Granulocyte transfusion therapy: update on potential clinical applications

Biomimetic and Materials-Potentiated Cell Engineering for Cancer Immunotherapy

In cancer immunotherapy, immune cells are the main force for tumor eradication. However, they appear to be dysfunctional due to the taming of the tumor immunosuppressive microenvironment. Recently, many materials-engineered strategies are proposed to enhance the anti-tumor effect of immune cells. These strategies either utilize biomimetic materials, as building blocks to construct inanimate entities whose functions are similar to natural living cells, or engineer immune cells with functional materials, to potentiate their anti-tumor effects. In this review, we will summarize these advanced strategies in different cell types, as well as discussing the prospects of this field.

Neutrophils Derived from Genetically Modified Human Induced Pluripotent Stem Cells Circulate and Phagocytose Bacteria In Vivo

Bacterial and fungal infections are a major cause of morbidity and mortality in neutropenic patients. Donor‐derived neutrophil transfusions have been used for prophylaxis or treatment for infection in neutropenic patients. However, the short half‐life and the limited availability of large numbers of donor‐derived neutrophils for transfusion remain a significant hurdle in the implementation of neutrophil transfusion therapy. Here, we investigate the in vitro and in vivo activity of neutrophils generated from human induced pluripotent stem cells (iPSC), a potentially unlimited resource to produce neutrophils for transfusion. Phenotypic analysis of iPSC‐derived neutrophils reveal reactive oxygen species production at similar or slightly higher than normal peripheral blood neutrophils, but have an ∼50%–70% reduced Escherichia coli phagocytosis and phorbol 12‐myristate 13‐acetate induced formation of neutrophil extracellular traps (NET). Signaling of granulocytic precursors identified impaired AKT activation, but not ERK or STAT3, in agonist‐stimulated iPSC‐derived neutrophils. Expression of a constitutively activated AKT in iPSC‐derived neutrophils restores most phagocytic activity and NET formation. In a model of bacterial induced peritonitis in immunodeficient mice, iPSC‐derived neutrophils, with or without corrected AKT activation, migrate similarly to the peritoneal fluid as peripheral blood neutrophils, whereas the expression of activated AKT significantly improves their phagocytic activity in vivo. stem cells translational medicine2019;8:557–567

Infections Caused by Acinetobacter baumannii in Recipients of Hematopoietic Stem Cell Transplantation

Acinetobacter baumannii (A. baumannii) is a Gram-negative, strictly aerobic, non-fermentative coccobacillus, which is widely distributed in nature. Recently, it has emerged as a major cause of health care-associated infections (HCAIs) in addition to its capacity to cause community-acquired infections. Risk factors for A. baumannii infections and bacteremia in recipients of hematopoietic stem cell transplantation include: severe underlying illness such as hematological malignancy, prolonged use of broad-spectrum antibiotics, invasive instrumentation such as central venous catheters or endotracheal intubation, colonization of respiratory, gastrointestinal, or urinary tracts in addition to severe immunosuppression caused by using corticosteroids for treating graft versus host disease. The organism causes a wide spectrum of clinical manifestations, but serious complications such as bacteremia, septic shock, ventilator-associated pneumonia, extensive soft tissue necrosis, and rapidly progressive systemic infections that ultimately lead to multi-organ failure and death are prone to occur in severely immunocompromised hosts. The organism is usually resistant to many antimicrobials including penicillins, cephalosporins, trimethoprim-sulfamethoxazole, almost all fluoroquinolones, and most of the aminoglycosides. The recently increasing resistance to carbapenems, colistin, and polymyxins is alarming. Additionally, there are geographic variations in the resistance patterns and several globally and regionally resistant strains have already been described. Successful management of A. baumannii infections depends upon appropriate utilization of antibiotics and strict application of preventive and infection control measures. In uncomplicated infections, the use of a single active beta-lactam may be justified, while definitive treatment of complicated infections in critically ill individuals may require drug combinations such as colistin and rifampicin or colistin and carbapenem. Mortality rates in patients having bacteremia or septic shock may reach 70%. Good prognosis is associated with presence of local infection, absence of multidrug resistant strain, and presence of uncomplicated infection while poor outcome is associated with severe underlying medical illness, bacteremia, septic shock, multi-organ failure, HCAIs, admission to intensive care facilities for higher levels of care, and culture of certain aggressive genotypes of A. baumannii.

