734_Del Vecchio - Neutropenia Del Pretermine

7/31/2019 734_Del Vecchio - Neutropenia Del Pretermine

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Division of NeonatologyNeonatal Intensive Care Unit

Di Venere HospitalBari, Italy

Antonio Del Vecchio

Neutropenia in preterms:to treat or to ignore?


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Neutrophils and Host Defense

Neutropenia in a Neonate

Severe Chronic Neutropenia in the Neonate

Neonatal Neutropenia Not Categorized as SevereChronic Neutropenia

Treatment of Neutropenia

Outline


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A Consistent Approach to the Use of rG-CSF in theNICU


Outline


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Outline


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Various treatments have been proposed as means of enhancingneutrophil production and function in preterm infants


Intravenous immunoglobulin

Corticosteroids

Granulocyte transfusions

Gamma interferon

Recombinant granulocyte colony-stimulating factor (rG-CSF)and recombinant granulocyte macrophage-colony-stimulating factor (rGM-CSF)


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Corticosteroids

Corticosteroids have also been tried in themanagement of immune-mediated neonatal

neutropenia and in the congenital bone marrowfailure syndromes

The inconsistent response does not encourage alarger use in neutropenic neonates


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Granulocyte transfusions

Current evidence does not show a clear beneficialrole for granulocyte transfusions in septicneutropenic neonates

A recent meta-analysis concluded that evidencefrom randomized controlled trials is insufficient toconfirm or refute the use of granulocyte transfusionsin neutropenic, septic neonates

Mohan P, Brocklehurst P. Cochrane Database Syst Rev 2003Pammi M, Brocklehurst P. Cochrane Database Syst Rev 2011


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Gamma interferon (IFN- )

Gamma interferon has been claimed to havepotential for correcting abnormalities of cellmovement and bacterial killing in vitro, raisingthe possibility that increasing IFN- levels might

be beneficial

No studies have focused on using IFN- among

neutropenic neonates

Hill HR, et al. J Exp Med 1991


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Recombinant granulocyte colony-stimulating factor (rG-CSF)

and recombinant granulocyte macrophage-colony-stimulating factor (rGM-CSF)

rG-CSF increases the number of circulating neutrophilsby stimulating the release of neutrophils from bonemarrow, inducing myeloid proliferation, expanding themarrow reserves, and reducing neutrophil apoptosis

rGM-CSF has been evaluated in neonates and theresults are similar to those obtained with rG-CSF

Kocherlakota P, La Gamma EF. Pediatrics 1997Carr R, Modi N. Arch Dis Child Fetal Neonatal Ed 1997

Schibler KR, et al. Pediatrics 1998Bedford Russell AR, et al. Arch Dis Child Fetal Neonatal Ed 2001

Miura E, et al. Pediatrics 2001

Kuhn P, et al. J Pediatr 2009Carr R, et al. Lancet. 2009

Taniguchi S, et al. Br J Haematol 1993Gillan ER, et al. Blood 1994

Gilmore MM, et al. J Pediatr 1994La Gamma EF, et al. J Pediatr 1995

Makhlouf RA, et al. J Pediatr 1995

Yakisan E, et al. J Pediatr 1997Barak Y, et al. Eur J Pediatr 1997


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Outline


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Neutrophils are the first line of innate immunedefense against infectious diseases

Kumar V, Sharma A. Int Immunopharmacol, 2010Mantovani A, et al. Nat Rev Immunol, 2011

Recent studies revealed their importance in theregulation of immune response and theemerging role of neutrophils in the regulation ofbothinnate and adaptive immunity duringacute infectious or inflammatory conditions

Compared with the acquired immune response,which requires time to develop and is

dependent on previous interaction with specificmicrobes, the ability of neutrophils to killmicroorganisms is immediate, nonspecific, andnot dependent on previous exposure tomicroorganisms



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This multifunctional cell is also anecessary actor of the acquired immuneresponse. Neutrophils have the capacityto degrade and process antigens as wellas efficiently present antigenic peptidesto lymphocytes

Neutrophil interactions with immunecells, in particulardendritic cells, lead tothe formation of IL-12 and TNF-alphadeviating the immune response towardsa Th1 phenotype. Thus, the neutrophilexhibits a cellular plasticity that explainsits capacity to transdifferentiatedepending on the local requirements ofthe immune response

The neutrophil is probably the mostunderappreciated immune cell amonghematopoietic leukocytes, and manyneutrophil functions remain to beunraveled


