Granulocyte transfusions in neutropaenic children: a systematic review of the literature

Use of granulocyte transfusion in early period in life-threatening infections of pediatric hematology and oncology patients: A single-center experience

Despite all the developments in medicine, infections continue to be one of the most important causes of mortality in pediatric hematology and oncology patients. The more severe the degree of neutropenia develops after intensive chemotherapy in cancer patients, and the longer the neutropenia duration, the higher the risk of infection. Granulocyte transfusion (GT) is used as supportive therapy in cases where the bone marrow needs time to recover in invasive bacterial or fungal infections along with severe neutropenia. The patients who had granulocyte transfusions in our clinic between June 2019 and June 2020 were reviewed retrospectively. A total of 15 units of granulocyte concentrate were used in 11 febrile neutropenia attacks of 9 patients. The demographic characteristics of the patients and features belonging to the period of GT were recorded. In our study, the clinical response rate after GT was 90.9 %, while the hematological response rate was 40 %. Most of the patients were treated succesfully, the mortality rate was 9%. We think that the most critical factor for success with GTs is determining the neutropenic patient in particular with a combination of high-risk malignancy and acute life-threatening infection for using GT. Also, early use of GT in those patients who do not recover despite appropriate antimicrobial and supportive treatment may contribute to improvement of the clinical conditon in a shorter period of time and reduction of repeated GTs.

Efficacy and safety of granulocyte transfusion in children: A single-center experience

BACKGROUND

Granulocyte suspension transfusion (GTx) can be used in severely neutropenic patients with infections that cannot be controlled despite appropriate antibiotic therapy.

OBJECTIVE

We aimed to evaluate the effectiveness and safety of GTx for the treatment of febrile neutropenia (FEN) in the pediatric age group.

METHODS

Patients who underwent GTx in the Hematology Clinic of Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital between 2013 and 2017 were evaluated retrospectively. Hematologic and clinical response rates, effects on survival, and adverse effects were investigated. Clinical response was defined at two time points: clinical response I was evaluated after each transfusion, while clinical response II was evaluated after the final GTx in a FEN episode.

RESULTS

During the study period, 343 GTx were given 107 FEN episodes of 74 patients. The mean number of granulocyte suspensions administered per patient and per FEN episode was 4.6 units and 3.2 units. The mean GTx volume administered was 237 ± 40 mL, and the mean granulocyte count was 2.8 ± 1.3 x 10¹⁰ /unit. Hematologic response was attained in 163 (47.6%) of 343 transfusions. Clinical response I was obtained in 88 (25.7%) of the GTx, and clinical response II was attained in 83 (78.5%) of 107 episodes. Life-threatening adverse event was not observed. The cumulative 1-month and 3-month survival rates were 87.8% and 76.5%, respectively.

CONCLUSION

High hematologic response and clinical recovery rates were achieved with GTx, with no limiting adverse effects. Granulocyte transfusion appears to be a safe and effective treatment in pediatric patients with FEN.

Characterization of buffy coat-derived granulocytes for clinical use: a comparison with granulocyte colony-stimulating factor/dexamethasone-pretreated donor-derived products

BACKGROUND AND OBJECTIVES

Buffy coat-derived granulocytes have been described as an alternative to the apheresis product from donors pretreated with dexamethasone and granulocyte colony-stimulating factor (G-CSF). The latter is - dependent on the local and national settings - obtained following a demanding and time-consuming procedure, which is undesirable in critically ill septic patients. In contrast, buffy coat-derived products have a large volume and are often heavily contaminated with red cells and platelets. We developed a new pooled buffy coat-derived product with high purity and small volume, and performed a comprehensive functional characterization of these granulocytes.

MATERIALS AND METHODS

We pooled ten buffy coats following the production of platelet concentrates. Saline 0·9% was added to decrease the viscosity and the product was split into plasma, red cells and a 'super' buffy coat. Functional data of the granulocytes were compared to those obtained with granulocytes from healthy controls and G-CSF/dexamethasone-pretreated donors.

