Disease	Allogeneic (%)	Autologous (%)
Severe combined immunodeficiency	90	N/A
Aplastic anemia	90	N/A
Thalassemia	90	N/A
Acute myeloid leukemia
First remission	55-60	50
Second remission	40	30
Acute lymphocytic leukemia
First remission	50	40
Second remission	40	30
Chronic myeloid leukemia
Chronic phase	70	ID
Blast crisis	15	ID
Chronic lymphocytic leukemia	50	ID
Myelodysplasia	45	ID
Multiple myeloma	30	35
Non-Hodgkin’s lymphoma, first relapse, second remission	40	40
Hodgkin’s disease, first relapse, second remission	40	50

ID, Insufficient data; N/A, not applicable.

^∗These estimates are based on data reported by the International Bone Marrow Transplant Registry.

What Are Progenitor Blood Cells?

Progenitor cells have the ability to evolve into different types of cells. Bone marrow and peripheral blood progenitor cells are capable of reconstituting a person’s immune system because they contain the precursor to the cells that make up the blood: lymphocytes, granulocytes, macrophages, and platelets. Progenitor cells that circulate in the bloodstream are called peripheral blood stem cells (PBSCs). PBSCs are found in much smaller quantities in the circulating blood than in the bone marrow. Hematopoietic stem cells are found in very small numbers in the peripheral blood and greater numbers in the marrow.

The hematopoietic stem cell population is not fully characterized, but the cell marker, CD34+ antigen, identifies a population of stem cells that can repopulate the bone marrow after chemotherapy. The required minimal dose of CD34+ cells is difficult to define, but most transplantation centers will infuse a minimal dose of 2 × 10⁶ CD34+ cells/kg patient weight in the autologous and allogeneic PBSC setting.

Historically, the dose of bone marrow has been based on the nucleated cell (NC) count (i.e., 2 to 4 × 10⁸ NC/kg recipient weight). There is no established amount of CD34+ bone marrow stem cells to infuse because there may be more primitive cells, and therefore likely to be CD34− cells, in the marrow that are capable of reconstituting the recipient’s marrow.

Types of Transplants

There are three major types of transplants:

• Allogeneic

• Syngeneic

• Autologous

In an allogeneic setting, a person receives bone marrow or PBSCs from a related or an unrelated donor, depending on the availability of a good human leukocyte antigen (HLA) match. Because HLA tissue types are inherited, patients are more likely to find a matched donor from within their own family, racial, or ethnic group. In syngeneic transplantation, patients receive stem cells from their identical twin. Patients who undergo an autologous transplantation have donated their own cells after PBSC mobilization with granulocyte colony-stimulating factor (G-CSF) or granulocyte-macrophage colony-stimulating factor (GM-CSF).

Traditional Treatment Options

To understand why bone marrow and PBSCs are used and how they work, it is helpful to understand how chemotherapy and radiation therapies affect these cells. Chemotherapy and radiation target rapidly dividing cells. These therapies are used to treat cancers because cancer cells divide more rapidly than healthy cells. Bone marrow cells also divide at a rapid rate and can be severely damaged or destroyed by high-dose treatment. Without healthy bone marrow, the patient cannot make the blood cells that are able to fight off infections, carry oxygen, and prevent bleeding.

Treatment for cancer includes chemotherapy, radiation therapy, surgery, hormone therapy, and/or immunotherapy. These therapies may be administered alone or in combination to eliminate malignant cells most effectively.

Chemotherapy

Chemotherapy may involve one drug or a combination of two or more drugs, depending on the type of cancer and its rate of progression.

Chemotherapeutic drugs can be divided into the following:

1. Agents that are active against both dividing and nondividing cells

2. Drugs that are active against dividing cells and affect a particular phase of cell division

3. Agents that affect all or most of the phases of the cell cycle (Box 32-2)

Box 32-2 Cancer Chemotherapy Agents

Direct DNA-Interacting Agents	Indirect DNA-Interacting Agents
Alkylators Cyclophosphamide Chlorambucil Melphalan BCNU (carmustine) CCNU (lomustine) Ifosfamide Procarbazine Cisplatin Carboplatin	Antimetabolites Deoxycoformycin 6-Mercaptopurine 2-Chlorodeoxyadenosine Hydroxyurea Methotrexate 5-Fluorouracil (5-FU) Cytosine arabinoside (ARA-C) Gemcitabine Fludarabine phosphate Asparaginase
Antitumor Antibiotics Bleomycin Actinomycin D Mithramycin Mitomycin C Etoposide (VP-16) Topotecan Doxorubicin and daunorubicin Idarubicin Mitoxantrone	Antimitotic Agents Vincristine Vinblastine Paclitaxel Estramustine phosphate

Whatever the mode of action of these drugs, they destroy malignant cells in the same proportion of cells that is killed for each dose of chemotherapeutic agent.

