Granulocyte transfusion therapy

Diagnostic accuracy of complete blood cell count and neutrophil-to-lymphocyte, lymphocyte-to-monocyte, and platelet-to-lymphocyte ratios for neonatal infection

Background

Complete blood cell (CBC) counts and neutrophil-to-lymphocyte (NLR), lymphocyte-to-monocyte (LMR), and platelet-to-lymphocyte ratios (PLR) are simple measurements that are conducted as part of routine diagnostic procedures.

Objective

To determine the diagnostic importance, specificity, and sensitivity of these measurements for the diagnosis of neonatal infections and in discriminating between neonatal sepsis and various other infections.

Methods

We conducted a retrospective study of data from a consecutive series of 232 neonatal patients admitted to Yildirim Beyazit University Yenimahalle Training and Research Hospital in Ankara for 2 years from 2016 to 2018. We included patients with a diagnosis of or clinically suspected infection, and healthy neonates were included as controls. Data included CBC counts, and bacterial culture results, considered the criterion standard for the diagnosis of neonatal sepsis. NLR, LMR, and PLR were calculated. We compared data using independent Student t and Mann-Whitney U tests and determined the sensitivity, specificity, and likelihood ratio (LHOR) of the characteristics for neonatal sepsis using receiver operating characteristic curve analyses.

Results

We included data from 155 neonatal patients with a diagnosis or suspicion of infection and 77 healthy neonates. NLR was significantly higher in neonates with sepsis or fever due to dehydration (P < 0.001) than in neonates with other infections or healthy neonates. LMR was significantly higher in neonates with sepsis or viral infection than in those with other infections or healthy controls (P = 0.003). In neonates with early-onset sepsis (EOS), we found cut-off values of ≥4.79 [area under curve (AUC) 0.845, 95% confidence interval (CI) 0.76-0.93, LHOR 11.6, specificity 98.7%, sensitivity 15%] for NLR, ≥1.24 (AUC 0.295; CI 0.18-0.41, LHOR 1.02, specificity 2.6%, sensitivity 100%) for LMR, and ≥37.72 (AUC 0.268; CI 0.15-0.39, LHOR 0.86, specificity 7.8%, sensitivity 80%) for PLR. We found cut-off values of ≥4.94 (AUC 0.667; CI 0.56-0.77, LHOR 4.16, specificity 98.7%, sensitivity 5.4%) for NLR and ≥10.92 (AUC 0.384; CI 0.26-0.51, LHOR 6.24, specificity 98.7%, sensitivity 8.1%) for LMR in those with late-onset sepsis (LOS).

Conclusions

CBCs, NLR, LMR, and PLR may be useful for the differential diagnosis of EOS and LOS, and neonates with sepsis from those with other infection. NLR may be a useful diagnostic test to identify neonatal patients with septicemia more quickly than other commonly used diagnostic tests such as blood cultures. NLR has high specificity and LHOR, but low sensitivity.

Management of the febrile neutropenic cancer patient: lessons from 40 years of study

Almost forty years ago the relationship between the circulating neutrophil count and the risk of pyogenic infection was established. Since that time, through the vehicle of clinical trials, much has been learnt about the etiologies, risk factors, pathogenesis, and natural history of first and subsequent febrile neutropenic episodes. Refinements to the empirical antibacterial management has reduced infection-related mortality to less than 10 percent. Algorithmic approaches to persistent fever in the setting of severe neutropenia have been developed. Circumstances wherein preventative strategies are most efficacious have been defined. Clinicians have learned that neutropenic patients comprise a heterogeneous population that does not encounter the same risks for infection-related morbidity and mortality. Tailored stratified approaches to management of the febrile neutropenic patient have been developed that are safe and cost-effective.

Granulocyte transfusion

PURPOSE OF REVIEW

Granulocyte transfusions have been used for more than four decades. Several issues have complicated the analysis of previous studies, including the utilization of improved antimicrobials, the effects of recipient alloimmunization and variable cell dose. The use of granulocyte colony-stimulating factor for donor stimulation has revived interest in granulocyte transfusion. The aim of this review is to evaluate the most recent studies in granulocyte transfusion therapy and their clinical applicability.

RECENT FINDINGS

Granulocyte colony-stimulating factor use has increased the granulocyte yield by approximately fourfold. Multiple recent studies have shown that granulocyte transfusions can be helpful in controlling severe infections progressing despite the use of appropriate antibiotics, with a response rate of 40-80% with variability in results depending on patient characteristics. This benefit is limited to a small patient population as the incidence of prolonged reversible neutropenia is relatively small. Severe side effects have been rare in those studies.