RESULTS

Buffy coat-derived granulocytes showed adhesion, chemotaxis, reactive oxygen species production, degranulation, NETosis and in vitro killing of Staphylococcus aureus, Escherichia coli and Aspergillus species comparable to control and G-CSF/dexamethasone-derived granulocytes. Candida killing was superior compared to G-CSF/dexamethasone-derived granulocytes. Immunophenotyping was normal; especially no signs of activation in the buffy coat-derived granulocytes were seen. Viability was reduced. Buffy coats are readily available in the regular blood production process and would take away the concerns around the apheresis product.

CONCLUSION

The product described appears a promising alternative for transfusion purposes.

Granulocyte transfusions in critically ill children with prolonged neutropenia: side effects and survival rates from a single-center analysis

Granulocyte transfusions for neutropenic patients have been used for over 40 years, although effectiveness, indications, and both patient and donor safety remain debated. This single-center study assessed the side effects, clinical course, and survival of granulocyte transfusions in critically ill pediatric patients, with underlying hemato-oncological disorders, prolonged neutropenia, and proven or suspected severe infection. Donor-specific side effects and influence of donor-specific characteristics on patient outcome were also investigated. A median of 4.02 × 10(10) cells was collected from 39 healthy donors for 118 granulocyte concentrates. Donors reported no significant side effects. Complications for patients were frequent but mostly minor and included vomiting, hypotension, and dyspnea. In one episode of life-threatening dyspnea, association with the granulocyte transfusion could not be ruled out. Overall survival on day 100 was 61.9 %. Patients received a median of 0.13 × 10(10) cells per kg body weight. Doses above this median were associated with a significantly better survival. Lower patient weight and age-/sex-adjusted weight were also associated with better survival.

CONCLUSION

Granulocyte mobilization and collection is a safe practice. Transfusions are well tolerated in critically ill patients. Patient weight and transfused cells per kg bodyweight are major determinants of survival in pediatric patients.

WHAT IS KNOWN

• Granulocyte transfusions for neutropenic patients have been used for over 40 years • The effectiveness of the technique remains controversial • Patient and donor safety remain debated • New mobilization protocols generate higher yields of granulocytes What is new: • Granulocyte collection can safely be performed • Granulocytes can safely be administered to patients • Lower patient weight and age-/sex-adjusted weight are associated with better survival rates • Patients receiving above 0.13 × 10 (10) cells per kg body weight had an excellent outcome • Further standardized, prospective studies are warranted.

Changing Trends in the Use of Granulocyte Transfusions in Neutropenic Children with Sepsis in India

We present our data on granulocyte transfusions in children undergoing treatment for cancer and HSCT at our centre and their changing indications. In this retrospective observational analysis of children who received granulocytes from 2007 to 2015, we divided children receiving granulocytes into two groups-the first from January 2007 till December 2013 and the second from January 2014 till December 2015. This division is based on the change in our policy to use granulocytes within 48 h of septicemia as the incidence of drug resistant bacterial strains had increased at our centre. Data on 72 children with febrile neutropenia treated with 230 granulocyte infusions was analyzed. From 2007 to 2013 (n = 48/72), 27/48 (56 %) had culture proven sepsis of which 14 (51 %) were carbapenem resistant gram negative bacilli. 11 of the 27 children survived the crisis (41 %). We then changed our policy to transfuse granulocytes early during sepsis. From 2014 to 2015 (n = 24/72) 22 patients had culture proven sepsis (91 %) of which 20 had carbapenem resistant gram negative bacilli. 12/22 (54 %) with culture proven sepsis survived the episode. The survival rate improved from 41 % in first group to 54 % after early intervention with granulocytes (P value 0.0347). Despite the increased incidence of resistant bacteria during the period of 2014-2015, early use of granulocytes improved survival rate from 41 to 54 %. This intervention cannot be taken in isolation and needs to be offered early in parallel with appropriate antibiotics.

