Asian Journal of Transfusion Science
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ORIGINAL ARTICLE  
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The impact of factors on autologous peripheral blood stem cell collection efficiency


1 Department for Hemapheresis with Tissue Bank, Blood Transfusion Institute of the Federation of Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina
2 Department for Stem Cell Transplantation, Hematology Clinic, University Clinical Centre, Sarajevo, Bosnia and Herzegovina

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Date of Submission12-Jul-2022
Date of Decision03-Sep-2022
Date of Acceptance23-Oct-2022
Date of Web Publication12-Dec-2022
 

   Abstract 

BACKGROUND: Peripheral blood stem cells are used for autologous transplantation in the treatment of hematological diseases. Collection efficiency (CE) is an objective quality parameter used to assess the quality of leukapheresis.
AIM: In this study, we analyzed the affection of various patient and procedural factors on CD34-positive (CD34+) CE in leukapheresis.
SETTINGS AND DESIGN: Demographics, stem cell collection, and laboratory measures from adult autologous donors undergoing leukapheresis, collected from medical records for 7 years, were retrospectively reviewed.
METHODS: A total of 86 consecutive leukapheresis procedures performed on 60 patients (33 males and 27 females) with malignant hematological diseases who are involved in the process of autologous transplantation were included. Various parameters such as diagnosis, sex, age, weight, preprocedural total leukocyte count (TLC), preprocedural absolute CD34+ cell count, preprocedural platelet cell count, preprocedural hematocrit, blood flow, and blood volume processed on CE were evaluated. The results were compared using regression analysis, statistical comparisons between groups, and statistical correlation.
RESULTS: The median CE was 53.6%. Higher preprocedural TLC was associated with lower CE. Preprocedural CD34+ cell count was found to be strongly correlated with the total number of CD34+ cells collected in product.
CONCLUSION: Preprocedural TLC was the factor affecting CE.

Keywords: CD34-positive cells, collection efficiency, leukapheresis


How to cite this URL:
Ahmetovic-Karic G, Catovic-Baralija E, Ibricevic-Balic L. The impact of factors on autologous peripheral blood stem cell collection efficiency. Asian J Transfus Sci [Epub ahead of print] [cited 2023 Jan 28]. Available from: https://www.ajts.org/preprintarticle.asp?id=363244



   Introduction Top


Collection and transplantation of peripheral blood stem cells (PBSCs) is used in the treatment of hematological diseases.[1],[2],[3],[4],[5] PBSCs quantified as CD34-positive (CD34+) cells are collected by leukapheresis.[5],[6] Normally, PBSCs are rare in peripheral blood and mobilization stimulates their exit from the bone marrow.[1],[7] The factors identified as important in determining CD34+ cell yields have been studied before.[8],[9],[10],[11],[12],[13],[14],[15],[16] Technical issues of leukapheresis were also studied by different authors.[3],[6],[8],[17] CD34+ collection efficiency (CE) is reportedly affected by different patient and procedural factors with a lot of variabilities.[5],[8],[18],[19],[20],[21],[22] In this study, we analyzed the affection of various factors on CD34+ CE in leukapheresis.


   Methods Top


A total of 86 consecutive leukapheresis procedures performed on 60 autologous donors (33 males and 27 females) for 7 years (between April 2013 and December 2019) were studied retrospectively. Those were the patients with malignant hematological diseases who are involved in the process of autologous transplantation. During that process, they undergo apheresis procedures for the collection of PBSCs and their cryopreservation and storage until reinfusion. Patient characteristics are shown in [Table 1].
Table 1: Patient characteristics

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Availability of the following data was essential for inclusion in the study: patient characteristics (diagnosis, sex, age, and weight), preprocedural peripheral blood cell count (platelet [PLT] count, total leukocyte count [TLC], and hematocrit) and CD34+ cell percent (%) and absolute count, postprocedural peripheral blood cell count (PLT, TLC, and hematocrit) and leukapheresis product blood cell count (PLT, TLC, and hematocrit), leukapheresis product CD34+ cell (%) and absolute count, as well as procedure parameters (blood volume processed, blood flow rate, product volume, and acid citrate dextrose [ACD]-A volume used).

