Respiratory complications after haematopoietic stem cell transplantation in a patient with chronic granulomatous disease.

Chronic granulomatous disease (CGD) is an inherited immunodeficiency disorder caused by defects in NADPH oxidase and characterized by recurrent life-threatening bacterial and fungal infections. Although CGD has been considered to be a target for gene therapy, bone marrow transplantation (BMT) is now selected as the radical treatment in most cases. We performed BMT in a patient with CGD with severe infections and experienced respiratory complications of diffuse alveolar haemorrhage and/or infection-associated alveolar haemorrhage. We suggest that attention be paid to signs of onset of alveolar haemorrhage during BMT in CGD patients.

Decrease in circulating hematopoietic progenitor cells by trapping in the pulmonary circulation.

BACKGROUND: When stem-cell grafts are infused into the venous circulation and stem/progenitor cells egress from BM, pulmonary capillary beds are the first microcirculation site that they encounter. This provides the potential for circulating progenitor cells to be trapped in the pulmonary circulation. METHODS: We compared the number of progenitor cells [CD34(+) cells, colony-forming unit-granulocyte-macrophage (CFU-GM), CD34(+) CD41(+) cells and CFU-megakaryocyte (CFU-meg)] and their expression of cell-adhesion molecules (CAM) in samples taken simultaneously from radial arteries and central veins of 21 patients following PBSC mobilization. RESULTS: The mean (+/- SD) frequency of progenitor cells in the radial arteries was reduced to 79% +/- 25% for CD34(+) cells, 73% +/- 27% for CFU-GM, 77% +/- 25% for CD34(+) CD41(+) cells and 70% +/- 29% for CFU-meg of the number in the central veins. This suggests that some progenitor cells might be trapped in the lung. No association between progenitor-cell expression of CAM and pulmonary trapping was observed. DISCUSSION: Our data demonstrate pulmonary trapping of PBSC during mobilization, suggesting a potential inhibitory effect on PBSC harvest and medullary trafficking following graft infusion. However, the impact associated with pulmonary PBSC trapping may be negligible in the clinical setting if sufficient cells are infused.

Application of nitric oxide for a case of veno-occlusive disease after peripheral blood stem cell transplantation.

A 5-year-old girl at high risk for acute lymphoblastic leukemia was treated with high-dose chemotherapy and autologous peripheral blood stem cell transplantation (PBSCT). However, her condition was complicated by veno-occlusive disease of the liver (VOD) after PBSCT. For treatment of VOD, transdermal isosorbide tape was applied as a nitric oxide (NO) donor. The signs of VOD improved immediately after NO treatment was initiated, and the patient showed no side effects from the transdermal isosorbide tape.

Nutritional assessment of peripheral blood stem cell transplantation in children.

Peripheral blood stem cell transplantation (PBSCT) has many advantages for patients because hematopoiesis and general condition return to normal more rapidly than they do following bone marrow transplantation. Thus, the authors hypothesize that the nutritional condition of patients also returns to normal more rapidly after PBSCT. The duration of insufficient nutrition was investigated in children undergoing PBSCT. The subjects of this study were 8 patients with malignant diseases. The factors measured were body weight, body fat, cholesterol, albumin, pre-albumin, and retinol-binding protein. These parameters were measured a day before transplantation, and then once a week for 4 weeks after transplantation. All parameters were recovered until day 28 from the lowest level in transplantation. In this study, all parameters returned to normal comparatively early. PBSCT causes little damage to patients' nutrition.

Protection of hematopoietic progenitor cells by nitric oxide.

The free radical gas nitric oxide (NO) has been reported to trigger apoptosis of a variety of cell types, but there have also been contradictory reports of an inhibitory effect of NO on this form of programmed cell death. We hypothesized that NO may inhibit apoptosis of hematopoietic cells. In this study, therefore, hematopoietic cells obtained from umbilical cord blood (CB) were incubated with NO, and NO inhibited apoptosis of hematopoietic cells in umbilical CB, although it did not affect the number of mononuclear cells (MNC). Inhibition of apoptosis of hematopoietic cells is important for their use in transplantation. Our results suggest that it might be possible to prevent the loss of hematopoietic cells using NO.