Alkylating Agents, Antimetabolites, and Alkaloids

The first chemotherapeutic agents to be used in bone marrow transplantation were alkylating agents such as cyclophosphamide and busulfan. Their common mechanism of action is that on entering the cells, the alkyl groups bind to the electrophilic sites in DNA and other biologically active molecules. This bifunctional alkylation of DNA results in efficient cross-linking of the DNA, leading to strand breakage and ultimately cell death.

Antimetabolites such as 5-fluorouracil (5-FU), cytarabine, and fludarabine induce cytotoxicity by serving as false substrates in biochemical pathways. Many are nucleoside analogues that are incorporated into DNA and RNA and therefore inhibit nucleic acid synthesis. They are cell cycle active and are specific mainly for cells in the S phase.

The vinca alkaloids, vincristine and vinblastine, which were isolated from the periwinkle plant, inhibit microtubule assembly by binding to tubulin. This microtubule stabilization prevents the cells from dividing; thus these alkaloids are cytotoxic predominantly during the M phase of the cell cycle. Bleomycin, an antitumor antibiotic, induces single-strand and double-strand breaks through free radical generation and is cytotoxic mainly during the G2 and M phases of the cell cycle.

Radiotherapy

Radiotherapy uses large doses of high-energy beams or particles to destroy cancer cells in a specifically targeted area. Radiation damages DNA and keeps the cells from dividing.

Radiotherapy is most often used on localized solid tumors and on cancers such as leukemia and lymphoma that affect the bloodstream. More than 50% of patients with cancer undergo radiation therapy; for some, it will be the only cancer treatment that they need. Radiation is often used in combination with other treatments to shrink the tumor or make surgery or chemotherapy more effective. Used after chemotherapy or surgery, radiation destroys any cancer cells that might remain. Normal cells that may be affected by radiotherapy will usually repair themselves.

Evaluation of Candidates for Peripheral Blood Stem Cell and Bone Marrow Transplantation

Factors that influence the eligibility for bone marrow transplantation include age, disease status, performance status for the recipient, organ function (i.e., heart, lung, liver, and kidney function), infectious disease status, compatibility of the donor and recipient, and psychosocial status. Patients who undergo high-dose chemotherapy and hematopoietic stem cell transplantation require a careful evaluation of all body systems to ensure that they are able to tolerate the aggressive therapy and the isolation of their hospital stay, which can last days to months.

Pretransplantation evaluation and testing (Fig. 32-1) may include HLA tissue typing, bone marrow biopsy and aspiration, electrocardiography, echocardiography, complete history and physical examination, chest x-ray study, pulmonary function tests, dental cleaning, blood tests such as complete blood count (CBC) and blood chemistries, and screening for viruses such as hepatitis, human T lymphotropic virus I and II, cytomegalovirus (CMV), herpes, and human immunodeficiency virus (HIV).

Figure 32-1 Pretransplantation checklist for allogeneic donor.

At some point before transplantation, a central venous catheter is usually placed in a large vein to help in drawing blood samples, infusing medications during and after the transplantation, and actually infusing bone marrow or PBSCs.

ABO Blood Group and Human Leukocyte Antigen Matching

The donor and recipient may be incompatible. HLA matching is the primary consideration in assessing whether a donor is acceptable for a given patient and overshadows any other non-HLA factors, including ABO incompatibility.

HLA matching is important because a close HLA match does the following:

• Improves the chances for a successful transplantation

• Promotes engraftment, the process of donated cells beginning to grow and produce new blood cells in the host

• Reduces the risk of post-transplantation graft-versus-host disease (GVHD)

There are a number of HLA markers. Some markers, such as HLA-A, HLA-B, HLA-C, and HLA-DRB1 are most important to the success of transplantation. The HLA-DQ is used for evaluation by some transplant centers but not by others. The impact of DQ is minimal.

