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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 2  |  Page : 83-85

Intermittent flow centrifugation technique used for large volume leucapheresis in a low-body weight paediatric patient


Department of Transfusion Medicine, Cancer Institute (WIA), Chennai, Tamil Nadu, India

Date of Web Publication26-Mar-2019

Correspondence Address:
Yalamanchili Swapna
Medical Officer, Department of Transfusion Medicine, Cancer Institute (WIA), Adyar, Chennai - 600 036, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCSR.JCSR_32_18

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  Abstract 


Paediatric leucapheresis is a preferred mode of stem cell collection compared to bone marrow harvest. However, the inherent risks of this procedure like difficult venous access, citrate toxicity, large extracorporeal volume and haemodynamic instability are of considerable importance. Leucapheresis can be done by continuous flow centrifugation (CFC) or intermittent flow centrifugation (IFC) technology. Based on the total blood volume that is processed; it is standard or large volume leucapheresis. The use of IFC blood cell separator in paediatric low body weight child to perform large volume leucapheresis is discussed.

Keywords: Intermittent flow centrifugation, Large volume leucapheresis, Low-body weight, Paediatric patient


How to cite this article:
Swapna Y. Intermittent flow centrifugation technique used for large volume leucapheresis in a low-body weight paediatric patient. J Clin Sci Res 2018;7:83-5

How to cite this URL:
Swapna Y. Intermittent flow centrifugation technique used for large volume leucapheresis in a low-body weight paediatric patient. J Clin Sci Res [serial online] 2018 [cited 2019 Oct 14];7:83-5. Available from: http://www.jcsr.co.in/text.asp?2018/7/2/83/254974




  Introduction Top


Apheresis is widely accepted as an effective procedure for peripheral blood stem cells (PBSC) collection. Paediatric leucapheresis in low-body weight children could pose specific technical and clinical challenges such as difficult venous access, patient intolerance, relatively large extracorporeal volume, citrate toxicity and haemodynamic instability. Most of the past studies or case reports dealt with PBSC collection using continuous flow centrifugation (CFC). The use of intermittent-flow centrifugation (IFC) blood cell separator in paediatric low-body weight children to perform large volume leucapheresis (LVL) is presented.


  Case Report Top


A 4-year-old child weighing 14 kg diagnosed to have neuroblastoma Stage IV was referred to the Department of Transfusion Medicine at Cancer Institute, Chennai, India for autologous PBSC collection. The patient was undergoing treatment with high-dose chemotherapy as per CCG 3891 protocol and stimulated with granulocyte colony-stimulating factor (G-CSF) before PBSC collection for 8 days. The patient presented with a history of abdominal pain of 7–8 months duration that gradually worsened. The patient also complained of decreased urinary output. On examination, an epigastric mass was palpable. The general condition of the patient was good. Bone marrow aspirate and biopsy revealed the features of neuroblastoma. Urine vanillylmandelic acid was 16.5. Computed tomography showed conglomerate left suprarenal mass with encasement of the celiac axis and multiple para-aortic nodes apart from hypodense lesions in both the upper and lower poles of the kidney. Bone scan was negative. Haemonetics MCS+ apheresis equipment using IFC technique was used for PBSC collection. The procedure was performed under the mild sedation. The venous access was obtained through a single venepuncture of the left femoral vein using a 9F dialysis double-lumen catheter. Anticoagulant citrate-dextrose solution A (ACD-A) was used in the ratio of 1:14 to whole blood and 439 mL of ACD-A was used. Prophylactic calcium gluconate (10 mL of 10% calcium gluconate in 500 mL of normal saline) was infused to prevent citrate-related hypocalcaemia and maintain the haemodynamic stability. With blood flow rate at 60 mL/min, 5124 mL, i.e., 4.5 times, the patients total blood volume (TBV) was processed. TBV was calculated at 80 mL/kg body weight. Nearly, nine cycles of blood circulation with recirculation ratio of 1:2 were performed, and the procedure lasted for 243 min. The extracorporeal volume was maintained at 15%. The PBSC collected product was 209 mL. No untoward reactions or incidents occurred during the procedure and post-procedure. Post-procedure vitals were stable, and no bleeding episodes were observed. Pre-and post-procedure laboratory reports are shown in [Table 1].
Table 1: Pre- and post-procedure laboratory investigation report

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The final PBSC product revealed CD34+ count of 8.8 × 106/kg body weight. The PBSC collection was cryopreserved using 10% of dimethyl sulfoxide in 1:1 proportion. These stem cells were infused after conditioning regime on day 7. The patient engrafted on day 15 for platelets and day 16 for neutrophils. The transfusion requirement during engraftment was two units of packed red blood cells (RBCs), six units of random donor platelets and one unit of fresh frozen plasma. The patient was subsequently discharged on day 31.


