Evans syndrome in a pediatric liver transplant recipient with an autoantibody with apparent specificity for the KEL4 (Kpb) antigen.

Although most warm red blood cell (RBC) autoantibodies react broadly with panel cells in addition to the patient's own RBCs, occasionally an autoantibody with specificity for a specific blood group antigen is encountered. Rare cases of warm autoantibodies with specificity for the Kpb antigen of the Kell blood group system have been described. We report a pediatric transplant recipient with anemia, immune-mediated hemolysis, thrombocytopenia, and a warm autoantibody with apparent anti-Kpb specificity. The patient's autoimmune anemia and thrombocytopenia responded well to discontinuing the immunosuppressant tacrolimus, trans- fusions with Kp(b-) RBCs, and intravenous immunoglobulin therapy, with disappearance of the pathologic antibody. During the autoimmune hemolysis, the patient's RBCs did not react with antisera specific for Kpb. However, repeat testing of the patient's RBCs with Kpb-specific antisera 15 months after the resolution of hemolysis showed reactivity, indicating that the RBC autoantibody was associated with a transient disappearance of the Kpb antigen.

Addition of peripheral blood stem cells collected without mobilization techniques to transplanted autologous bone marrow did not hasten marrow recovery following myeloablative therapy.

A randomized prospective trial was conducted to determine if the addition of cryopreserved autologous peripheral blood stem cells (PBSC) collected without mobilization techniques to autologous cryopreserved bone marrow for patients receiving an autologous bone marrow transplant (ABMT) affected the time to marrow function recovery. Thirty-five evaluable patients with various malignancies were studied. Sixteen received PBSC + ABMT and 19 received ABMT alone. The PBSC were collected with 4 h leukapheresis procedures on 3 consecutive days. No manipulations to increase the number of circulating stem cells were used during the collections. The median time to recover 0.5 x 10(9)/l circulating granulocytes was 20 days after transplantation in the ABMT group and 27 days in the PBSC + ABMT group (p = 0.12). The median time to recover 20 x 10(9)/l platelets was 22 days after transplantation in the ABMT group and more than 27 days in the PBSC + ABMT group (p = 0.29). The day of discharge from the hospital was earlier for the ABMT group (median 29 days) than the PBSC + ABMT group (median 35 days, p = 0.03). We did not find that the addition of non-mobilized PBSC to infused autologous marrow accelerates marrow recovery.

Counterflow centrifugation apheresis for the collection of autologous peripheral blood stem cells from patients with malignancies: a comparison with a standard centrifugation apheresis procedure.

Two apheresis methods used to collect hematopoietic stem cells from peripheral blood were compared in eight patients with a variety of malignancies. The standard lymphocyte collection method was alternated with the counterflow centrifugation or lymphocyte surge protocol. The number of clonogenic cells (CFU-GM and BFU-E), the red cell volume, and the number of mononuclear cells in each collection were assessed as well as the changes in circulating leukocytes, platelets, and blood hemoglobin produced by each apheresis procedure. There was no statistically significant difference found in the number of clonogenic cells collected with either method, but the number of mononuclear cells collected with the standard procedure was significantly higher (P = 0.001). The red cell volume collected with the standard procedure was significantly higher, (P = 0.0001), but corrected for the number of mononuclear cells the difference was not significant. The counterflow centrifugation apheresis produced significantly less thrombocytopenia (P = 0.005). The counterflow centrifugation apheresis procedure used collected fewer mononuclear cells than the standard procedure, however, with less red cell contamination but a comparable number of CFU-GM and BFU-E in four hour apheresis procedures. Each collection method resulted in a comparable amount of anaemia and leukopenia but the lymphocyte surge method produced less thrombocytopenia following the collection.

Recurrent neurologic symptoms during peripheral stem cell apheresis in two patients with intracranial metastases.

Leukapheresis recently has been used to harvest circulating hematopoietic stem cells for autologous transplantation. This technique is especially useful when involvement of the bone marrow by tumor precludes its use as a source for stem cells. Thirty-five patients have had peripheral blood stem cells harvested for transplantation by this technique at our institution. Two patients with adenocarcinoma of the breast developed severe headaches during apheresis, and both were found to have extensive intracranial metastases. For one patient, the pain was excruciating and associated with hypotension at the end of each collection phase of the apheresis procedure and resolved approximately 5 minutes after reinfusion of the patient's red cells and plasma. Subsequently this patient had a documented subdural hydroma. Following an apheresis procedure, while receiving local low dose thrombolytic therapy for thrombosis of the brachiocephalic vein, she suffered a fatal intracerebral hemorrhage. The second patient had a severe exacerbation of a headache of recent onset. Leukapheresis was abandoned when extensive intracranial disease was documented. We conclude that recurrent neurologic symptoms, especially cranial pain, during the withdrawal phase of intermittent flow apheresis may predict intracranial pathology in patients. Peripheral stem cell apheresis and lymphocytapheresis are bringing patients with metastatic malignancies to the apheresis department with increasing frequency, and the apheresis staff must be alert to previously undescribed complications of apheresis.

