Survey-based assessment of hematopoietic stem cell graft manipulation (minimal) by cell therapy labs supporting hematopoietic stem cell transplants in India.

BACKGROUND AIMS: Hematopoietic stem cell transplants (HSCTs) are increasingly being offered to patients in India for various conditions. The Indian Stem Cell Transplant Registry shows that a total of 2533 transplants were done in India in 2019. METHODS: An epidemiological descriptive cross-sectional survey (55 questions) of centers providing HSCT in India was planned to analyze variations in policies and practices regarding HSCT graft manipulation (i.e., plasma reduction, red blood cell [RBC] depletion and cryopreservation). A total of 63 of 102 centers responded to the survey (response rate, 61.7%), mostly from the northern part of India (27 of 63 [42.8%]). RESULTS: The majority of responding centers reported performing >50 HSCTs annually (n = 24 [38%]), and 92% (58 of 63) performed stem cell collections from a pediatric donor/patient (age <18 years). A total of 56 of 63 responding centers indicated that they did product manipulations involving cryopreservation (n = 45), plasma reduction (n = 42) and RBC depletion (n = 28). Cryopreservation was primarily done by blood centers (27 of 45 [60%]), with dimethyl sulfoxide (DMSO) being the primary constituent, used most commonly at a concentration of 5-10% (28 of 45 centers). Dump freezing was most commonly used (27 of 45) with a -80°C deep freezer. A 7-aminoactinomycin D based viability assessment was also most commonly used (30 of 45). Thawing of the product was done mainly at the bedside (30 of 45) using a wet-type thawer (36 of 45), and washing of DMSO was done by a few centers (seven of 45). Plasma reduction and RBC depletion were primarily done for ABO incompatibility at blood centers. CONCLUSIONS: This survey demonstrates the lack of standardization and uniformity in the minimal manipulation of hematopoietic stem cell grafts in centers supporting HSCT in India. This work also highlights the need for more studies and country-specific recommendations to establish best practices.

Use of face mask by blood donors during the COVID-19 pandemic: Impact on donor hemoglobin concentration: A bane or a boon.

BACKGROUND: COVID-19 virus has caused the world's deadliest pandemic. Early April 2020, the Delhi Government made it compulsory for people to wear face masks while going outdoors to curb disease spread. Prolonged use of surgical masks during the pandemic has been reported to cause many adverse effects. Intermittent hypoxia has been shown to activate erythropoietin (EPO leading to increased hemoglobin mass. AIM: To analyze whether face mask induced intermittent hypoxia has any effect on the hemoglobin levels of healthy blood donors. MATERIALS AND METHODS: We retrospectively analyzed donor data from 1st July 2019-31st December 2020 for hemoglobin distribution across hemoglobin ranges and donor deferral on basis of hemoglobin. Study population was divided into two cohorts Group 1- (1st July 2019-31 st March 2020): before implementation of mandatory face masks Group 2- (1st April 2020-31 st December 2020): after implementation of mandatory face masks RESULTS: Mean Hb of blood donors in Group 2 (15.01 ± 1.1 g/dl) was higher than Group1 (14.49 ± 1.15 g/dl), (p < 0.0001). 47.1 % group2 donors had Hb of 16.1-18 g/dl compared to group1 (38.4 %). 52.9 % group 2 donors had Hb between 12.5-15 g/dl compared to 61.6 % Group 1 (p < 0.05). Deferral due to anemia was lesser in group 2 compared to group 1 (p < 0.00001). Group 2 had significantly higher deferral due to high Hb (>18 gm/dl) was than Group 1 (p = 0.0039). CONCLUSION: This study including 19504 blood donors spanning over one and a half year shows that prolonged use of face mask by blood donors may lead to intermittent hypoxia and consequent increase in hemoglobin mass.

Thrombotic Thrombocytopenic Purpura in a Patient with Brucella Infection.