A case of malignant lymphoma in a patient with high levels of CA125 and CA19-9.

The authors encountered a case of malignant lymphoma in a patient who had high levels of CA125 and CA19-9. These tumor markers showed almost identical changes during the clinical course of the disease. To date, there has been no investigation of these markers as they relate to malignant lymphoma. Unfortunately, the normal values of CA125 and CA19-9 in children were not known and thus this case could not be compared with disease-free children. This study shows CA125 and CA19-9 levels of the children that do not have the malignant diseases, and reports on one case of malignant lymphoma in a patient who presented with high levels of these markers.

Allogeneic peripheral blood stem cell transplantation in children with hematologic malignancies from HLA-matched siblings.

BACKGROUND: Despite the ethical problem of using granulocyte colony-stimulating factor (G-CSF) in normal children, allogeneic peripheral blood stem cell transplantation (PBSCT) might have advantages over allogeneic bone marrow transplantation (BMT). PROCEDURE: Eleven HLA-matched sibling donors aged 2-16 years received 10 microg/kg/day G-CSF for 5 days and underwent apheresis to harvest peripheral blood stem cells (PBSC). PBSC were then cryopreserved until infusion. The 11 corresponding patients aged 8 months to 14 years with high-risk hematological malignancies received busulfan (16 mg/kg or 600 mg/m(2)) and melphalan (210 mg/m(2)) as a preparative regimen. Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine and methylprednisolone. RESULTS: All of the donors tolerated G-CSF administration and apheresis procedures. The patients received a median of 5.8 (range 1. 4-11.5) x 10(6)/kg CD34(+) cells, 17.2 (3.8-36.0) x 10(5)/kg colony forming units-granulocyte/macrophage (CFU-GM), and 3.5 (1.4-7.1) x 10(8)/kg CD3(+) cells. All of the patients showed prompt engraftment, with a median time to reach an absolute neutrophil count (ANC) above 0.5 x 10(9)/liter of 10 (9-13) days. Grade I acute GVHD occurred in seven patients (64%), whereas grade II-IV acute GVHD was not seen. Chronic GVHD occurred in four patients (40%) among 10 patients evaluable for chronic GVHD. Three patients showed extensive chronic GVHD. Currently, eight patients (73%) are alive and disease-free for a median follow-up of 775 (103-1,069) days. CONCLUSIONS: Allogeneic PBSCT is feasible in the pediatric population, and PBSC harvest is an alternative to BM harvest in donors who are not eligible for BM harvest. Furthermore, PBSC were successfully collected in pediatric donors with peripheral access. The choice of a stem cell source should be based on the risk/benefit assessment for both patients and donors.

A case of hemolytic uremic syndrome improved with nitric oxide.

Hemolytic uremic syndrome (HUS) after transplantation is difficult to treat, and there is no consensus regarding optimal mode of treatment. We attached transdermal isosorbide tape as a nitric oxide (NO) donor to patients with HUS after bone marrow transplantation (BMT). This was very effective in ameliorating the hemolysis and increasing platelet numbers. We report here the successful use of an isosorbide in a patient with HUS after transplantation. Bone Marrow Transplantation (2000) 25, 109-110.

A case of myelodysplastic syndrome complicated by pulmonary alveolar proteinosis with a high serum KL-6 level.

Serious hematological diseases often cause respiratory disorders. Because these are related to the prognoses of patients with hematological diseases, their early diagnosis is necessary. This study describes a 6-year-old girl with myelodysplastic syndrome complicated by pulmonary alveolar proteinosis who showed a remarkable increase in her serum KL-6 level. Three years and 2 months after the end of therapy for neonatal melanoma, a diagnosis of myelodysplastic syndrome with leukemic change was made. Ten months after the onset of leukemia, she had respiratory distress with an increased serum KL-6 level of 75,000 U/mL (reference range; < 500 U/mL). Despite various treatments for pulmonary complications, she died 3 months after developing respiratory distress. A diagnosis of pulmonary alveolar proteinosis was made at autopsy. Earlier treatment of respiratory distress could be achieved if serum KL-6 levels were examined earlier.