Thrombotic complications of subclavian apheresis catheters in cancer patients: prevention with heparin infusion.

Twenty-two silicone rubber apheresis catheters were placed into the subclavian veins of 18 cancer patients to allow serial leukapheresis for collection of circulating hematopoietic stem cells. The tips of the catheters were placed in the innominate vein to avoid reinfusion of citrate into the right atrium and the resulting tendency to cardiac arrhythmias. Sixteen catheters were placed without prophylactic anticoagulation. Anticoagulation was prematurely discontinued in one patient because of the inconvenience of the portable heparin infusion pump. Six of these 17 catheters developed venographically proven thrombotic complications and five others had presumed thrombosis-related access failure or caused symptoms of venous obstruction, but confirmation of the presence of a thrombus with venography was not obtained. Three catheters spontaneously withdrew from the vein, one during urokinase infusion for thrombosis. Only three catheters had uncomplicated apheresis courses. Prophylactic heparin infusions via portable infusion pumps were given after placement of six catheters. As long as the heparin infusions were continued all patients had uncomplicated apheresis courses. One patient's heparin was prematurely discontinued. Within 3 days of its discontinuance, radiographically proven thrombotic catheter occlusion occurred. Patients given heparin were less likely to develop complications (P less than 0.001). No unexpected complications of apheresis were encountered as a result of the use of these catheters. Silicone rubber subclavian catheters can be used for peripheral stem cell collection but have a high frequency of thrombotic complications. Systemic anticoagulation with heparin can minimize the likelihood of these complications.

Allogeneic transplantation of blood-derived, T cell-depleted hemopoietic stem cells after myeloablative treatment in a patient with acute lymphoblastic leukemia.

This report describes an allogeneic peripheral blood stem cell transplant in a patient who had received marrow ablative therapy. The patient was an 18-year-old white male with acute lymphocytic leukemia in third remission for whom an allogeneic bone marrow transplant was recommended. His HLA-identical sibling preferred to donate peripheral blood stem cells rather than marrow. The donor cells were collected with 10 apheresis procedures and depleted of T lymphocytes to prevent excessive graft-versus-host disease. Nine collections were cryopreserved. The patient received high-dose cytosine arabinoside and 12 Gy of total body irradiation, followed by infusion of all cryopreserved donor cells. A portion of the tenth apheresis product collected on the day of transplant containing 1.8 x 10(9) T lymphocytes was infused without further processing to approximate the number of T lymphocytes given in an allogeneic bone marrow transplant; the remainder was T lymphocyte depleted and infused. More than 1 x 10(9)/l granulocytes were present on day +11. A bone marrow biopsy on day +27 showed trilineage engraftment. Cytogenetic studies demonstrated that the recipient's marrow and peripheral blood were populated exclusively with donor cells. Allogeneic peripheral stem cell transplantation produced an early hematopoietic engraftment. Since the patient died on day +32, sustained engraftment could not be evaluated.

High-dose therapy and autologous peripheral blood stem cell transplantation for patients with lymphoma.

Forty patients with refractory Hodgkin's disease (24 patients) or non-Hodgkin's lymphoma (16 patients) who were considered for high-dose therapy but not for autologous bone marrow transplantation (ABMT) due to BM metastases, previous pelvic irradiation, a history of marrow involvement by tumor or hypocellular marrow in conventional harvest sites received high-dose therapy and autologous peripheral blood (PB) hematopoietic stem cell transplantation. Disappearance of circulating neutrophils and development of RBC and platelet transfusion-dependence was followed, in the evaluable patients, by reappearance of 0.5 x 10(9)/L circulating granulocytes and sufficient platelets to obviate the need for platelet transfusions at a median of 25 days after transplantation. Twenty-three patients experienced a clinical complete remission (CR). The projected 2-year event-free survival was 24% for all 40 patients and 49% for the non-Hodgkin's lymphoma patients. The projected 18-month event-free survival for the Hodgkin's disease patients was 15%. PB stem cell transplantation provided an opportunity to administer high-dose salvage therapy to patients with refractory lymphoma who otherwise were not candidates for such therapy. For some of those patients, the high-dose therapy produced prolonged survival, free of tumor progression.