SUMMARY

Granulocyte transfusions are beneficial in neutropenic patients with severe uncontrolled infection. The underlying disease process is the major determinant of outcome in these patients. Because granulocyte transfusions are not commonly used, centers are not currently able to provide transfusions in a timely fashion. Nonalloimmunized patients can receive cells from nonmatched ABO compatible donors, while alloimmunized patients should receive granulocytes from either HLA-matched donors or donors selected by leukoagglutination or lymphocytotoxicity crossmatching. Further studies are needed to clarify the optimal starting time and frequency of transfusions, and the best method for identifying donor-recipient compatibility.

Collection of two consecutive neutrophil concentrates for transfusion from donors mobilized with glycosylated granulocyte-CSF plus dexamethasone

BACKGROUND

The objective of this study was to establish a mobilization and apheresis regimen for collection of two consecutive polymorphonuclear neutrophil (PMN) concentrates from the same donor.

STUDY DESIGN AND METHODS

In this prospective study, 111 healthy unrelated volunteers underwent either one (Group 1, n = 57) or two consecutive granulocyte apheresis procedure (Group 2, n = 54) using the a cell separator (Spectra). Both Group 1 and 2 donors were initially mobilized with glycosylated G-CSF 6.0 micro g per kg (range, 5.2-7.0 micro g/kg) subcutaneously plus oral dexa-methasone (DXM, 8 mg) and underwent granulocyte apheresis (GA-1) 16 hours (range, 13-18 hr) after initial G-CSF+DXM. Group 2 donors were remobilized with a second DXM dose of 8 mg (n = 13), 4 mg (n = 15), 1.5 mg (n = 13), or none (n = 13), and a second apheresis (GA-2) was run 40 hours (range, 37-42 hr) after G-CSF+DXM administration and 12 hours after remobilization with DXM alone.

RESULTS

Based on equivalent median preapheresis WBC and PMN counts of around 35 x 10(9) WBCs per L and 33 x 10(9) PMNs per L after initial mobilization the GA-1 yields were 85 x 10(9) PMNs per U (range, 34-150) in Group 1 and 75 x 10(9) PMNs per U (range, 35-135) in Group 2 (p = 0.14, NS). In Group 2, median preapheresis values of 19.6 x 10(9) WBCs per L (range, 9.5-37.0) and 16.6 x 10(9) PMNs per L (range, 8.8-34.8) were measured after remobilization and GA-2 yields of 49 x 10(9) WBCs per U (range, 26-113) and 42 x 10(9) PMNs per U (range, 21-95) were obtained. Borderline statistical differences in the GA-2 yields were observed from the remobilized donors: 8 mg: 36 x 10(9) PMNs per U (range, 23-60); 4 mg: 47 x 10(9) PMNs per U (range, 21-56) (p </= 0.04); 1.5 mg: 45 x 10(9) PMNs per U (range, 23-79); placebo: 36 x 10(9) PMNs per U (range, 26-95) (p </= 0.04).

CONCLUSION

Two consecutive neutrophil concentrates for transfusion can be obtained after single stimulation with Lenograstim+DXM. A second application of DXM alone is necessary, but of limited value.

Equivalent mobilization and collection of granulocytes for transfusion after administration of glycosylated G-CSF (3 microg/kg) plus dexamethasone versus glycosylated G-CSF (12 microg/kg) alone

BACKGROUND

The aim of this study was to find a regimen for mobilization and collection of granulocytes that combines low-dose G-CSF administration with satisfactory PMN mobilization and apheresis at a low rate of donor adverse reactions.

STUDY DESIGN AND METHODS

In a prospective study, 52 healthy unrelated volunteers received a single subcutaneous injection of glycosylated G-CSF (Lenograstim Chugai-Pharma, Frankfurt, Germany) at medians of 3.1 (range, 2.4-3.6) microg per kg plus dexamethasone (8 mg orally; n = 29) or at 11.8 (7.1-18.5) microg of lenograstim per kg (p < or = 0.0001) without dexamethasone (n = 23) and underwent standard apheresis using the PMN program of a cell separator (Spectra, COBE [now Gambro] BCT). WBC and PMN mobilization results and apheresis yields were compared and the severity and clinical significance of donor adverse reactions was evaluated.

