Successful stem cell harvest and autologous transplantation in a patient with cold agglutinin syndrome and aggressive lymphoma

Approach to autologous stem cell transplantation in a patient with severe cold agglutinin disease, a case report

BACKGROUND

Cold agglutinin disease (CAD) or syndrome (CAS) can be particularly challenging when autologous stem cell transplant (ASCT) is needed. Standard peripheral blood stem cell (PBSC) collection and manipulation involve ex vivo blood manipulations at lower than body temperature, predisposing to agglutination during graft collection, handling, processing, and infusion.

STUDY DESIGN AND METHODS

We describe the first case of ASCT for relapsing lymphoma in a patient with high-titer CAD requiring anti-complement therapy and chronic transfusion. To prevent agglutination, five therapeutic plasma exchange sessions were performed prior to PBSC collection. Optimal thermal conditions were maintained using various approaches to increase the temperature of the room, venous return lines, and the apheresis device. Ex vivo graft manipulation was conducted under similar conditions. An infusion test was performed with a fraction of the graft a month prior to ASCT to confirm tolerability.

RESULTS

The infusion test was performed without complications. A month later, the patient was admitted for ASCT. The aplasia phase was particularly challenging, as the patient experienced a rapid drop in hemoglobin levels due to hemolysis without compensatory reticulocytosis. Twelve months after ASCT, chronic hemolysis persists, but the patient is now transfusion-free, and the lymphoma remains in remission.

DISCUSSION

Performing ASCT in patients with clinically significant CAS or CAD is challenging but can be done safely. Strong coordination between the apheresis team, cell therapy laboratory, and clinical unit is paramount to the success of this procedure. The experience gained from this case may also be applicable to other cell therapy procedures.

Collection and processing of hematopoietic progenitor cell products at risk of presenting with cold agglutination

BACKGROUND AIMS

Cold agglutinins are commonly identified in transfusion laboratories and are defined by their ability to agglutinate erythrocytes at 3-4°C, with most demonstrating a titer >64. Similarly, cryoglobulins can precipitate from plasma when temperatures drop below central body temperature, resulting in erythrocyte agglutination. Thankfully, disease associated from these autoantibodies is rare, but unfortunately, such temperature ranges are routinely encountered outside of the body's circulation, as in an extracorporeal circuit during hematopoietic progenitor cell (HPC) collection or human cell therapy laboratory processing. When agglutination occurs ex vivo, complications with the collection and product may be encountered, resulting in adverse events or product loss. Here, we endeavor to share our experience in preventing and responding to known cases at risk of or spontaneous HPC agglutination in our human cell therapy laboratory.

CASE REPORTS

Four cases of HPC products at risk for, or spontaneously, agglutinating were seen at our institution from 2018 to 2020. Planned modifications occurred, including ambient room temperature increases, tandem draw and return blood warmers, warm product transport and extended post-thaw warming occurred. In addition, unplanned modifications were undertaken, including warm HPC product processing and plasma replacement of the product when spontaneous agglutination of the product was identified. All recipients successfully engrafted after infusion.

CONCLUSIONS

While uncommon, cold agglutination of HPC products can disrupt standard processes of collection and processing. Protocol modifications can circumvent adverse events for the donor and minimize product loss. Such process modifications should be considered in individuals with known risks for agglutination going to HPC donation/collection.

How do I warm HPC(A) products to maximize cell viability in the setting of cold agglutinin disease?

BACKGROUND

High titers of cold agglutinins jeopardize the quality of an apheresis product meant for autologous or allogeneic transplant. Management of transplant patients with cold agglutinin disease (CAD) is often experience-based and under reported, yet decisions must be made quickly to optimize product management and patient outcomes. There remains a lack of data quantifying cell recovery and viability when using various warming methodologies.

STUDY DESIGN AND METHODS

To expand the published experimental data on this subject, our human cellular therapy lab compared cellular recoveries and viabilities after manipulation of cryopreserved apheresis products through various warming methodologies: (1) extended warming in a water bath, (2) warming via blood warmer and infusion pump, and (3) warming in a water bath followed by infusion pump as a control to assess potential shear stress effects.

RESULTS

The presented studies demonstrate that all methods of product warming produce the same rates of recovery of total and viable cells across vital cell types prior to patient administration. Statistically, use of an extended water bath protocol provided a marginal benefit in recovery of total nucleated cells, though this effect is diminished when products are held for an extended period to simulate a delay in administration.

DISCUSSION

These results can inform decisions to improve patient care and minimize product manipulation and loss. Centers are encouraged to use this information to guide proactive measures to establish a standard operating procedure to manage CAD cases.