Chakravarti A, et al. Med Sci (Paris), 2007

delay in their spontaneousprogrammed cell death


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Neutrophils are pivotal to antibacterial host defense

People who lack neutrophils, whether by a congenital or anacquired defect, will experience a natural history that includesrepeated local and systemic infections and early death

neutrophil function and neutrophil kinetics during infection differconsiderably from those of adults

Borregaard N. Immunity, 2010Bouma G, et al. Br J Haematol, 2010

Christensen RD, Calhoun DA. Clin Perinatol, 2004



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Infected adults neutrophilia

they accelerate the release of neutrophils fromtheir marrow reserve into the circulation, andas they simultaneously recruit quiescentneutrophil progenitors into cycle

Infected pretermneonates

neutropeniathe result of depleting their relatively smallmarrow neutrophil reserves before it can bereplaced by granulocytopoietic acceleration


Borregaard N. Immunity, 2010Bouma G, et al. Br J Haematol, 2010



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Neutrophil function of neonates,particularly preterm neonates, isless robust than that of adults andmight also contribute to the

increase in propensity to infection

A postnatal improvement ofchemotaxis, phagocytosis, andrespiratory burst activity begins atabout two to three weeks of age

and thereafterimproves slowly

Borregaard N. Immunity, 2010


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Neutrophil Maturation in the Marrow

Myeloblast Promyelocyte Myelocyte Metamyelocyte Band Seg

--PROLIFERATIVE POOL--- -------STORAGE POOL----

Christensen RD, and Rothstein G. Pediatr Res, 1984

Studies on neonatal rats revealed that the neonates neutrophilproliferative and storage pools are only approximately 25% of adultvalues, when measured on a cell per gram body weight basis



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Outline


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Neutropenia - Kinetic Classification

Diminished Production Excessive Margination

PIH EndotoxemiaSGA PseudoneutropeniaDonors in twin-twin TxRh hemolytic disease Accelerated Usage or

Destruction

Chronic Idiopathic Bacterial or fungal sepsisKostmann AlloimmuneCyclic AutoimmuneSyndromic Causes



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Left shift, toxic

granulation, neutrophilvacuolization, Dohlebodies, falling plateletcount, acidosis andhypotension

Neutropenia can besevere but is notprolonged

Accelerated Usage/Destruction


Sepsis


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Christensen RD. Hematologic Problems of the Neonate. Philadelphia, PA: WB Saunders Co; 2000Funke A, et al. Pediatrics 2000

Neutropenia is a relatively frequent finding in the neonatalintensive care unit, with an overall incidence reported atabout 8% of all patients at sometime during their NICU stay


Neutropenia is more common in VLBW, affecting up to 50%in the first week of life

The presence of neutropenia itself might place VLBWneonates at higher risk forsepsis and mortality, especially ifthe neutropenia is severe and prolonged


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Normal RangeEstablished by testing normal, healthyvolunteers

Reference RangeEstablished by compiling clinically-ordered tests performed on patientswith minimal relevant pathology


What is a normal neutrophil countfor a neonate?


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Example: Collect CBCs drawn on thousands of neonates who didnot have: Infection, SGA, PIH, Down Syndrome

Express the 5th % value as the lower reference range and the

95th

% value as the upper reference range

0

5

10

15

20

25

30

0 6 12 18 24 30 36 42 48 54 60 66 72

Hours of Age

Neutrophils103/uL

5th Percentile 95th Percentile Average

Reference Range


Schmutz N, et al. J Perinatol, 2008


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In 1979Manroeet al the range ofneutrophils during the first 60 h Datafrom 108 neonates 1974 to 1976

In 1992Mouzinhoet al neutrophilconcentrations from VLBW neonates.The range of counts differed from thatof higher gestation neonates, withlower counts and a wider range 63counts formed the basis of the chart

Manroe BL, et al. J Pediatr, 1979

Mouzinho A, et al. Pediatrics, 1992


What is the Reference Range forblood neutrophils in neonates?


