Management of Disease by CELLULAR BLOOD ELEMENTS (Cellular Therapeutics)
Akram Al-Hilali 2010
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CELLULAR ELEMENTS OF THE BLOOD • MAJOR – Red cells – Leukocytes – Platelets
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• MINOR – Haemopoietic Stem cell – Mesenchymal stem cell – Dendritic cell
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RED BLOOD CELLS
Landmarks in Transfusion History • • • • • • •
Animal to human. Direct human Transfusion. Incompatible blood. Blood group discovery. Anticoagulant and storage era. Improvements in storage period and conditions. Biological Hazards 08/13/14
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RED BLOOD CELLS Negative Selection • Whole Blood transfusion • Packed red cells • Leukodepleted red cells • Erythrapheresis harvest • Irradiated red cells • Frozen washed red cells 08/13/14
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RED BLOOD CELLS Erythrapheresis • THERAPEUTIC – Erythrocytoses – Acute deafness
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• DONOR
APHERESIS- for red cell collection.
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Effect of a Red cell Unit on Hb • Same for packed red cell or whole blood
unit. • For a 50 kg patient: 70/40=1.75 g/dl rise. • For a 70 kg patient: 70/56=1.25 g/dl rise. • This is regardless of original Hb level of patient.
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RED BLOOD CELLS Substitutes
• Hb-based Oxygen Carriers:
Solutions or particulate • Chemical Oxygen Carriers: Perfluorocarbons Neither is considered a suitable replacement yet. 08/13/14
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LEUKOCYTES • Neutrophils
• Lymphocytes – Crude – T cells – NK cells
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NEUTOPHILS Transfusion Issues • Ineffective number in random units • Storage makes them non-viable. • Leukapheresis for severe febrile neutropenia- ? Effective.
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LEUKAPHERESIS PRACTICE • In the 80’s and 90’s this was widely practiced to harvest • • • • •
granulocytes for treatment of the severely neutropenic febrile patient. Steroids and then GCSF to donor for higher counts Dextran or HES for higher yields in the procedure. It then was almost completely abandoned because of the ambiguous clinical effectiveness. In the late 90’s some workers claimed they are getting good results when the yield is much higher than before (1X1011, instead of 1X1010 per cycle) Its use, however, is not popular at all, especially with the advent of new and effective antibiotics for prophylaxis. 08/13/14
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Experience with Leukapheresis Granulocyte Therapy (1986) • 120 patients, 95 of whom were • • • •
hematologic malignancies 40 cases of AML Average yield per cycle 0.82X109, increased to 1.0 with dextran and to 1.04 with HES. Total cycles per episode 10 or more Hematologist’s remarks on outcome after therapy : 27.5% “improved”, 10% deteriorated and 62.5% no change
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NEUTROPHILS Negative Effects • Platelet refractoriness due to common antigens. • Immune modulation. Effect shared by • • • • •
lymphocytes Febrile transfusion reactions Transfusion-associated thrombocytopenia Red cell hemolysis by protease. TRALI- most probably due to antibody in donor’s plasma reacting with recipient’s neutrophils. Other theories on etiology. Harboring of viruses and other infective agents.
