|Year : 2021 | Volume
| Issue : 1 | Page : 106-109
A case report of apheresis granulocyte concentrates and the whole blood-derived pooled buffy coat transfusions in a neutropenic hematopoietic stem cell transplant recipient
Abhaykumar Malind Gupta, Shashank Ojha, SH Sumathi, Minal Poojary
Department of Transfusion Medicine, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India
|Date of Submission||21-Sep-2020|
|Date of Decision||01-Mar-2021|
|Date of Acceptance||18-Mar-2021|
|Date of Web Publication||29-May-2021|
Dr. Shashank Ojha
Department of Transfusion Medicine, Advanced Centre for Treatment Research and Education in Cancer, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai
Source of Support: None, Conflict of Interest: None
Granulocytes may be procured either as apheresis granulocyte concentrate (AGC) or as a pooled buffy coat granulocytes (PBCG) derived from whole blood donations. The chronic myelomonocytic leukemia patient with active pneumocystis pneumonia infection, received two transfusions of AGC and PBCG each, for prolonged severe neutropenia. AGCs had a higher mean white blood cells count per bag (1.63 × 1010 vs. 1.53 × 1010), neutrophil count per bag (1.05 × 1010 vs. 0.76 × 1010), and mean neutrophils percentage (62.45% vs. 49.25%), whereas PBCGs had a higher mean red blood cells volume per bag (196.1 vs. 62.5 ml) and platelet counts (5.03 × 1011 vs. 3.6 × 1011). The rise in patients' absolute neutrophil count was comparable with both AGC and PBCG transfusions. Granulocyte transfusions helped in the management of an acute neutropenic crisis. Whole blood-derived PBCGs may be a viable alternative in to AGCs. PBCGs have a lot of logistic issues and each blood center should have its standard operating procedure.
Keywords: Apheresis, buffy coat, granulocytes, neutropenia, pooling
|How to cite this article:|
Gupta AM, Ojha S, Sumathi S H, Poojary M. A case report of apheresis granulocyte concentrates and the whole blood-derived pooled buffy coat transfusions in a neutropenic hematopoietic stem cell transplant recipient. Glob J Transfus Med 2021;6:106-9
|How to cite this URL:|
Gupta AM, Ojha S, Sumathi S H, Poojary M. A case report of apheresis granulocyte concentrates and the whole blood-derived pooled buffy coat transfusions in a neutropenic hematopoietic stem cell transplant recipient. Glob J Transfus Med [serial online] 2021 [cited 2021 Dec 7];6:106-9. Available from: https://www.gjtmonline.com/text.asp?2021/6/1/106/317181
| Introduction|| |
Even in the modern era of newer antimicrobials and the use of hematopoietic growth factors to reduce the duration of posttreatment neutropenia, infection remains a major cause of morbidity and mortality in high-dose chemotherapy regimens and hematopoietic stem cell transplantation (HSCT) patients.
Logistic difficulties in supplying apheresis granulocytes concentrate (AGC) like donor availability and donor mobilization (granulocyte colony-stimulating factor and steroids) are well acknowledged. The alternative source of granulocytes, derived from whole blood donations, may be easily available as a by-product of blood component separation. In vitro tests have demonstrated that the neutrophil function of pooled buffy coat granulocytes (PBCG) was well preserved during the 24 h storage.,,
| Case Report|| |
Our patient was a 36-year-old male, allogeneic HSCT recipient with the diagnosis of chronic myelomonocytic leukemia. The patient had clinically fungal pneumonia, active pneumocystis pneumonia infection and was treated with granulocyte infusions.
