Precautions support safe stem cell transplant in man with CAD
Case report highlights feasibility of temperature management strategies
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Careful planning, warming measures, and close teamwork between medical specialists may allow for the safe collection and transplant of blood-forming stem cells in people with cold agglutinin disease (CAD) to rebuild a healthy bone marrow after high-dose chemotherapy.
That’s according to a study reporting a successful procedure in a 49-year-old man with active CAD, as well as data published so far on such procedures in this patient population.
“This case highlights the feasibility of pragmatic, multidisciplinary temperature management strategies during stem cell collection and processing in patients with cold agglutinin disease,” researchers wrote.
The study, “Temperature Safeguards and Peri-Procedural Strategies for Stem Cell Collection in Cold Agglutinin Disease: A Case Report and Literature Review,” was published in the Journal of Clinical Apheresis by researchers in the U.S.
Stem cell transplant in CAD patients remains challenging
CAD is an autoimmune disease in which self-reactive antibodies, called cold agglutinins, mistakenly attack red blood cells at low temperatures, marking them for destruction (hemolysis). The disease can occur on its own or secondary to other conditions, most often an infection or a blood cancer involving antibody-producing plasma cells.
An autologous stem cell transplant (ASCT), commonly used to treat blood cancers, involves the collection of healthy blood-forming stem cells, which can give rise to all types of blood cells, from a patient. After chemotherapy or radiotherapy, the cells are infused back into the patient to replenish the body with new healthy blood cells.
However, because the procedure involves many steps at lower than body temperatures, conducting it in people with CAD remains challenging, as it can result in red blood cell clumping and hemolysis.
Team of specialists worked together to create detailed treatment plan
In this study, a team of researchers in the U.S. described the preventive measures used to conduct a safe and successful ASCT in a 49-year-old African-American man with CAD.
The man visited the hospital after experiencing heart palpitations and fainting. Tests showed that he had profound anemia, or very low levels of the protein hemoglobin in red blood cells that transport oxygen throughout the body. He also showed signs of hemolysis and both CAD and autoimmune hemolytic anemia, a related disease in which self-reactive antibodies bind to red blood cells at normal temperatures.
He also tested positive for two different viruses, which may have triggered or worsened his CAD symptoms. Off-label immunosuppressive treatment with a corticosteroid and rituximab, marketed as Rituxan and available as biosimilars, temporarily eased his symptoms and allowed him to become free from blood transfusions.
However, his anemia later returned, as did his need of blood transfusions.
Several months later, further testing at the researchers’ hospital showed that he had multiple myeloma, a blood cancer in which abnormal plasma cells build up in the bone marrow and produce large amounts of an abnormal antibody called M protein.
The man was treated with a combination of anti-cancer medications and corticosteroids. This treatment eased his anemia and reduced the amount of M protein in his blood. Because his multiple myeloma responded well, doctors recommended an ASCT.
To reduce risk of hemolysis, a team of specialists worked together to create a detailed treatment plan. Before collecting his stem cells, they prescribed chemotherapy to reduce the number of cancer cells and granulocyte colony-stimulating factor to move stem cells from the bone marrow into the bloodstream so they can be collected more easily.
He was also treated with Enjaymo (sutimlimab), an approved medication for CAD that blocks the complement cascade, a part of the immune system that contributes to CAD.
Autologous stem cell transplantation can be safely performed in patients with [cold agglutinins], including those with … myeloma, when proactive [warming] precautions are employed.
Stem cell collection was conducted at a room temperature of 30 °C (86 °F), warming blankets covered both the patient and parts of the equipment, and the tubing carrying blood was insulated and gently warmed.
After collection, the stem cells were carefully transported and processed using equipment and solutions warmed to normal body temperature (37 °C or 98.6 °F). The stem cells were washed and frozen for storage. No visible clumping occurred, and doctors successfully collected enough stem cells for transplantation.
The man then received high-dose melphalan, a chemotherapy medication used to destroy remaining myeloma cells before transplantation. His frozen stem cells were thawed in warm water and infused back into his bloodstream without any complications. The transplanted stem cells successfully settled in the bone marrow and began producing healthy blood cells again.
Three months after the transplant, there were no signs of anemia, hemolysis, or M protein. Imaging scans showed no sign of active myeloma, and he started maintenance treatment for myeloma.
Fourteen months later, the man remained free of blood transfusions, and continued to be in remission from both CAD and multiple myeloma.
“Autologous stem cell transplantation can be safely performed in patients with [cold agglutinins], including those with … myeloma, when proactive [warming] precautions are employed,” the researchers wrote. “This case contributes to the limited literature and provides practical guidance for centers encountering cold-sensitive hemolysis during [blood stem cell] mobilization, collection, processing, and infusion.”
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