Rasika Setia

Prophylactic low dose continuous calcium infusion during peripheral blood stem cell (PBSC) collections to reduce citrate related toxicity.

BACKGROUND Citrate toxicity is one of the most frequent complications of apheresis procedures. It is caused by the infusion of the acid citrate dextrose (ACD), which chelates the calcium ions. AIMS The aim of this study is to assess the effectiveness of prophylactic continuous infusion of calcium gluconate over intermittent bolus infusion to reduce citrate toxicity during large volume peripheral blood stem cell collection. MATERIALS AND METHODS We retrospectively analysed the records of PBSC collection procedures performed from March 2010 to December 2013. Donors were selected as per the set guidelines. Machine used to perform the procedures was Cobe spectra. The study population was divided into 2 groups. One composed of intermittent intravenous bolus infusion at the onset of hypocalcaemic symptoms, the other composed of calcium gluconate administration as continuous infusion throughout the procedure. RESULT The most common reported hypocalcaemic symptoms were mild perioral paresthesia followed by digital numbness. Of the 50 individuals who were injected with bolus calcium 40 (80%) individuals suffered from symptoms of hypocalcaemia, whereas 23 of 66 individuals (34.8%) suffered from hypocalcaemia in the continuous infusion group. This difference was significant (P < 0.001). Both groups were compared with respect to age, gender ratio, weight of the individuals, total blood volume processed, ACD used, calcium gluconate dose used, time taken for the procedure, the product volume. Significant difference was noticed only with respect to the product volume. This implies that the groups were comparable with respect to parameters such as age, gender ratio, weight of the individuals, total blood volume processed, ACD used, calcium gluconate dose used, and the time taken for the procedure. Also that significantly more products (244 v/s 204 ml) was collected in the continuous infusion group. CONCLUSIONS Our results show that prophylactic continuous IV administration of low dose calcium-gluconate throughout the PBSC harvesting procedure reduced the incidence as well as the severity of citrate related toxicity. This increases his/her tolerance to withstand longer durations of the procedure and collect more volume of the product, hence may reduce the number of sittings of the procedure.

Comparison of Amicus and COBE Spectra for allogenic peripheral blood stem cell harvest: Study from tertiary care centre in India

INTRODUCTION Most common source of stem cell graft for both autologous and allogenic haematopoietic transplants are peripheral blood haematopoietic progenitor stem cells. Adequate collection of the CD34+ cells and safety of the allogenic donor during the leukapheresis are of prime importance to an apheresis physician. Our retrospective analysis is a comparison between of two platforms namely, COBE Spectra and Amicus, for CD34+ mononuclear cell collection. MATERIAL AND METHOD The study included the data of GSCF (Granulocyte-Colony-Stimulating Factor) mobilized allogenic PBSC collections at our centre from January 2015 to June 2016. The apheresis platforms used were COBE Spectra and Amicus. Blood cell counts were done using LH750 Beckman Coulter (Florida, Miami, USA). CD45+ & CD34+ cell counts were done using BD FACS Canto-II Flow-Cytometer by ISHAGE guidelines. RESULTS A total of 170 PBSC (100 COBE Spectra & 70 Amicus) harvests were done on 143 donors, of which 116 completed the collection in a single session and 27 required a second session. Demographic details and pre harvest peripheral blood counts for both the groups did not show any statistical differences. Amicus processed higher blood volume with higher ACD exposure and procedure time compared to COBE Spectra. Higher platelets loss was with COBE Spectra harvests with higher product volumes collection. Collection efficiency (CE2), collection ratio, CD34+ cells dose was similar on both the platforms. RBC contamination, absolute lymphocyte and monocytes counts were significantly higher with Amicus harvest product compared with COBE Spectra. A total of 14 (8.2%; citrate toxicity) adverse reactions were reported out of 170 allogenic PBSC collections. DISCUSSION/CONCLUSION Our study suggests that both Amicus and COBE Spectra platforms offer comparable results for allogenic PBSC collections. Amicus offers a concentrated PBSC product with lesser volume and platelets loss but higher RBC contamination.

Making type and screen policy an essential component of pretransfusion testing: Need of the hour in India

Introduction: “Type and screen” policy involves the prior determination of patient blood group and antibody screening at the time of admission irrespective of the need of the blood transfusion to the patient. Materials and Methods: As a part of our retrospective analysis, we have evaluated our data from January 2014 to June 2016. Blood grouping was done by column agglutination technology (CAT) using DiaClon ABO/D+ Reverse Grouping cards (BIO-RAD, Switzerland). Antibody screening and identification were done using three cell panels (ID-DiaCell I-II-III Asia panel by BIO-RAD, Switzerland) and 11 cell panels (ID-DiaPanel-P by BIO-RAD, Switzerland) on CAT with LISS/Coombs cards. Results: A total of 17,896 patients requests for “type and screen” were received by the department during the study. Out of which 201 (1.12%; 1 in 89 patients) patients were found to have positive antibody screen. Out of 201 patients (132 females; 69 males); mean age group of 45.6 years (range: 1 day–85 years). Out of 201, 145 patients developed single antibody, 15 patients had double antibody, and in 41 positive antibody screens the specificity of alloantibodies were not identified either due to an interfering autoantibody (n = 10) or the specificity was not resolved on extended panels (n = 31) even with enzymes. Conclusion: “Type and screen” policy helps in timely blood group typing of the patients and providing enough time for the blood bank to arrange for blood. Our analysis shows the presence of an alloantibody in every 89 requests received for “type and screen.”