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Manroe et al, J Peds 1979

108


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Mouzinho et al Pediatrics 1992

63


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Reference range for blood neutrophil concentrations during the first 72hours after birth of term and late-preterm neonates. A total of 12,149 valueswere used in this analysis. The 5th percentile, mean, and 95th percentile

values are shown.Schmutz N, et al. J Perinatol, 2008

Neutropenia can be definedstatistically as a blood neutrophilconcentration below the 5th

percentile of the reference rangepopulation

12,149


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Schmutz N, et al. J Perinatol, 2008


For neonates, this definition is complicated because the referencerange varies according to several situations, including gestational age,postnatal age, gender, type of delivery (vaginal delivery vs. cesareansection), and altitude (meters above sea level)


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Reference range for blood neutrophil concentrations, with superimposition of the

Manroe (Dallas,Tex) and Schmutz (Intermountain Healthcare) curves. The dots

represent neonates in Utah who would have been regarded as having an elevated

neutrophil count using the sea level (Dallas) curve, but who fell within the highaltitude

(Intermountain) Schmutz curve.

The definition ofneutropenia is very similarin the sea level and high-altitude reference ranges


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Sea-level. Neonates >1500gm, use the Manroe chart (JPediat 1979)

Sea-level. Neonates 1500gm, use the Mouzinho chart,(Pediatr1992)

Centers 1200 m, use theSchmutz chart (J Perinatol2008)

Neutropenia - Definition

0

5

10

15

20

25

30

0 6 12 18 24 30 36 42 48 54 60 66 72

Hours of Age

Neutrophils103/uL

5th Percentile 95th Percentile Average


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Although this approach lacks the accuracy of data-derived reference rangeapproaches, it offers the advantages that it is easy to remember, and it is in keepingwith the standard definitions for neutropenia used in pediatric and adult medicine

Watts RG. Neutropenia. In: Greer JP, Foerster J, Rodgers GM, et al, editors. Wintrobe s Clinical Hematology.12th

ed. Lippincott: Williams & Wilkins; 2010:1527.


to use a neutrophil concentration less than1000/Lto define severe neutropenia by a countless than 500/L

It is not clear whether blood neutrophil counts labeled aslow by the reference range approach actually convey ahost-defense deficiency, unless they are less than 1000/L

A much simpler approach to define neutropenia in a neonate is:

Al-Mulla ZS, Christensen RD. Clin Perinatol, 1995

Carr R. Br J Haematol, 2000


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Outline


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Severe chronic neutropenia (SCN) consists of a cluster of diagnosesthat bear the common feature of very low circulating neutrophilconcentrations from birth


Dale DC, Welte K. Cancer Treat Res, 2011


VARIETIES OF NEUTROPENIA AMONG NEONATES WHO GENERALLYARE CONSIDERED TO HAVE SEVERE CHRONIC NEUTROPENIA

Kostmann syndrome, autosomal recessive typeSevere congenital neutropenia, autosomal dominant type

Shwachman-Diamond syndrome

Barth syndromeCartilage-hair hypoplasiaCyclic neutropeniaGlycogen storage disease type 1bSevere neonatal immune-mediated neutropenias


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SCN International Registry, established in 1994 at the University of Washington

Enrollment in the SCN International Registry can be accomplished at thewebsite http://depts.washington.edu/registry/ using the entry criteria andexclusion criteria

http://depts.washington.edu/registry/http://depts.washington.edu/registry/


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Rarely, patients with SCN are diagnosed as neonates, or even

as patients in neonatal intensive care unitsMost patients with SCN are not diagnosed until several monthsof age, after infectious episodes have prompted aninvestigation into immunologic deficiencies

Welte K, Zeidler C. Hematol Oncol Clin North Am, 2009

When SCN is diagnosed in a neonate, that patient

should receive the benefit of rG-CSF treatment

The advent of rG-CSF dramatically improved the lives ofpatients with SCN, in most cases elevating their circulatingneutrophil concentrations, reducing infectious illnesses, andextending their life expectancy


Borregaard N. Immunity, 2010

Bouma G, et al. Br J Haematol, 2010

Zeidler C, et al. Br J Haematol, 2000

Calhoun DA, Christensen RD. Pediatrics, 1997


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Is there biologic plausibility to

propose the use of rG-CSFin

neonates with varieties ofneutropenia distinct from SCN?

