Charles F. Arkin

Haematologic manifestations of the human immune deficiency virus (HIV)

A variety of haematologic abnormalities are associated with infection by HIV, the human retrovirus that is the primary aetiologic agent of the acquired immunodeficiency syndrome (AIDS). We have reviewed the haematologic findings in well‐characterized cohorts of patients with AIDS, AIDS‐related complex (ARC) and asymptomatic homosexual men at risk for this retrovirus. Anaemia, granulocytopenia and thrombocytopenia were found in increasing prevalence according to the severity of clinical disease associated with retroviral infection. Bone marrow aspirations and biopsies revealed frequent hypercellularity, dysplasia, plasmacytosis and lymphoid infiltrates. These marrow morphologic findings were strongly associated with anaemia and granulocytopenia. Review of transfusion records of patients with HIV antibodies revealed a 21% prevalence of a positive direct antiglobulin test. The pathophysiology of the observed haematologic abnormalities may involve direct retroviral infection of bone marrow progenitors, abnormal regulation of haematopoiesis and/or autoimmune phenomena.

Mobilized CD34+ cells selected as autografts in patients with primary light‐chain amyloidosis: rationale and application

BACKGROUND: Concern about tumor cell contamination in stem cell preparations has led to the use of CD34+ cell selection as a means of purging. Increasing the number of CD34+ cells per leukapheresis may help to provide an adequate dose of CD34+ cells. STUDY DESIGN AND METHODS: The reverse transcriptase polymerase chain reaction (RT‐PCR) was employed to clone overexpressed clonotypic immunoglobulin light‐ chain variable region genes (Ig VL) from bone marrows of patients with primary light‐chain amyloidosis (AL). Patient‐specific primers were designed to evaluate stem cell collections for contamination. CD34+ cell selection was performed on components from AL patients who underwent mobilization with granulocyte‐colony‐stimulating factor (G‐ CSF) (filgrastim; 16 microg/kg/d for 4 days) and collection by large‐ volume leukapheresis (LVL;25L) on Days 4 and 5. The selected cells alone were transfused after patients received mephalan (200 mg/m2). RESULTS: Contamination was found in collections from 4 to 7 patients, which provided the rationale for a subsequent trial of CD34+ cell selection. The median number of CD34+ cells per kg collected on Days 4 and 5, and in toto, was 4.0 × 10(6)(1.1‐12.7), 7.9 × 10(6)(1.8‐12.7), and 10.7 × 10(6)(2.9‐25.4), respectively (n = 9 patients). The median yield per selection was 38 percent, with a purity of 85 percent (45‐ 97%), and the viability of CD34+ cells averaged 96.4 +/− 3.6 percent (n = 18 selections). The median number of CD34+ cells infused was 5.9 × 10(6) per kg (2.1‐10.1). In comparison with AL patients given unselected autografts, patients receiving selected CD34+ cells experienced similar reconstitution of neutrophils and platelets but slower lymphocyte recovery. CONCLUSION: Patients with AL often have contamination with clonotypic cells in their blood autografts. G‐CSF mobilization and LVL provide components that allow the selection of adequate doses of CD34+ cells. The use of CD34+ cells in patients with AL achieves rapid neutrophil and platelet recovery but delayed lymphocyte recovery. CD34+ cell selection is feasible in the treatment of AL, but its effectiveness in purging clonotypic cells remains to be ascertained.