Thrombotic thrombocytopenic purpura (TTP) is characterized by disseminated thrombotic occlusions in the microcirculation and a syndrome of microangiopathic hemolytic anemia (MAHA), thrombocytopenia, fever, renal and neurologic abnormalities. Several factors such as viral and bacterial pathogens, pancreatitis, drugs, collagen-vascular diseases, cancers, and pregnancy have been reported to cause TTP, Brucellosis is an exceptional cause of this disorder. We present a case of a 33 year old male who was found to have Brucella antigen (IgG) positivity who responded well to antibiotic therapy directed to Brucella infection. He subsequently reported back with B/L diminution of vision, fever and was found to have severe thrombocytopenia. Ophthalmology opinion revealed retinal hemorrhages. In view of severe thrombocytopenia with a normal coagulogram, raised LDH, renal azotemia and peripheral blood smear showing fragmented RBCs he was diagnosed to have Thrombotic Thrombocytopenic Purpura (TTP) secondary to Brucellosis. He was immediately treated with Plasma exchange; however, he relapsed after initial cycles. He underwent further plasma exchanges with unsatisfactory response, thus was eventually started on Rituximab to which he responded well.

Allogenic Hematopoietic Cell Transplantation in Thalassemia Major: A Single-center Retrospective Analysis From India.

Thalassemia is a major public health problem in developing countries. Sibling matched hematopoietic stem cell transplantation (HCT) is the recommended treatment for thalassemia major (TM). We retrospectively analyzed our data of thalassemia major patients who underwent HCT at a tertiary care center in Northern India from January 2008 to September 2017. The primary end points were overall survival (OS) and thalassemia-free survival (TFS), and secondary end points were complications post HCT (graft-versus-host-disease [GVHD], hemorrhagic cystitis [HC], and sinusoidal obstruction syndrome [SOS]). Data of 203 transplants for 200 patients (3 s transplants) were evaluated. Median follow-up period was 29.1 months (range, 0.3 to 116.7 mo). The overall survival (OS) was 88.5% and TFS was 82%. Class risk analysis showed a significantly higher OS and TFS in class I and class II compared to class III high risk group (OS: P=0.0017; TFS: P=0.0005) and (OS: P=0.0134; TFS: P=0.0027) respectively. Acute and chronic GVHD was seen in 59 (29.5%) and 18 (9%) patients, respectively, and SOS and HC were seen in 23 (11.5%) and 11 (5.5%) patients, respectively. This study reconfirms that allogenic HCT is feasible in developing world with the overall survival and TFS comparable to that reported in Western literature and should be considered early in all TM patients with available matched sibling donors.

Comparison of Amicus and COBE Spectra for allogenic peripheral blood stem cell harvest: Study from tertiary care centre in India.

INTRODUCTION: Most common source of stem cell graft for both autologous and allogenic haematopoietic transplants are peripheral blood haematopoietic progenitor stem cells. Adequate collection of the CD34+ cells and safety of the allogenic donor during the leukapheresis are of prime importance to an apheresis physician. Our retrospective analysis is a comparison between of two platforms namely, COBE Spectra and Amicus, for CD34+ mononuclear cell collection. MATERIAL AND METHOD: The study included the data of GSCF (Granulocyte-Colony-Stimulating Factor) mobilized allogenic PBSC collections at our centre from January 2015 to June 2016. The apheresis platforms used were COBE Spectra and Amicus. Blood cell counts were done using LH750 Beckman Coulter (Florida, Miami, USA). CD45+ & CD34+ cell counts were done using BD FACS Canto-II Flow-Cytometer by ISHAGE guidelines. RESULTS: A total of 170 PBSC (100 COBE Spectra & 70 Amicus) harvests were done on 143 donors, of which 116 completed the collection in a single session and 27 required a second session. Demographic details and pre harvest peripheral blood counts for both the groups did not show any statistical differences. Amicus processed higher blood volume with higher ACD exposure and procedure time compared to COBE Spectra. Higher platelets loss was with COBE Spectra harvests with higher product volumes collection. Collection efficiency (CE2), collection ratio, CD34+ cells dose was similar on both the platforms. RBC contamination, absolute lymphocyte and monocytes counts were significantly higher with Amicus harvest product compared with COBE Spectra. A total of 14 (8.2%; citrate toxicity) adverse reactions were reported out of 170 allogenic PBSC collections. DISCUSSION/CONCLUSION: Our study suggests that both Amicus and COBE Spectra platforms offer comparable results for allogenic PBSC collections. Amicus offers a concentrated PBSC product with lesser volume and platelets loss but higher RBC contamination.