Minimum matching levels must be met before a donor or unit of cord blood cells can be transplanted. The National Marrow Donor Program (NMDP) program requires that at least a 6 out of 8 match exist. However, some transplant centers set more stringent requirements for a 7 out of 8 match between patient and donor (Fig. 32-2).

Figure 32-2 HLA matching of patient and donor.
A, All the patient’s markers match the donor’s. The 8 of 8 match means that there is a match at A, B, C, and DRB1. A 10 of 10 match means that there is a match at A, B, DRB1, C and DQ. B, One of the patient’s A markers does not match one of the donor’s A markers. Therefore, this is a 7 of 8 match or a 9 of 10 match. (©National Marrow Donor Program, 2012, www.marrow.org/patient. Reprinted with permission.)

For adult donors, a match of at least six of these eight HLA markers is required. For cord blood units, which require less strict matching criteria, a match of at least four of six markers is required at HLA-A, HLA-B, and HLA-DRB1.

Obtaining Cells for Transplantation

Bone Marrow

In the procedure for harvesting bone marrow, the donor is given general or regional anesthesia and marrow is usually aspirated with large needles from the posterior iliac crest; the anterior crest can also be used in certain cases (Fig. 32-3). The goal of the procedure is to collect 10 to 15 mL of marrow/kg of recipient weight. Approximately 600 to 900 mL of marrow is collected. The aspirated marrow is collected in bags containing a buffered isotonic solution and heparin to prevent coagulation.

After the marrow has been collected, it is filtered to remove any bone chips, fat, and clots that may have been collected or formed during the procedure. The bone marrow is frequently processed to remove undesired volume and cells. If the marrow is matched and no further manipulation is needed, it is transfused within 12 to 24 hours after collection, depending on the location of the recipient. If it is not transfused within 24 hours, it is cryopreserved.

Peripheral Blood Progenitor Cells

Peripheral blood progenitor cells have been increasingly used in place of bone marrow as a source of stem cells for allogeneic transplants. Reasons for this trend are the large amount of hematopoietic stem cells that can be collected, more rapid hematologic recovery, elimination of the surgical procedure and anesthesia risk for the donor, and reduced transplantation costs. However, a patient who receives allogeneic peripheral blood progenitor cells may be at a greater risk for chronic graft-versus-host disease (GVHD; see following discussion and Chapter 31), possibly because of the high amount of lymphocytes in the product. Up to a log increase in lymphocytes is collected in a PBSC collection compared with a bone marrow collection. Conversely, this increase in lymphocytes could aid in the patient’s immune reconstitution and also impart a graft-versus-leukemia effect.

Peripheral blood progenitor cells are obtained for transplant by a procedure called apheresis or leukapheresis. For 4 or 5 days before apheresis, normal donors are given G-CSF, which increases the amount of stem cells released into the bloodstream. Typically, in the autologous setting, the patient is mobilized, with G-CSF given for 7 to 10 days after myelosuppressive chemotherapy. Disease status and prior treatment influence the ability to mobilize autologous PBSCs. The levels of hematopoietic stem cells rise up to 50-fold in the recovery phase after myelosuppressive chemotherapy and the administration of G-CSF.

In apheresis, the blood is removed through a central venous catheter or vein in the arm. The blood goes through a continuous flow apheresis machine in which mononuclear cells (presumably including the desired stem cells) are separated by centrifugation from the red blood cell (RBC) and plasma fractions, which are returned to the donor during the procedure. The process usually takes one or two sessions of 3 to 5 hours per collection. The collected cells are then cryopreserved (frozen) in liquid nitrogen for later use or transplanted into the recipient.

Transplantation

The high-dose chemotherapy given before transplantation leads to prolonged cytopenias, which account for much of the morbidity and mortality associated with the procedure. After the bone marrow or PBSCs are transplanted into the recipient via a central catheter, the cells migrate to the bone marrow, where they begin to produce new blood cells in a process known as engraftment. The primary measure of hematopoietic recovery, or engraftment, is when the neutrophil count reaches at least 0.5 × 10⁹/L for 3 consecutive days and a platelet count of 20 × 10⁹/L is maintained without platelet transfusion. Engraftment usually occurs within 2 to 4 weeks after the infusion of stem cells. The type of transplant, source, and dose of stem cells are factors influencing engraftment times. Complete recovery of immune function takes much longer, up to several months for autologous transplant recipients and 1 to 2 years for allogeneic transplant recipients. Studies have shown that patients receiving allogeneic PBSCs are less likely to have infections after transplantation than bone marrow recipients.