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Neutrophils- Harbored infective agents Viruses • Cytomegalovirus • Epstein-Barr virus • Human Herpes V-6 • HTLV 1& 2
Bacteria • Yersinia monocytogenes • Non specific bacterial species phagocytized at donation
PRION 08/13/14
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LEUKODEPLETION • Bedside filters from 2-log to current 4-log • Blood Bank filtration by the bedside filters. • Universal leukodepletion in Blood Bank by in-built filters. • Leukodepletion at aphaeresis
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LYMPHOCYTES Utilization of Positive Role • Mononuclear cell Harvest (crude
lymphocytes) by mononuclear apheresis for Stem cell transplantation. • Paternal Lymphocyte Injection for repeated miscarriages. A kind of immunologic adaptation ? Any use. 08/13/14
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MONONUCLEARS COLLECTION FOR HSC HARVEST • Number of blood volumes exchanged in apheresis process. • One or 2 days. • Yield of mononuclear cells ( at least 6-8X108/ kg of patient) • Yield of HSC (CD34+) within the mononuclears (2.5-5X106/ kg of patient, but at least 1.0X 106/kg) 08/13/14
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LYMPHOCYTES T cells • MANAGEMENT OF
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NEGATIVE ROLE GVHD from transfusion – Irradiation of blood and components – Advise against directed relative donations – Methotrexate – ATG – Cyclosporine APLASTIC ANAEMIA AND MDS – ATG – Cyclosporine
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• UTILIZATION OF
POSITIVE ROLE – GVL : DLI – Cytolytic effect in cancer vaccines. – Ex vivo expansion, stimulation and education of CD4 cells to go in combination with dendritic cells and adjuvants in tumour vaccines 17
LYMPHOCYTES NK Cells Activation for non-MHC-restricted killing of cancer cells (Îą -galactosyl ceramide) Trials only
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PLATELETS • Random donor units vs. Thrombapheresis • Pooling of random units. Adult platelet • • • • • •
unit Leukodepletion, photochemical bacterial elimination and irradiation. Bacterial contamination and management Thrombopoietin Frozen platelets Freeze-dried platelets Use of photochemicals (Psoralen, riboflavin) to kill bacteria and other infective agents. 08/13/14
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PROBLEM OF BACTERIAL CONTAMINATION OF PLATELETS
• Storage temperature. • Time between donation and
separation of platelets • Trap pouch effect. • Screening check by non-culture techniques. • Quality Control on components 08/13/14
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PLATELET TRANSFUSION ?WHEN? HOW MUCH
• Cut off value of count : 10K • Exceptions: Fever, chemotherapy, DIC,
bleeding. • Avoid in ITP but give more than calculated if you have to. • One adult unit raises count by 50 unless one or more of the exceptions are present. 08/13/14
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Minor cellular elements HAEMOPOIETIC STEM CELL • • • • • • • •
HSC is: CD34+, CD38- HLADR-, CD33Sources of crude stem cells: BM, PB, Cord blood. Improvement of harvest from blood. Pre-aphaeresis CD34+ count in donor is a good indicator of yield expected. (5-6X106/L is optimal) Chemotherapy (for patients in cases of autologous Tx) raises yield up to 10 fold. GM-CSF is more effective than GCSF in mobilizing CD34+ cells to the blood. CSF+ chemotherapy may raise yield 100 times. Storage pending infusion: DMSO.
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HSC from Cord Blood cells in a unit varies a lot (6• Nucleated 6
• • • • • •
110X10 6/ kg of patient). CD34+ cells 0.1-3.6X106 /kg Successful transplants have been reported with those figures. Storage, viability checks, thawing and washing Full match is not quite necessary Incidence of GVHD is less than with other sources of stem cells. Severity is also less. Quicker implantation than HSC from other sources. 08/13/14
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HAEMOPOIETIC STEM CELL Transplantation • Autograft vs. allograft. • Non-hematologic indications: Storage disorders • • • •
and metabolic enzyme deficiencies. Positive selection by magnetic, avidin-coated beads and other techniques. Negative selection or purging for autotransplantation in cancer cases, by antibodies specific to cancer antigens like cytokeratin or Ig. Expansion by culture and numerous cytokine addition Gene manipulation by adding a chemotherapy resistance gene (MDR), anti-apoptosis, or a donor marker gene 08/13/14
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MESENCHYMAL STEM CELL • Present in very small number in peripheral • • • •
blood. Potentially multipotent for all mesodermal tissues. Responsible for the reconstitution of bone marrow stroma in BMT. Future carries a wide range of possible uses in disease management and tissue repair. However, the embryonic stem cell is essentially more pluripotent and attention has shifted to it. 08/13/14
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DENDRITIC CELL • Antigen presenting cell (APC) • Can be produced from monocytes
and HSC in vitro. • Can be expanded in cultures • Gene manipulation being practiced to expand effectiveness. • Being used in tumour vaccines with CD4 cells, adjuvants, etc.
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CELLULAR THERAPEUTICS ?What is the Future MAJOR BLOOD CELLS
• May be moving from traditional red cell • • • • •
transfusion to oxygen carriers. Granulocyte transfusion ?showing a comeback. Platelets may have better storage time and less contamination Leukodepletion use is on the rise. T lymphocyte usage, for GVL and Tumour vaccines, is expected to increase. NK cell activation may be a therapeutic modality in cancer.
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CELLULAR THERAPEUTICS ?What is the future • • •
MINORITY CELLS HSC use to continue and increase. Novel modifications introduced. MSC experimental work shows wide potentials, but ease of obtaining ESC will probably lead to neglect of MSC. Dendritic cells role in immunologic-based cellular therapeutics is growing with various manipulations 08/13/14
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