The mobilization process included the use of chemotherapy followed by daily stimulation with granulocyte colony-stimulating growth factor (G-CSF), G-CSF alone in one patient during the second mobilization and plerixafor with G-CSF in two patients, during their second and third mobilization.

All procedures were carried out using two continuous flow cell separators based on the availability of collection sets, Amicus (Baxter, Lake Zurich, IL, USA, software version 3.21; Fenwal Inc., Lake Zurich, IL, USA, software version 4.4; Fresenius Kabi, Bad Homburg, Germany, sofware version 4.4) and Spectra Optia (Terumo BCT, Lakewood, CO, USA, software version 7, 11.3) cell separators with MNC collection protocols. All patients had a double-lumen blood access catheter (Medical Components, Inc., Harleysville, PA, USA). If some flow problems occurred during the procedure, peripheral venous access was used (peripheral apheresis/dialysis needles, 17 GA, Fresenius Medical Care, Bad Homburg, Germany). Extracorporeal anticoagulation was achieved with ACD-A, with an ACD: blood ratio of 1:12. Usually, we begin CD34+ cell harvesting when its number in peripheral blood achieved >15 × 10e6/L and PLT count >30 × 10e9/L. However, some patients did not achieve this peripheral blood CD34+ cell count prior to leukapheresis. Two patients with peripheral blood CD34+ cell count of <10 × 10e6/L prior to procedure underwent remobilization. Daily collections were performed in order to reach a yield of minimum ≥2 × 10e6/kg, preferably ≥2.5 × 10e6/kg, and optimum ≥5 × 10e6/kg CD34+ cells in the leukapheresis product for one transplant, according to the patient's treatment scheme. Two to four whole blood volumes were processed. In those patients whose high CD34+ cell count predicted adequate yields, smaller blood volumes were processed. In order to avoid severe hypocalcemia during the procedure, all patients received an intravenous infusion of 10% calcium gluconate (10–20 mL) prior to procedure according to the calcium blood level and oral calcium tablets (two-three effervescent tablets, 500 mg) during the procedure. The vitals were monitored at the beginning, in the middle, and at the end of each procedure, and patients were monitored for adverse events during the leukapheresis. The cell products collected were frozen right after the collection using a controlled rate freezer (Consarctic BIOFREEZE BV45 Freezer, Schollkrippen, GmbH). Cryopreserving solution contained 10% dimethyl sulfoxide in autologous plasma. A number of bags used for cryopreservation (CryoMACS Freezing Bag 500, 750, Miltenyi Biotec, GmbH) depended on the product volume and cell numbers. Cryopreserved products were stored in a container with liquid nitrogen (Consarctic BSF 350, Schollkrippen, GmbH) up to the time of reinfusion in the transplant process.

Leukapheresis characteristics are shown in [Table 2].
Table 2: Leukapheresis characteristics

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CD34+ cells (absolute number and percent) were determined by flow cytometry on FacsCanto II (FacsCanto software, Becton Dickinson, San Jose, USA) in the peripheral blood prior to leukapheresis and in the leukapheresis product prior to processing and cryopreservation.

Complete blood cell count of the peripheral blood prior to leukapheresis and after the leukapheresis, as well as complete blood cell count of the leukapheresis product prior to processing and cryopreservation, was done using cell counters (Cell-Dyn 3200; 3700, Sapphire, Ruby, Abbott, Illinois, USA, and Siemens Advia 2120i, Siemens Healthcare, GmbH).

Peripheral blood and product characteristics are shown in [Table 3].
Table 3: Peripheral blood and product characteristics

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The CD34+ cell CE (%) was calculated for each procedure as follows:[5] CE1 = (leukapheresis product CD34+ [%] × TLC × volume of product)/(preprocedural peripheral blood CD34+ [%] × TLC × apheresis volume processed).

Apheresis volume processed was the volume of total blood volume processed by the apheresis machine subtracting ACD used.

Data were expressed as medians with a range or arithmetic means ± standard deviation depending on the data distribution. All statistical analyses were carried out using software GraphPad Prism version 8.1.0, 8.2.0 i 8.3.0 for Windows (GraphPad Software, San Diego, CA, USA) and Microsoft Excel (Microsoft Corporation, Washington, USA). P = 0.05 was considered statistically significant.