Collection of mobilized blood progenitor cells for hematopoietic rescue by large-volume leukapheresis

BACKGROUND: Mobilized blood progenitor cells rapidly reconstitute hematopoiesis in patients after dose‐intensive chemotherapy. However, optimal timing and methods of mobilized blood progenitor cell collection have yet to be fully defined. STUDY DESIGN AND METHODS: The utility of large‐volume leukapheresis (LVL; > 15 L blood processed) in collecting target doses of mononuclear cells (7 × 10(8)/kg) for use in autologous hematopoietic rescue was investigated. LVL was begun at a standardized interval (14 days) after a course of limited chemotherapy and subsequent daily recombinant human granulocyte‐macrophage‐colony‐ stimulating factor administration to mobilize blood progenitor cells into the circulation. With each LVL procedure, mononuclear cells, colony‐forming units‐granulocyte‐macrophage (CFU‐GM), burst‐forming units‐erythroid, mixed colonies, total clonogenic progenitor cells, and CD34+ cells collected per kg of patient weight were counted. After high‐ dose chemotherapy and infusion of cryopreserved mobilized blood progenitor cells, the days needed for neutrophils to reach levels of > 0.5 × 10(9) per L and for platelets to reach levels of > 20 × 10(9) per L were recorded. RESULTS: In 14 previously treated cancer patients, an average of 28.9 +/− 4.9 L of blood was processed per LVL (n = 35) to collect medians of 2.5 × 10(8) mononuclear cells per kg (range, 1.0‐ 7.4), 14 × 10(4) CFU‐GM per kg (0‐208), 27 × 10(4) clonogenic progenitor cells per kg (0‐370), and 2.8 × 10(6) CD34+ cells per kg (0‐ 112.5). Fifty‐seven percent of patients (8/14) required one or two LVL procedures to collect adequate blood progenitor cells (range, 1–4). After dose‐intensive chemotherapy, 13 patients received medians of 6.8 × 10(8) mononuclear cells per kg (range, 5.1‐9.9), 53 × 10(4) CFU‐GM per kg (9‐208), and 12 × 10(6) CD34+ cells per kg (3.6‐112.5). Rapid hematopoietic reconstitution occurred with 10 days (range, 8–12) and 9 days (6‐15), respectively, for neutrophil and platelet recoveries. CONCLUSION: Scheduled LVL, beginning on Day 14 after the administration of granulocyte‐macrophage‐colony‐stimulating factor following chemotherapy, is a convenient and efficient method of collecting blood progenitor cells. The mononuclear cells so obtained effected consistent and rapid hematopoietic reconstitution in a highly reproducible manner in a group of heavily treated patients.

Histopathology of the donor gallbladder removed at orthotopic liver transplantation: Correlation with graft function☆

The histopathology of 50 consecutive donor gallbladders removed during orthotopic liver transplantation was reviewed and correlated with graft function. Multiple sections of the gallbladders were examined for the presence of mucosal congestion, hemorrhage, and necrosis, without prior knowledge of the clinical outcome. Each pathologic feature was graded as absent (0), involving less than 10% (1+), 10% to 50% (2+), or more than 50% (3+) of the histologically examined mucosa. Graft function was determined by two transplant surgeons, a poor diagnosis being worsening of liver function tests associated with declining mental status and resulting in immediate retransplantation or early postoperative death; all others were categorized as good. Of 39 patients with good graft function, 18 had normal donor gallbladders, 11 had congestion only, and 10 had hemorrhage and/or necrosis. Of 11 patients with poor graft function, eight had hemorrhage and/or necrosis (2+ in seven), three had congestion only, and none had a normal gallbladder mucosa. Congestion alone was found to be a poor predictor of graft damage. Presence of any grade of hemorrhage and/or necrosis in donor gallbladders as related to poor liver graft function had a sensitivity of 73%, a specificity of 74%, a positive predictive value of 44%, and a negative predictive value of 91%. When hemorrhage and/or necrosis of 2+ severity was separately grouped and correlated with poor graft function, the specificity rose to 97% and the positive predictive value to 88%, and the negative predictive value was similar at 90%. We conclude that donor gallbladders often show mucosal abnormalities consisting of varying degrees of congestion, hemorrhage, and necrosis. The finding of hemorrhage and/or necrosis affecting more than 10% of the mucosa appears to be a specific lesion of ischemic damage that correlates highly with poor liver graft function.