Transplantation-Related Complications

Complications after transplantation of bone marrow or PBSCs can range from infection, GVHD, rejection, and organ damage to infertility and death. Early complications usually occur within the first 100 days after transplantation. After receiving an allogeneic transplant, rejection rates can range between 1% and 2% in HLA-matched recipients and 5% to 10% in the mismatched recipients. GVHD can be attributed to many factors, including HLA mismatch between donor and recipient, conditioning regimen, viral exposure of donor and recipient, and dose of T cells infused into the patient.

Acute GVHD affects at least 40% to 60% of allogeneic hematopoietic stem cell transplant patients after conditioning with myeloablative regimens and is a major cause of early morbidity and nonrelapse mortality in these patients. Acute GVHD occurs within the first weeks after transplantation, is the result of complex interactions among the donor T cells, and involves the recognition of major histocompatibility complex (MHC) antigens on the recipient’s organs (liver, gastrointestinal tract, skin, mucosal membranes).

Chronic GVHD occurs later and is defined as the presence or persistence of GVHD beyond 100 days since transplantation.

GVHD can be prevented or controlled by corticosteroids, calcineurin inhibitors (e.g., cyclosporin A, tacrolimus), and T cell depletion of the graft.

Graft Manipulation and Storage

The processing of bone marrow and PBSCs varies from laboratory to laboratory, with different techniques to accomplish the same result. A bone marrow harvest results in the collection of a large volume of marrow that contains progenitor blood cells. Therefore, it is desirable to concentrate the marrow in the autologous and allogeneic settings. The purpose is twofold, to reduce the volume and remove RBCs.

ABO incompatibility between donor and recipient is encountered in 23% to 30% of all hematopoietic cell transplantations. A major incompatibility exists between donor and recipient when the recipient possesses antibodies against the RBC antigens of the donor, which would result in lysis of the transfused donor cells (e.g., group A donor and group O recipient).

Differences between donor and recipient’s ABO or Rh blood groups have no effect on marrow engraftment, rejection, or GVHD. As long as the transplant recipient has antibodies against the RBCs of the donor, erythrocytes will be destroyed inside the marrow at an early stage. This could result in a state of chronic hemolysis that can last for 4 to 6 weeks after the marrow infusion, although durations of up to 8 months have been reported.

To prevent acute hemolysis, the main objective of the laboratory is to remove as many RBCs as possible while preserving the hematopoietic progenitor cells to ensure timely engraftment. This is mainly accomplished by automated means, but manual methods are still used. Low-speed centrifugation sediments the cellular elements of the marrow so that the plasma and collection media can be removed and the WBC-rich buffy coat expressed into a separate container while the RBCs are retained in the original container. This manual method has an increased risk of contamination of the graft, depends on the technique of the technologist for good recovery of the cells, and is labor-intensive.

Automated procedures involving apheresis equipment; such as the COBE Spectra (Terumo BCT, Lakewood, Colo) and Fenwall (Americus, Lake Zurich, IL) use a closed sterile system that rapidly recovers the desired mononuclear cells (Fig. 32-4).Minor ABO mismatches are present in 15% to 20% of HLA-matched donor-recipient pairs. Patients who receive hematopoietic progenitor cells from a minor ABO-incompatible donor are at risk of developing immediate immune hemolysis caused by isohemagglutinins infused with the marrow or PBSCs, or delayed hemolysis caused by isohemagglutinins produced by the donor lymphocytes (i.e., B cells). Immediate hemolysis can be avoided by simple removal of plasma from the graft before infusion. However, delayed hemolysis caused by antibody production from donor-derived B lymphocytes requires the ex vivo removal of lymphocytes or suppression of T lymphocyte function by cyclosporine.

Figure 32-4 COBE Spectra Apheresis System. (Courtesy Terumo BCT, Lakewood, Colo.)

