4. PBSC yang didapatdarileukapheresis volume standar (SVL): - memproses 10-16 liter darah - menghasilkan 1-2 x 106/kg yield sel CD34+ autolog - membutuhkanwaktu 4 jam 4
5. 5 Maka, untukmendapatkansel yang cukup, donor autolog yang tidakmenjalanikemoterapiatauradiasisebelumnya, dilakukanleukapheresistiaphari, 1-5 kali hinggamencapaijumlahsel yang ditargetkan
6. Beberapapasien yang telahditerapi, terutama yang telahdiberithalidomidedanatauderivatnya (lenalidomide), menjalanileukapheresislebihdarijumlah rata-rata 20- 30 % calontransplantasiautologtidakmencapaijumlah target sel. 6
7. Leukapheresis volume besar (LVL)memproseslebihdari 20 liter darah Jumlahselmononukleardansel CD34+ yang didapatkanlebihbanyak LVL dibanding SVL. 7
9. Subyekpenelitian 9 35 menjalani LVL diklinik Mayo Scottsdale, Arizona 35 Wanita 87 pasien MM Total 260 leukapheresis Nilai median usiasubyek 63 tahun (33-76 tahun) 52 menjalani SVL diKlinik Mayo, Jacksonville Florida 52 laki-laki
10. Metode PBSC Collection Donor diberi 10 µg/kg filgastrim 1 kali/harisubkutanselama 4-5 hariuntukmemobilisasistem cell pool. Sel CD34+ dalamdarahperiferdimonitortiaphari, danleukapheresisdimulaisaatkadarsel CD34+ mencapai 10/µl ataulebih. 10
11. Injeksifilgastrimtiaphariberlanjuthingga: - sesaatsebelum LVL berakhir - sesudah SVL berakhir. Proses LVL dan SVL menggunakanmesinCobe Spectra (Gambro BCT, Lakewood, CO) yang di-maintenancesecararutindandijalankanoleh operator berkompeten Mesindioperasikandengansoftware versi 7. 11
17. Mobilisasiadekuatbila donor mampumenghasilkan≥ 2 jutasel CD34+/kg yield sekalileukapheresis. Donor yang gagalmobilisasisaatpertama kali leukapheresisdiberikankombinasi G-CSF dan GM-CSF ataucyclophosphamide Total target sel CD34+/kg adalah 3-5 x 106 untuksatu kali transplantasi, dan 6-10 x 106untuk 2 kali transplantasi. 17
18. EnumerasiSel CD34+ Hasilleukapheresis, diukurjumlahsel CD34+. Sampelditambah anti-CD45-FITC dan anti-CD34- PE, dandianalisismenggunakanFACS Caliburflowcytometer Jumlahsel CD34+ diukurpadasampelbarusebelumdibekukan Ditentukanpersentasesel CD34+ tiapsampel, danjumlah total CD34+ yang diinfuskandikalkulasi 18
25. Diskusi Tujuanleukapheresis PBSC adalahmendapatkanjumlahsel CD34+ sesuaitarget denganmengurangifrekuensipengambilandanmeminimalisasiketidaknyamanan . Penelitidkktelahmelaporkanadanyakorelasi linear yang signifikanantarajumlahsel CD34+ padadarahperifer pre-leukapheresisdenganjumlahsel CD34+/kg yield yang didapatdarileukapheresis 25
26. Proses SVL padapenelitianini, memprosesdarahlebihbanyakdaripadapenelitian lain, sehingganilai median sel CD34+/kg yang didapatkanlebihtinggi Resipienproduk SVL mendapatkansel CD34+ lebihbanyakuntuksatu kali transplantasi, sehinggaengraftmentnetrophildan platelet lebihcepatdibandingresipienproduk LVL 26
35. Dogma yang menyatakanlebihbanyaksel yang ditranplantasikan, hasil yang didapatkanlebihbaik, ternyatabelumtentubenar. Padatransplantasiautolog, adanilaiambangengraftment, dimanalebihbanyakseltidakakanmemperbaikikecepatanengraftment. Olehkarenaitumentransplantasisedikitlebihrendahsel CD34+ padaresipien LVL, tidakmerugikan 32
36. Tantanganmunculketikaanalisiscost-benefit dilakukanpada LVL terhadap SVL Seringpadapasiendengansel CD34+ yang cukup 2 kali transplantasi, tetapitidakmelakukantransplantasikedua Hal inidisebabkanefeksampingselamaperiodenetropeniadankondisimedis lain karenatransplantasi yang pertama Sedikitpasien yang gagalmendapatkansel CD34+/kg yang cukup, kembaliuntukleukapheresis yang kedua. 33
