Blut

B A N D 3 2 - HEFT 4 A P R I L 1976

Z E I T S C H R I F T F O R D I E G E S A M T E BLUTFORSCHUNG Organ der Deutschen Gesellschaft f6r H~matologie Organ der Deutschen Gesellschaft fur Bluttransfusion und Immunh~matologie

LE ITARTIKEL Department of Developmental Therapeutics, The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, Houston, Texas

Granulocyte Transfusions: Analysis of Donor, Procedure, Recipient Variables Jeane P. Hester, Kenneth B. McCredie and Emil J. Freireich The separation of whole blood into individual components, packed red cells, platelet concentrates, plasma protein fractions, has provided for more efficient and effective therapy with a valuable human resource. Improvements in technology of collection has made it possible for granulocytes from normal donors to be added to the list of blood components now available for replacement therapy. The collection of red cells and platelets routinely yields a standard quantity of ceils, which is sufficient for evaluation of the effectiveness of the transfused product in alleviating anemia and thrombocytopenia in the recipient. Granulocyte replacement, on the other hand, is influenced by donor and procedure variables which affect total granulocyte collection. Recipient variables related to effectiveness of the transfusion are complex and are still being defined. Based on the short half life of granulocytes, daily or even more frequent replacement is necessary. Given a limited number of donors per patient, undertaking such replacement requires documentation of safety for the donor, adequate collection of granulocytes, and a post transfusion recovery of sufficient granulocytes to effect a therapeutic response in the recipient. Due to the low leukocyte count in whole blood per cubic millimeter, collection of granulocytes requires continuous processing of the total blood volume of a donor, in order to separate and collect sufficient granulocytes for transfusion purposes. This is currently accomplished by two methods: 1) continuous flow cell separation (CFCS) and 2) filtration leukapheresis (FL). CFCS fractionates whole blood, anticoagulated extracorporally, in a spinning centrifuge bowl and returns to the donor the recombined red cell and plasma fraction, while retaining leukocyte-rich plasma collected through a separate port. Collection is enhanced by stimulation of the donor prior to leukapheresis with Etiocholanolone or steroids and by the addition of a red cell sedimentation agent, hydroxyethyl starch, to the input line of the separator. Our mean granulocyte yield for 980 procedures was 13.6 x 109. A significantly superior yield was obtained with Etiocholanolone - HES combination compound to steroids. Eingegangen am 1.3. 1976.

254

J. P. Hesper, K. B. McCredie and E. jr. Freire#h

Filtration leukapheresis requires anticoagulation of the donor with heparin. Whole blood is passed through a series of nylon filters, granulocytes adhere to the fibers, while other blood components flow through the filters, and are returned to the donor. The granulocytes are eluted from the fibers, suspended in plasma and used :for the transfusion product. Reported ranges of collection are 20-50 • 109 granuloytes. There is an increased incidence of recipient reaction in the form of shaking, chills, temperature elevation and dyspnea reported for recipients receiving FL cells [ / ]. A recent report [2] indicates these ceils are complement activated and have decreased chemotatic function, and increased degranulation. Methods of collection and the use of agents which induce a leukocytosis and granulocytosis, the dosage of such agents, and the time of administration in relation to the procedure varies among investigators. Frequent procedures on individual donors have been previously reported by us [3] to result in hematologic changes in hemoglobin, white count, and platelet count, serum proteins, all of which were reversible. A comparison of donor granulocyte counts, prior to leukapheresis, with total yields of granulocytes in 31 donors leukapheresed on four consecutive days revealed a decline in mean donor granulocyte count and granulocyte yields. In this group of donors, mean total granulocytes collected on day 1 was 15.0X 10~ compared to 12.5 • 109 on day 4, but these changes were not statistically significant. Procedure variables which affected granulocyte yield involved primarily the amount of red cell contamination in the collection bag. Marginal buffy coat separation at the red cell interface results in increasing numbers of red cells collected with the leukocyte fraction. The mean hematocrit for 980 collection procedures was 5%. Granulocyte yields in bags with less than 5 ~ hematocrit were significantly better, 16.3 • 109, when compared to bags containing greater than 5% hematocrit, 11.8 • 109 (p. 001). The length of time of each procedure, the total volume of blood processed, the speed of centrifugation, and flow rates through the centrifuge also vary among investigators and with collection methods used. The effectiveness of granulocyte replacement therapy has been reported in terms of 1) observed increase in granulocytes in the peripheral blood post transfusion, 2) lysis of temperature, 3) clearing of infection, and 4) survival. Post tranfusion granulocyte recovery can be influenced by both the kinetic properties of granulocyte and patient variables. Leukocyte kinetics indicate that a large portion of granulocytes are not in the mainstream of circulation. There are, in essence, two "pools" of granulocytes, a circulating pool and a marginated pool. The total granulocyte pool is estimated to be 7.0 • l0 s cells/kg, with about 44% (3.1 • 10s) in the circulating pool (CGP), and 56% (3.9 • 10~) in the marginating pool (MGP). The rate of egress of granulocytes into the tissues and areas of infection can also affect the total number of ceils in the blood. Sequestration in the MGP, the spleen, and possibly the marrow renders quantitative evaluation of recovery of transfused granulocytes complex. Present methods do not allow quantitation of transfused granulocytes into tissue spaces, and it is not known to what extent these tissue spaces must be filled before granulocytes appear in the circulating pool. Theoretically, if one transfused 10• 109 granulocytes into a patient whose body surface area is

