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Published on: March 20, 2021
Increased risk of citrate reactions in patients with multiple myeloma during peripheral blood stem cell leukapheresis
Jill Adamski1, Adrienne Carruth Griffin, Christa Eisenmann
1Department of Pathology and Laboratory Medicine, Division of Transfusion Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Insights
Patients with multiple myeloma (MM) experience more citrate reactions during apheresis due to hypocalcemia. Prophylactic strategies are recommended for MM patients undergoing stem cell collection to improve safety and comfort.
Area of Science:
- Hematology
- Oncology
- Clinical Trials
Background:
- Citrate-based anticoagulants like ACD are standard in apheresis.
- Citrate can cause hypocalcemia, leading to symptoms like paresthesias and cramps.
- An increased incidence of citrate reactions was observed in multiple myeloma (MM) patients undergoing autologous stem cell leukapheresis.
Purpose of the Study:
- To investigate the higher incidence of citrate reactions in MM patients compared to other malignancies during autologous stem cell collection.
- To evaluate potential contributing factors for increased citrate sensitivity in MM patients.
Main Methods:
- Retrospective chart review of 139 patients (MM, amyloidosis, hematological, and solid malignancies) undergoing autologous peripheral blood stem cell collection.
- Documented citrate reactions, their severity, and treatments (e.g., intravenous calcium gluconate) were analyzed.
- Laboratory values related to calcium homeostasis, liver, and renal function were examined.
Main Results:
- 37% of MM patients (23/63) experienced citrate reactions, significantly higher than other malignancy groups (20%; P < 0.05, RR = 1.9).
- Reaction severity was similar between groups, with ~50% in each receiving calcium gluconate for hypocalcemia.
- No correlation found between bisphosphonate therapy and citrate reactions. No clear mechanism identified from laboratory values.
Conclusions:
- Multiple myeloma patients exhibit increased sensitivity to citrate-induced hypocalcemia during leukapheresis.
- Prophylactic measures, such as supplemental calcium and adjusted return rates, should be considered for MM patients to enhance safety and comfort.
Abstract:
The citrate based anticoagulant ACD is commonly used in apheresis procedures. Due to its ability to decrease ionized calcium, citrate may cause unpleasant symptoms, such as paresthesias and muscle cramps, in patients undergoing therapeutic and donor apheresis. We noticed that patients with multiple myeloma (MM) undergoing autologous stem cell leukapheresis appeared to have more citrate reactions when compared to other patients undergoing the same procedure. A retrospective chart review was performed to evaluate 139 (of 151) consecutive patients with MM, amyloidosis, hematological and solid malignancies who had autologous peripheral blood stem cell collection between January 2007 and February 2008. Citrate reactions, ranging from mild (e.g., perioral tingling and parasthesias) to severe (e.g., nausea/vomiting and muscle cramps) were noted for 35 patients. Twenty-three of 63 patients with MM had documented citrate reactions, which was significantly higher than those with other hematological and solid malignancies (37% vs. 20%; P < 0.05, Relative Risk (RR) = 1.9). The severities of citrate reactions were the same in both groups; approximately 50% of patients in each group received i.v. calcium gluconate for treatment of hypocalcemia. No correlation between bisphosphonate therapy and citrate reactions were noted in our study group. Examination of available laboratory values related to calcium homeostasis, liver, and renal function failed to reveal a mechanism for the increase in citrate reactions observed. In summary, this single institution retrospective study indicates that patients with MM are more sensitive to citrate-induced hypocalcemia during leukapheresis when compared to patients with other hematological and solid malignancies. Strategies for decreasing citrate reactions (e.g., supplemental calcium and slowing return rates) should be considered for patient safety and comfort, especially in the MM population, on a prophylactic rather than reactive basis.
