

Effect of in vitro X-irradiation on lymphocyte and granulocyte function

Granulocyte transfusions have been complicated by graft-versus-host disease (GVHD) in the recipients. This risk can be eliminated by irradiation of the cell product. The effect of in vitro irradiation on elements of lymphocyte and granulocyte function was therefore studied in order to determine the dose of irradiation which blocked lymphocyte function without affecting the function of granulocytes. Lymphocyte blast transformation after stimulation with mitogens was reduced by 90% after irradiation with 1500 rad and by 97% after 5 000 rad. The response to microbial agents and allogeneic cells was far more radio-sensitive, being completely abolished after irradiation with 1 000 and 500 rad, respectively. Mobility was the function of polymorphonuclear leucocytes (PMN) most affected by irradiation, being slightly but significantly reduced after irradiation with 10 000-20 000 rad. The bactericidal activity was reduced only after irradiation with 40 000 rad or more, while the hexose monophosphate shunt activity and the myeloperoxidase activity were largely unaffected by irradiation with doses of up to 120 000 rad. Hence the results indicate that the irradiation of leucocytes intended for transfusion with a dose of 2 000 rad is likely to prevent GVHD without causing any apparent damage to the PMN.

Graft-versus-host disease in consecutive patients with acute myeloid leukaemia treated with blood cells from normal donors

Two consecutive patients with acute myeloid leukaemia (AML) developed severe probable graft-versus-host disease (GVHD) following transfusion of blood products from normal donors. In one patient the AML had arisen de novo, while in the other it occurred four years after the patient developed non-Hodgkin's lymphoma (NHL) and was treated with radiotherapy and combination cytotoxic chemotherapy. Both patients received anti-leukaemic treatment with doxorubicin and cytosine arabinoside and intensive haematological supportive care with transfusions of red cell, white cell and platelet concentrates obtained from normal donors. Clinically the GVHD in each patient was manifest by a severe erythematous rash, intractable diarrhoea and abnormalities in the liver function tests. On pathological examination the skin in each case showed the typical changes of GVHD. Both patients died. There have been few previous reports of GVHD occurring after accidental engraftment of immunosuppressed patients undergoing therapy for acute leukaemia. Our experience suggests that it may occur more often than has hitherto been recognised. At present there is controversy concerning the possible anti-leukaemic effects of granulocyte transfusions. Until the relative importance of the benefits and deleterious effects of cells with the potential for engraftment is determined by further studies, we recommend the routine irradiation of all cellular blood products intended for administration to acute leukaemia patients undergoing intensive cytoreductive chemotherapy.

Toxic epidermal necrolysis

Toxic epidermal necrolysis is one of the rarest events -- a dermatologic emergency. The clinical presentation is characteristic -- disseminate erythema and widespread bullous necrosis of the epidermis and mucous membranes. Toxicity is universal and mortality is substantial even with prompt and intensive therapy. Drugs are the most commonly incriminated agents and therapy remains controversial, the majority favoring high-dose systemic corticosteroids.

Acute nonlymphocytic leukemia

The discovery of cytosine arabinoside, and then the anthrocycline antibiotics, 6-thioguanine, vincristine, cyclophosphamide, and other drugs, has added to the armamentarium of known effective agents. The use of combination chemotherapy, the recognition of the need during induction for virtual marrow aplasia to obtain a remission, and recognition of the predilection of the disease for the central nervous system requiring prophylaxis constitute major advances. The impediment to long-term survival is the lack of effective maintenance therapy.

Cure of aplastic anaemia in paroxysmal nocturnal haemoglobinuria by marrow transfusion from identical twin: Failure of peripheral-leucocyte transfusion to correct marrow aplasia

The ability of syngeneic peripheral leucocytes to cure marrow aplasia was tested in a patient with paroxysmal nocturnal haemoglobinuria (P.N.H.). Transfusion of 7.1X10(10) white cells obtained by leucopheresis from an identical-twin donor, providing 3.4X10(4) myeloid progenitors (C.F.U.-C)/kg, failed to improve marrow function within two months. In contrast, transfusion of 1.3X10(10) nucleated bone-marrow cells, representing 6.4X10(4) C.F.U.-C/kg, from the same donor resulted in prompt bone-marrow recovery. These observations support the hypothesis that aplastic anaemia in P.N.H. is a stem-cell defect that may be corrected by the simple infusion of relatively small numbers of normal bone-marrow cells. They also seem to indicate a distinct advantage of marrow cells over peripheral-blood mononuclear cells in their ability to correct marrow aplasia.