Granulocyte transfusions in children and adults with hematological malignancies: benefits and controversies

Bacterial and fungal infections continue to pose a major clinical challenge in patients with prolonged severe neutropenia after chemotherapy or hematopoietic stem cell transplantation (HSCT). With the advent of granulocyte colony-stimulating factor (G-CSF) to mobilize neutrophils in healthy donors, granulocyte transfusions have been broadly used to prevent and/or treat life-threatening infections in patients with severe febrile neutropenia and/or neutrophil dysfunction. Although the results of randomized controlled trials are inconclusive, there are suggestions from pilot and retrospective studies that granulocyte transfusions may benefit selected categories of patients. We will critically appraise the evidence related to the use of therapeutic granulocyte transfusions in children and adults, highlighting current controversies in the field and discussing complementary approaches to modulate phagocyte function in the host.

Granulocyte transfusion experience in pediatric neutropenic fever: Splitted product can be an alternative?

The granulocyte transfusion (GTX) has been used for a long time due to uncontrolled neutropenic fever with antimicrobial agents. In some cases, the product needs to be splitted for using in the next 12 hours. The aim of this study is to evaluate the efficacy of splitted product and clinical response to GTX. In this study, 15 patients with malignancy with 19 neutropenic fever, who had received 56 GTX, were included. Seventeen of 56 GTX were splitted and used in maximum 12 hours during infections which did not respond to antibacterial and antifungal therapy in 7 days. The patients were divided in to response groups as a complete, partial and progressive. The predictive factors for response group were evaluated. GTX were well tolerated in all patients. The median granulocyte dose was 1.26 (0.38-5.22) × 10(9)/kg. Total response rate was 89.5%. The infection-related mortality rate was 10.5%. Although the granulocyte doses are the same in both of the product groups, an hour later ANC increment of primer product was higher than that of splitted product (p = 0.001). Among the products, 48.7% of primer product and 17.6% of splitted product had induced ≥ 1000/mm(3) ANC increment after an hour (p = 0.039). Granulocyte transfusion is safe and effective in controlling the febrile neutropenia attack. GTX should be applied in a short time to provide effective ANC increment. For now, main granulocyte product instead of splitted product should be preferred in case of uncontrolled neutropenic fever with antibacterial/antifungal agents.

Granulocyte transfusions in hematologic malignancy patients with invasive pulmonary aspergillosis: outcomes and complications

BACKGROUND

Granulocyte transfusions (GTXs) have been used successfully as an adjunctive treatment option for invasive infections in some neutropenic patients with underlying hematologic malignancy (HM).

PATIENTS AND METHODS

We sought to determine the impact of GTX as an adjunct to antifungal therapy in 128 patients with HM and prolonged neutropenia (≥14 days) with a proven or probable invasive aspergillosis (IA) infection by retrospectively reviewing our institutional database.

RESULTS

Fifty-three patients received GTX and 75 did not. By univariate analysis, patients with invasive pulmonary aspergillosis who received GTX were less likely to respond to antifungal therapy (P = 0.03), and more likely to die of IA (P = 0.009) when compared with the non-GTX group. Among patients who received GTX, 53% developed a pulmonary reaction. Furthermore, IA-related death was associated with the number of GTX given (P = 0.018) and the early initiation of GTX within 7 days after starting antifungal therapy (P = 0.001). By multivariate competing risk analysis, patients who received GTX were more likely to die of IA than patients who did not receive GTX (P = 0.011).

CONCLUSIONS

Our study suggests that GTX does not improve response to antifungal therapy and is associated with worse outcomes of IA infection in HM patients, particularly those with pulmonary involvement.

Granulocyte transfusion therapy in pediatric patients after hematopoietic stem cell transplantation: a 5-year single tertiary care center experience

BACKGROUND

Granulocyte transfusion (GTx) has been used in neutropenic patients to treat infections; however, there are few studies that document its efficacy, especially in pediatric patients after hematopoietic stem cell transplantation (HSCT). We, therefore, reviewed the use of GTx in these patients.

MATERIALS AND METHODS

A retrospective observational analysis was performed on all pediatric HSCT patients between January 2005 and January 2010 who met our institution's criteria for GTx and received more than 1 GTx. Unstimulated granulocyte donors were used until June 2007, followed by dexamethasone-stimulated donors thereafter. Outcomes were infection clearance, safety profile of GTx, and 30-day survival.

