105

Of the 18 patients reporting a history of a major depression, 15dated its onset subsequent to the onset of ESRD. Of these 15patients, 8 indicated that their depression was associated withlearning the diagnosis of chronic renal failure, 2 experienced asevere-depression between diagnosis and the start of maintenancetherapy, and the othen5 had a significant depression after treatmentbegan. Thus two-thirds of the patients who experienced a majordepressive episode subsequent to the onset ofESRD were depressedbefore the start of maintenance therapy, a time when few resourceswere made available to them to help them adapt to life with thischronic disease.While the need for psychosocial intervention among dialysis

patients has been widely recognised,6-10 the results of our studysuggest a comparable need for psychosocial support during thepretreatment phase of ESRD. Such pre-treatment contact mayenhance patient compliance, adaptation, and, ultimately, survival.

Department of Psychiatry,Health Administration and Planning Programand Department of Pediatrics,

Washington University School of Medicine,Saint Louis, Missouri 63110, U.S.A.

BARRY A. HONGMARC D. SMITHTHOMAS J. VALERIUSALAN M. ROBSON

HYPERTRANSFUSION FOR ADULT ACUTELEUKAEMIA

SIR,-In children with acute lymphocytic leukaemia who arehypertransfused during induction chemotherapy, platelet and

neutrophil counts are reported to recover more rapidly To see ifhypertransfusion is also useful in adult acute leukaemia we tried it inadults receiving their first course of induction chemotherapy foracute leukaemia.Informed consent was obtained from seventeen men and seven

women aged 17-78 years (mean 52) with acute leukaemia

(myelogenous in seventeen, myelomonocytic in four, lymphocyticin one, and erythroleukaemia in two). Induction chemotherapy

3

consisted of doxorubicin 40 mg/m or zorubicin (eight patients) 200mg/m2, vincristine 2 mg, prednisone 100 mg daily for 5 days, andcytarabine 70 mg/m daily for 7 days. Patients were randomisedeither to hypertransfusion (haemoglobin maintained with packedred blood cells at 12 g/dl or more during the first induction course)or transfusions only as needed. Platelet transfusions were given toboth groups at the discretion of the clinical staff, usually for signs ofbleeding. The chemotherapy, age, type of leukaemia, and sexdistribution were comparable for the two groups.Results are shown in the table. As expected, both mean

haematocrits (37-7% vs 28-0%, and red-blood-cell transfusions12 - 2 M 7 - 8 [omitting one patient with several major bleeds]) werehigher in the hypertransfused group. There was no significantdifference in either time to recovery (500 granulocytes/1 or>100 000 platelets/fl) or the need for platelet transfusions (seetable).There are several possible explanations why hypertransfusion

might result in earlier marrow recovery after chemotherapy. Wholeblood transfusion by itself has been reported to cause remissions.4

4

Transfusion may protect stem cells from the cytotoxic effects ofchemotherapy. Smith and Ekertl proposed that stem-cell

6 Seime RJ, Zimmerman J. Adjustment to dialysis: a brief review. Behav Med Update1981, 3: 9-11

7 De-Nour AK, Shaltiel J, Czaczkes JW. Emotional reactions of patients on chronichemodialysis. Psychosom Med 1968; 30: 521-22.

8. Levy NB The psychology and care of the maintenance hemodialysis patient HeartLung 1973; 2: 400-5.

9. Flannery JG. Adaption to chronic renal failure. Psychosomatics 1978; 19: 784-8710. Levy NB Psychological sequelae to hemodialysis Psychosomatics 1978, 19: 329-31.

1 Smith PJ, Ekert H Evidence of stem-cell competition in children with malignantdisease a controlled study of hypertransfusion Lancet 1976, i: 776-79.

2 Toogood IRG, Ekert H, Smith PJ, Firkin FC Controlled study of hypertransfusionduring remission induction in childhood acute lymphocytic leukaemia. Lancet1978, ii: 862-64

3 Keating MJ, Smith TL, McCredie KB, Bodey GP, Hersh EM, Gutterman JU, GehanE, Freireich EJ A four-year experience with anthracycline, cytosine arabinoside,vincristine and prednisone combination chemotherapy in 325 adults with acuteleukaemia. Cancer 1981; 47: 2779-88

4. Hayhoe FGJ, Whitby L The management of acute leukaemia in adults Br J Haematol1954; 1: 1-19.

5 Willie GR Hypertransfusion during remission induction in A L.L. Lancet 1978, ii:

1152-53.

competition was the cause of the more rapid recovery. Since theoptimal timing of hypertransfusion relative to therapy has beenquestioned, we maintained hypertransfusion from the onset oftherapy until recovery, the start of the second course of

chemotherapy or death.Failure of hypertransfusion in this study and that of Helson et al.’

(in contrast to the successful reports I ,2) may be attributed to severalfactors. Our patients were adults with acute leukaemia rather thanchildren with acute lymphocytic leukaemia; however, since

hypertransfusion increases the proliferative activity of leukaemicmyeloblasts,8,9 the possibility for efficacy of hypertransfusion inAML is suggestive. Lack of effect may also be due to differences inthe transfusion schedule in that our patients were maintained athaemoglobins 12 g/dl with multiple transfusions over 16 - 46 days(mean 29) rather than with a single transfusion to a haemoglobin of16-18 g/dl2 or 14-16 g/dL1 If the mechanism is stem-cell

competition, maintenance of a higher haemoglobin should havebeen helpful.Hypertransfusion remains an interesting possibility for reducing

the toxicity of chemotherapy, but more studies in man and in animalmodels are needed to define its clinical role and mechanism ofaction.

Department of Medicine,University of Texas Medical Branch,Galveston, Texas 77550, U S.A.

GARY B. WEISSETHEL PATTEN

JACK B. ALPERINJAMES A. HOKANSONJ. DAVID BESSMANJOHN J. COSTANZIFRANK H. GARDNER

6 Hughes-Davies TH. Hypertransfusion of children with malignancy Lancet 1976, i:

970.

7. Helson L, Polesir E, Silvermann M Lack of effect of pretreatment blood transfusionson drug-induced myelodepression Lancet 1976, ii: 1033

8. Toogood IRG, Ekert H, Dobrostanski B, Waters K Hypertransfusion in AML canincrease the percentage of blasts in DNA synthesis Leukemia Res 1978, 2: 247-49.

9. Paton CM, Ekert H, Toogood IRG, Waters KD, Dobrostanski B Transfusion canchange the labelling index in AML Association of post-transfusion LI andremission status Br J Haematol 1980, 46: 157-60.

RECOVERY FROM CHEMOTHERAPY FOR ACUTE LEUKAEMIA

Sand G represent single donor platelet transfusions and granulocyte transfusions given maddition to the units of random donor platelets They are equivalent to approximately 7 and10 units of random platelets respectively and these values v. ere used to calculate the groupmean platelet usage shown in parentheses XR represents no recovery before the secondcourse of chemotherapy or early death (patient 14)