Prophylactic low dose continuous calcium infusion during peripheral blood stem cell (PBSC) collections to reduce citrate related toxicity.

BACKGROUND: Citrate toxicity is one of the most frequent complications of apheresis procedures. It is caused by the infusion of the acid citrate dextrose (ACD), which chelates the calcium ions. AIMS: The aim of this study is to assess the effectiveness of prophylactic continuous infusion of calcium gluconate over intermittent bolus infusion to reduce citrate toxicity during large volume peripheral blood stem cell collection. MATERIALS AND METHODS: We retrospectively analysed the records of PBSC collection procedures performed from March 2010 to December 2013. Donors were selected as per the set guidelines. Machine used to perform the procedures was Cobe spectra. The study population was divided into 2 groups. One composed of intermittent intravenous bolus infusion at the onset of hypocalcaemic symptoms, the other composed of calcium gluconate administration as continuous infusion throughout the procedure. RESULT: The most common reported hypocalcaemic symptoms were mild perioral paresthesia followed by digital numbness. Of the 50 individuals who were injected with bolus calcium 40 (80%) individuals suffered from symptoms of hypocalcaemia, whereas 23 of 66 individuals (34.8%) suffered from hypocalcaemia in the continuous infusion group. This difference was significant (P < 0.001). Both groups were compared with respect to age, gender ratio, weight of the individuals, total blood volume processed, ACD used, calcium gluconate dose used, time taken for the procedure, the product volume. Significant difference was noticed only with respect to the product volume. This implies that the groups were comparable with respect to parameters such as age, gender ratio, weight of the individuals, total blood volume processed, ACD used, calcium gluconate dose used, and the time taken for the procedure. Also that significantly more products (244 v/s 204 ml) was collected in the continuous infusion group. CONCLUSIONS: Our results show that prophylactic continuous IV administration of low dose calcium-gluconate throughout the PBSC harvesting procedure reduced the incidence as well as the severity of citrate related toxicity. This increases his/her tolerance to withstand longer durations of the procedure and collect more volume of the product, hence may reduce the number of sittings of the procedure.

Treosulfan-thiotepa-fludarabine-based conditioning regimen for allogeneic transplantation in patients with thalassemia major: a single-center experience from north India.

Hematopoietic stem cell transplantation (HSCT) is the definite treatment for patients with thalassemia major. A busulfan (Bu) and cyclophosphamide (Cy)-based regimen has been the standard myeloablative chemotherapy, but it is associated with higher treatment-related toxicity, particularly in patients classified as high risk by the Pesaro criteria. Treosulfan-based conditioning regimens have been found to be equally effective and less toxic. Consequently, we analyzed the safety and efficacy of treosulfan/thiotepa/fludarabine (treo/thio/flu)-based conditioning regimens for allogeneic HSCT in patients with thalassemia major between February 2010 and September 2012. We compared those results retrospectively with results in patients who underwent previous HSCT with a Bu/Cy/antithymocyte globulin (ATG)-based conditioning regimen. A treo/thio/flu-based conditioning regimen was used in 28 consecutive patients with thalassemia major. The median patient age was 9.7 years (range, 2-18 years), and the mean CD34(+) stem cell dose was 6.18 × 10(6)/kg. Neutrophil and platelet engraftment occurred at a median of 15 days (range, 12-23 days) and 21 days (range, 14-34 days), respectively. Three patients developed veno-occlusive disease, 4 patients developed acute graft-versus-host disease (GVHD), and 2 patients had chronic GVHD. Treatment-related mortality (TRM) was 21.4%. Two patients experienced secondary graft rejection. We compared these results with results in patients who underwent previous HSCT using a Bu/Cy/ATG-based conditioning regimen. Twelve patients were treated with this protocol, at a median age of 7.2 years (range, 2-11 years). One patient had moderate veno-occlusive disease, 2 patients developed acute GVHD, 2 patients had chronic GVHD, and 2 patients experienced graft rejection. There was no TRM in this group. We found no significant differences between the 2 groups (treo/thio/flu vs Bu/Cy/ATG) in terms of the incidence of acute GVHD, chronic GVHD, TRM, and graft failure, although a trend toward higher TRM was seen with the treo/thio/flu regimen.