RESULTS

One hundred fifty-three GTxs were administered to 16 pediatric HSCT patients. Indications for GTx: bacterial (69%), fungal (19%), and combined infection (12%). Concurrent infections, mostly bacterial, developed in 60% patients. One adverse reaction (pulmonary toxicity) was reported. The absolute neutrophil count of the stimulated products was significantly higher compared with the unstimulated products; however, neither the average number of granulocytes transfused by weight nor outcomes difference was noticed between these groups.

CONCLUSIONS

GTx is safe in neutropenic and infected pediatric patients after HSCT. However, no difference in the outcomes was noticed between the group that received stimulated products and the group that received unstimulated products.

Antibiotic prophylaxis for bacterial infections in afebrile neutropenic patients following chemotherapy

BACKGROUND

Bacterial infections are a major cause of morbidity and mortality in patients who are neutropenic following chemotherapy for malignancy. Trials have shown the efficacy of antibiotic prophylaxis in reducing the incidence of bacterial infections but not in reducing mortality rates. Our systematic review from 2006 also showed a reduction in mortality.

OBJECTIVES

This updated review aimed to evaluate whether there is still a benefit of reduction in mortality when compared to placebo or no intervention.

SEARCH METHODS

We searched the Cochrane Cancer Network Register of Trials (2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2011), MEDLINE (1966 to March 2011), EMBASE (1980 to March 2011), abstracts of conference proceedings and the references of identified studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention, or another antibiotic, to prevent bacterial infections in afebrile neutropenic patients.

DATA COLLECTION AND ANALYSIS

Two authors independently appraised the quality of each trial and extracted data from the included trials. Analyses were performed using RevMan 5.1 software.

MAIN RESULTS

One-hundred and nine trials (involving 13,579 patients) that were conducted between the years 1973 to 2010 met the inclusion criteria. When compared with placebo or no intervention, antibiotic prophylaxis significantly reduced the risk of death from all causes (46 trials, 5635 participants; risk ratio (RR) 0.66, 95% CI 0.55 to 0.79) and the risk of infection-related death (43 trials, 5777 participants; RR 0.61, 95% CI 0.48 to 0.77). The estimated number needed to treat (NNT) to prevent one death was 34 (all-cause mortality) and 48 (infection-related mortality).Prophylaxis also significantly reduced the occurrence of fever (54 trials, 6658 participants; RR 0.80, 95% CI 0.74 to 0.87), clinically documented infection (48 trials, 5758 participants; RR 0.65, 95% CI 0.56 to 0.76), microbiologically documented infection (53 trials, 6383 participants; RR 0.51, 95% CI 0.42 to 0.62) and other indicators of infection.There were no significant differences between quinolone prophylaxis and TMP-SMZ prophylaxis with regard to death from all causes or infection, however, quinolone prophylaxis was associated with fewer side effects leading to discontinuation (seven trials, 850 participants; RR 0.37, 95% CI 0.16 to 0.87) and less resistance to the drugs thereafter (six trials, 366 participants; RR 0.45, 95% CI 0.27 to 0.74).

AUTHORS' CONCLUSIONS

Antibiotic prophylaxis in afebrile neutropenic patients significantly reduced all-cause mortality. In our review, the most significant reduction in mortality was observed in trials assessing prophylaxis with quinolones. The benefits of antibiotic prophylaxis outweighed the harm such as adverse effects and the development of resistance since all-cause mortality was reduced. As most trials in our review were of patients with haematologic cancer, we strongly recommend antibiotic prophylaxis for these patients, preferably with a quinolone. Prophylaxis may also be considered for patients with solid tumours or lymphoma.

Polycythemia in an infant secondary to granulocyte transfusions

Granulocyte transfusions may be useful for neutropenic pediatric patients with refractory bacterial or fungal infections. Many potential adverse sequelae associated with granulocyte transfusions are well recognized, including febrile reactions, fluid overload, alloimmunization, and lung injury. Other potential adverse sequelae, however, are less well known. This case report describes an infant with familial hemophagocytic lymphohistiocytosis who developed polycythemia (hemoglobin 10-17.6 g/dl) following four daily transfusions of 20 ml/kg of apheresis collected, steroid stimulated donor granulocytes. Expanded knowledge of potential risks of transfused granulocytes will allow for rapid recognition of transfusion-related complications, should they occur.

