Therapeutic transfusions of granulocytes collected by simple bag method for children with cancer and neutropenic infections: results of a single-centre pilot study

Navigating the neutropenic abyss with granulocyte transfusions: Retrospective single-center analysis of effectiveness and safety in India

BACKGROUND

Hemato-oncologic patients receiving intensive chemotherapy may develop severe neutropenia and serious bacterial and/or fungal infections. Granulocyte transfusions (GTs) may be beneficial as a bridging therapy in hemato-oncologic patients with febrile neutropenia.

AIM

To evaluate the clinical effectiveness of GTs in hemato-oncologic patients with febrile neutropenia.

MATERIALS AND METHODS

This retrospective study evaluated the effectiveness of 150 GTs in 88 hemato-oncologic patients. Donors were mobilized with granulocyte colony-stimulating factors and dexamethasone. Patients' hematological parameters (pre- and post-GT) and safety and effectiveness of GTs were analyzed.

RESULTS

The safety and effectiveness of GTs were assessed in the patients with various underlying conditions, including 78% with acute myeloid leukemia. In total, 150 GTs were administered, mostly during the chemotherapy induction phase. The GTs were well-tolerated by the patients, and a significant increment in white blood cell count and absolute neutrophil count (ANC) was noticed in 95% of patients after the transfusion. The granulocyte dose was positively correlated with ANC after the transfusion. The average time to neutrophil recovery from the last day of GT was 6.7 days, and the 30-day survival rate was 77%. The donors were all men, and a significant increase in WBC count was observed post-mobilization. The median granulocyte yield was 2.28 × 1010 /unit. All granulocyte products were crossmatched and irradiated before the transfusion.

CONCLUSION

GTs can be a useful adjunctive treatment for febrile neutropenia in hemato-oncologic patients with multidrug-resistant sepsis. However, additional studies are required for confirming their effectiveness and establishing guidelines for their use.

Granulocyte Transfusion Therapy: Institutional Experience of Benefit in Cancer Patients with Prolonged Neutropenic Sepsis—A Retrospective Study

Introduction Patients undergoing intensive chemotherapy for hematological malignancy and stem cell transplantation are at increased risk of neutropenia.

Neutropenia is among the frequent side effects of intensive treatments, and when absolute neutrophil count (ANC) falls < 500/µL, the risk of microbial and fungal infection increases significantly.

As neutropenia is the main cause of these infections, transfusion of granulocyte immediately as a replacement is a life-saving therapeutic option to support these patients by restoring neutrophil counts and aiding in the resolution of infection.

Objective The present study is a retrospective single institutional analysis of granulocyte transfusion therapy in children and young adults with cancer who received treatment with GT during prolonged and profound life threatening neutropenia.

Materials and Methods This study was a retrospective analysis of 66 granulocyte transfusions in 36 patients of hematological and solid malignancy with severe and prolonged neutropenia in the department of Medical Oncology, Sri Aurobindo Institute of Medical Sciences Indore, between September 2019 and March 2022.

Donors were either patients' relatives or voluntary donors without comorbidities.

All granulocyte concentrates were collected by centrifugation leukapheresis and irradiated with 2500 centigray and immediately transfused in full, to the patient over 60 ot 120 minutes with appropriate premedication.

Results A total of 36 patients (M:F, 19:17) with a median age of 16 years (2–43) received 66 granulocyte transfusions. The diagnosis of patients included acute myelogenous leukemia (n = 17), B cell acute lymphoblastic leukemia (n = 10), non-Hodgkin lymphoma (n = 3), Ewing's sarcoma (n = 2), neuroblastoma (n = 1), malignant melanoma (n = 1), aplastic anemia (n = 1), osteosarcoma (n = 1). All had severe neutropenia with absolute neutrophil count < 0.5 × 109/L. The median duration of severe neutropenia was 16 days. Patients received a median cell dose of granulocytes 2.9 × 1010/L. A favorable response was seen in 28 (78%) patients, whereas an unfavorable response was seen in 8 patients (23%).