When SCN is diagnosed in a neonate, that patientshould receive the benefit of rG-CSF treatment


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Outline


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VARIETIES OF NEUTROPENIA AMONG NEONATES WHO ARE NOTCLASSIFIED AS HAVING SEVERE CHRONIC NEUTROPENIA

Pregnancy-induced hypertension

Severe intrauterine growth restriction

Twin-twin transfusion syndrome

Rh hemolytic disease

Bacterial infection

Fungal infectionNecrotizing enterocolitis

Chronic idiopathic neutropenia of prematurity


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Pregnancy-Induced Hypertension (PIH)

1. Neutropenia due to PIH is the most common variety ofneutropenia seen in the neonatal intensive care unit

2. 50% of neonates born to mothers with PIH have this variety ofneutropenia

3. The ANC can be very low, frequently less than 500/L, but thecount generally rises spontaneously within the first days and is

almost always greater than 1000/L by day 2 or 3

4. Usually no leukocyte left shiftis seen, and no toxicgranulation, Dhle bodies, orvacuolization is present in theneutrophils



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5. It is not clear whether this variety of neutropenia predisposesneonates to acquire bacterial infection

6. Usually the condition is so transient that such a predisposition isunlikely

7. The condition probably is caused by an inhibitor of neutrophil

production of placental origin that might functionmechanistically by depressing natural G-CSF production

Koenig JM, Christensen RD. N Engl J Med, 1989

Paul DA, et al. Am J Perinatol, 1998

Tsao PN, et al. J Pediatr, 1999



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Kocherlakota P, La Gamma EF. Pediatrics, 1998

Miura E, et al. Pediatrics, 2001Kuhn P, J Pediatr, 2009

1. Kocherlakota found a protective effect of rG-CSFadministration toward early infection

2. Miura reported a protective effect toward late-onsetinfection

3. Kuhn, in a large, multicenter, randomized, placebo-controlled trial in France (n = 200), found that rG-CSFrecipients had only a transient (2-week) period of fewerinfections, but did not have an overall significantimprovement in infection-free survival

Several clinical trials have investigated prophylacticadministration of rG-CSF to neonates with neutropenia, most ofwhom have neutropenia associated with PIH


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Conclusions

In this population, prophylactic rG-CSF did not significantlyincrease survival free of infection at 4 weeks after treatment.The transient effect observed at 2 weeks in the most immature

infants should be evaluated further

(J Pediatr 2009;155:324-30)

no clear benefit of rG-CSFadministration


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Neutropenia Associated With Severe Intrauterine Growth Restriction

No difference in onset, duration, orseverity of neutropenia in small forgestational age (SGA) neonates versus neonates born after PIHObviously, some neonates born after PIH are also SGA, and it might betrue that the most severe neutropenias in this category occur amongthose with both PIH and SGA

The neutropenias of PIH and SGA are similar, and both are transient withfew clinical consequences

Christensen RD, Henry E, Wiedmeier SE, Stoddard RA, Lambert DK. Low blood neutrophil concentrations amongextremely low birth weight neonates: data from a multihospital health-care system.J Perinatol. 2006;26:682-687.


This variety of neonatal neutropenia seems to be mechanistically identicalto that associated with PIH



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The Twin-Twin Transfusion Syndrome

The donor in a twin-twin transfusion is generally neutropenicthe recipient can also have neutropenia, although it is usually not

as severeAs with the varieties of neutropenia accompanying PIH and SGA,no leukocyte left shiftis usually noted, nor are neutrophilmorphologic abnormalities reportedThis condition is transient, with the ANC generally spontaneously

rising to greater than 1000/L by 2 or 3 days

Koenig JM, Hunter DD, Christensen RD. Neutropenia in donor (anemic) twins involved in the twintwin transfusionsyndrome.J Perinatol. 1991;11:355-358.




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Rh Hemolytic Disease

Neonates with anemia from Rh hemolytic disease are almostalways neutropenic on the first day of life

This type of neutopenia is similar to that of PIH/SGA and ofdonors in a twin-twin transfusionit is likely due to reduced neutrophil productionNeutropenia is transient, generally resolving in a day or two

Koenig JM, Christensen RD. Neutropenia and thrombocytopenia in infants with Rh hemolytic disease.J Pediatr.1989;114:625-631.




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Bacterial Infection

Evidence is currently insufficient to support the introduction of rG-CSFor rGM-CSF into neonatal practice, either as treatment for establishedsystemic infection to reduce resulting mortality, or as prophylaxis toprevent systemic infection in high-risk neonates

Carr R, Modi N, Dore C. G-CSF and GM-CSF for treating or preventing neonatal infections. Cochrane Database SystRev. 2003;(3):CD003066.