Educational paper: Defects in number and function of neutrophilic granulocytes causing primary immunodeficiency

The neutrophilic granulocyte (neutrophil) is the most important cellular component of the innate immune system. A total absence of neutrophils or a significant decrease in their number leads to severe immunodeficiency. A mature neutrophil, released from the bone marrow, should be able to migrate from the blood towards the tissues, following a chemotactic gradient to a pathogen. In order to be neutralized, this pathogen has to be recognized, phagocytosed, and destroyed by lytic enzymes contained in the neutrophil's granules and reactive oxygen species formed by the enzyme complex NADPH oxidase. Rare genetic defects leading to the loss of each one of these biological properties of the neutrophil have been described and are associated with immunodeficiency. This review provides a summary of the normal development and biological functions of neutrophils and describes the diseases caused by defects in neutrophil number and function.

Anesthetic considerations for the pediatric oncology patient--part 2: systems-based approach to anesthesia

One of the prices paid for chemo- and radiotherapy of cancer in children is damage to the vulnerable and developing healthy tissues of the body. Such damage can exist clinically or subclinically and can become apparent during active antineoplastic treatment or during remission decades later. Furthermore, effects of the tumor itself can significantly impact the physiologic state of the child. The anesthesiologist who cares for children with cancer or for survivors of childhood cancer should understand what effects cancer and its therapy can have on various organ systems. In part two of this three-part review, we review the anesthetic issues associated with childhood cancer. Specifically, this review presents a systems-based approach to the impact from both tumor and its treatment in children, followed by a discussion of the relevant anesthetic considerations.

The resurgence of granulocyte transfusions

Granulocyte transfusion can be used as supportive therapy in patients with life-threatening neutropenia caused by bone marrow failure or in patients with neutrophil dysfunction. Emerging evidence demonstrates the benefits of granulocyte transfusions to treat infections in patients after treatment with high-dose chemotherapy, particularly the chemotherapy associated with conditioning for hematopoietic stem cell transplant. There has been an increased interest in the use of therapeutic granulocyte transfusion in recent years due to the ability to use granulocyte colony-stimulated factors to produce higher doses of granulocytes for transfusion. Other factors that influence the outcome of transfusion include the type of infection being treated, the likelihood of recipient marrow recovery, and recipient alloimmunization. This article provides a historical perspective on granulocyte transfusion and an overview of its clinical use.

Granulocyte transfusions for pediatric patients and the establishment of national treatment guidelines and donor registry

G-CSF/dexamethasone stimulated donor derived granulocyte transfusion (GTX) has been shown in non-randomized studies to be a useful co-therapy in immune-compromised patients unresponsive to conventional antimicrobial treatments. Reports of GTX are however usually single institution adult experiences. Substantiated pediatric data, other than in neonates, is less common.

[Granulocyte transfusion]

BACKGROUND

Granulocyte transfusion is used in the treatment of severe, sustained or complicated infection and neutropenia. In recent years, the method's efficacy has improved and its availability increased. After the introduction of granulocyte colony-stimulating factor (G-CSF) there has been a growing interest for granulocyte transfusion, and effective methods for collection and transfusion of granulocytes are now in clinical use. This paper presents clinical, immunological and ethical challenges, our own experience with granulocyte harvesting and documentation of efficacy.

MATERIAL AND METHODS

The paper is based on our own experience with granulocyte transfusion and literature retrieved though a non-systemic search.

RESULTS

The efficacy of granulocyte transfusion with respect to morbidity and mortality is still debated, and the method currently has no place in routine treatment of documented infection and neutropenia. However, the treatment could be an alternative for patients with inadequate response to conventional treatment and for whom sustained neutropenia is expected. The combined use of G-CSF, hydroxyethyl starch and corticosteroids considerably increases the yield of granulocytes collected for transfusion.

INTERPRETATION

Granulocyte transfusion is clinically feasible, but more research is needed to define clinical indications and to document the procedure's efficacy. Larger randomized controlled efficacy trials are needed.