A Case Report of Occult Weak 'A' Subgroup: An Important Message for Renal Transplant Physicians.

Accurate ABO grouping is the cornerstone of a successful ABO-compatible organ transplant. While conventional methods identify blood groups accurately in most cases, rare and weak blood groups could occasionally be misread/missed. Weak A subgroups such as A3, Ax, Aend, Am, Ay, and Ael are often mistyped as group O. We present one interesting case of 'weak A' subgroup in a renal transplant donor, who was wrongly typed as 'O' Rh D positive by conventional grouping techniques. It was a near miss as the donor was almost selected for transplant for the patient with blood group B positive.

Allogeneic stem cell transplant for myelofibrosis- A retrospective single-center study.

Introduction: Allogeneic hematopoietic stem cell transplantation (HSCT) is currently the only curative treatment option for myelofibrosis (MF). Despite the benefits of long-term relapse-free survival, HSCT can be associated with substantial treatment-related morbidity and mortality. Methods: This is an observational retrospective study of 15 consecutive patients with MF who underwent allogeneic HSCT at a tertiary care center in Northern India between June 2012 and January 2020. The pre-transplant Dynamic International Prognostic Scoring System (DIPSS) and hematopoietic cell transplantation-specific co-morbidity index (HCT-CI) scores were used. The primary endpoints were overall survival (OS) and disease-free survival (DFS), and the secondary endpoints were post-transplant complications (acute and chronic graft-versus-host-disease [GvHD], graft failure [GF], and cytomegalovirus reactivation [CMV]). Results: The OS and DFS in our study were 60% with no relapse at a median follow-up of 364 days (range 7-2,815 days). Twenty-seven percent of patients developed acute GvHD and 27% of patients developed chronic (limited) GvHD. The non-relapse mortality (NRM) was 40%, with the main cause of death being sepsis, followed by acute GvHD. Conclusion: MF remains a challenging condition to treat, with a poor prognosis. Our study showed that reduced toxicity conditioning provided good DFS and OS. Thus, it should be offered to patients with high DIPSS scores. Sepsis was the predominant cause of mortality in this cohort.

Hematopoietic Stem Cell Transplant for Hematological Malignancies: Experience from a Tertiary Care Center in Northern India and Review of Indian Data.

Sanjeev Kumar SharmaHematopoietic stem cell transplantation (HSCT) is the preferred treatment for high-risk and relapsed/refractory hematological malignancies. Moreover, with the improved supportive care and increasing acceptance of haploidentical transplantations as an alternative treatment modality, more patients are opting for HSCT as a definite treatment for hematological malignancies. We report here the real-world data and outcome of HSCT done for hematological malignancies at our transplant center. Five hundred and sixteen patients underwent HSCT from August 2010 to November 2019. The most common indications for allogeneic and autologous HSCT were acute myeloid leukemia and multiple myeloma, respectively. The 5-year overall survival and disease-free survival for all transplants were 65% and 33%, respectively. Though outcome of matched sibling donor allogeneic transplant is better than haploidentical donor (HID) transplant, patients having only HID can still be considered for allogeneic HSCT for high-risk diseases. The most common cause of death was infections followed by relapse of the disease.

Development and validation of novel kit for quantification of SARS-CoV-2 antibodies on clinical samples.

Since the pandemic occurred due to the emergence of SARS-CoV-2, there has always been a demand for a simple and sensitive diagnostic kit for detection of SARS-Cov-2 infection. In January 2020, WHO approved the Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) for detecting the presence of Covid-19 genetic material in individuals. Till date many diagnostic kits have arrived in the market for quantification of SARS-CoV-2 antibodies. In spite of being the gold standard method of Covid-19 detection, there are some drawbacks associated with RT-PCR which leads to false-negative results. Hence, in order to fulfil the need for an antibody testing kit for evaluating seroconversion and immunity acquisition in the population, an efficient, highly specific and sensitive assay, Chimera Soochak, an enzyme-linked immunoassay (ELISA) Kit has been developed. It works on the principle of detecting IgG antibodies developed specifically against the S1-RBD by employing a recombinant strain of S1-RBD produced in the HEK293 cell line. The developed kit was validated using different modes and methods to attain the utmost confidence on the samples collected from patients. The validation methodology included, validation with known samples, blind study, third-party validation, validation using WHO Reference Panel and comparison with FDA approved Surrogate virus neutralization kit. The kit was found successful in detecting IgG against the S1-RBD of SARS-CoV-2. The kit had been validated on multiple parameters. A total of 900 samples had been tested by using this kit and it has exhibited the sensitivity, specificity and accuracy for all the above-mentioned parameters.

