Transfusion in Transfusion in Hemotopoietic Stem Cell Hemotopoietic Stem Cell

Transplantation (HSCTTransplantation (HSCT((

Rafiq Ahmad, Rafiq Ahmad,

MBBS, MTM, FASCPMBBS, MTM, FASCP

Stem CellsStem Cells PPopulaopulation of tion of

undifferentiated cells undifferentiated cells which are ablewhich are able To divide To divide for for

indefinite periodindefinite period To To self renewself renew To generate a To generate a

functional progeny functional progeny of highly specialized of highly specialized cellscells

HierarchHierarchyy

Hematopoietic stem cell transplantationHematopoietic stem cell transplantation

Definition:Definition: Intravenous infusion of autologous or allogeneic stem cells Intravenous infusion of autologous or allogeneic stem cells

collected from bone marrow, peripheral blood or umbilical collected from bone marrow, peripheral blood or umbilical cord bloodcord blood

Re-establish hematopoietic function in patients with Re-establish hematopoietic function in patients with damaged/defective bone marrow or immune systemsdamaged/defective bone marrow or immune systems

Potentially curative for a widePotentially curative for a wide

variety of disordersvariety of disorders

BackgroundBackground First successful transplants—l959First successful transplants—l959

Noble prize for Noble prize for Donnall Thomas and Joseph Donnall Thomas and Joseph E. Murray E. Murray

50,000-60,000 transplants50,000-60,000 transplants performed yearly performed yearly worldwideworldwide

Number continues to increase by 10-20% Number continues to increase by 10-20% each yeareach year

>20,000 patients have survived >5 years>20,000 patients have survived >5 years

Hematopoietic stem cellsHematopoietic stem cells

Charakteristic: • CD34+

• CD 133

•Lin-

•C-kit (CD117)

• BCRP

Graft SourcesGraft Sources Bone Marrow (HSC-M)Bone Marrow (HSC-M) Peripheral Blood Circulation (HSC-A)Peripheral Blood Circulation (HSC-A) Umbilical Cord Blood (HSC-C)Umbilical Cord Blood (HSC-C)Types of HSCTTypes of HSCT Autologous: from the patientAutologous: from the patient Allogeneic: from another personAllogeneic: from another person Syngeneic: from an identical twinSyngeneic: from an identical twin

Choice of graft is based on disease type, patient condition, Choice of graft is based on disease type, patient condition,

donor compatibility and health.donor compatibility and health.

Autologous TransplantAutologous Transplant No evidence of disease in the blood or bone No evidence of disease in the blood or bone

marrowmarrow Transplant related mortality (TRM) lowest with Transplant related mortality (TRM) lowest with

autos (<5%)autos (<5%) Relapse rates are higher Relapse rates are higher

depending on the diseasedepending on the disease Absence of graft versus tumor Absence of graft versus tumor

effectseffects

Diseases treated by HSCTDiseases treated by HSCT

Malignant disorders Malignant disorders NHLNHL Hodgkin’s diseaseHodgkin’s disease AMLAML Multiple myeloma*Multiple myeloma* NeuroblastomaNeuroblastoma Ovarian cancerOvarian cancer Germ-cell tumorsGerm-cell tumors

Non-Malignant disordeNon-Malignant disordersrs Autoimmune disordersAutoimmune disorders

SLE, Systemic sclerosisSLE, Systemic sclerosis AmyloidosisAmyloidosis

Autologous TransplantAutologous Transplant

Allogenic TransplantsAllogenic Transplants

Patients above 50 age - high TRM (30-50%)Patients above 50 age - high TRM (30-50%) Graft versus host effects Graft versus host effects Lower relapse rates due to graft versus tumor Lower relapse rates due to graft versus tumor

effectseffects

Diseases treated by HSCTDiseases treated by HSCT

Malignant disordersMalignant disorders AMLAML NHLNHL Hodgkin’s DiseaseHodgkin’s Disease ALLALL CMLCML CLLCLL MPDMPD MDSMDS Multiple Myloma*Multiple Myloma*