44. Acid citrate dextrose Acid Citrate Dextrose Solution (sometimes called Anticoagulant Citrate Dextrose Solution) is a solution of citric acid, sodium citrate and dextrose in water. It is mainly used as an anticoagulant to preserve blood specimens required for tissue typing, it is also used during procedures such as plasmapheresis instead of heparin. Two different solutions (Solution A and B) are defined by the United States Pharmacopeia. 41
45. Solution A (per 1000 mL) : Total Citrate (as Citric acid, anhydrous (C6H8O7)) 20.59 to 22.75g Dextrose (C6H12O6*H2O) 23.28g to 25.73g Sodium (Na) 4.90g to 5.42g 42
46. Solution B (per 1000 mL) Total Citrate (as Citric acid, anhydrous (C6H8O7)) 12.37 to 13.67g Dextrose (C6H12O6*H2O) 13.96 to 15.44g Sodium (Na) 2.94 to 3.25g 43
47. CD34+ Cells expressing CD34 (CD34+ cell) are normally found in the umbilical cord and bone marrow as hematopoietic cells, a subset of mesenchymal stem cells, endothelial progenitor cells, endothelial cells of blood vessels but not lymphatics (except pleural lymphatics), mast cells, a sub-population dendritic cells (which are factor XIIIa negative) in the interstitium and around the adnexa of dermis of skin 44
48. CD 45 CD45 is expressed on cells of the hematopoietic lineage with the exception of mature red cells. It is not detected on differentiated cells of other tissues 45
50. Granulocyte colony-stimulating factor Granulocyte colony-stimulating factor (G-CSF or GCSF) is a colony-stimulating factor hormone. G-CSF is also known as colony-stimulating factor 3 (CSF 3). It is a glycoprotein, growth factor and cytokine produced by a number of different tissues to stimulate the bone marrow to produce granulocytes and stem cells. G-CSF then stimulates the bone marrow to release them into the blood. G-CSF also stimulates the survival, proliferation, differentiation, and function of neutrophil precursors and mature neutrophils. G-CSF regulates them using Janus kinase (JAK)/signal transducer and activator of transcription (STAT) and Ras /mitogen-activated protein kinase (MAPK) and phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt) signal transduction pathway 47
51. Granulocyte macrophage colony-stimulating factor Granulocyte-macrophage colony-stimulating factor, often abbreviated to GM-CSF, is a protein secreted by macrophages, T cells, mast cells, endothelial cells and fibroblasts. GM-CSF is a cytokine that functions as a white blood cellgrowth factor. GM-CSF stimulates stem cells to produce granulocytes (neutrophils, eosinophils, and basophils) and monocytes. Monocytes exit the circulation and migrate into tissue, whereupon they mature into macrophages. It is thus part of the immune/inflammatorycascade, by which activation of a small number of macrophages can rapidly lead to an increase in their numbers, a process crucial for fighting infection. The active form of the protein is found extracellularly as a homodimer. 48
52. Filgastrim Filgrastim is a granulocyte colony-stimulating factor (G-CSF) analog used to stimulate the proliferation and differentiation of granulocytes. It is produced by recombinant DNA technology. The gene for human granulocyte colony-stimulating factor is inserted into the genetic material of Escherichia coli. The G-CSF then produced by E. coli is only slightly different from G-CSF naturally made in humans. 49