T-cell replete Haplo-identical HSCT with Post transplant Cyclophosphamide for Hemoglobinopathies: A retrospective analysis from a single center.

We report herein haplo-identical hematopoietic stem cell transplantation (haplo-HSCT) by T-cell replete graft infusion, with post-transplant cyclophosphamide (PTCy) in patients with hemoglobinopathies. Patients received a conditioning regimen consisting of either busulfan, fludarabine, cyclophosphamide, with antithymocyte globulin or Thiotepa, antithymocyte globulin, fludarabine, cyclophosphamide, and TBI. The median follow-up period was 14.3 months (range, 1-63 months). Overall survival (OS) and disease-free survival (DFS) were 80% and 62.8%, respectively. Incidence of secondary graft failure was 14%. Incidences of acute graft-versus-host disease (aGvHD) and chronic graft-versus-host disease (cGvHD) were 22.5% and 20%, respectively. Cytomegalovirus (CMV) reactivation was observed in 42.5% of cases. The 100-day mortality rate was 20%, with sepsis and aGvHD being the predominant causes of death.

Myeloablative Versus Reduced Intensity Conditioning Regimens for Allogeneic Hematopoietic Stem Cell Transplant for Acute Myeloid Leukemia and Myelodysplastic Syndrome: A Retrospective Analysis.

The conditioning regimens used for the allo-HSCT include either myeloablative conditioning (MAC) or reduced intensity conditioning (RIC) regimens based on the age, performance status and co-morbidities. Studies comparing the survival outcomes of RIC and MAC allo-HSCT in AML and MDS patients have reported contradictory results. We therefore retrospectively analyzed our data of AML and MDS patients who received MAC and RIC allo-HSCT at our center and compared the long term outcome of the two conditioning regimens. One hundred twenty six consecutive patients were evaluated, 32 (25.4%) underwent MAC allo-HSCT and 94 (74.6%) underwent RIC allo-HSCT. The most common MAC regimen used was busulfan plus cyclophosphamide and the most common RIC regimen used was fludarabine plus melphalan. The median age was higher in RIC group (44 years, range 4-75 years) compared to MAC group (31 yrs, range 6-51 yrs, p = 0.001). There was no significant difference in terms of overall survival (p = 0.498), relapse-free survival (p = 0.791) and non-relapse mortality (p = 0.366) between the two groups. In multivariate analysis, only chronic graft-versus-host disease resulted in decreased risk of relapse and improved overall survival irrespective of the conditioning regimens used.

Convalescent plasma therapy and remdesivir duo successfully salvaged an early liver transplant recipient with severe COVID-19 pneumonia.

The impact and clinical spectrum of COVID-19 infection in liver transplant recipients/solid organ transplants are being unveiled during this recent pandemic. The clinical experience of use of current antiviral drugs and immunomodulators are sparse in solid organ transplantation. We present the clinical course of a 49-year-old male recipient who underwent living donor liver transplant for recurrent gastrointestinal bleed and contracted severe COVID-19 pneumonia during the third postoperative week. Herein we report the successful management of severe COVID-19 pneumonia using convalescent plasma therapy and remdesivir. Recipient's clinical deterioration was halted after three consecutive convalescent plasma transfusions with improvement in hypoxia and inflammatory markers (interleukin-6 and C-reactive protein). The use of convalescent plasma therapy along with remdesivir may be an ideal combination in the management of severe COVID-19 pneumonia in solid organ transplant recipients.

Hematopoietic Stem Cell Transplantation for Fanconi Anemia: A Single Center Experience from India.