Pretreatment with phosphatase and tensin homolog deleted on chromosome 10 (PTEN) inhibitor SF1670 augments the efficacy of granulocyte transfusion in a clinically relevant mouse model

The clinical outcome of granulocyte transfusion therapy is often hampered by short ex vivo shelf life, inefficiency of recruitment to sites of inflammation, and poor pathogen-killing capability of transplanted neutrophils. Here, using a recently developed mouse granulocyte transfusion model, we revealed that the efficacy of granulocyte transfusion can be significantly increased by elevating intracellular phosphatidylinositol (3,4,5)-trisphosphate signaling with a specific phosphatase and tensin homolog deleted on chromosome 10 (PTEN) inhibitor SF1670. Neutrophils treated with SF1670 were much sensitive to chemoattractant stimulation. Neutrophil functions, such as phagocytosis, oxidative burst, polarization, and chemotaxis, were augmented after SF1670 treatment. The recruitment of SF1670-pretreated transfused neutrophils to the inflamed peritoneal cavity and lungs was significantly elevated. In addition, transfusion with SF1670-treated neutrophils led to augmented bacteria-killing capability (decreased bacterial burden) in neutropenic recipient mice in both peritonitis and bacterial pneumonia. Consequently, this alleviated the severity of and decreased the mortality of neutropenia-related pneumonia. Together, these observations demonstrate that the innate immune responses can be enhanced and the severity of neutropenia-related infection can be alleviated by augmenting phosphatidylinositol (3,4,5)-trisphosphate in transfused neutrophils with PTEN inhibitor SF1670, providing a therapeutic strategy for improving the efficacy of granulocyte transfusion.

Cryopreservable neutrophil surrogates: Granule-poor, motile cytoplasts from polymorphonuclear leukocytes home to inflammatory lesions in vivo

Cytokineplasts (CKP) are anucleate, motile, granule-poor fragments induced from polymorphonuclear leukocytes on surfaces by the brief application of heat. Derived from the peripheral cytoplasm and membranes of PMN, they retain the sensing, transducing, and effector mechanisms necessary for chemotaxis and phagocytosis, and appear to represent a functional, self-purification of the motile apparatus. Unlike their parent PMN, CKP are cryopreservable. We have shown that they can adhere to endothelial cell monolayers, open interendothelial cell junctions, and migrate to the abluminal side when stimulated by a chemoattractant. Employing an animal model, we now show that, given intravenously, they can home to an inflammatory target lesion in vivo.

The effect of peptide stimulation on haematopoietic stem cell mobilisation including engraftment characteristics and a note on donor side effects

Aplasia or irreversible bone marrow failure and a variety of haematologic malignancies, as well as an increasing number of solid tumours, currently include various forms of marrow or equivalent transplantation in routine management. In both allogeneic and autologous procedures stable recipient immunohaematopoietic reconstitution depends upon infusing the requisite population harvested at a precise time following commencement of a stimulatory peptide. In a first step this prospective study documented the safety of apheresis, defined side effects and enumerated mononuclear, CD34+ and CD3+ cells obtained. In the second stage delivery of the graft, characterised in this way and with the additional measurement of in vitro growth in clonogenic assay, to the suitably conditioned patient was correlated with recovery of neutrophil and platelet numbers appearing in the circulation. In a third and ongoing analysis the influence of passenger T-lymphocytes is being evaluated for impact on infection and a potential anti-tumour effect. The conclusion is that this technology is reliable, has a high degree of patient acceptability without untoward complications, and that local results correspond to international experience thereby providing an important and relevant measure of quality control.

