Urszula Jaworska Foundation

Separation of hematopoietic cells vs
bone marrow harvesting - the choice is yours!

You decided to become a bone marrow donor. You would like to give away the part of yourself to someone else.
You may save the life of another person.
You have gone through the blood tests in the laboratory.
Your genetic data are on the Bone Marrow Registry.
They are coded under the special symbol FUJ XXXX.
Every donor has its own symbol.
A year, two years, five years go by.
And then it happens.
The phone rings and you hear a question: "Do you still want to donate your bone marrow? There is someone who needs your help. Your antigenes are the same as patient's. The life of that person depends on you."

After the surprise, disbelief and joy are over, your response is: you are ready to donate your bone marrow. The preparations for the donation begin.

It is then that you, together with the Bone Marrow Registry, have to take the decision on the method of harvesting of the hemopoietic cells, i.e. the cells that decide on your donee's future.

It was not long ago that the bone marrow could be harvested mainly by performing procedures under general anesthesia by series of injections in the back upper crest of the pelvic bone.
A lot has been said and written on this method and the majority of potential donors and those interested believe this is the only or the most popular method of hematopoietic cells harvesting.

However, the collecting of hematopoietic cells form the peripheral blood becomes even more popular alternative method for bone marrow harvesting all over the world. Such procedure, also known as apheresis or separation is non-invading, does not require the application of general anesthesia and is less burdening for the donor. In Poland, the separations have been performed a few times in case of unrelated donors, two donors form the Urszula Jaworska's Foundation have given away their hematopoietic cells with the application of this method.
All over the world, this method becomes more and more popular and many transplantation centres use it more often than the bone marrow harvesting under general anesthesia.

You are sure to ask.
Which method should I choose? Which one is safer for the donor, which one is more favourable for the donee? What is the difference?

The decision on the method depends, above all, on the donor.
Below we try to tell you more about the separation of the hematopoietic cells form the peripheral blood.
This method may soon become more popular than bone marrow harvesting form the pelvic bone.

A low number of such cells is circulating in your peripheral blood. They may be harvested from this blood with the use of separation method, i.e. decomposing of the blood to elements. As the number of hematopoietic cells in the peripheral blood is low, it is necessary to increase it by means of administering G-CSF injections. The process is technically described as mobilisation and consists in giving the donor the injections of Filgastrin (Neupogen) or Granocyte that causes the hematopoietic cells to be released form the bone marrow to the peripheral blood. The G-CSF injections causes the increase in the number of granulocytes: the cells that defend the organism from bacteria and fungi. It may cause side-effects such as skin allergy, boneaches (as with the flu), shivers, light headaches, or increased body temperature. Such symptoms may appear. A part of donors gets no side-effects, others complain about the above disorders. Generally, each donor reacts individually. All the symptoms disappear after the G-CSF injections are over.

In the blood of a healthy man there are 5-10 hematopoietic cells (so called CD34+/microliter of blood). After the mobilization the number increases up to a few dozen, sometimes even 100/microlite of blood. The number of granulocytes increases up to around 50 000/microliter of blood.

The G-CSF injections are administered for 5 days and the donor has to do the blood test every day, so that the number of hematopoietic cells in the peripheral blood is determined. The donor does not have to stay at the hospital and everything is done at the outpatients' clinic. When the blood test shows that the number of the hematopoietic cells is high enough, the separation (apherasis) may be performed.

The blood is taken form the elbow vein (the usual needle or special separating needle, similar to the one used for blood donations is inserted), filtered by the apparatus called cells separator where the mononuclear cells, including hematopoietic cells are separated, than the remaining blood is returned to the donor through the elbow vein of the other hand.

The separation takes up to 4 hours and usually has to be repeated once or twice in order to collect the sufficient quantity of hematopoietic cells. The method does not require general anesthesia and is less burdening for the donor.

It has its drawbacks: the donor has to lie on bed (or in the special armchair), may not move (read, eat, drink or e.g. scratch himself/herself as the person cannot move his/her hands). The donor may feel weak and dizzy. In the course of separation the level of calcium in the blood decreases as a result of administering medicine that prevents the blood from clotting. That may result in the parts of face, fingers and legs going numb. If such effects appear, the donor receives calcium preparations and the effects disappear.

Every donor, asked to give his/her bone marrow may undergo separation as well as harvesting under general anesthesia. Everything depends, above all, on the donor's decision. The separation (apherasis) requires no general anesthesia, thus is less burdening for the donor. No stay at the hospital is required. But separation involves mobilization period, i.e. the G-CSF injections lasting 5 days, which may be troublesome or burdening.