Daratumumab (Anti-CD38) interference with serological testing: An emerging challenge for blood banks in developing countries

Daratumumab (DARA), a monoclonal anti-CD38 antibody, belongs to the new generation of immunotherapy in refractory relapsed multiple myeloma. CD38 is weakly expressed on human erythrocytes. By its intrinsic anti-CD38 activity, DARA also interferes in routine pretransfusion compatibility testing such as antibody screening for red blood cells (RBCs) alloantibodies and compatibility testing. Treating RBCs with dithiothreitol eliminates the DARA interference. We report two cases of serological interference of DARA in pretransfusion testing and how timely information before starting the second patient on DARA prevented the delay in pretransfusion compatibility testing and blood availability.

Extracorporeal photopheresis: Review of technical aspects

Extracorporeal photochemotherapy (ECP) is considered as an immune modulating therapy majorly targeting the T cells of the Immune system. ECP induces an anti-inflammatory condition with tolerogenic responses without inducing a global immunosuppression state which is a typical feature of other therapeutic options such as steroids. Clinical indication of ECP has grown over time since its initial applications. Our review discusses the technical aspects of the concept of photopheresis with the available methods for its clinical applications.

Hematopoietic Stem Cell Transplant in Elderly Patients: Experience from a Tertiary Care Centre in Northern India

One-fifth of the world’s population resides in India. The burden of hematological diseases both malignant and nonmalignant is huge in the country. According to the registry data the total number of leukemia and lymphoma patients living in India in 2010 was about 100,000 [1]. The estimated size of the elderly population in India is expected to rise from 77 million in 2001 to 140 million by 2021. With the increasing awareness about hematological diseases and the rising economy, many patients are opting for hematopoietic stem cell transplant (HSCT) as a definite treatment for many hematological diseases. The role of HSCT for various hematological diseases in young patients is well established. Older patients have traditionally been considered ineligible for stem cell transplantation and data of HSCT in elderly is scarce, particularly from developing countries. Here we report our experience with stem cell transplantation in the elderly population in India. We reviewed the transplant database at Bone Marrow Transplant (BMT) centre, BLK Superspeciality Hospital, New Delhi. The conditioning regimen for allogeneic HSCT was reduced intensity conditioning (with fludarabine 30 mg/m for 5 days and melphalan 140 mg/m for 1 day). For autologous HSCT for multiple myeloma and lymphoma, melphalan 200 mg/m and BEAM regimens (BCNU 300 mg/m, etoposide 200 mg/m, cytarabine 200 mg/m and melphalan 200 mg/m) respectively were used as conditioning regimens. The transplants were performed in High Efficiency Particulate Air (HEPA) filtered rooms. Peripheral blood stem cell harvest was done after granulocyte-colony stimulating factor (G-CSF) mobilization. Graft versus host disease (GVHD) prophylaxis for allogeneic HSCT included cyclosporine and methotrexate. Patients received standard anti-viral prophylaxis with acyclovir and Pneumocystis jiroveci prophylaxis with trimethoprim-sulfamethoxazole. Patients were treated with broad spectrum antibiotics at the time of their first neutropenic fever, and with antifungal agents as per institutional policy. The study was approved by the Institutional Review Board. Out of 440 patients who underwent HSCT at BLK Superspeciality hospital from Feburary 2010 to August 2015, 19 (4.32 %) were C60 years of age. Median age was 63 years (range 60–73 years). There were 14 males and 5 females. Seven patients underwent allogeneic HSCT and 12 patients underwent autologous HSCT. All patients had normal liver and kidney functions and normal left ventricular ejection functions prior to HSCT. Six patients had diabetes well controlled with oral hypoglycemic agents. All allogeneic HSCTs were sibling matched peripheral blood stem cell transplantations. The most common indications for allogeneic and autologous HSCT were acute myeloid leukemia (AML) and multiple myeloma (MM) respectively (Table 1). The donors for allogeneic HSCT were females in five cases and males in two cases with a median age of 56 years (range 51–62 years). The median CD34? stem cell dose was 3.7 9 10/kg recipient body weight (range 1.88–8.77 9 10/kg). Neutrophil engraftment occurred at a median of 11 days (range 9–13 days) and platelet engraftment at 15 days (range 11–26 days). None of the patients had cytomegalovirus (CMV) reactivation. One patient developed grade 2 acute gut GVHD and three patients had limited chronic skin GVHD. Twelve patients & Sanjeev Kumar Sharma sksanjeev13@yahoo.com