The relation between the number of PBSC and number of leukaphereses in children.

Although PBSC transplantation has an advantage over BM transplantation in that fewer burdens are placed on the patient at the time of stem cell collection, the number of collected cells decreases when leukapheresis is done repeatedly. We examined the relation between the number of times leukapheresis is performed and the number of mononuclear cells (MNC), CD34+ cells, and colony-forming unit-granulocyte-macrophages (CFU-GM) collected. The percentage of CD34+ cells was measured by flow cytometry and the number of CFU-GM was measured by a progenitor assay. The number of cells collected was significantly decreased by the third collection. Therefore, to secure enough cells for transplantation, leukapheresis ideally should be performed no more than twice if PBSC collection is to be efficient.

Clinically applicable bulk isolation of blood CD34+ cells for autografting in children.

CD34+ cells were purified in bulk from apheresis-collected cells of children with cancer using monoclonal antibody (MoAb) and magnetic beads (Baxter ISOLEX system). To improve the purity of the final product for possibly better tumor cell purging and to make the manufacturer's original procedure more cost-effective, we incubated the cells for 30 min with l-phenylalanine methylester hydrochloride (PME) to reduce the cell number by removing contaminating granulocytes and monocytes in the initial step before incubation with MoAb. Our modification prevented nonspecific interactions between MoAb and magnetic beads, and thereby saved expensive materials for purification. A total of 40 purifications were performed with samples containing a mean of 3.1 x 10(9) blood cells mobilized from 15 children by chemotherapy plus granulocyte colony-stimulating factor (G-CSF). The entire purification procedure, from the end of apheresis to storage, was completed within 5h. After incubation with PME and double-layered (40/60%) Percoll separation, the number of CD34+ cells was reduced to 48+/-29%, which suggests the possibility that half of the CD34+ cells in the inoculum were nonclonogenic in the hematopoietic progenitor assay. PME/Percoll-treated cells were then subjected to a final isolation procedure with MoAb according to the manufacturer's suggestions, and 52+/-42% and 32+/-22%, respectively, of the CFU-GM and CD34+ cells present in the initial bag inoculums were recovered. The recovery rates were, respectively, 54% and 67%, when the calculation was limited to the isolation procedure with MNoAb. The purity of isolated CD34+ cells and the plating efficiency in methylcellulose culture were, respectively, 77+/-24% and 33+/-13%. Fourteen children were subsequently autografted with purified CD34+ cells after marrow ablative chemotherapy. The median number of days to achieve an ANC of 0.5 x 10(9)/l was 12 and that to achieve a platelet count of 50 x 10(9)/l was 22.5, which were comparable to those in our historical group of 55 patients who underwent transplant with unmanipulated blood cells (13 and 16 days). These results suggest that our modified purification procedure with PME is useful for the initial reduction of cell numbers to save costly materials, and that cells isolated by this procedure can be directly used in clinical transplantation procedures.

Partially mismatched pediatric transplants with allogeneic CD34(+) blood cells from a related donor.