   Results Top


Eighty-six autologous PBSC collections with the Amicus (61 procedures) and the Spectra Optia (25 procedures) were performed within the study period. Thirty-nine patients collected a sufficient number of CD34+ cells by a single leukapheresis procedure. The median patient age was 47 years (range: 18–65 years) and the median weight was 79 kg (range: 47–117 kg). There were 33 (55%) men and 27 (45%) women [Table 1]. The median CD34+ cell CE was 53.6% (range: 42.7%–67.4%). Additionally, the median CE for Amicus was 51.4% (range: 44.6%–61.2%) and for Spectra Optia 61.7% (range: 41.3%–72.1%) [Table 2]. Out of 60 patients, 3 (5%) of them collected a dose of ≥2 × 10e6/kg, 16 (26.7%) of them collected a dose of ≥2.5 × 10e6/kg, and 41 (68.3%) of them collected a dose of ≥5 × 10e6/kg CD34+ cells in the leukapheresis product for one transplant [Table 3].

Out of all analyzed factors, only preprocedural absolute CD34+ cell count and preprocedural TLC showed a significant relationship with CE (P = 0.014, P = 0.000) [Table 4]. CE was significantly lower with TLC ≥20 × 10e9/L. This illustrates that for the given range of preprocedural TLC, the highest CE was when preprocedural TLC was ≤10 × 10e9/L with a median of 60.8% (range: 49.4%–75.4%) [Table 5]. The median CE for preprocedural CD34+ cell count of <20 × 10e6/L was 46.9% (range: 36.4%–74.3%). Further, for preprocedural CD34+ cell count between 20 and 60 × 10e6/L, the median CE was 57.4% (range: 46.8%–68.3%), and for the highest preprocedural CD34+ cell count, it was slightly lower with a value of 52% (range: 43.3%–64.7%). However, for the given range of preprocedural CD34+ cell count, an insignificant influence on CE was observed [Table 6]. As expected, the preprocedural CD34+ cell count was found to be strongly correlated with the total number of CD34+ cells collected in apheresis product [rs = 0.88; P < 0.000; [Figure 1]]. Twenty-one patients underwent repeat procedures to collect an adequate yield. Eighteen of them needed two and three of them needed more than two collections on consecutive days. CE did not differ significantly on different days of collections (data not shown).
Figure 1: Correlation of collected CD34+ cell count with preprocedural peripheral CD34+ cell count in all procedures. rs: Spearman's correlation coefficient, CD34+/L: Preprocedural peripheral CD34+ cell count, CD34+/kg: Collected CD34+ cell count in apheresis product

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Table 4: Results of multiple regression analysis performed on factors affecting collection efficiency

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Table 5: Comparison of collection efficiency for different total leukocyte count ranges

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Table 6: Comparison of collection efficiency for different CD34+ cell count ranges, diagnosis, and sex

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We saw no severe adverse effects necessitating interruption or cessation of the PBSC collection process.

Multiple regression analysis was performed to evaluate the impact of patient characteristics (age and weight), preprocedural peripheral blood cell count (CD34+ cells, TLC, PLT, and hematocrit), and procedure parameters (blood flow and blood volume processed) on CE. Wilcoxon test, Kruskal–Wallis test, and Mann–Whitney test were used to compare differences between groups. Spearman's correlation was used to assess the correlation between the preprocedural CD34+ cell count and the total CD34+ cell quantity collected.


   Discussion Top


Autologous transplantation includes PBSC collections for preparation of autologous transplant, in which the stem cells are infused back to the patient.[4] Hematopoietic stem cell transplantation is a standard care for patients with different hematologic diseases.[23] PBSCs are commonly used as the source for autologous transplantation.[6] There is a lower incidence of documented infections, decreased transfusion requirements, lower demand for antibiotics, and shorter hospitalization compared with bone marrow as a source.[1],[6] Various mobilization regimens can be used to enhance stem cell collection.[7] The leukapheresis procedure using cell separators requires several hours, usually 3–5. In some cases, several procedures may be required on consecutive days to obtain a sufficient number of stem cells in the leukapheresis product.[21] The general requirement of CD34+ cell count for successful hematopoietic reconstruction is 2 × 10e6/kg, but the higher yields are considered to be ideal for quick reconstruction of hematopoiesis.[24] However, some authors consider 2.5 × 10e6/kg of recipient weight to be a minimum dose of CD34+ cells in leukapheresis product.[25] Larger cell doses have been associated with a more rapid time to PLT and neutrophil recovery, so according to others, the dose of ≥3–5 × 10e6/kg CD34+ cells is considered an optimal target.[26],[27] The CD34+ cell yields obtained during leukapheresis are also determined by the CE.[5] It is a reflection of the proportion of cells passing through a cell separator that is harvested.[20] The CE is an objective quality parameter for assessing the quality of leukapheresis.[5] Data on CE of CD34+ cells are in general inconsistent and limited.[5],[18]