Removal of the plasma from the graft is used to minimize the risk of immediate hemolysis. This is accomplished by placing the marrow or PBSCs into standard blood transfer bags, centrifuging, and removing supernatant plasma. Normal saline or other media can be added to the product in a volume equivalent to about 50% of the volume of the discarded plasma to dilute the remaining donor antibody and lower the hematocrit for easier infusion.

With the development of monoclonal antibodies (MAbs), there has been an increase in stem cell selection (e.g., CD34+ cells) and purging of grafts (e.g., CD19+/CD20+ B cells). These techniques have resulted in decreased tumor reinfusion into autologous recipients and decreases in the amount of T cells infused in allogeneic recipients. Cryopreservation of the product is usually accomplished by the addition of 10% dimethyl sulfoxide (DMSO) and autologous plasma or 5% DMSO with 6% pentastarch and 4% human albumin. DMSO and pentastarch are thought to keep the cells from dehydrating during the freezing process, which would cause them to lyse. The product is then frozen in a controlled-rate freezer, which reduces the temperature of the product by 1° to 3° C (34° to 37° F)/minute, or by dump freezing in a −80° C (−112° F) freezer. After the product is frozen, it is kept in a liquid nitrogen freezer, vapor or liquid phase, until the time of transplantation.

Cell Infusion

At transplantation, the product is thawed in a 37° C (98.6° F) water bath in the laboratory or at the patient’s bedside and is then infused without a filter through a central line. Toxicities and side effects have been associated with the infusion of cryopreserved products, mainly from the DMSO and volume overload. The most common symptoms are mild nausea, vomiting, and hypertension. Side effects of the infusion are rare and often mild. DMSO can cause patients to experience an immediate garlic-like taste. Sucking on hard candies during and after the infusion may help. Most patients undergoing allogeneic or syngeneic transplantation do not experience this problem, because the cells most likely were not mixed with DMSO or cryopreserved.

Transplants from Unrelated Donors

About 70% of patients who need a transplant do not have a suitable donor in their family. The National Marrow Donor Program (NMDP), which operates Be The Match, is a nonprofit organization that facilitates unrelated marrow and blood stem cell transplants for patients who do not have matching donors in their families. Through a network of national and international affiliates, the program aids in more than 450 transplants each month. More than 18.5 million potential donors and more than 590,000 cord blood units are connected in the affiliated system. Approximately 40% of the transplants facilitated by the NMDP involve a U.S. patient receiving stem cells from an international donor or an international patient receiving stem cells from a U.S. donor.

Cord blood from unrelated donors has become an important source of hematopoietic stem cells (HSCs). Benefits include greater availability of stem cells and possible antileukemia effects in patients with hematologic malignancies when a noninherited maternal antigen of the cord blood donor matches the patient’s mismatched antigen.

The donor-recipient HLA mismatch level affects the outcome of unrelated cord blood transplantation. Possible permissive mismatches involve the relationship between direction HLA mismatch vector or direction and transplantation outcomes. In most cord blood transplants, a mismatched HLA antigen is present in recipient and donor. This type of mismatch is bidirectional between the graft and host. The preferred type of mismatch is when the donor is homozygous at an HLA locus but the patient has two antigens identified (one matching the donor) at that locus, only donor cells have an HLA target, and the mismatch is in the graft-versus-host (GVH) direction with a rejection mismatch. If all mismatched loci have this type of mismatch, these are GVH-only mismatches. Engraftment of myeloid cells is significantly faster with grafts having GVH-only mismatches.

A major advantage of cord blood has been the ability to transplant grafts that are partially HLA-mismatched because of a relatively low incidence and severity of GVHD for the level of mismatch, a probable consequence of immunologic tolerance of this neonatal HSC source. Most cord blood transplantations to date (estimated at >30,000 globally) have been performed with grafts having one or two HLA-A, HLA-B, and HLA-DRB1 mismatches.

Immune reconstitution after stem cell transplantation is a complex process involving various components of the innate and adaptive immune systems. Two main pathways of T cell regeneration contribute to post–T lymphocyte recovery, thymopoiesis and peripheral blood expansion of mature T cells. Thymopoiesis provides a new pool of naïve T cells that is essential for sustained long-term immunity. Challenges to thymopoiesis can lead to a higher risk of opportunistic infections and an adverse outcome. Secondary cytopenia is a common complication of stem cell transplantation. Causes of secondary cytopenia include viral infection, septicemia, GVHD, and myelotoxic drugs. Older patients appear to be more prone to cumulative toxicities of post-transplantation drug regimens, but nonmyeloablative conditions, optimized HLA matching, and higher doses of CD34+ cell infusion may reduce the risk of cytopenia after day 28.