Hematopoietic stem cell transplantation (HSCT) is the only treatment option for the hematological manifestations of Fanconi anemia (FA). Fludarabine based reduced intensity conditioning regimens have helped in improving outcomes significantly in FA patients. We retrospectively analyzed the outcomes of FA patients who underwent allogeneic HSCT at BLK Superspeciality Hospital, New Delhi from June 2011 to September 2019. Twenty FA patients underwent 23 transplants at our center. Overall survival and disease free survival were 65% and 50%, respectively at a median of 23 months. Overall mortality was 30%. HSCT for FA is a feasible option even in developing countries although children present late to transplant centers after multiple transfusions and infections.

Real-world outcomes of stem cell transplantation for severe aplastic anemia: A single-center experience in Northern India.

Introduction: Stem cell transplantation is the cornerstone of therapy for transplant-eligible patients with severe aplastic anemia. Materials and methods: Patients with severe aplastic anemia undergoing stem cell transplantation (including matched haplo-identical related donors) with a standard conditioning regimen and graft-versus-host disease (GVHD) prophylaxis were analyzed. High-risk patients were identified as having undergone >20 pre-transplant transfusions, having febrile neutropenia at the time of transplantation, or having undergone failed immunosuppressive therapy. Results: A total of 111 patients underwent stem cell transplantation, with a median age of 17 years. Seventy-six patients received matched related donor (MRD) transplants, and 35 received haplo-identical donor (HID) transplants. Among all patients, 65.7% were high-risk patients, with a significantly higher proportion among those receiving HID transplants (38% for MRD vs. 83% for HID). Acute GVHD grades 2-4 was observed in 9% of patients, and chronic GVHD in 16.2% of patients. Primary graft rejection was more common in 9.9% of patients (21% for HID, 5% for MRD). The 2-year overall survival and disease-free survival were 67% and 66%, respectively, with better outcomes for MRD and low-risk HID transplants than for high-risk HID transplants. The most common cause of mortality was sepsis-related death (accounting for 27% of the total deaths). Sepsis-related early deaths were significantly more common among high-risk patients who received HID transplants. Conclusion: We conclude that MRDs remain the preferred donor source for allogeneic stem cell transplants in patients with aplastic anemia; however, HIDs can be considered as a life-saving treatment for patients with aplastic anemia.

Outcome of 51 autologous peripheral blood stem cell transplants after uncontrolled-rate freezing ("dump freezing") using -80°C mechanical freezer.

BACKGROUND AND OBJECTIVE: Controlled-rate freezing is a complicated, expensive, and time-consuming procedure. Therefore, there is a growing interest in uncontrolled-rate freezing (UCF) with -80°C mechanical freezers for cryopreservation of hematopoietic stem cells. This is a retrospective analysis of efficiency of UCF and outcome of autologous peripheral hematopoietic stem cell (PBSC) transplants at our center from December 2011 to June 2016. MATERIALS AND METHODS: Cryoprotectant solutions used included 5% dimethyl sulfoxide and 5% albumin with 2% hydroxyethyl starch and stored at -80°C mechanical freezer till transplant. Evaluation of cryopreservation was studied by analyzing the variation in cellularity, viability, and CD34+ stem cell dose recovery as well as clinical follow-up with engraftment. RESULTS: A total of 51 patients (23 females and 28 males) underwent autologous PBSC transplantations with a median age of 31 years (range: 3-60 years) for both hematological and nonhematological indications. Mean recovery post by UCF at -80°C mechanical was 92.9% ± 15.5% for nucleated cells, 86.6% ± 15.5% for viability, and 80% ± 21.5% in CD34+ dose. The median day to neutrophil engraftment was 10 (range 5-14 days) and platelets engraftment was 15 (range 8-45 days). The cryopreserved products were stored at -80°C for median 7 days (range 2-41 day) before transplant. DISCUSSION/CONCLUSION: Our analysis shows that PBSC can be successfully cryopreserved with mechanical uncontrolled rate freezing. This is a cheap and simple method to freeze the stem cells for a short period in resource-constrained setting.

Extracorporeal photopheresis: Review of technical aspects.

Extracorporeal photochemotherapy (ECP) is considered as an immune modulating therapy majorly targeting the T cells of the Immune system. ECP induces an anti-inflammatory condition with tolerogenic responses without inducing a global immunosuppression state which is a typical feature of other therapeutic options such as steroids. Clinical indication of ECP has grown over time since its initial applications. Our review discusses the technical aspects of the concept of photopheresis with the available methods for its clinical applications.