This was a phase I, multi-center study of 13 pediatric patients (median age, 11 years) to evaluate toxicity, hematopoietic recovery, and graft-versus-host disease (GVHD) after allogeneic transplantation of enriched blood CD34(+) cells obtained from genotypically haploidentical but partially HLA-mismatched related donors (8 parents and 5 siblings). With regard to rejection, donor HLA disparity was 1 (5), 2 (6), or 3 loci (2). With regard to GVHD, recipient HLA disparity was 0 (1), 1 (3), 2 (8), or 3 (1). The patients suffered from acute myelogenous leukemia (6), chronic myelogenous leukemia (4), acute lymphoblastic leukemia (2), or hemolytic anemia plus immunodeficiency disorder (1). To reduce the risk of graft failure through the infusion of a large amount of stem cells, peripheral blood cells (PBC) were mobilized by recombinant granulocyte colony-stimulating factor (G-CSF; lenograstim, 10 microgram/kg/d for 5 days) and collected by 2 to 5 aphereses. To both enhance engraftment and reduce GVHD, CD34(+) cells were enriched using immunomagnetic procedures with the Baxter ISOLEX 300 system (Baxter Healthcare Corp, Irvine, CA) and cryopreserved. After variable cytoreductive regimens, a median of 7.7 (range, 2.2 to 14) x 10(6)/kg of CD34(+) cells and 1.03 (0.05 to 2.09) x 10(5)/kg CD3(+) cells were infused. Using Center-specific posttransplant supportive care and immunosuppressive GVHD prophylaxis, two patients experienced early death; one from veno-occlusive disease at day 17 and one from sepsis at day 18. Nine of 11 patients showed signs of engraftment; however, subsequent rejection was seen in 4 patients, 2 of whom had autologous recovery. Eight patients were evaluated in the early phase of marrow recovery. The median number of days to achieve an absolute granulocyte count of 0.5 x 10(9)/L was 14 (range, 9 to 20) and that to achieve a platelet count of 20 x 10(9)/L was 17.5 (range, 12 to 23). Donor chimerism persisted in five patients until death or current survival. All of the surviving patients with functioning-donor-type hematopoiesis were given total body irradiation. De novo acute GVHD (grades II and IV) was observed in two of the eight evaluated patients. Scheduled donor lymphocyte infusion (DLI), using the CD34(-) fraction, was administered to four patients, free of de novo acute GVHD, beginning between 28 to 43 days after transplant. Three of these patients developed acute GVHD (grades I, II, and IV). Cytomegalovirus infection was a major infectious complication but was successfully managed with gamma-globulin and gancyclovir treatment with or without additional DLI. Five patients are currently surviving, free of disease, with a follow-up ranging from 476 to 937 days. Each survivor has functioning hematopoiesis, three of donor origin and two of autologous origin. In conclusion, our results show that enriched blood CD34(+) cells from a mismatched haploidentical donor are a feasible alternative source of stem cells, but do not appear to ensure engraftment. Because none of the patients who were administered DLI survived, the therapeutic efficacy and safety of periodic DLI, as an integrated part of such transplants, needs to be clarified in further studies.

Intra-apheresis recruitment of blood progenitor cells in children.

BACKGROUND: Determination of the optimal duration of apheresis requires a careful examination of blood progenitor cell (BPC) kinetics during apheresis. Intra-apheresis recruitment of BPCs should be evaluated. STUDY DESIGN AND METHODS: Twenty-six apheresis procedures were performed in 13 children with various malignant disorders (ages, 10 months to 17 years; median, 7 years) to collect BPCs for autologous transplant, using a blood cell separator with 2 to 5.2 blood volumes processed. The subjects were divided into three groups according to age: below 1 year (n = 4), 2 to 10 years (n = 5), and 11 to 20 years (n = 4). BPCs were mobilized by a combination of chemotherapy and granulocyte-colony-stimulating factor (G-CSF; 2-7.5 micrograms/kg/day intravenous drip). The levels of circulating CD34+ cells and colony-forming units-granulocyte-macrophage (CFU-GM) were monitored to examine intra-apheresis recruitment. For every 50 mL per kg or 2 L of processed blood, 5-mL blood samples were collected via a central line. RESULTS: In the first apheresis procedure, more CD34+ cells were mobilized by the procedure itself in the infant group than in the older groups, and the number of cells decreased with the subject's age. When the same analysis was made during the second apheresis procedure, performed 1 day later, the levels of both CD34+ cells and CFU-GM had decreased to below the preapheresis values in all of the populations. Cell yields in the second apheresis procedure were significantly lower than those in the first. CONCLUSION: Although several factors prevent a reliable analysis, the data suggest that the intra-apheresis recruitment of BPCs may be age-specific; the continuous and prolonged supply of cells from the bone marrow to peripheral blood that occurs during apheresis is more predominant in infants, which leads to the collection of proportionately more BPCs in younger children than in their older counterparts.