Current Directions

Genetic engineering of hematopoietic stem cells holds the promise of potentially treating many hereditary and acquired diseases. The promise of this therapy is laudable but it does have limitations. The technologies used to date have occasionally resulted in clonal expansion, myelodysplasia, or leukemogenesis.

At present, technology is challenged by the inability to expand or clone genetically modified HSCs from adult or cord blood specimens. New genetic material must be permanently introduced to correct the underlying disease mutation in the treatment of genetic disorders. Patient-specific induced pluripotent stem (iPS) cells can be generated from various cell types obtained from patients with inherited or acquired disorders. Safer and more effective methods will rely on the therapeutic use of pluripotent stem cells. One recent approach bypasses the need for iPS cells and the obstacles to generating human stem cells from embryonic-type cells. It consists of direct reprogramming of skin cells to a multipotent progenitor stage by the introduction of a single transcription factor, Oct4. Oct4-reprogrammed progenitor cells may possess desirable traits. Another potential game-changing advancement would be the ability to reprogram human adult stem cells to an expandable condition without reducing the long-term self-renewal properties and their safety.

Another aspect of adult stem cell transplantation has been studied in the field of regenerative medicine. The general goal of this field is transplanting donor stem cells to replace or repair defective cells in a patient. In the case of an HLA mismatch between donor and recipient, transplantation is hampered by the risks of immunologic recognition and rejection of the stem cell graft.

There are two critical concerns in the transplantation of umbilical cord blood:

1. Initial time to engraftment

2. Restoration of immune function

Umbilical cord blood transplantation (CBT) has been a successful alternative therapeutic option for transplant patient who have no suitable related allogeneic donors. But the significant delay in recovery of all hematopoietic blood cell lines is a major complication. The initial engraftment of cells that develop into the myeloid cell line (red blood cells, platelets, and granulocyte/monocyte) is 1 month. Development of T- and B-lymphocytes commonly takes 6 months or more after transplantation. Two factors have been found to be of extreme importance: (1) the total dose of progenitor (CD34+) cells in a cord blood unit has been associated with patient survival; and (2) the total dose of clonogenic progenitors with the graft correlates with engraftment of the transplant. Research studies continue to delineate these challenging issues.

A new idea is to transplant stem cells into a fetus early in gestation. The benefit is that in utero transplantation would occur when the immune system of the fetus is immature, which would provide the theoretical opportunity to induce fetal tolerance of foreign cells. This would avoid rejection and the need for immunosuppressive therapy. To date, a major problem has been achieving adequate levels of engraftment.

CASE STUDY

MC is an obese 46-year-old white woman with diabetes. She came to the emergency department with complaints of rectal bleeding and a feeling of significant fatigue.

History and Physical Examination

Medical History

The patient has a long-standing history of infected foot ulcerations that are not secondary to vascular insufficiency or diabetes. She received a prolonged course of chloramphenicol for the foot infections in Brazil. After treatment, she was found to be pancytopenic and required transfusions of packed RBCs and platelets on a regular basis.

Her medical history also includes a history of a positive purified protein derivative (PPD) test, for which she received antituberculosis therapy for 4 months. She sustained facial fractures in a car accident several years ago.

Medications

The patient takes rifampin (daily), INH (daily), pyridoxine (daily), cyclosporine (Sandimmune), insulin morning and evening, and metformin (Glucophage).

Social History

MC is a citizen of Brazil. Her husband died several years ago. She has three children, one living in the United States and two living in Brazil.

Allergies

She has no known allergies.

Family History

The patient’s father died of heart disease at age 63; her mother died of cancer at age 48. The patient has nine siblings, six in Brazil and three in the United States. One sister, age 42, lives in the United States and is HLA-matched.

Physical Examination

The patient weighs 233 lb; her blood pressure is 120/70 mm Hg; and her pulse is 66 beats/min and regular.

Her temperature is 37.1° C (98.8 ° F). She has ecchymoses and petechiae of the skin, with mild bruising on her left shoulder. She has multiple scars on her feet and legs. There are no other abnormal physical findings.