Conclusion A granulocyte therapy was effective in many critically sick patients with prolonged and profound neutropenia. Granulocyte transfusions may be more beneficial in selected patients where it provides more time to overcome refractory infections with broad-spectrum antibiotics. Granulocyte transfusion are at best a “bridge” that gives time to marrow recovery. The challenges to using GT are clinical, finding patients who may get benefitted, and logistical, selection of donors and harvest technique. Randomized trials with large numbers of patients are required to prepare guidelines for granulocyte use.

Transfusion support: Considerations in pediatric populations

Over 400,000 units of blood and blood products are transfused to pediatric patients annually, yet only sparse high-quality data exist to guide the preparation and administration of blood products in this population. The direct application of data from studies in adult patients should be undertaken with caution, as there are dissimilarities in the pathology and physiology between adult and pediatric patients. We provide an overview of available evidence in the field of pediatric transfusion medicine, summarizing indications for blood product transfusion, thresholds for transfusion and indications for blood product modifications.

Role of granulocyte transfusions in combating life-threatening infections in patients with severe neutropenia: Experience from a tertiary care centre in North India

Bacterial and fungal infections still remain an important cause of mortality in patients with hematological malignancies and in recipients of hematopoietic stem cell transplants (HSCT) especially in developing countries like India. Granulocyte transfusions (GTX) from healthy donors may lead to early clearance of index infection and thus prevent mortality. The aim of the present study was to evaluate the efficacy of GTX in combating life-threatening infections and preventing mortality in patients of hematological disorders/recipients of HSCT with severe neutropenia. This study was a prospective, observational analysis of patients with different hematological disorders/recipients of HSCT, who received GTX from January 2014 to December 2017. All patients had an Absolute neutrophil Count (ANC) < 0.5 x 109/L and a life threatening sepsis defined by presence of hemodynamic instability/ impending septic shock/ continuous high fever despite the use of the highest line of antimicrobials. A total of 143 granulocyte collections were done for 66 infectious episodes (IEs) in 60 patients. Multidrug resistant organisms (MDROs) were observed in 47/66 IEs (71.2%) and fungal infections were seen in 9/66 IEs (13.6%). Resolution of index infection after GTX was seen in 45/66 IEs (68.2%), and the 30 day overall survival (OS) was 67.7%. OS was significantly higher in patients who received GTX within 7 days of neutropenic sepsis (p = 0.01). Patients with MDROs who received early GTX therapy had a better OS as compared to those who received late GTX (p = 0.02). GTX were well tolerated and only 6 patients' developed mild features of transfusion related acute lung injury (TRALI) which was managed conservatively, and 1 patient demonstrated hypocalcemic tetany. GTX may be of particular relevance in countries like India, where the incidence of infections is very high in neutropenic patients and there is an increasing emergence of MDROs.

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.

Granulocyte transfusions in children and adults with hematological malignancies: benefits and controversies

Bacterial and fungal infections continue to pose a major clinical challenge in patients with prolonged severe neutropenia after chemotherapy or hematopoietic stem cell transplantation (HSCT). With the advent of granulocyte colony-stimulating factor (G-CSF) to mobilize neutrophils in healthy donors, granulocyte transfusions have been broadly used to prevent and/or treat life-threatening infections in patients with severe febrile neutropenia and/or neutrophil dysfunction. Although the results of randomized controlled trials are inconclusive, there are suggestions from pilot and retrospective studies that granulocyte transfusions may benefit selected categories of patients. We will critically appraise the evidence related to the use of therapeutic granulocyte transfusions in children and adults, highlighting current controversies in the field and discussing complementary approaches to modulate phagocyte function in the host.

Successful cord blood transplantation after repeated transfusions of unmobilized neutrophils in addition to antifungal treatment in an infant with chronic granulomatous disease complicated by invasive pulmonary aspergillosis

BACKGROUND

Chronic granulomatous disease (CGD) is a rare inherited primary immunodeficiency that affects phagocytic cells. CGD patients are susceptible to fungal infections, especially Aspergillus infections. The management of life-threatening Aspergillus infections in CGD is particularly difficult because some infections cannot be eradicated with standard antifungal treatments and, hence, result in death.