Separation, on the other hand, requires no hospital stay, harvesting in the operating room and presence of the operating team (doctors, anesthesiologist, nurses). The separation is performed by one doctor assisted by one nurse.

By performing separation and mobilization more hematopoietic cells may be harvested than by bone marrow harvesting. The more hematopoietic cells in the transplantation material, the quicker recovery of the donee after the graft. But there are downsides The transplantation material obtained by separation has various lymphocyte T cells. If there are too many of them, there is a risk of s serious after-graft complication for the donee, known as graft versus host disease (GvHD).

Thus, the material collected by separation provides for quicker recovery of the donee after the graft, but implies higher risk of rejecting the graft. The decision on which method will be more favourable for the donee is made individually in each case.

One thing is certain: the transplantation center may suggest its preferences: either bone marrow or hematopoietic cells from the peripheral blood. The final decision rests with the donor. Both, the cells collected by separation and as a result of bone marrow harvesting may be transplanted to the donee.

• The separation does not require the donor to stay at the hospital and apply general anesthesia
• It is painless and non-invading
• The donee who received hematopoietic cells taken form the peripheral blood of the donor usually recovers quicker
• In the course of the separation a few times more hematopoietic cells may be collected than in the process of bone marrow harvesting performed under general anesthesia.

Against

• The hematopoietic cells separation from the peripheral blood requires to donor to receive G-CSF injections for5-6 days; the donor has to report for the injections to the clinic two times a day
• The donor may - as a result of G-CSF injections develop symptoms of flu: boneaches, shivers, general fatigue, increased body temperature.

Two donors form Urszula Jaworska's Foundation have given their bone marrow twice.
Iwona and Michał have undergone bone marrow under general anesthesia and by separation.

We asked them, which method, in their opinion, is more favourable for the donor and which one would they choose if they were to give their bone marrow once more.

In the donor's opinion:

Iwona: "It is difficult to say which method I would choose, if I were to donate my bone marrow once more. I think it would depend on my feeling as well as on the situation in my professional and private life. The bone marrow harvesting under general anesthesia meant one day at the hospital (for certain donors - two days), so I didn't have to give up too much time and was able to come back to work quickly (I worked at full blast two days after the donation). The separation of the hematopoietic cells from the peripheral blood meant visits to the clinic every day two times a day for the G-CSF injections in the arm. Every day at 8 and at 20 (every 12 hours) I took a medicine called Neupogen and every morning the blood test was done to check whether the number of hematopoietic cells increased in my peripheral blood. Unfortunately I couldn't sleep longer on Saturday or Sunday because I had to rush to the clinic. On the other hand, I am a late riser, so I could at last see the spring coming and feel the smell of the spring morning. And they did smelt wonderful. Guess I liked getting up early. The separation was performed within 2 days. I had to take my vacation from work for the time. I think not every donor may afford to do so. But then again the separation does not require your stay in the operating room, the whole hospital atmosphere that doesn't go down with everybody, there is no general anesthesia, no waking up from it, no operating team that looks scary, so if someone dislikes hospitals and procedures he/she should decide on the separation. The only invasion is inserting two needles (and G-CSF). I think every donor, depending on the private situation, will choose the method suitable for him/her at a given time. One thing is for sure: both separation and bone marrow harvesting are painless, safe for the donor and regardless of the method, the organism recovers at the same pace. I have undergone both and it is really difficult to decide which one would I choose if I were to donate bone marrow once more. This is an individual decision and depends on the private situation at a given moment of your life."

Michał: "So let's discuss this hypothetical situation: I am to donate bone marrow once more and I could decide on the method (injections under general anesthesia or separation) There are various "for" and "against". Each method has its advantages and disadvantages. And thus, first of them entails anesthesia which is usually unpleasant and involves certain risks. Separation is the alternative, first one week of taking a medicine releasing the hematopoietic cells than 3.5 hours of staying without a move in the course of the separation. For me, the most important is the time I would have to devote. The bone marrow harvesting under general anesthesia took 2 days at the hospital; the separation - a few hours. The doctors wanted to put me at the hospital for the time of administering G-CSF, but I disagreed - my study plan did not allow me to stay at the hospital. I heard that the medicine causes general weakening, fatigue - I observed no such symptoms. To sum up, taking into account the grottiness of the separation method I would decide on this method (unless, this time I couldn't escape one week vacation' at the hospital).

If you think that the above information are not sufficient and you have any other questions or doubts, please reach us under: iwona@fundacjauj.pl and we will try to answer all your questions.