Laboratory Data

See Table 32-2.

Table 32-2

Case Study: Laboratory Results (1)

Parameter	Patient Result	Reference Range
White blood cell (WBC) count	2.1 × 10⁹/L	4.5-11 × 10⁹/L
Hematocrit (Hct)	20.4%	36%-46%
Hemoglobin (Hgb, Hb)	6.9 g/dL	12-16 g/dL
Red blood cell (RBC) count	1.83 × 10¹²/L	4-5.20 × 10¹²/L
Platelet count^∗	49 × 10⁹/L	150-350 × 10⁹/L
Mean corpuscular volume (MCV)	112 fL	80-100 fL
Red cell distribution width (RDW)	20.2%	11.5%-14.5%
Reticulocyte count	1.5%	0.5%-1.9%
Leukocyte differential
Segmented neutrophils	27%	40%-70%
Lymphocytes	57%	22%-44%
Monocytes	13%	4%-11%
Eosinophils	0%	0%-8%
Basophils	0%	0%-3%
Variant lymphocytes: 3%
Anisocytosis: 2+
Hypochromia: 1+
Macrocytes: 3+
Blood Chemistry
Electrolytes: within normal limits
Liver Function Tests
Alkaline phosphatase (ALP)	131 IU/L	30-100 IU/L
Alanine transaminase (ALT/SGPT)	167 IU/L	7-30 IU/L
Aspartate transaminase (AST/SGOT)	56 IU/L	9-25 IU/L
Lactic dehydrogenase (LDH)	266 IU/L	110-210 IU/L
Plasma glucose	123 mg/dL	70-110 mg/dL

^∗Posttransfusion.

Immunologic Studies

• Hepatitis A antigen—positive.

• Hepatitis B and hepatitis C screening tests—negative.

Follow-up Evaluation

A bone marrow biopsy was performed. Histologic study of the aspirate and clot revealed a hypocellular marrow with trilineage hematopoiesis and dyserythropoiesis. Cytogenetic studies were normal (karyotype: 46,XX). Flow cytometry revealed polyclonal (kappa+ and lambda+) CD19+ B cells and CD4+ and CD8+ T cells. The iron stain was normal.

HLA Typing

• Patient: A11, 68; B18, 52; DR4, 15; DQ3, 6

• Donor: A11, 28; B18, 52; DR4, 15; DQ3, 6

At 3 Months

The patient is feeling well. The pain and swelling in her right arm have resolved. She has had no fever, nausea, vomiting, diarrhea, rash, chest pain, shortness of breath, dysuria, hematuria, headache, or edema.

Medications

The patient was receiving fluconazole (Diflucan), ursodiol (Actigall), valganciclovir, cyclosporine, sulfamethoxazole, magnesium oxide (norgestimate–ethinyl estradiol).

Physical Examination

The patient now weighs 152.6 lb; her blood pressure is 139/93 mm Hg, temperature 35.9° C (96.6° F), and pulse 69 beats/min and regular. She has no skin rash.

Her eyes and mouth are without scleral icterus or mucositis and the lungs are clear. Her heartbeat has a regular rate and rhythm. Her abdomen is soft and nontender, without masses or organomegaly. Extremities are without edema. Her neurologic examination revealed no tremors.

Laboratory Data

See Table 32-3.

Table 32-3

Case Study: Laboratory Results (2)

Assay	Patient Result	Reference Range
Sodium (Na⁺)	139 mEq/L	135-145 mEq/L
Potassium (K⁺)	4.7 mEq/L	3.5-5 mEq/L
Magnesium (Mg²⁺)	1.6 mEq/L	1.4-2 mEq/L
Blood urea nitrogen (BUN)	28 mg/dL	8-25 mg/dL
Creatinine	1.8 mg/dL	0.6-1.5 mg/dL
Total bilirubin	0.2 mg/dL	0-1 mg/dL
Direct bilirubin	0.1 mg/dL	0-0.4 mg/dL
ALP	99 IU/L	30-100 IU/L
AST/SGOT	16 IU/L	9-25 IU/L
LDH	208 IU/L	100-210 IU/L
WBC count	3.7 × 10⁹/L	4.5-11 × 10⁹/L
Hct	39%	36%-46%
Platelet count	173,000	200-400 × 101²/L