Increasing access to hematopoietic cell transplantation in Latin America: results of the 2018 LABMT activity survey and trends since 2012.

A total of 5642 hematopoietic cell transplants (HCT) in 5445 patients (2196-40% allogeneic and 3249-60% autologous) were reported by 127 teams in 14 Latin American countries that answered the 2018 LABMT/WBMT Global Transplant Activity survey. The transplant rate (defined as the number of first transplants per 10 million inhabitants per year) was 85 (51 autologous and 34 allogeneic) in 2018. The main indications for allogeneic HCT were acute leukemias (60%), while plasma cell disorders and lymphomas were the most common conditions warranting autologous HCT (50 and 36%, respectively). In the allogeneic HCT, HLA-identical siblings were the main type of donor (44%) followed by related mismatched/haploidentical donors (32%). Peripheral blood stem cells were used in 98% of the autologous and in 64% of the allogeneic transplants. From 2012 to 2018, there was a 64% increase of reported HCT (54% in autologous and 80% in allogeneic). In the allogeneic setting, the most pronounced increase in donor type was observed in haploidentical relatives (from 94 procedures in 2012 up to 710 in 2018), surpassing unrelated donors as of 2017. Significant trends detected in Latin America include rising numbers of the procedures reported, a faster increase in allogeneic HCT compared with autologous HCT and a significant increase in family mismatched/haploidentical donors. The LABMT/WBMT activity survey provides useful data to understand the HCT activity and trends in Latin America.

The paradox of haematopoietic cell transplant in Latin America.

Hematopoietic cells transplants are technically complex and expensive imposing a huge burden on health care systems, especially those in developing countries and regions. In 2017 > 4500 transplants were done in 13 Latin American countries with established transplant programmes. We interrogated data on transplant rate, cost, funding source, hospital type, Gini coefficient and the United Nations Development Programme Inequality-Adjusted Human Development Index to determine co-variates associated with transplant development. Transplant rates varied almost 30-fold between the 13 countries from 345 in Uruguay to 12 in Venezuela with a regional transplant rate 7-8-fold lower compared with the US and EU. We found significant correlations between higher transplant cost, public funding, transplants in private hospitals with transplant rate. Low cost per transplant regardless of payor and transplants done in public hospitals were associated with low transplant rates. In contrast, high cost per transplant funded by the government and transplants done in private hospitals were associated with high transplant rates. Surprisingly, we found transplant rates were higher when transplants cost more, when they were done in private for-profit hospitals and payed for with public funds. These data give insights how to increase transplant rates in Latin America and other developing regions.

Caso Clínico: Citopénia Autoinmune como complicación inmunológica de Trasplante Alogénico de Donante no emparentado, en paciente pediátrico con Anemia Drepanocítica / Clinical Case: Autoimmune Cytopenia as an immunological complication of Allogeneic Unrelated Donor Transplantation, in a pediatric patient with Sickle Cell Anemia