Granulocyte transfusions in neutropenic patients: beneficial effects proven?

Despite the huge armamentarium of modern antibiotics and anti-fungals, infections remain life-threatening events in patients with profound neutropenia. For decades, the value of granulocyte transfusions (GT) has been explored and results are still not conclusive. However, it has been shown that GT increase peripheral blood neutrophil counts of recipients and lead to migration of functional neutrophils into inflamed tissues. A favourable increment of absolute neutrophil counts is observed after concentrates from technically up-to-date apherese from granulocyte-colony stimulating factor-stimulated donors. Most studies indicated a potential positive effect on infection elimination with a minimum cell content of GT (1.5-3 x 10(8)/kg recipient body weight). Although to date the beneficial effect of GT is not proven in prospective randomized trials, in specific situations GT is an option to treat infections along with antibiotics when there is profound neutropenia. However, these patients in critical situations need to be treated within carefully designed studies based on the best known methods for providing granulocyte concentrates in sufficient dose and frequency, standardized similar to other blood product transfusions. That includes definition of minimum cell content, maximum interval between apheresis and application, storage conditions, methods of donor stimulation according to patient's body weight and frequency of GT. This review considers the results of recent studies using GT from cytokine-stimulated donors and the consequences and effects in recipients and donors.

Granulocyte transfusions for preventing infections in patients with neutropenia or neutrophil dysfunction

BACKGROUND

Since the late 1990s there has been increasing demand for donated granulocyte transfusions to treat or prevent severe infections in patients who lack their own functional granulocytes. Other than in neonates, no systematic reviews have been performed for over 10 years relating to the efficacy of prophylactic granulocyte transfusions.

OBJECTIVES

To determine the effectiveness and safety of granulocyte transfusions compared with a control population not receiving this intervention for preventing mortality due to infection or due to any other cause in patients with neutropenia or disorders of neutrophil function.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2008, MEDLINE, EMBASE and other specialised databases up to October 2008. We also searched reference lists of articles and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing patients receiving granulocyte transfusions to prevent the development of infection with a control group receiving no granulocyte transfusions. Neonates have been the subject of a recent review and were excluded. There was no restriction by outcomes examined, but this review focuses on mortality, mortality due to infection and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed potentially relevant studies for inclusion. Data were extracted by two review authors and the methodological quality was examined. Data were analysed using random and fixed effects models.

MAIN RESULTS

Ten trials met the inclusion criteria. Allocation in all trials was random, with the control arm receiving no prophylactic therapy, except one trial in which the control group received specific prophylactic antibiotics. One study reported biological randomisation based upon the availability of suitably matched, related donors rather than strict randomisation. All trials were conducted over twenty years ago with one exception, a study from 2006 in which donors were pre-medicated with granulocyte colony stimulating factor (G-CSF) resulting in significantly higher mean doses of granulocytes collected for transfusion. Different policies otherwise applied for the schedule for transfusion, method of granulocyte procurement and criteria for defining infection. Combining the results showed a relative risk (RR) for mortality of 0.94 (95% confidence intervals (CI) 0.71 to 1.25). Exclusion of the two trials which reported transfusion of an average number of granulocytes below 1 x 10(10) indicated a summary RR for mortality and mortality due to infection of 0.89 (CI 0.64 to 1.24) and 0.36 (0.14 to 0.96) respectively.

IMPLICATIONS FOR CLINICAL PRACTICE

The controlled trials that have been identified raise the possibility that prophylactic granulocyte transfusions at a dose of at least 1 x 10(10) may reduce the risk of mortality from infection. Overall mortality was not affected. However, the majority of studies were performed decades ago, and standards of supportive care have advanced considerably. These earlier trials were also based on transfusing lower yields of collected granulocytes than currently recommended. It is difficult to recommend prophylactic granulocyte transfusions outside the setting of ongoing controlled trials, given the resource and cost implications.

IMPLICATIONS FOR RESEARCH

Larger trials are needed to establish the validity of the potential benefits raised by this review, in view of the methodological limitations, the small sample sizes and the heterogeneous definitions of infection that were encountered in the included studies.