Density gradient isolation of peripheral blood mononuclear cells using a blood cell processor.

Large numbers of mononuclear cells (MNC) are needed for hematologic reconstitution using peripheral blood stem cells. The possibility of isolating those cells by discontinuous Ficoll-diatrizoate density gradient centrifugation in two blood cell processors (the Haemonetics V50 [V50] and the Cobe 2991 [2991]) were examined. Buffy coats from peripheral blood containing 6.23 X 10(8) MNC were separated in the V50, resulting in a recovery of 75 percent. The purity of the cells, defined as the percentage of lymphocytes and monocytes among all leukocytes, was 95 percent. With larger cell loads (3 to 7 X 10(9) MNC), the yield was higher in the V50 than in the Cobe 2991 (92 versus 75%). After separation in the V50 or the 2991, the cloning efficiencies of hematopoietic progenitor cells (CFU-GM and BFUe) were not different from those of cells isolated on 5 ml Ficoll-diatrizoate gradients in centrifuge tubes. Both leukapheresis and MNC separation can be carried out with the same bowl and tubing set in the V50. With that approach, an average of 6 X 10(9) MNC were processed in 16 experiments. An average recovery of 82 percent with 95 percent purity was achieved. The authors conclude that, in terms of simplicity of operation, cost effectiveness, and maintenance of sterility, the V50 may be better suited than the 2991 for the purification of MNC from peripheral blood.

Autologous peripheral hematopoietic stem cell transplantation restores hematopoietic function following marrow ablative therapy.

From ten patients with advanced malignant disease involving the bone marrow, autologous hematopoietic stem cells were collected from the peripheral blood during eight four-hour pheresis procedures and cryopreserved. No manipulations to increase the number of stem cells circulating in the blood were used during the collections. Following marrow ablative chemotherapy or chemoradiotherapy, the autologous cells were thawed and infused intravenously (IV). WBCs reappeared in the circulation at a median of eight days (range seven to 11 days) after stem cell infusion. Two patients died early, whereas the other eight reached normal numbers of circulating granulocytes that have persisted for up to greater than 20 months. These eight patients became independent of RBC transfusions (hemoglobin concentration greater than 10 g/dL) at a median of 27 days (range 11 to 58 days) after transplantation. One patient received platelet transfusions for counts less than 50 x 109)/L, one patient developed a clinical picture of idiopathic thrombocytopenic purpura, and six patients maintained a platelet count greater than 20 x 10(9)/L at a median of 23 days (range 14 to 25 days) following stem cell infusion. This technique allows patients ineligible for autologous bone marrow transplantation due to unacceptable anesthetic risks, prior pelvic irradiation, or bone marrow metastases to receive marrow ablative therapy.

Graft versus host disease following transfusion of normal blood products to patients with malignancies.

A patient undergoing treatment with cytotoxic chemotherapy for Hodgkin's disease developed graft versus host disease (GVHD) following a transfusion of packed red cells. This is the 28th reported patient with a malignancy who did not have a bone marrow transplant and developed GVHD after transfusion of normal blood or blood products. All patients had received cytotoxic chemotherapy prior to acquiring GVHD. The underlying malignancies included lymphoma, acute leukemia, neuroblastoma, rhabdomyosarcoma, and glioblastoma. Twenty-three of the 28 patients died of GVHD. The incidence of transfusion-related GVHD in this patient population is low but the illness is often fatal as treatment is largely ineffective. Transfusion-related GVHD can be prevented by irradiating all blood products with 1500 rad prior to administration.

Reconstitution of human hematopoietic function with autologous cryopreserved circulating stem cells.

Complete hematopoietic reconstitution using nonleukemic peripheral blood mononuclear cells has been achieved in animal models but not in humans. We treated two patients who had metastatic breast carcinoma involving the bone marrow and who had failed conventional therapy with high-dose chemotherapy and total body radiation. Cryopreserved autologous peripheral blood mononuclear cells (6.3-8.4 X 10(8)/kg patient weight) obtained by leukapheresis before high-dose therapy were returned to the patients intravenously. In one patient, evidence of bone marrow engraftment was present, but the patient died before full reconstitution of the peripheral blood cells occurred. Bone marrow engraftment and return of all cell lines to the peripheral blood occurred in the second patient. These findings demonstrate that human hematopoietic reconstitution can be achieved with autologous, peripheral blood, mononuclear cell transfusions following high-dose therapy. This approach may be useful to patients who have contraindications for a bone marrow harvest but who are otherwise candidates for autologous bone marrow transplantation.