The CD34+ cell CE in the present study ranged from 42.7% to 67.4% and the median CE was 53.6%. The median CE for Amicus was 51.4% and for Spectra Optia 61.7%. A study of Altuntas et al. shows similar results,[6] including the use one of the same cell separator (51%), although studies of Lee et al. and Tiwari et al. show lower values, including the use of the same and different cell separators (42.1%, 41.2%).[3],[5]

Multiple regression analysis carried out in this study evaluated the impact of age, weight, preprocedural TLC, preprocedural CD34+ cell count, preprocedural PLT count, preprocedural hematocrit, blood flow, and blood volume processed on CE, and only preprocedural TLC and preprocedural CD34+ cell count were predictors for it. The increase of TLC is mostly related to the effects of G-CSF, which is used during the mobilization.[5] This had an effect on the CE in the present study, and it was significantly lower with higher TLC, similar to the finding of Sakashita et al., Verlinden et al., Gidron et al., and Ford et al., who found that CE inversely correlated with peripheral white cell count,[18],[19],[20],[21] whereas in others, it did not show a significant correlation.[5],[22] Additionally, our study also showed that the highest CE was when preprocedural CD34+ cell count was between 20 and 60 × 10e6/L. With a lower preprocedural CD34+ cell count, a lower CE was shown, but with a further increase of it, the CE decreased slightly and it did not differ significantly for the given range of preprocedural CD34+ cell count. Tiwari et al. found a positive correlation, while Sarkodee-Adoo et al. showed an inversed correlation of CD34+ cell count on CE,[5],[22] but Ford et al. did not find a relationship between these two parameters.[21]

The CE did not differ significantly on different days of collection in the present study, similar to the finding of Tiwari et al. and Ford et al. Similarly, age was not a significant factor in the present study, finding also supported by Tiwari et al. and Ford et al.[5],[21]

No significant association was found between weight and CE, similar to the finding of Tiwari et al., Ford et al., and Sarkodee-Adoo et al.[5],[21],[22]

Factors which did not show a relationship with CE in the present study but are recorded elsewhere as significant include preprocedural hematocrit,[5],[21] blood volume processed,[19],[20],[22] and sex.[22]

Similar to other studies,[5],[8],[15],[16],[18],[20],[23],[28] the present study shows a significant correlation between peripheral CD34+ cells and collected CD34+ cells in apheresis product.

In analyzed patients, minimal or desirable or optimal CD34+ cell counts were successfully collected and no collection failure occurred. Most patients collected a sufficient number of CD34+ cells by a single leukapheresis procedure.

Limitation of this study involved retrospective data collection, then analysis with relatively small number of participants and some outcomes that were not significantly different between the groups, such as comparison of the CE for different preprocedural CD34+ cell count ranges, may reflect this. There were also different mobilization regimens and inability to calculate CE2 parameter for comparison. Other factors such as prior chemotherapy, radiation therapy, disease severity, and marrow involvement were not taken into account. Regardless, we believe that this study contributes to previous studies on the influence of various factors on CE.


   Conclusion Top


CE is one of the quality control parameters to monitor PBSC collections, and it can be affected by various patient characteristics and procedural factors. It varies among different centers, showing inconsistent results. Preprocedural TLC was the factor affecting CE. Monitoring of CD34+ cells in peripheral blood before stem cell collection is a good predictor of the optimal time for adequate harvesting.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Correspondence Address:
Gorana Ahmetovic-Karic,
Department for Hemapheresis with Tissue Bank, Blood Transfusion Institute of the Federation of Bosnia and Herzegovina, Cekalusa 86, Sarajevo
Bosnia and Herzegovina
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajts.ajts_91_22



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