Use of serial analysis of gene expression (SAGE) technology reveals new granulocytic markers

Because of its short life span in blood, its low RNA content and its highly condensed nucleus, the granulocyte was initially considered as a terminally differentiated cell unable to express novel genes. However, mature granulocytes still contain a variety of mRNAs and may respond to external stimuli by rapid and complex changes in gene expression. The present work was undertaken to provide a wider view of the gene expression profile in unstimulated circulating PMNs. We used serial analysis of gene expression (SAGE) adapted to downsized extracts (SADE) to cope with their small mRNA content. As cell samples of the highest degree of purity were crucial for this project, we adapted a magnetic cell sorting method to reach the required high levels of purity (99.55 +/- 0.19%) together with low activation rates (1.37 +/- 0.28). We analyzed 20,787 tags identifying 8547 different transcripts, of which 47.8% were unknown, 34.6% were transcripts of known genes, and 13.8% matched with expressed sequence tags (EST). Highly expressed genes were those involved in cell mobility, diapedesis, cell signaling and destruction of micro-organisms. In addition, this method led to the identification of genes which had not previously been reported in granulocytes. These results could provide new molecular markers and a reliable reference for the investigation of pathologies involving alteration of the granulocyte gene expression profile.

Efficacy of granulocyte transfusions for neutropenia-related infections: retrospective analysis of predictive factors

BACKGROUND

The transfusion of G-CSf-primed granulocytes (GTX) might represent an important treatment option for neutropenia-related infections unresponsive to conventional antimicrobial therapies and to recombinant hematopoietic growth factors. However, few studies to date have identified the factors that can predict clinical outcome and the patient populations who are likely to benefit most from GTX. The primary endpoint of the present retrospective study was to evaluate the efficacy of GTX in 22 patients with hematological malignancies who developed neutropenia-related bacterial and fungal infections that were unresponsive to appropriate antimicrobial therapies.

METHODS

Peripheral blood granulocytes were collected by continuous-flow leukapheresis from HLA-identical siblings after priming with G-CSF. The response to GTX was classified as 'favorable' if clinical symptoms and signs of infection resolved or 'unfavorable' if clinical symptoms and signs of infection were unchanged or worsened. Control of infection at Day 30 after the enrollment in the GTX program was considered as the outcome variable in multiple regression analysis.

RESULTS

Two patients died of infection before receiving the granulocyte concentrates. Bacterial infections (monomicrobial or mixed bacteremias) were documented in 11 patients, whereas fungal infections (fungemia or focal fungal infections) were diagnosed in seven patients. In two patients, no infecting agent could be isolated (clinical infection). Control of infection at Day 30 after the first GTX was achieved in 10 of 20 assemble patients. Overall, 54% of patients with bacterial infections had a favorable response, compared with 57% of patients with fungal infections. No differences in terms of survival were found when comparing patients with bacterial and those with fungal infections at a median follow-up 90 days from the first GTX. In univariate analysis, disease status before GTX, e.g., complete or partial remission, and spontaneous recovery of the neutrophil count were significantly associated with control of infection. when multivariate regression models were formed, the recovery 0.5 x 10 (9)/L PMN was the only parameter that significantly and independently correlated with a favorable response to GTX.

DISCUSSION

GTX can be used to successfully treat bacterial as well as fungal infections in severely neutropenic patients when administered early after the onset of febrile neutropenia in patients with remission of the underlying disease and who are likely to recover marrow function.

Granulocyte concentrates: how can we assess their quality?