CASE REPORT

A 2-week-old girl developed invasive pulmonary aspergillosis, which rapidly progressed to respiratory failure. Liposomal amphotericin B, micafungin, and voriconazole were not effective. At the age of 2 months, she was diagnosed with p67phox-deficient CGD. In addition to antifungal treatment, the patient received 21 granulocyte transfusions (GTX), which were obtained from 300- or 400-mL whole blood samples from healthy random donors who were not treated with granulocyte-colony-stimulating factor or dexamethasone. The median neutrophil count of the GTX was 1.88 × 10(8) /kg body weight. Rituximab was administered to reduce alloimmunization to human leukocyte antigens (HLA) after the eighth GTX, resulting in their absence of anti-HLA before and after cord blood transplantation (CBT). A marked improvement in her invasive pulmonary aspergillosis was achieved, although the first CBT was rejected. Complete hematopoietic recovery was obtained after the second CBT.

CONCLUSION

Repeated GTX containing relatively low doses of neutrophils might be able to control severe Aspergillus infections in infants with CGD.

Maintenance of surface antigens and the absence of an apoptotic marker are observed during storage of granulocyte concentrates collected by bag separation method

Granulocytes were collected by the bag separation method and stored in whole blood for up to 72h. We evaluated the expressions of various surface antigens: CD62L, CD11b, CD18, CD64, CD16b, and CD95. Apoptosis was assessed both by flow cytometry and by light microscopy. Expression levels of all the surface antigens were shown to be maintained during storage for up to 72h. Approximately 80% of granulocytes were annexin V negative until 72h after collection. The storage of granulocyte concentrates collected by the bag separation method may maintain granulocyte surface antigens and lack an apoptotic marker.

Adverse events and safety issues in blood donation--a comprehensive review

Although blood donation is generally safe, a variety of risks and complications exist, the most common being iron deficiency, vasovagal reactions and citrate-related events. In the last decades, extensive efforts have significantly improved recipient and product safety, but there is still great potential to optimise donor care. Many therapies in modern medicine depend on the prompt availability of blood products, therefore it is crucial to maintain a motivated and healthy donor pool in view of a limited number of healthy volunteers willing and able to give blood or blood components. We present a comprehensive review on adverse events addressing all types of blood donation including whole blood, plasma, platelet, peripheral blood stem cell, leucocyte and bone marrow donation. In addition, we outline strategies for the prevention and treatment of these events and give a blueprint for future research in this field.

Extended storage of granulocyte concentrates mobilized by G-CSF with/without dexamethasone and collected by bag separation method

The aim of this study was to examine the extended storage of granulocyte concentrates mobilized by granulocyte-colony-stimulating factor (G-CSF) with/without dexamethasone (DEX) and collected by a bag separation method. Ten healthy adult volunteers donated blood three times: twice after granulocyte mobilization by (1) injecting G-CSF at 3 microg kg(-1) subcutaneously (s.c.) and (2) injecting G-CSF at 3 microg kg(-1) s.c. + DEX at 8 mg per oral and once (3) for a baseline control without any forms of mobilization. Granulocytes were collected by a bag separation method. The functions (phagocytosis and oxidative killing levels), viability and levels of interleukin (IL)-1beta, IL-8, IL-6 and tumour necrosis factor-alpha of granulocytes were measured. The average numbers of granulocytes collected from 200-mL samples of whole blood from the G-CSF and G-CSF + DEX groups were 35.1 x 10(8) and 49.4 x 10(8), respectively. Phagocytosis level, oxidative killing level and the viability of the granulocytes mobilized by G-CSF with/without DEX were well maintained for up to 72 h of storage after collection. The levels of the cytokines increased in a time-dependent manner. The in vitro phagocytosis level, oxidative killing level and the viability of granulocytes mobilized by G-CSF with/without DEX and collected by bag separation method can be maintained for as long as 72 h after collection.

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.