RESULTS

For the low-dose G-CSF plus dexamethasone versus the high-dose G-CSF alone group, similar mobilization results were observed for WBCs with 31.3 (19.1-44.9) x 10(9) per L versus 27.5 (19.2-44.0) x 10(9) per L (p = 0.21, NS) and PMNs with 29.0 (17.6-42.2) x 10(9) per L versus 25.2 (16.2-39.0) x 10(9) per L (p = 0.08, NS). The PMN apheresis yields were equal with 70 (39-139) x 10(9) per unit with low-dose G-CSF versus 68 (33-120) x 10(9) per unit in the high-dose G-CSF group (p = 0.83, NS). Regarding donor adverse reactions, 7 out of 29 (24%) and 8 out of 23 donors (35%) reported moderate or severe symptoms. The character of these reactions was different; symptoms of greater clinical significance and a higher need for analgesics were observed in the high-dose G-CSF group.

CONCLUSIONS

A Lenograstim dose of 3 microg per kg plus DXM assures effective PMN mobilization and acceptable apheresis components. The combination of glycosylated G-CSF with DXM allows a significant dose reduction in G-CSF for PMN mobilization and collection as compared with higher G-CSF doses alone. In the high-dose G-CSF mobilization group, adverse reactions were more severe and required more analgesics.

Acute myeloid leukaemia in children

Acute myeloid leukaemia (AML) is characterized by a block in differentiation and an unregulated proliferation of myeloid progenitor cells. While the cause of AML in children is unknown, risk factors that have been identified include exposure to toxins such as ethanol, pesticides and dietary topoisomerase II inhibitors, prior chemotherapy with alkylating agents or topoisomerase II inhibitors, constitutional disorders such as Down's syndrome and type I neurofibromatosis, and haematopoietic failure syndromes such as Fanconi anaemia and severe congenital neutropenia. With intensified chemotherapy including high-dose Ara-C, followed in many cases by bone marrow transplantation, and with improvements in supportive care, current survival rates approach 50%. Future advances in paediatric AML will include better risk stratification to determine optimal treatment and targeted cytotoxic therapy.

Clinical efficacy of granulocyte transfusion therapy in patients with neutropenia-related infections

Granulocyte transfusions have been advocated by some for the treatment of severe, progressive infections in neutropenic patients who fail to respond to antimicrobial agents and recombinant hematopoietic growth factors. We conducted the current study to determine an appropriate method of granulocyte mobilization in healthy donors, and to evaluate the safety and efficacy of granulocyte transfusion therapy in patients with neutropenia-related infections. To mobilize granulocytes (n=55), healthy normal donors were stimulated in one of the following ways: (1) dexamethasone, 3 mg/m2 intravenously 15 min prior to leukapheresis (n = 5); (2) granulocyte colony-stimulating factor (G-CSF), 5 microg/kg subcutaneously 12 to 14 h prior to collection (n=37); or (3) G-CSF and dexamethasone (n= 13). The mean granulocyte yield from stimulation with G-CSF plus dexamethasone was significantly higher than from stimulation with dexamethasone or G-CSF alone. Twenty-five patients with severe neutropenia-related infections unresponsive to appropriate antimicrobial agents received a total of 55 granulocyte transfusions. The patients from whom fungi or Gram-negative organisms were isolated showed a more favorable response than those infected with Gram-positive organisms. However, the responses to the granulocyte transfusion therapy could not be correlated with the transfused dose, mobilization agents, or the 1 h or 24 h post-transfusion absolute neutrophil counts. We conclude that granulocyte transfusion therapy may be clinically useful for neutropenia-related infections by fungi or Gram-negative organisms.

Return of granulocyte transfusions

Recently, several groups have begun to administer granulocyte colony-stimulating factor (G-CSF), a hematopoietic growth factor, with or without dexamethasone to mobilize peripheral blood neutrophils. Granulocyte colony-stimulating factor (600 microg subcutaneously) and dexamethasone (8 mg orally) given 12 hours before standard leukapheresis routinely results in the collection of approximately 80 x 10(9) granulocytes. This number of cells is sufficient to increase the neutrophil count of a severely neutropenic patient to normal and restore the recipients' ability to develop a neutrophil response in tissues. Several trials are ongoing to establish the clinical benefit of this new approach to supportive care for neutropenic patients.

Fatal disseminated infection by Scedosporium prolificans during induction therapy for acute leukemia: a case report and literature review

We report a case of fatal disseminated fungal infection by Scedosporium prolificans which occurred in a patient with acute leukemia during induction chemotherapy. Rapid clinical deterioration despite high-dose empirical amphotericin B highlights both the pathogenicity of this fungus in immunocompromised hosts and its resistance to standard antifungal therapy.