The use of granulocyte transfusions to treat and prevent life-threatening infection in patients lacking neutrophil numbers or function may become increasingly important in aiding advances in the treatment of haematological malignancies. A critical factor in determining the outcome of granulocyte transfusion is the number of cells transfused, and collection of sufficiently high concentration of cells from donors remains challenging. A number of tests of granulocyte function can be performed in vitro to assess the quality of granulocyte concentrates, which may be useful in helping to optimize granulocyte collection, processing and storage methods. Studies that have examined neutrophil function in granulocyte concentrates to date have tended to focus on the assessment of viability, chemotaxis, phagocytosis and oxidative killing. How useful in vitro tests of neutrophil function are in predicting neutrophil function following granulocyte transfusion remains to be established in conjunction with well-designed clinical trials.

Protection of killer antiidiotypic antibodies against early invasive aspergillosis in a murine model of allogeneic T-cell-depleted bone marrow transplantation

Antiidiotypic monoclonal antibodies (MAbs) representing the internal image of a yeast killer toxin (KT) have therapeutic potential against several fungal infections. The efficacy of KT MAbs against Aspergillus fumigatus was investigated in a mouse model of T-cell-depleted allogeneic bone marrow transplantation (BMT) with invasive pulmonary aspergillosis. Mice were highly susceptible to infection at 3 days post-BMT, when profound neutropenia was observed both in the periphery and in the lungs. Treatment with KT MAbs protected the mice from infection, as judged by the long-term survival and decreased pathology associated with inhibition of fungal growth and hyphal development in the lungs. In vitro, similar to polymorphonuclear neutrophils, KT MAbs significantly inhibited the hyphal development and metabolic activity of germinated Aspergillus conidia. These results indicate that mimicking the action of neutrophils could be a strategy through which KT MAbs exert therapeutic efficacy in A. fumigatus infections.

Adoptive therapy with monocyte-derived macrophages in the setting of high-dose chemotherapy and peripheral blood stem cell transplantation

In an attempt to ameliorate chemotherapy-induced side-effects after transplantation of autologous peripheral blood stem cells (PBSCT), we tested the reinfusion of autologous macrophages (MAC) that are known to be potent antimicrobial effector cells and cytokine producers. Ten patients were treated with two sequential cycles of high-dose chemotherapy followed by PBSCT. Before the second cycle of PBSCT, mononuclear cells were harvested, cultured for 8 d in order to induce MAC maturation and reinfused 3 d after PBSCT without clinical problems. However, MAC infusions did not substantially alleviate the toxicity of autologous PBSCT.

Cataracts in neutrophil donors stimulated with adrenal corticosteroids

BACKGROUND

A relatively young man (43 years old) was found to have a cataract after receiving prednisone before each of 35 neutrophil (PMN) donations over several years. Because corticosteroids are known to induce posterior subcapsular cataracts (PSCs), additional repeat PMN donors were examined ophthalmologically.

STUDY DESIGN AND METHODS

A controlled, blinded study was performed in 11 PMN donors who received prednisone with or without G-CSF before 17 to 46 leukapheresis donations over an average of 8.5 years. Control subjects were nine plateletpheresis donors of comparable age and donation experience, but they had never donated PMNs. A complete eye examination was performed by an ophthalmologist who was unaware of the donor's status (PMN vs. platelet).

RESULTS

Mild PSCs were found in 36 percent (4/11) of PMN donors versus 0 of 9 platelet donors (p = 0.068). Five of the 22 PMN donor eyes involved versus 0 of the 18 platelet donor eyes involved exhibited PSCs (p = 0.040). Cortical and nuclear cataracts were found similarly in both groups of donors (82% PMN vs. 56% platelet donors; p = 0.217); this indicated that lifestyle factors, independent of corticosteroids, that might predispose to cataract formation probably were comparable.

CONCLUSION

Corticosteroids given before PMN donations by leukapheresis might increase the risk of PSCs. Because of widespread renewed interest in PMN transfusions, this potential risk factor--if confirmed by studies of additional PMN donors--is of great international importance. Other centers are urged to perform ophthalmologic examinations on repeat PMN donors to clarify this issue.