Non-Malignant disorderNon-Malignant disorderss Aplastic anemiaAplastic anemia ThalassemiaThalassemia Sickle Cell DiseaseSickle Cell Disease SCIDSCID Fanconi’s anemiaFanconi’s anemia Blackfan-DiamondBlackfan-Diamond Wiskott-AldrichWiskott-Aldrich Inborn errors of Inborn errors of

metabolismmetabolism Auto immune disordresAuto immune disordres

Allogenic Transplant

Donor SourcesDonor Sources

Matched Related Donor (siblings)Matched Related Donor (siblings) 25% chance a sibling will be a match25% chance a sibling will be a match The more siblings a patient has the better chance for a The more siblings a patient has the better chance for a

matchmatch

Donor SourcesDonor Sources Alternative DonorsAlternative Donors

Matched Unrelated Donors (MUD)Matched Unrelated Donors (MUD) NMDPNMDP WMDAWMDA Severe GVHDSevere GVHD Higher TRMHigher TRM

Haploidentical DonorsHaploidentical Donors From parent, child or siblingFrom parent, child or sibling Must have many stem cells to overcome risk of graft rejectionMust have many stem cells to overcome risk of graft rejection Increased risk of GVHDIncreased risk of GVHD

Donor selection for HSCT Qualifies as blood donor Routine studies:

- History/Physical exam.

- CBC

- Electrolytes, RFT, LFT

- Viral studies/VDRL

- HLA, ABO

- XRC, ECG

HLA TypingHLA Typing HLA typing became feasible in 1960sHLA typing became feasible in 1960s Linked on chromosome 6Linked on chromosome 6 Inherited as haplotypesInherited as haplotypes 1 in 4 chance a sibling will be identical1 in 4 chance a sibling will be identical

HLA MatchingHLA Matching 6/6, 8/8, or 10/106/6, 8/8, or 10/10

HLA loci on chromosome 6HLA loci on chromosome 6 HLA-A, HLA-B, HLA-C(Cw), HLA-DR (DRB1), HLA-HLA-A, HLA-B, HLA-C(Cw), HLA-DR (DRB1), HLA-

DQ alleles (‘’10 of 10 match”), HLA-DPDQ alleles (‘’10 of 10 match”), HLA-DP

IDENTIFICATION OF A RELATED ALLOGENEIC DONORIDENTIFICATION OF A RELATED ALLOGENEIC DONOR Identical TwinIdentical Twin < 1% < 1% HLA-matched SiblingHLA-matched Sibling 6 antigen6 antigen 25 - 30%25 - 30% 5 antigen5 antigen 10 - 20%10 - 20% 4 antigen4 antigen 50 - 60%50 - 60% 3 antigen3 antigen > 90% > 90%

ABO incompatibility is not an exclusionABO incompatibility is not an exclusion

Patient EligibilityPatient Eligibility Age < 65Age < 65

Autologous, mini-alloAutologous, mini-allo

Age < 55Age < 55 Myeloablative allogeneicMyeloablative allogeneic

ExclusionsExclusions CHF, uncontrolled diabetes mellitus, active CHF, uncontrolled diabetes mellitus, active

infections, renal insufficiencyinfections, renal insufficiency

Preparative RegimensPreparative Regimens

MyeloablativeMyeloablative High doses of chemotherapy +/- radiationHigh doses of chemotherapy +/- radiation 3 goals3 goals

Eliminate malignancyEliminate malignancy Immunosuppression to allow engraftmentImmunosuppression to allow engraftment Decrease graft versus host effectsDecrease graft versus host effects

Preparative RegimenPreparative Regimen Non-Myeloablative (Reduced induction Non-Myeloablative (Reduced induction

conditioning - mini transplant)conditioning - mini transplant) Reduction in mortalityReduction in mortality Reduction in non-relapse mortalityReduction in non-relapse mortality Reduced PRBC and platelet transfusionsReduced PRBC and platelet transfusions Duration of neutropenia reducedDuration of neutropenia reduced Reduced numbers of bacteremiasReduced numbers of bacteremias Able to give to heavily pretreated patientsAble to give to heavily pretreated patients Reduced GVHD compared to myloablative therapyReduced GVHD compared to myloablative therapy Late onset acute GVHD occuring beyond day 100Late onset acute GVHD occuring beyond day 100

Principals of ConditioningPrincipals of Conditioning

Donor Lymphocyte Infusions (DLI)Donor Lymphocyte Infusions (DLI) T cells and NK cellsT cells and NK cells Additional anticancer effectsAdditional anticancer effects Preventing relapse or eliminating active diseasePreventing relapse or eliminating active disease

