Effects of recombinant human granulocyte-macrophage colony-stimulating factor (rhGM-CSF) on single CD34-positive hemopoietic progenitors from human bone marrow

A Multinational Observational Study Exploring Adherence With the Kidney Disease: Improving Global Outcomes Recommendations for Prevention of Acute Kidney Injury After Cardiac Surgery

BACKGROUND

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend a bundle of different measures for patients at increased risk of acute kidney injury (AKI). Prospective, single-center, randomized controlled trials (RCTs) have shown that management in accordance with the KDIGO recommendations was associated with a significant reduction in the incidence of postoperative AKI in high-risk patients. However, compliance with the KDIGO bundle in routine clinical practice is unknown.

METHODS

This observational prevalence study was performed in conjunction with a prospective RCT investigating the role of the KDIGO bundle in high-risk patients undergoing cardiac surgery. A 2-day observational prevalence study was performed in all participating centers before the RCT to explore routine clinical practice. The participating hospitals provided the following data: demographics and surgical characteristics, AKI rates, and compliance rates with the individual components of the bundle.

RESULTS

Ninety-five patients were enrolled in 12 participating hospitals. The incidence of AKI within 72 hours after cardiac surgery was 24.2%. In 5.3% of all patients, clinical management was fully compliant with all 6 components of the bundle. Nephrotoxic drugs were discontinued in 52.6% of patients, volume optimization was performed in 70.5%, 52.6% of the patients underwent functional hemodynamic monitoring, close monitoring of serum creatinine and urine output was undertaken in 24.2% of patients, hyperglycemia was avoided in 41.1% of patients, and no patient received radiocontrast agents. The patients received on average 3.4 (standard deviation [SD] ±1.1) of 6 supportive measures as recommended by the KDIGO guidelines. There was no significant difference in the number of applied measures between AKI and non-AKI patients (3.2 [SD ±1.1] vs 3.5 [SD ±1.1]; P = .347).

CONCLUSIONS

In patients after cardiac surgery, compliance with the KDIGO recommendations was low in routine clinical practice.

Effect of recombinant human granulocyte macrophage-colony stimulating factor in long-term marrow cultures from patients with aplastic anemia

The hematopoietic system in patients with aplastic anemia (AA) shows both quantitative and qualitative deficiencies, i.e., reduced numbers of hematopoietic progenitor cells (HPC) and impaired HPC proliferation in long-term marrow cultures (LTMC). Since recombinant human granulocyte macrophage-colony stimulating factor (rhGM-CSF) has been shown to be a potent stimulator of normal hematopoiesis, both in vivo and in vitro, in the present study we wanted to assess the possibility of stimulating hematopoiesis in LTMC from 17 patients with AA, by weekly addition of rhGM-CSF (10 ng/ml). In LTMC from 11 patients (group of responders), rhGM-CSF induced a significant increase (4.8-fold, compared with untreated cultures) in the levels of myeloid progenitor cells; in contrast, in six patients (group of nonresponders), myeloid progenitors were refractory to this cytokine. In the group of responders, rhGM-CSF also induced a pronounced increment in the levels of nonadherent and adherent cells (5.99- and 5.18-fold, respectively, compared with untreated cultures). Among the different myelopoietic lineages, rhGM-CSF preferentially stimulated the macrophagic lineage; this was evident both at the progenitor and mature cell levels. Interestingly, the effect of rhGM-CSF in LTMC from AA patients was only transient. Indeed, the effects mentioned above were observed only during the first three weeks of culture; afterwards, myeloid progenitor and nonadherent cell levels in treated cultures declined, practically reaching the levels observed in untreated cultures. At the moment, we do not know whether this transient stimulatory effect is due to the production of inhibitory cytokines, by macrophages generated in response to rhGM-CSF, or to the exhaustion of the HPC pool in AA cultures. In all 17 patients, rhGM-CSF had no effect on the kinetics of erythroid or multipotent progenitor cells. These results are in keeping with clinical studies in which it has been observed that most AA patients treated with rhGM-CSF show increments in circulating monocytes and granulocytes, as well as in bone marrow cellularity. However, little or no effect is observed on erythropoiesis. The actual mechanisms involved in the in vitro effects of rhGM-CSF on myeloid progenitor cells from AA bone marrow are still not completely understood. Future studies on this issue should be encouraged, since they may help to understand the in vivo (clinical) effects of this cytokine.

Characterization of CD34+HLA-DR-CD38+ and CD34+HLA-DR-CD38- progenitor cells from human umbilical cord blood

In this study we show that depletion of cells expressing mature cell markers, including HLA-DR, followed by positive cell sorting for cells expressing CD34 and CD38, can be used to define functionally distinct hematopoietic cells from human umbilical cord blood (HUCB). The CD34+HLA-DR-CD38+ population contained the majority of directly clonogenic cells, while the optimal ability to maintain long term co-culture with bone marrow stromal cells was present within the CD34+HLA-DR-CD38- population. 1.2 +/- 0.4% of the CD34+HLA-DR-CD38- cells plated at 1 cell/well and grown in the presence of hematopoietic growth factors (HGF) formed hemopoietic colonies. Mesenchymal elements were observed in 20% of these cultures. No cell growth, however, was observed when the CD34+HLA-DR-CD38- cells were cultured in the absence of HGF. This is in contrast with the findings in fetal bone marrow which demonstrated the presence of stem cells that were independent of HGF. Thus, while it is possible to isolate very immature hemopoietic progenitor cells from HUCB defined by the phenotype Lin-CD34+HLA-DR-CD38-, these cells do not appear to exhibit the pluripotentiality of the analogous population reported in fetal bone marrow. We conclude that these cells are absent or at a very small frequency in HUCB.

Formation of haematopoietic microenvironment and haematopoietic stem cells from single human bone marrow stem cells

Haematopoietic stem cells are a population of cells capable both of self renewal and of differentiation into a variety of haematopoietic lineages. Enrichment techniques of human haematopoietic stem cells have used the expression of CD34, present on bone marrow progenitor cells. But most CD34+ bone marrow cells are committed to their lineage, and more recent efforts have focused on the precise characterization of the pluripotent subset of CD34+ cells. Here we report the characterization of two distinct subsets of pluripotent stem cells from human fetal bone marrow, a CD34+, HLA-DR+, CD38- subset that can differentiate into all haematopoietic lineages, and a distinct more primitive subset, that is CD34+, HLA-DR-, CD38-, that can differentiate into haematopoietic precursors and stromal cells capable of supporting the differentiation of these precursors. These data represent, to our knowledge, the first identification of a single cell capable of reconstituting the haematopoietic cells and their associated bone marrow microenvironment.

Flow cytometry: clinical applications in haematology

The time interval between the development of a new technique or methodology and its acceptance, if successful, as a recognized clinical application can be many years. The application of flow cytometry to reticulocyte counting, for example, has taken 8 years from the appearance of the first publication, and in 1990 it is still in its infancy as a clinical method. It is therefore a challenging task to anticipate which of the methodologies currently under development will achieve acceptance. It would be impossible to deal with all the candidates in the space available, and so a review is provided to those methods that may have potential applications in clinical haematology, together with some of the more practical details of methods that have recently been demonstrated to be viable in the clinical laboratory. The first category consists of leukocyte enumeration and studies on bone marrow, neutrophils, platelets and cellular DNA content, whilst the second covers reticulocyte counting and total red cell volume measurement. The contribution of flow cytometry to the field of immunophenotyping haematological disorders is probably unique in already being clinically acceptable. Finally, the question of quality control is addressed, as this is an essential prerequisite to the adoption of any new method in the clinical laboratory.