GranuIocyte transfusions: analysis of donor, procedure, recipient variables

255

1.0 m s and whose, blood volume is 2.5 liters, the concentration in the total pool would be 4.0 • 10a/mm a, with 3.24• 10a/mm a in the MGP, and 1.76 • 10a/mm a in the CGP. The post transfusion peripheral count, then reflects quantitatively that fraction of transfused cells present in the circulating p o o l The observed increment in granulocytes/mm a post transfusion (post count - pre count) is directly related to the number of cells transfused, and inversely related to body surface area. Increments, therefore, must be corrected for both body surface area and total cells transfused, so that transfusions are comparable in analysis for effects of other recipient variables which influence granulocyte recovery. Some recipient variables recently analyzed for 980 transfusions included: 1) level of pretransfusion granulocyte count, 2) height of pre-transfusion temperature, 3) ABO compatibility, 4) H L A compatibility between donor-recipient pairs, 5) total granulocytes transfused, and 6) multiple, sequential transfusions. A logistic regression analysis indicated ABO (p. 005) and H L A (p. 05) were the two most significant determinants of the corrected increment immediately post transfusion and only HLA (p. 02) one hour post transfusion. A summary of granulocyte yield and post-transfusion increment, as reported by several investigators at the 1974 London International Symposium of Leukocyte Separation and Tranfusion, is shown in Table 1, and is compared to our own recent analysis, as well as that of Graw in an earlier published report [4]. Great variability is seen both in numbers of ceils transfused and post transfusion increment. Reports to date appear to confirm the higher post transfusion increments with CFCS granulocytes compared to ceils collected by FL. Investigator

Collection Method

Number Procedures

Mean PMN • 109

Corrected Increment PMN • lOa/mma

Benbunan

CFCS

115

Reich Cliff

CFCS CFCS FL FL CFCS FL FL

32 300 167 193 315 137 42

< 50 < 50 5.9 17.5 12.5 20 5.0 28.2 22.2

252 136 450-885

CFCS FL CFCS

980 28 68

13.5 20.4 5.6

Herzig Schiller Ruder Hester, McCredie (1975) Grarv (1972)

110 60 225 225 239 5351 2332 8502

1 All transfusions 2 Only leukocyte antibody negative transfusions Tab. 1: Summary of granulocyte collection methods: corrected post transfusion granulocyte (PMN) increment at one hour as reported at the international leukocyte symposium on leukocyte separation and transfusion: London 1974.

J. P. [-fr

256

K. B. McCrcdt'r and E. J. Frr

The use of granulocyte replacement has been directed to desperately iR myelo-suppressed patients with established infections, unresponsive t o appropri~e antibiotics, and results in improved survival in almost aI1 studies reporte& McCredie and Hester [5] correlated clinical response with multiple granulocyte transfusiorm. The =clinical response to transfusions, as summarized from the 1974 L o n d o ~ symFrosium,, .confirms this observation and is shown in Table 2. Investigator

~o Response

Patients

Trars~fu,ie~a~

_McCredie, Hester 66 130 716 Reich 42-54 19 25 Benbunan 70 74 115 atarigby 88 19 76 &hiffer 50 t 24 137 Herzig 56z 9 36 Clift 60a 20 ? 1 Reported as improved or stable. ~ Response of bacteremia. Table 2: Clinical response to granulocyte transfusions for estab'~shed infection, a5 sm'za~trized from investigators reporting at the InternatioJnal Symposium on leukozyte ~eparatiwa and transfusion: London 1974. Although reporting of granulocyte collection is fairly standardized, reporting o f increments and evaluation o f recipient response is not yet uniform, arLd revaders evaluation of granulocyte replacement therapy incomplete. In summary, it can be said that 1) present grartulocyte collection methods recover sufficient cells which when transfused produce a predictable increase in recipient granulocyte count, 2) the methods o f collection are safe for normal donors, 3) adequate yields are obtained in the multiply leukapheresed donor, 4) clinical response t o infection and improved survival are seen. Granulocyte kinetics, recipient variables and infection variables which affect post transfusion granulocyte recovery require further investigation into the relationships between these variables.

d~gf#rencg$

Press, Edited by J. M. Goldman & R. M. 1. Higby D. & Henderson E.: GranuloLowenthal, p. 75-80, 1974. cyte transfusion therapy. Annual Review 4. Graw R. G. Jr., Herzig G., Perry S. of Medicine 26, 289-306, 1975. & Henderson E. : Normal granulocyte 2. Fehr J., Craddock P. R. & Jacob H. S. : transfusion therapy : New England Journal Complement (C') medicated granuloof Medicine 287, 367-371, August 24, cyte (PMN) and pulmonary disfunetion 1972. during nylon fiber leukapheresis: Ab5. McCredie K. B., Hester J. P., Freireich stract 162, p. 100. American Society of E. J., Brittin G. M. & Vallejos C.: Hematology, December 1975. Platelet and leukocyte transfusions in 3. Hester J. P., McCredie K. B. & Freiacute leukemia: Human Pathology 5, reich E. J.: Effects of leukapheresis on 699-707, November 1974. normal donors : Leucocytes; Separation, Collection and Transfusion. Academic Author's address : Jeane P. Hester, M. D., Department of Developmental Therapeutics, The University of Texas System Cancer Center, M.D. Anderson Hospital and Tumor Institute, Houston, Texas 77030.

Granulocyte transfusions: analysis of donor, procedure, recipient variables.

Blut B A N D 3 2 - HEFT 4 A P R I L 1976 Z E I T S C H R I F T F O R D I E G E S A M T E BLUTFORSCHUNG Organ der Deutschen Gesellschaft f6r H~matolo...
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