CML and multiple myelomaCML and multiple myeloma

Collection of Stem CellsCollection of Stem Cells

Bone Marrow HarvestBone Marrow Harvest General anesthesiaGeneral anesthesia Equivalent of 50-100 bone marrow biopsiesEquivalent of 50-100 bone marrow biopsies Used much less oftenUsed much less often

Collection of Stem CellsCollection of Stem Cells ApheresisApheresis

Stem Cell Collection (mobilization)Stem Cell Collection (mobilization) Stem cells circulate in the bloodStem cells circulate in the blood Identified by CD34+ by flow cytometryIdentified by CD34+ by flow cytometry Filgrastim, Sargramostim, AMD 3100Filgrastim, Sargramostim, AMD 3100 Stem cells are collected through an apheresis catheterStem cells are collected through an apheresis catheter More cells are collectedMore cells are collected Higher chronic GVHD than bone marrow harvestHigher chronic GVHD than bone marrow harvest More rapid marrow recoveryMore rapid marrow recovery

Umbilical Cord BloodUmbilical Cord Blood 11stst UCB transplant 26 years ago UCB transplant 26 years ago

Child with FanconiChild with Fanconi’’s anemias anemia Cell dose is given per recipient weightCell dose is given per recipient weight

Lower patient weights the high the cell doseLower patient weights the high the cell dose 2 x 102 x 1077 nucleated cells/kg nucleated cells/kg 1.7 x 101.7 x 1077 CD 34+ cells/kg CD 34+ cells/kg

4/6 match UCB with sufficient cells has a similar 4/6 match UCB with sufficient cells has a similar outcome to a matched or one antigen mismatched outcome to a matched or one antigen mismatched MUDMUD

Umbilical Cord BloodUmbilical Cord Blood Umbilical Cord BloodUmbilical Cord Blood

CryopreservedCryopreserved Small number of stem cellsSmall number of stem cells Higher incidence of engraftment failureHigher incidence of engraftment failure

Using more than one unit in adultsUsing more than one unit in adults

Lower risk of GVHDLower risk of GVHD Degree of matching not as stringentDegree of matching not as stringent TRM not different than MUDTRM not different than MUD Can be used with myeloablative or nonmyeloablative Can be used with myeloablative or nonmyeloablative

conditioning (on a clinical trial)conditioning (on a clinical trial)

HarvestingHarvesting

Depends upon collection methodsDepends upon collection methods TargetTarget

2-4x102-4x1088 nucleated cells/Kg of recipient weight nucleated cells/Kg of recipient weight

or 2-10x10or 2-10x1066 CD 34+ cells/Kg of recipient CD 34+ cells/Kg of recipient weightweight

Umbilical cord blood is obtained from one of Umbilical cord blood is obtained from one of the umbilical cord veins and frozen with an the umbilical cord veins and frozen with an anticoagulant and nutrient mediaanticoagulant and nutrient media

Stem Cell ManipulationStem Cell Manipulation ABO incompatibleABO incompatible

Removal of Isoagglutinins or RBCsRemoval of Isoagglutinins or RBCs T-cell depletionT-cell depletion

Reduce incidence of GVHDReduce incidence of GVHD Increased graft failureIncreased graft failure Increased relapse ratesIncreased relapse rates

In vitro purgingIn vitro purging Removal of tumor cellsRemoval of tumor cells Positive selection of CD34+ cellsPositive selection of CD34+ cells

Units that may result from post-collection Units that may result from post-collection processingprocessing

HPC, (RBC reduced)HPC, (RBC reduced) HPC, (Plasma reduced) HPC, (Plasma reduced) HPC, (CD34 enriched)HPC, (CD34 enriched) HPC, (Buffy coat enriched)HPC, (Buffy coat enriched) HPC, (Mononuclear cell enriched)HPC, (Mononuclear cell enriched) Cryopreserved HPCCryopreserved HPC

Infusion of Stem CellsInfusion of Stem Cells Stem cells may be infused fresh within a few Stem cells may be infused fresh within a few

hours of collectionhours of collection May be frozen using DMSOMay be frozen using DMSO

