Canterbury DHB

Allogeneic Bone Marrow or Peripheral Blood Harvest and Infusion

Donor Hospital Admission

• In some instances it is possible for the donor to be managed as a “day case”.
  • The donor is pre-admitted the day preceding the harvest on the Day Ward or the B6.
  • They then leave to return fasting the next morning to the B6 ready for their harvest at 0700.
  • Most donors are well enough to be discharged later the same day.
• At pre-admission, a blood sample must be taken for group and cross match against their autologous blood unit, if taken, and 5 ml of blood taken in EDTA for DNA storage (Haematology Laboratory). A donor sample is also required for ABO grouping to confirm ABO compatibility with recipient. It is important to ensure that, where appropriate, MRSA swabs have been taken prior to admission and the results known.

  Note: Use of homologous blood is undesirable for obvious reasons and is rarely necessary (e.g., small infant donors where autologous donation not feasible). If the donor is transfused prior to or during harvest the homologous blood must be irradiated.

• A check CBC is taken post harvest to detect the need for transfusion and patient is discharged with a prescription of simple analgesia and oral iron.

Donor Bone Marrow Harvest

• Bone marrow is obtained by a series of aspirations from the posterior iliac crests, and occasionally anterior iliac crests and/or the sternum. For adult donors and patients, this usually takes between 1 and 2 hours. Normally the donor is under a general anaesthetic; occasionally a spinal anaesthetic is used.
• In the case of an HLA identical sibling, sufficient marrow is aspirated to provide a nucleated cell count of >3.0 x 10⁸/kg patient. In cases of severe aplastic anaemia >4.0 x 10⁸ cells/kg is considered optimal. In the case of a major ABO incompatibility between donor and patient a nucleated cell count of 4.0 x 10⁸/kg of patient is aimed for to compensate for the red blood cell depletion process. If the donor is an unrelated donor, a nucleated cell count of 3.0 x 10⁸/kg of patient is obtained. See 5014 BM Harvest Procedure for full details.
• A donor sample for ABO grouping is required for confirmatory ABO grouping at the time of harvest.

See links for:

• Bone Marrow processing for ABO incompatibility.
  • See 5012 Infusion of Fresh Cellular Therapy Products.
  • Major ABO incompatibility most frequently occurs when a group O recipient receives an allograft from a group A, B or AB donor. Less commonly a group A or B recipient receives cells from a group AB donor. The complications of major ABO-incompatible transfusions are immediate red cell haemolysis, delayed haemolysis and red cell aplasia.
  • In the case of major ABO incompatible peripheral blood stem cell products the residual volume of red cells is usually low enough that red cell depletion is unnecessary.
  • In the case of bone marrow the volume of cells may exceed 1 litre. The optimal approach is not known but starts with measurement of donor and recipient iso-agglutinin titres. One approach is to deplete red blood cells from the harvested marrow using centrifugation before its infusion into the patient but this also depletes the CD34 cell content and may be undesirable if the cell dose is low. An alternative approach is to reduce the titre of recipient iso-agglutinins using plasma exchange. An individual approach is taken by the transplant program director in conjunction with the NZBS.
  • In cases of minor ABO incompatibility, that is when donor plasma contains an ABO antibody to antigens expressed on recipient red cells, or when the patient is a child and there is concern about volume overload, the marrow will be centrifuged and plasma removed prior to its infusion.
  • For further information see Booth, G. S., et al. (2013). "Clinical guide to ABO-incompatible allogeneic stem cell transplantation." Biol Blood Marrow Transplant 19(8): 1152-1158 .
• Collection of Allogeneic Bone Marrow from Overseas.
  • When collecting stem cells from anywhere in the world the courier has only a total of 40 hours to return to Christchurch.
  • The harvested stem cells will be contained in hermetically sealed blood transfer packs. Each transfer pack will contain no more than 1 litre of bone marrow. All lines will either be tightly clamped or heat-sealed. Each transfer pack will be placed in an outer plastic bag and heat-sealed. These in turn will be wrapped in incontinence sheets and placed in a chilly bin approximately 35 x 28 x 22 cm which is appropriately labelled and lined with pre-frozen ice packs which are covered with bubble wrap. A further bubble wrapped ice pack will be placed between each bag of bone marrow if there is sufficient room. The ice packs, as well as extra ice packs, are frozen in a separate chilly bin measuring approximately 26 x 18 x 22 cm in which dry ice pellets or the equivalent of dry ice blocks are placed. At no stage is the dry ice to be placed in the container containing marrow.
  • 1 kg of dry ice is requested at each touchdown point to replenish the second chilly bin, thereby keeping the extra ice packs frozen. A thermometer is attached to a probe that is placed between the incontinence pad and the plastic bag and is checked every 30 - 60 minutes. The temperature must be maintained between 4-8°C and this is facilitated by exchanging the pre-frozen ice packs with those frozen in the second chilly bin. The chilly bin should NOT be opened unless adjusting the temperature by replacing or removing ice bricks.
  • In most cases the anticoagulant used is ACD (ratio 1:5) which is effective for the entire period of transfer. ACD is an inappropriate anticoagulant if marrow manipulation using monoclonal antibodies and complement is contemplated. However, ACD or CPD is recommended by ABMDR for MUD collections where extended storage is required.
  • Letters are prepared for Customs and the Quarantine service by NZBMDR, so that the courier can go through Customs quickly. See NZBMDR guidelines.

Donor Peripheral Blood Harvest

• An outline of SCT and PBSC Harvest procedures and protocols is given in the Autologous section. The infusion of peripheral blood stem cells is carried out in the same manner as bone marrow stem cells.
• G-CSF primed PBSC may be considered in normal donors under specific circumstances. This is a consultant decision.
• The following schedule is recommended:
  • G-CSF 10 mcg/kg SC is given for 4 days with harvest on Day 5 at least 6 hours after the administration of the last G-CSF injection.
  • For HLA identical sibling PBSC standard allograft a target yield of CD34⁺ cells of ³ 5 x 10⁶/kg is considered optimal. The minimum requirement is ³2 x 10⁶/kg.
  • In other situations, higher CD34 yields may be required.

    Day	Time	Plan
    -4 (Sunday)	1700	G-CSF 10 mcg/kg
    -3 (Monday)	1700	G-CSF 10 mcg/kg
    -2 (Tuesday)	1700	G-CSF 10 mcg/kg
    -1 (Wednesday)	1700	G-CSF 10 mcg/kg
    0 (Thursday)	0800	Donor to haem day ward CBC, ONCO
    	1300	Peripheral blood stem cell harvest 6 ml EDTA sample to Surface markers - for cell count and to measure CD34 content of the product given to the recipient.

  Note: Subcutaneous infusion catheter (insuflon) may be used.

• For detailed schedule, see Stem Cell Mobilisation - G-CSF Pre Allo PBSC.
• It is essential to minimise risk to the donor and to ensure adequate follow up.
• Bone marrow from normal donors is obtained with the same precautions as for an Autologous PBSC donation.
• Peripheral blood stem cells from normal donors are obtained following G-CSF mobilisation, no other mobilisation methods are used.
• G-CSF primed bone marrow harvests may also have a potential role in RIC SCT regimens, to reduce acute GvHD (fewer T-cells) and to accelerate engraftment. This could be considered if the donor fails to mobilise an adequate number of PBSCs.

Topic Code: 8906