New consecutive high-dose chemotherapy modality with fractionated blood stem cell support in the treatment of high-risk pediatric solid tumors: a feasibility study.

For the treatment of childhood solid tumors, we performed a pilot feasibility study of consecutive high-dose therapies, in which each course was followed by transplantation with granulocyte colony-stimulating factor-mobilized peripheral blood cells which had been separated into CD34-positive and -negative fractions by an Isolex system (Baxter). Positive selection of CD34+ cells has been associated with inevitable cell loss. To overcome this loss, CD34+ cells that had migrated into the negative fraction were saved and used for the first transplant, which was followed by a second transplant after a 3- to 5-month interval. In this phase I feasibility study, the results in six children were evaluated for safety and engraftment. Multi-drug cytoreductive regimens using ranimustine (MCNU), melphalan, thiotepa, carboplatin, cyclophosphamide or VP-16 were comparable between the two transplant procedures in terms of their intensity. The number of CD34+ cells in the 'CD34(+) fraction' was 3.31 x 10(6)/kg (0.63-4.3 x 10(6)/kg), while this number in the 'CD34(-) fraction' could not be evaluated correctly due their scarcity (<0.1%). The median numbers of infused MNC and CFU-GM were, respectively, 4.2 x 10(6)/kg and 1.75 x 10(5)/kg in the CD34(+) fraction, and 4.8 x 10(8)/kg and 3.35 x 10(5)/kg in the CD34(-) fraction. The number of days required to achieve an ANC >0.5 x 10(9)/l and a platelet count >20 x 10(9)/l and >50 x 10(9)/l were, respectively, 14.5, 15.0 and 19.5 in the first transplant with CD34- cells, and 13.5, 18.0 and 25.0 in the second transplant with CD34+ cells, with no essential difference between the two treatments. Although the small number of patients, the variation in clinical status and treatment, and the short follow-up invalidate any evaluation of the therapeutic benefit of this strategy, the encouraging results support the feasibility of this strategy, which enables an escalation of dose intensity with an improved cost/benefit ratio.

Continuous monitoring of hematocrit values during apheresis for allogeneic peripheral blood stem cell collection.

Rapid changes in the circulating blood volume or hemoglobin level during apheresis may pose a risk for healthy individuals donating allogeneic PBSC. In this study, a real-time noninvasive monitor CRIT-LINE was used for continuous monitoring of hematocrit values in a total of 16 aphereses performed in 4 adult (median age 30 years) and 4 pediatric donors (4 years). Donors received recombinant G-CSF (10 microg/kg s.c. for 5 days) for mobilization of PBSC. A CS3000 plus blood cell separator (Baxter) was used in two different procedures. Adults donors were subjected to modified program 1-120 using a combination of the granulocyte chamber and the small volume collection chamber (SVCC), and pediatric donors were subjected to specialized program 4 with a combination of the newly developed small volume separation chamber holder (SVSCH) and SVCC. In all of the procedures for children, the extracorporeal line was primed with 400 ml leukocyte-depleted allogeneic RBC or 200 ml autologous RBC after regular priming with normal saline, whereas none of the adult donors received this treatment. We found a marked contrast in the hematocrit kinetics during apheresis in the two cohorts/procedures. In adults, the initiation of apheresis was followed by an immediate decline in the hematocrit value over the initial 10 min until a stable plateau level was reached (7% decrease). In children, the values decreased slowly but progressively throughout the entire procedure to finally reach a 9% decrease at the completion of apheresis. These data may suggest that the use of SVSCH plus SVCC or priming with RBC can eliminate the abrupt decline in blood hemoglobin levels that occurs during apheresis.