Creamed corn or garlic smellCreamed corn or garlic smell

RecoveryRecovery

For Autologous & AllogenicFor Autologous & Allogenic Bone Marrow (2-6 weeks) Bone Marrow (2-6 weeks) PBSC ( 8-10 days for neutrophil & 10-12 days PBSC ( 8-10 days for neutrophil & 10-12 days

for platelets ) for platelets ) for cord blood (Neutrophil is 4 weeks) for cord blood (Neutrophil is 4 weeks)

ComplicationsComplications EarlyEarly

MucositisMucositis Sinusoidal obstructive syndrome (VOD)Sinusoidal obstructive syndrome (VOD)

Fluid retention, jaundice, hepatomegalyFluid retention, jaundice, hepatomegaly

Transplant related infectionsTransplant related infections Damage to mouth, gut and skin, hemorrhagic cystitisDamage to mouth, gut and skin, hemorrhagic cystitis Prolonged neutropeniaProlonged neutropenia

PancytopeniaPancytopenia PRBC and platelet transfusionsPRBC and platelet transfusions Broad spectrum antimicrobialsBroad spectrum antimicrobials Antifungals if prolonged fevers 3-5 daysAntifungals if prolonged fevers 3-5 days

ComplicationsComplications EarlyEarly

Graft Versus Host DiseaseGraft Versus Host Disease Acute GVHD to day 100Acute GVHD to day 100

Skin, GI tract, liverSkin, GI tract, liver Graft RejectionGraft Rejection

Host versus graftHost versus graft Drug injury to marrowDrug injury to marrow Viral infections: CMV, HHV-6 & 8Viral infections: CMV, HHV-6 & 8

Interstitial PneumonitisInterstitial Pneumonitis Diffuse alveolar hemorrhageDiffuse alveolar hemorrhage Too few donor stem cellsToo few donor stem cells ARDS often caused by CMVARDS often caused by CMV

ComplicationsComplications DelayedDelayed

Chronic GVHDChronic GVHD Scleroderma or Sjogrens syndromeScleroderma or Sjogrens syndrome BronchiolitisBronchiolitis KeratoconjunctivitisKeratoconjunctivitis MalabsorptionMalabsorption CholestasisCholestasis Esophageal strictureEsophageal stricture

Late ComplicationsLate Complications Secondary TumorsSecondary Tumors

Acute leukemias, solid tumors, MDSAcute leukemias, solid tumors, MDS Months to years after transplantMonths to years after transplant Increased incidence with TBIIncreased incidence with TBI

Late InfectionsLate Infections Bacterial, viral, fungalBacterial, viral, fungal Months after transplantMonths after transplant Associated with GVHDAssociated with GVHD Need repeat vaccinationsNeed repeat vaccinations

Pneumovax, Hep B, Hemophilus influenza b, poliovirus, Pneumovax, Hep B, Hemophilus influenza b, poliovirus, diphtheria/tetanus, fludiphtheria/tetanus, flu

Transfusion in HSCTTransfusion in HSCT3 phases3 phases Pre-transplantPre-transplant Peri-transplantPeri-transplant Post-transplantPost-transplant Pre-transplantPre-transplant Leukocyte reduced and irradiated blood Leukocyte reduced and irradiated blood

productsproducts Avoid family member transfusionAvoid family member transfusion

Transfusion in HSCTTransfusion in HSCT

OO

Recipient Type Donor Type Mismatch RBC type FFP type

O A Major O A, AB

O B Major O B, AB

O AB Major O AB

A AB Major A AB

B AB Major B AB

A O Minor O A, AB

B O Minor O B,AB

AB O Minor O AB

AB A Minor A AB

AB B Minor B AB

A B Bidirectional O AB

B A Bidirectional O AB

Transfusion in HSCTTransfusion in HSCT

Peri-transplantPeri-transplant Continue support as aboveContinue support as above Follow the chart Follow the chart

Transfusion in HSCTTransfusion in HSCT Post-transplantPost-transplant Irradiated products give for 1 yearIrradiated products give for 1 year Continue CMV vigilance Continue CMV vigilance ABO mismatchABO mismatch After engraftment (original ABO antibodies After engraftment (original ABO antibodies

disappear after several months), transfuse ABO disappear after several months), transfuse ABO identical blood , but after proper compatibility identical blood , but after proper compatibility test.test.

In case of incompatibility use tableIn case of incompatibility use table

The EndThe End!!

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