This clinical guideline explains the process at Great Ormond Street Hospital (GOSH) when donors are required for granulocyte transfusions.
The donor is ultimately referred to Kings College Hospital (KCH) which is the MHRA licensed site for granulocyte collection. The role of GOSH is baseline preselection only (Rationale 1).
Granulocytes are obtained by apheresis on a cell separator from healthy family members or other volunteer donors (eg friends), following treatment of the donor with granulocyte colony-stimulating factor (GCSF) and steroids (Rationale 2).
Indications for granulocyte transfusion
- Severe neutropenia (ANC<0.5x 109/L) complicated with proven or highly probable bacterial/fungal infection not responding to antibiotics/antifungal drugs (Rationale 3).
- Patients with known congenital or acquired disorder of neutrophil function, regardless of the neutrophil count, and a proven or highly probable bacterial/fungal infection not responding to antibiotics/antifungal drugs (Rationale 3).
The plan to treat a patient with granulocyte transfusions should be discussed between the consultants in charge of the patient.
Selection of donors for apheresis
GOSH will ask parents to identify potential donors from friends and relatives of recipient and test potential donors' ABO blood group and CMV serology. Only ABO-compatible and CMV-suitable donors should be referred to KCH but these results will NOT be made available to KCH and will be used to identify potential donors for referral to KCH. KCH will be responsible for the complete medical screening of all donors (Rationale 4).
Selection of donors for apheresis
When a decision to administer granulocytes is taken, the following procedure must be followed.
Person responsible for donors
For BMT (bone marrow transplant) patients the main person in charge of liaising with donors is Annette Hill, BMT CNS or the consultant in charge of the patient. For all other patients the haematology laboratory SpR will be responsible for explaining the process to donors and organising the blood tests and referral to KCH and liaise with the consultant in charge of the patient (Rationale 5).
Counselling and procedure at GOSH
The whole process, from identification of donors to collection, should take 48-72 hours. Each patient will require at least four donors. Therefore it is reasonable to initially screen 10-15. The exclusion criteria should be broadly explained to the parent so that they only bring forward potentially suitable donors although the majority of the screening process will occur at KCH (Rationale 6).
At GOSH explanation to the donor should include the need for a blood test to check ABO blood group and CMV serology and if there is no major ABO incompatibility they will be referred to KCH. The results of these tests must only be discussed with the donor and should not be discussed with the family. These results will NOT be made available to KCH, as they will only be used to identify potential donors for referral to KCH.
Blood tests should be organised with phlebotomy on Safari Ward. It must be clear on 'down time' forms that this is a potential granulocyte donor as they will not always have a hospital number and therefore only two identification points (name and DOB) and blood bank may not process the sample. Ensure blood bank and virology are aware that the samples are being sent.
The donor should be informed that they will have further suitability screening at KCH as per NHSBT (National Health Service Blood and Transplant) selection, including pre-donation screening (blood tests, including virology and questionnaire) and a medical check-up.
If suitable they will receive 5mcg/kg GCSF 12-18 hrs prior to collection and 8mg dexamethasone, and will then go on to have venous access and be attached to a apheresis machine for two to three hours. They may give multiple donations, typically three maximum, and will receive GCSF and dexamethasone prior to every donation. Rarely they may require a central line for donation. This process will be explained in greater detail at KCH (Rationale 7).
The donor should be informed that if they have donated and become unwell they must inform KCH/GOSH – haematology laboratory SpR so that appropriate action can be taken regarding granulocytes. They themselves must attend their GP surgery or local accident and emergency department if medical attention is required. Long-distance travel in the week following donation is not recommended (Rationale 8).
Potential donors will be excluded from donation of granulocytes for any of the following reasons (Rationale 9):
- Age <17 or >70 years.
- A serious ongoing illness, including psychiatric disease.
- History of a myocardial infarction or stroke.
- Previous allergic reaction to starch or GCSF.
- A positive answer to a question in the donor health check questionnaire (if travelled to malarious zone <12 months prior to donation or lived in malarious zone >6months, antibodies will be tested. For discussion at KCH.
- Bilaterally poor arm veins (unless consent for venous catheter obtained). For discussion at KCH.
- Major deviation from normality of any of the blood tests. For discussion at KCH.
- Major ABO incompatibility with the recipient (eg donor group A, recipient group O). If minor, for discussion at KCH.
- Positive microbiology screen (except CMV for discussion at KCH).
- If the recipient has anti-HLA antibodies and refractoriness or reactions to platelets and/or granulocytes have occurred, the selected donor must be HLA-compatible.
- Donations from multiparous women are not encouraged.
Referral process to KCH
A referral letter is required on behalf of the lead consultant of the patient with the following information and should be faxed to a safe haven fax (Rationale 10):
- recipient details
- full name
- date of birth
- GOSH hospital number
- weight of recipient
- volume required - a typical single dose is >1.5x108/kg
Annette Hill, BMT CNS will coordinate the referral for BMT patients and the haematology laboratory SpR will liaise with KCH for all other patients. KCH will then give the referring team details of appointments for donor medicals and collection dates (Rationale 11).