Sarkar S, Bhagat I, Hieber S, Donn SM.Can neutrophil responses in very low birth weight infants predict the organisms

responsible for late-onset bacterial or fungal sepsis? J Perinatol 2006;26:501-5

In ill VLBW infants, the occurrence of neutropenia during a course of sepsiscan suggest a Gram-negative bacterial infection


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In VLBW infants, common organisms causing infection have differenteffects on neutrophil responses. Occurrence of neutropenia duringevaluation of sepsis in sick VLBW infants is more common with Gram-

negative bacterial infection

Bacterial Infection


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Thrombocytopenia is known to accompany fungal infection inthe NICU, but neutropenia can also accompany such infections

Early-onset neutropenia is a risk factor for Candida colonization invery low birth weight neonates

No studies have specifically focused on the use of rG-CSF among

neutropenic neonates with fungal infection

Fungal Infection



Manzoni P. et al. Diagn Microbiol Infect Dis, 2007

Sarkar S, et al. J Perinatol, 2006


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Neutropenia is relatively common among severe cases of NEC

Some cases are transient and resemble the neutropenia thatfollows endotoxin

No studies have focused on using rG-CSF among neutropenicneonates with NEC

Necrotizing Enterocolitis


Hutter JJ Jr, et al. J Pediatr, 1976

Kling PJ, Hutter JJ. J Perinatol, 2003



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Chronic Idiopathic Neutropenia of Prematurity

Certain preterm neonates develop neutropenia when 4 to 10 weeks old

This variety of neutropenia is often associated with a patientsspontaneous recovery from anemia of prematurity

Neutrophil counts are generally less than 1000/L but rarely less than500/L

The condition is transient, lasting a few weeks to perhaps a month or

longer

It appears to be a hyporegenerative neutropenia because it is notaccompanied by a leukocyte left shift nor by morphologicabnormalities of the neutrophils

Chirico G, et al. Acta Paediatr Suppl., 2002


Juul SE, Christensen RD. J Perinatol., 2003

Juul SE, et al. Acta Paediatr, 1998


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Patients with this condition have an rG-CSF mobilizable neutrophilreserve meaning that if rG-CSF is given, neutrophil count increaseswithin hours

This fact has been taken as evidence that patients do not have asignificant host-defense deficiency, because in theory they can supplyneutrophils to tissues when needed

Thus, although patients are neutropenic, this condition is likely benignand requires no treatment

Chronic Idiopathic Neutropenia of Prematurity

Chirico G, et al. Acta Paediatr Suppl., 2002

Juul SE, Christensen RD. J Perinatol., 2003

Juul SE, et al. Acta Paediatr, 1998


O tli


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Outline


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Calhoun DA, Christensen RD, Edstrom CS, et al. Consistent approaches to procedures andpractices in neonatal hematology. Clin Perinatol. 2000;27:733-753.



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Neutropenia - Kinetic Classification

Diminished Production Excessive Margination

PIH EndotoxemiaSGA PseudoneutropeniaDonors in twin-twin TxRh hemolytic disease Accelerated Usage or

Destruction

Chronic Idiopathic Bacterial or fungal sepsisKostmann AlloimmuneCyclic AutoimmuneSyndromic Causes

FDA approved usage of rG-CSF

G CSF


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rG-CSF

Consider rG-CSF when the neonatal neutropenia issevere ( 5 - 7 days)

Alloimmune

Kostmann

Cyclic

Syndromic

rG-CSF is not recommended for varieties of


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rG CSF is not recommended for varieties of

neonatal neutropenia likely to be transient (or

mild): Sepsis, PIH/SGA, Twin-Twin, Rh hemolytic,

chronic-idiopathic of preterm


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1. We propose beginning treatment with a dose of 10g/kg subcutaneously, once per day for 3consecutive days

2. Doses are given as needed to titrate the ANC toaround 1000/L

3. We propose that if a neonatal patient has

neutropenia, and the variety of neutropenia is NOT

one of the varieties of SCN, rG-CSF treatment shouldnot be used

4. We propose that if a neonatal patient has

neutropenia, and the variety of neutropenia is NOTknown (and therefore might be a SCN variety), whilethe type of neutropenia is evaluated, rG-CSFtreatment can be instituted if the ANC was less than500/L for 2 or more days, or less than 1000/L for 5 to

7 days or longer

Conclusions


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5. There is insufficient evidence forrGM-CSF use in theNICU

6. If one follows this schema, rG-CSF will be used very little

in any given NICU

7. The schema should focus rG-CSF usage on thosepatients with the most to gain and the least to lose by

its application

8. As additional pertinent investigative work is published,

these guidelines should be modified accordingly

Conclusions

A C i t t A h t th U f G CSF i th


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