Introducción: La enfermedad de células falciformes es una condición heredada en la quese produce una hemoglobina anómala que desfavorece a la oxigenación tisular, crisis vaso-oclusivas y reacciones hemolíticas. Los pacientes con esta enfermedad presentan una activación anómala de la vía del complemento llevándolos al aumento en frecuencia de infecciones y enfermedades autoinmunes. Presentamos un caso de asociación de una enfermedad autoinmune en un paciente con enfermedad de células falciforme. Caso clínico: Niño de 10 años con Anemia drepanocítica (2009) con esplenectomía y crisis veno-oclusivas recurrentes, fue sometido a trasplante Alogénicoen abril del 2019fuera de la institución con donante isogrupo O+ no emparentado (10/10). Tratado con: Fludarabina ­Busulfan, Timoglobulina+ y Metotexate. Desarrolló Bicitopenia autoinmune y síndrome febril al día +165 post TPH. Glóbulos blancos: 360 uL, neutrófilos: 14 %, hemoglobina: 7.90 g/dL, plaquetas: 25000 uL, ferritina: 4695 ng/ml, IgG total: 9.88 gr/l, LDH: 190 UI/l. Proteína C reactiva: 2.79 mg/dL, Procalcitonina 0.13 ng/mL. Evolución: posterior a descartar infección viral, se completó un tratamiento antibiótico de amplio espectro y se realizó la suspensión del tratamiento inmunosupresor por sospecha de toxicidad, sin respuesta. Se realizó un estudio medular por citometría de flujo determinando una disminución de la línea linfoide B, y se concluye Citopenia Autoinmune como complicación inmunológica del trasplante. Desenlace: recibióterapia transfusional (plaquetoféresis + glóbulos rojos concentrados). Se utilizó metilprednisolona IV por 3 días y prednisona 30 mg por 14 días con reducción posterior gradual para inicio de Rituximab y ciclosporina. Se completó el tratamiento con Imnunoglobulina 6g IV por 5 días. Al alta glóbulos blancos: 5080 uL, neutrófilos: 67%, hemoglobina: 9.20 g/dL, plaquetas: 20000 uL, después de 18 días de ingreso hospitalario. Conclusión: Los resultados con el tratamiento en este caso sugieren que puede serrazonable considerar las citopeniasautoinmunes como una manifestación hematológica diagnóstica de la EICH crónica. Alternativamente, es posible que el tratamiento de citopenia inmune con esteroides, Rituximab y otros inmunosupresores

Introduction: Sickle cell disease is an inherited condition in which an abnormal hemoglobin is produced that impairs tissue oxygenation, vaso-occlusive crises and hemolytic reactions. Patients with this disease present an abnormal activation of the complement pathway, leading to an increase in the frequency of infections and autoimmune diseases. We present a case of association of an autoimmune disease in a patient with sickle cell disease. Clinical case:10-year-old boy with sickle cell anemia (2009) with splenectomy and recurrent veno-occlusive crisis, underwent Allogeneic transplantation in April 2019 outside the institution with an unrelated isogroup O + donor (10/10). Treated with: Fludarabine -Busulfan, Thymoglobulin + and Metotexate. He developed autoimmune bicytopenia and febrile syndrome at +165 day post HSCT. White blood cells: 360 uL, neutrophils: 14%, hemoglobin: 7.90 g / dL, platelets: 25,000 uL, ferritin: 4695 ng / ml, total IgG: 9.88 gr / l, LDH: 190 IU/l. C-reactive protein: 2.79 mg/dL, procalcitonin 0.13 ng / mL. Evolution:after ruling out viral infection, the patient completed a broad-spectrum antibiotic treatment and underwent suspension of immunosuppressive treatment due to suspected toxicity, with no response. A medullary study by flow cytometry was performed, determining a decrease in the B lymphoid line, and autoimmune cytopenia was concluded as an immunologicalcomplication of the transplant. Outcome:The patient received transfusion therapy (plateletpheresis + concentrated red blood cells). He also received IV methylprednisolone for 3 days and 30 mg prednisone for 14 days with gradual subsequent reduction to start Rituximab and cyclosporine. The treatment with Immunoglobulin 6g IV for 5 days was completed. At discharge, white blood cells: 5080 uL, neutrophils: 67%, hemoglobin: 9.20 g / dL, platelets: 20,000 uL, after 18 days of hospital admission. Conclusion:The results with treatment in this case suggest that it may be reasonable to consider autoimmune cytopenias asa diagnostic hematological manifestation of chronic GVHD. Alternatively, it is possible to treat immune cytopenia with steroids, rituximab, and other immunosuppressants

Evaluación entre dos tecnologías usando Técnicas de Aglutinación en Columna (TAC) para la titulación e identificación de aloanticuerpos anti-eritrocitarios (columnas de micro-esferas de cristal y columnas de gel) / Evaluation between two technologies using Column Agglutination Techniques (TAC) for the titration and identification of anti-erythrocytic alloantibodies (columns of glass microspheres and gel columns)