Method of pooled buffy coat granulocytes preparation
The process of PBCG preparation is depicted in [Figure 1]. Red cell reduction was not performed as the patient was also having severe anemia. AGC/PBCGs viability was performed by the trypan blue dye exclusion method.
|Figure 1: Schematic flow diagram for the pooled buffy coat granulocyte concentrates|
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Patients' course in hospital
The patient received two transfusions of AGC on day +3 and day +6 post-HSCT on account of persistent neutropenia (ANC <0.5 × 109/L). Both the AGCs were collected on Spectra Optia (Terumo BCT, Lakewood, USA) after granulocyte colony-stimulating factor (G-CSF) (10 μg/kg) and dexamethasone (8–12 mg) mobilization but without hydroxyethyl starch as a sedimenting agent. As the patient continued to have severe neutropenia and no apheresis donors were available, PBCGs were decided to be transfused. PBCGs were transfused on day +11 and day +18, post-HSCT. Individual AGC and PBCG product values are summarized in [Table 1]. Changes in patient's hematological parameters after AGCs and PBCGs transfusions are shown in [Table 2]. AGCs had a higher mean white blood cells (WBC) count per bag (1.63 × 1010 vs. 1.53 × 1010), neutrophil count per bag (1.05 × 1010 vs. 0.76 × 1010), and mean neutrophils percentage (62.45% vs. 49.25%) in comparison to PBCG, whereas PBCGs had a higher mean red blood cells volume per bag (196.1 ml vs. 62.5 ml) and platelet counts (5.03 × 1011 vs. 3.6 × 1011) in comparison to AGC. All the transfusion events were uneventful. As per the DGHS Transfusion Medicine Technical Manual, every granulocyte component must contain at least 1 × 1010 granulocytes and one of the AGC and both PBCGs did not fulfill this criteria but were transfused in view of the dire need.
|Table 2: Patient's hematological parameters pre-and post (at 1 h and 24 h) apheresis granulocyte concentrate/pooled buffy coat granulocyte transfusion|
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The rise in patients' absolute neutrophil count was insufficient but comparable with both AGCs and PBCGs transfusions. Granulocyte transfusions (GTX) helped in the management of an acute neutropenic crisis.
| Discussion|| |
PBCGs are still an unexplored territory in India. Many times, physicians request the GTX on an emergency basis and the cross-match compatible apheresis donor may not be available. Blood centers must have all the standard operating procedures in place for any form of granulocyte preparations in such emergencies.
The shelf life of pooled buffy coat granulocytes
Despite the preservation of functional activities, the total WBC counts of granulocyte concentrate decreases 24 h after storage. Hence, PBCGs should be transfused as early as possible. The preparation of PBCGs may take a longer duration for its preparation but it may still be effective.
Ethical consideration of granulocyte colony-stimulating factor/steroids and hydroxyethyl starch to donors
The UK Transfusion Services do not permit the administration of G-CSF and steroids to volunteer, unrelated donors. The recent RING trial suggested that patients receiving ≥0.6 × 109 granulocytes/kg/transfusion tended to have better clinical outcomes.
Disadvantages of pooled buffy coat granulocytes
On average, a single buffy coat had a neutrophil count of 0.1 × 1010 per bag and to get the least adequate dose, at least 10 buffy coats must be pooled.,,>/sup> The RING trial suggested that the effective adult dose should be at least 4 × 1010. Alloimmunization is a possible threat due to large donor exposures. Moreover, a higher dose of granulocytes was not possible with PBCGs.
Logistic issues with pooled buffy coat granulocytes
After the blood donation, the component separation, blood grouping, with TTI testing takes a great deal of time. After the results, cross-match, pooling, gamma irradiation, and quality control will take extra time. Hence, the PBCG transfusion may happen, 8–12 h after the collection of the first blood unit. Overall, it will still take a shorter time to pool buffy coats as compared to select, mobilize and do the apheresis procedure on a donor.
The dilemma of granulocyte transfusions
The recent randomized controlled “RING” trial also did not show any survival benefits of GTX. However, it had a low accrual rate, and the required statistical significance may not have reached due to the lower power of the study. GTX may be beneficial in countries like India, where neutropenic patients have a very high incidence of infection and multidrug-resistant organisms are common. Hence, the need and effectiveness of GTX should be decided on an individual patient basis.
| Conclusions|| |
High-dose AGCs are the product of choice for neutropenic patients. Whole blood-derived PBCGs may be a viable alternative to AGCs when the same are not available. PBCGs have a lot of logistic issues and each blood center should have its standard operating procedures. The efficacy of GTX is still uncertain and further research is required in this field.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]