  Discussion Top


Neuroblastoma is a childhood malignancy with poor prognosis. The usual site of origin is either the adrenal glands or in nerve tissue that runs alongside the spinal cord. In advanced stages of neuroblastoma, high-dose chemotherapy with PBSC rescue is used after the initial courses of chemotherapy. Autologous and allogeneic PBSCs transplantations ensure a complete haematopoietic and immunogenic reconstitution in patients.[1] High-dose chemotherapy and haemopoietic stem-cell rescue (i.e., myeloablative therapy) might improve survival despite the poor prognosis of high-risk neuroblastoma.[2]

Apheresis technology is being used for a wide variety of therapeutic indications apart from the blood component donation.[3] Paediatric therapeutic apheresis, especially in low-body weight patients poses a real challenge when compared to the adults. Past studies have identified numerous risk factors in paediatric PBSC collection such aslike difficult venous access, G-CSF priming, significantly large extracorporeal blood volume, citrate toxicity, transfusion reactions, coagulopathies, exposure to blood products, anaesthesia and problems such as platelet clumping or clotting.[4],[5] In low-body weight children, their small TBV requires special attention considering the blood volume in the extracorporeal circulation, product volume and the blood volume in separator set after the collection.[6]

LVL involves processing of >3–5 patient blood volumes in a single session, thereby reducing the requirement for additional procedures to obtain adequate or target PBSC dose.[7],[8] LVL is an efficient procedure, but may expose low-body weight children to the risk of anaemia, thrombocytopenia and also metabolic imbalances due to the infusion of large volumes of anticoagulants. During the procedure, initial intravascular volume deficit and red-cell deficit are followed by the net fluid gain at the end when the contents of the extracorporeal circuit are returned along with priming fluids and anticoagulant used. LVL must be reserved for selective cases and performed by an experienced team.[6],[9]

In IFC, the apheresis is done in interrupted cycles that include withdrawal of whole blood, separation of required cells and reinfusion of remaining components. CFC on the other hand is an uninterrupted or continuous flow for withdrawal, separation and reinfusion. The advantage of IFC is single venepuncture when compared to CFC which requires two venepunctures. The disadvantage of IFC is mainly due to the large extracellular volume (ECV), haemodynamic fluctuations and longer duration of the procedure. IFC is safe with a careful clinical assessment, monitoring and manual control of ECV according to the patient's body weight. There is no need for RBC priming of the instrument when the patient's haematocrit value is within an acceptable range during the procedure.[10] The usual optimal CD34+ target cell count is ≥5 × 106/kg bodyweight.[8]

The paediatric therapeutic LVL procedure was safe and well-tolerated recording a high-quality yield with no necessity for the repeated procedure. Continuous monitoring helps to avoid the usual complications of haemodynamic instability and citrate toxicity during the procedure. LVL using IFC process can be safely recommended for auto-PBSC collection even in low-body weight children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gasová Z, Marinov I, Vodvárková S, Böhmová M, Bhuyian-Ludvíková Z. PBPC collection techniques: Standard versus large volume leucapheresis (LVL) in donors and in patients. Transfus Apher Sci 2005;32:167-76.  Back to cited text no. 1
    
2.
Yalçin B, Kremer LC, Caron HN, van Dalen EC. High-dose chemotherapy and autologous haematopoietic stem cell rescue for children with high-risk neuroblastoma. Cochrane Database Syst Rev 2015;10:CD006301.  Back to cited text no. 2
    
3.
Meyer EK, Wong EC. Pediatric therapeutic apheresis: A critical appraisal of evidence. Transfus Med Rev 2016;30:217-22.  Back to cited text no. 3
    
4.
Pahys J, Fisher V, Carneval M, Yomtovian R, Sarode R, Nieder M, et al. Successful large volume leucapheresis on a small infant allogeneic donor. Bone Marrow Transplant 2000;26:339-41.  Back to cited text no. 4
    
5.
Liao YM, Yeh CJ, Shu HL, Lin PC, Chang TT, Chiou SS, et al. Successful large-volume leucapheresis for hematopoietic stem cell collection in a very-low-weight brain tumor infant with coagulopathy. Pediatr Neonatol 2013;54:211-3.  Back to cited text no. 5
    
6.
Bojanic I, Mazic S, Rajic L, Jakovljevic G, Stepan J, Cepulic BG, et al. Large volume leucapheresis is efficient and safe even in small children up to 15 kg body weight. Blood Transfus 2017;15:85-92.  Back to cited text no. 6
    
7.
Reik RA, Noto TA, Fernandez HF. Safety of large-volume leucapheresis for collection of peripheral blood progenitor cells. J Clin Apher 1997;12:10-3.  Back to cited text no. 7
    
8.
Díaz MA, Garcia-Sanchez F, Lillo R, Vicent MG, Vicario JL, Madero L, et al. Large-volume leucapheresis in pediatric patients: Pre-apheresis peripheral blood CD34+ cell count predicts progenitor cell yield. Haematologica 1999;84:32-5.  Back to cited text no. 8
    
9.
Kanold J, Halle P, Berger M, Rapatel C, Palcoux JB, Rouzier C, et al. Large-volume leucapheresis procedure for peripheral blood progenitor cell collection in children weighing 15 kg or less: Efficacy and safety evaluation. Med Pediatr Oncol 1999;32:7-10.  Back to cited text no. 9
    
10.
Kim HC. Therapeutic pediatric apheresis. J Clin Apher 2000;15:129-57.  Back to cited text no. 10
    



 
 
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