Introducción: La presencia de anticuerpos anti eritrocitarios disminuye la sobrevida de los eritrocitos mediante la presencia de enfermedad hemolítica post transfusional en los pacientes oncológicos. La selección de la tecnología más conveniente para la determinación de los anticuerpos antieritrocitarios está directamente relacionada con la prevención de las reacciones transfusionales hemolíticas que son las responsables de la morbilidad y mortalidad relacionadas con la transfusión. El objetivo del presente estudio fue valorar la asociación estadística entre la técnica tradicional del gel versus la técnica de microesferas de cristal. Métodos: El estudio fue realizado en el laboratorio Clínico del Instituto Oncológico Nacional Dr. Juan Tanca Marengo, Solca-Guayaquil el período de estudio enero 2017 a marzo del 2017. Se realizaron técnicas de titulación a partir de muestras de sangre periférica con aloanticuerpos anti-eritrocitarios de especificidad única que habían sido detectados durante la realización de las pruebas pre-transfusionales. Las muestras fueron procesadas con la tecnología conocida usando la Técnica de Aglutinación en Columnas, columnas con gel. Posterior a realizar las pruebas pretransfusionales en los casos que presentaran positiva la prueba de escrutinio de anticuerpos o test de Coombs indirecto, inmediatamente después se llevaba a cabo la identificación del anticuerpo usando la misma técnica.Simultáneamente se realizaba las mismas pruebas usando la misma muestra con la otra tecnología de microesferas cristalizadas. Las reacciones de aglutinación se clasificaron como fuertemente positivas (4+ y 3+), moderadamente positivas (2+ y 1+) y positivo débil (w+). El análisis estadístico se utilizó correlación de Spearman. Resultados: En el período de estudio se efectuaron detección e identificación en 9 muestras. Seis muestras mostraron títulos idénticos, para ambas tecnologías, en 2 muestras se mostró títulos más altos con la tecnología en gel, y en 1 muestra se observó títulos más altos con la tecnología en micro esferas de cristal. La asociación Mediante Rho de Spearman entre las dos pruebas fue de R=0.84; r2=0.72, P=0.005. Conclusión: Existen una buena asociación entre las técnicas de gel y microesferas de cristal para la identificación de anticuerpos antieritrocitarios.

Introduction: The presence of anti-erythrocyte antibodies reduces the survival of erythrocytes by the presence of post-transfusion hemolytic disease in cancer patients. The selection of the most convenient technology for the determination of antierithrocytic antibodies is directly related to the prevention of hemolytic transfusion reactions that are responsible for the morbidity and mortality related to transfusion. The aim of the present study was to evaluate the statistical association between the traditional gel technique versus the crystal microsphere technique. Methods: The study was conducted in the Clinical Laboratory of the Dr. Juan Tanca Marengo National Oncological Institute, Solca-Guayaquil during the study period January 2017 to March 2017. Titration techniques were performed from peripheral blood samples with anti-alloantibodies-erythrocytes of unique specificity that had been detected during the pre-transfusion tests. The samples were processed with the known technology using the Agglutination Technique in Columns, columns with gel. After carrying out the pretransfusion tests in cases that presented a positive antibody test or indirect Coombs test, the antibody was immediately identified using the same technique. Simultaneously, the same tests were performed using the same sample with the other crystallized microsphere technology. The agglutination reactions were classified as strongly positive (4+ and 3+), moderately positive (2+ and 1+) and weak positive (w +). The statistical analysis was used Spearman's correlation. Results: In the study period, detection and identification were made in 9 samples. Six samples showed identical titers, for both technologies, 2 samples showed higher titers with gel technology, and in 1 sample higher titers were observed with the technology in crystal micro spheres. The association by Rho of Spearman between the two tests was R = 0.84; r2 = 0.72, P = 0.005. Conclusion: There is a good association between gel techniques and crystal microspheres for the identification of antierithrocytic antibodies.