Primary contacts at KCH
Dr Aleksandar Mijovic (primary contact)
Kings College Hospital NHS FT, London SE5 9RS
Telephone: 020 3299 2034
Out-of-hours contact telephone (after 6pm): Please phone KCH switchboard on 020 3299 9000 and ask to bleep the haematology registrar on call.
Liaising between KCH and GOSH blood bank
Annette Hill/Haematology Laboratory SpR will liaise with blood bank regarding timing of arrival and quantity of granulocytes (Rationale 12).
Administration of granulocytes
See Blood Transfusion Policy for types of components available for transfusion as well as the preparation of the child and family, prescription and transfusion process.
Because of the relatively high red cell content of granulocyte collections, the donor must be compatible with the recipient by the technique used for pre-transfusion testing in the Blood Transfusion Laboratory. (Rationale 13).
Granulocytes must be irradiated (Rationale 14) and transfused as soon as possible after collection, through a standard red cell giving set. The duration of transfusion should be one to two hours. For children the total volume infused should typically not exceed 10-15 ml/kg (Rationale 15).
- Decision to stop granulocyte transfusion will be made if:
- Endogenous neutrophil recovery has unequivocally begun.
- Resolution of infection occurs.
- Patient has severe reactions to granulocytes.
- Patient deteriorates despite a minimum of three days of granulocyte transfusions.
Occassionally buffy coats are given in the event of severe neutropenic infection, often in the interim period before granulocytes are available. There is limited evidence of benefit and all decisions must be made by a bone marrow transplant or haematology consultant.
The volume required is similar to a blood transfusion (10-15ml/kg) given over three hours. Buffy coats usually come in 50ml volumes and should be ordered from Colindale NHSBT. GOSH blood bank must be informed of all orders. Daily buffy coats can be used until there is clinical improvement.
Clinical Nurse Specialist and Lead for BMT
Telephone: 020 7813 8584 bleep 0575
Blood Transfusion Laboratory Manager
Telephone: 020 7813 8467
Senior Biomedical Scientist, Blood Transfusion
Telephone: 020 7813 8527
Telephone: 020 7405 9200 (ext 5396 bleep 0189)
Dr Nick Goulden/Sujith Samarasinghe /Phil Ancliff
Telephone: 020 7405 9200 extn 8190 bleep via switchboard
Out-of-hours contact the Biomedical Scientist on call bleep 0590 or haematology laboratory SpR on call via switchboard.
A copy of the SLA between KCH and GOSH and the KCH standard operating procedure for granulocyte transfusions listed in the references are available to view from the transfusion practitioner.
King's College Hospital NHS Foundation Trust (King's) and Great Ormond Street Hospital NHS Trust (GOSH) (2014) Terms and conditions for the provision of a Granulocyte Transfusion service from King's. King's College Hospital NHS Foundation Trust, Service Level Agreement.
Dr Aleksander Mijovic (2012) Standard Operating Procedure Donor Selection and Evaluation for Granulocyte Collection by Apheresis and Granulocyte Transfusions. King's College Hospital NHS Trust, King's College Hospital NHS Trust.
Hennem S, Nulty H (2013) Great Ormond Street Hospital Blood Transfusion Policy. Great Ormond Street Hospital NHS Trust, Great Ormond Street Hospital NHS Trust.
National Health Service Blood and Transplant (2013) Guidelines for the Blood Transfusion Services in the United Kingdom, 8th Edition. London, TSO.
Rationale 1: To prevent unsuitable potential donors attending KCH.
Rationale 2: To ensure a good yield.
Rationale 3: To improve response to bacterial/fungal infection.
Rationale 4: GOSH is not licensed to screen donors or collect granulocytes, therefore results cannot be used by KCH. Results can only be used to prevent ABO incompatible and CMV unsuitable potential donors being referred.
Rationale 5: To prevent confusion over donor and recipient.
Rationale 6: To ensure sufficient, appropriate donors available.
Rationale 7: To ensure donor aware of process prior to attending KCH.
Rationale 8: To ensure safety of donor if donor develops an adverse reaction. To ensure safety of donor and recipient if donor develops a transfusion transmissible disease.
Rationale 9: To ensure only appropriate donors are selected.
Rationale 10: To ensure KCH have accurate details of recipient and volume required from collection.
Rationale 11: To ensure donors are notified of appointment/collection dates.
Rationale 12: To ensure appropriate communication between KCH and GOSH.
Rationale 13: To prevent incompatible transfusion.
Rationale 14: To prevent TA-GVHD (Transfusion Associated - Graft versus Host Disease).
Rationale 15: To prevent fluid overload.