I-JAMM-(I): A survey providing an insight into the practices of isoagglutinin titration in ABO incompatible kidney and liver transplantation.

BACKGROUND AND OBJECTIVES: ABO-incompatible transplantations allow patients to receive timely transplants. Isoagglutinin titration to ascertain levels of incompatible antibodies in the recipient is important in determining patient selection and transplant survivability. To find out the prevalent trends in India, the largest, first of its kind survey was carried out among the transplant centers regarding their practices in isoagglutinin titration. METHODS: The survey was drafted by a working group of Transfusion and Transplant Immunology specialists from six different centers. Data was obtained via the use of an online questionnaire. RESULTS: Results were categorized into four categories, Hospital information, Titration methodology, Role of transfusion specialists and cut-off titers. Most centers had a well-established solid-organ transplant program with considerable number of ABO-incompatible transplantations. Most centers performed isoagglutinin titration in Transfusion Medicine department. Column Agglutination Technique (CAT) was the most common method, using EDTA blood samples and freshly-prepared in-house pooled cells. Most centers had a turn-around time of less than 12 h. While the policy for ascertaining baseline and threshold titers is well-defined in ABO-incompatible renal transplants, variations from center to center still exist for ABO-incompatible liver transplants. Most centers required a Transfusion Medicine consultation for the patients before such transplants. CONCLUSION: With increasing ABO-incompatible kidney and liver transplants across the country, the role of Transfusion medicine specialists has become vital in pre-conditioning regimes enabling the viability and success of such transplants. This was a unique survey that provided a snapshot of current trends and practices of isoagglutinin titration for ABO-incompatible transplants in India.

A retrospective observational study to estimate the risk of HLA alloimmunization with blood transfusion: Can the risk be reduced by leucodepletion?

BACKGROUND: In this retrospective study, our aim was to find the effect of leucodepleted (LD) blood transfusions on the formation of anti-HLA-antibodies when compared to non-leucodepleted (non-LD) transfusions using Luminex-based method. METHODS: In this study, Luminex single antigen bead assay (L-SAB) and HLA typing were performed on 310 patients. Test positivity rates (as MFI - Mean florescence intensity) were analyzed according to the different sensitization events and gender. RESULTS: Of the 310 patients included in the study, 58.06% (180) patients were male and 41.93% (130) were female. The average age of the patients was 42.86 (±12.37) years. In this study, test positivity rates were significantly lower in the patients who received LD RBC units than in those who received non-LD RBC units (28.43% = 29 of 102 Vs 55.22% = 74 of 134, p < 0.05). In our study, transfusion combined with a history of pregnancy had higher number of significant HLA antibodies compared to cases where transfusion was the only sensitization event (81.81% = 18/22 Vs 39.71% = 85/214, p < 0.05). In addition, anti-HLA-antibodies-MFI were significantly (p < 0.01) higher in non-LD patients compared to LD patients. CONCLUSION: Patients who received LD RBC units had a significantly lower rate of transfusion-associated alloimmunization compared to those who received non-LD RBC units. Multiparous women had a high risk for transfusion-related alloimmunization compared to both nulliparous women and male patient. Furthermore, class I-anti-HLA-antibodies (HLA-B and HLA-A + B) were significantly associated with pregnancy sensitization and/or blood transfusion as a single sensitization.

Immunohematological challenges in COVID infected patients.

BACKGROUND: Several autoimmune disorders have been reported to be related with COVID infection. In continuation to these autoimmune phenomenon, autoimmune hemolytic anaemia (AIHA) also has been noted in COVID infected patients. The aim of the study was to find out the prevalence of red cell alloimmunization, ABO discrepancy and positive direct antiglobulin test (DAT) results in COVID infected patients hospitalised in a tertiary care centre in North India. METHODOLOGY: This was a retrospective observational study done from July 2020 to June 2021. All symptomatic patients admitted to ICU tested positive for SARS CoV-2 whose blood samples were received in the immunohematology laboratory of department of Transfusion Medicine for determination of blood group and issue of packed red cells, and found to have positive antibody screen, blood group discrepancy and positive DAT results, were included in the study. RESULTS: A total of 10,568 tests were run, out of which 4437 were for determination of blood group, 5842 were for antibody screen and 289 were for direct antiglobulin test. Included in this study were 146 patients who either had blood group discrepancy, or had a positive antibody screen or had a positive DAT. Out of 115 positive antibody screen, 66 patients had only alloantibodies, 44 patients had only autoantibodies while only 5 patients had both auto as well as alloantibodies. Total number of positive DAT cases was 50 (50/289 = 17.3 %). There were 26 ABO discrepancies (26/4437 =0.58 %) found. CONCLUSION: Our results also indicate that there is rise in rate of alloimmunization and DAT positivity among COVID patients.

Single center experience of therapeutic plasma exchange in a resource-constrained setting: A study of trends in scope and complications.

BACKGROUND: Therapeutic apheresis procedures are becoming an increasingly integral part of modern medical practice, be it as a part of therapy or pre-conditioning regimes for solid organ transplants. In our center, we follow the American Society for Apheresis (ASFA) guidelines for categorizing these procedures. However, lack of a centralized registry for therapeutic apheresis in India, lack of consolidated data as well as a resource-constrained setting prevent it from being utilized to its full potential. STUDY DESIGN AND METHODS: This study was a retrospective analysis of therapeutic plasma exchange (TPE) procedures performed from January 2015 to October 2022 in the Department of Transfusion Medicine at a large tertiary care hospital in North India. All consecutive TPE procedures were included. Overall and specialty-wise scoring for all patients was performed. Mean scores were calculated. RESULTS: A total of 1434 procedures were performed during the study duration of 7 years. These procedures were performed for 284 different patients. Majority of the procedures were referred from nephrology (895 of 1434, 62.4%), followed by neurology, gastroenterology, and liver transplant teams, hematology, critical care, rheumatology, pediatrics, and internal medicine. Complete response, partial response, and no-response were observed in 1077 (75.1%), 201 (14%), and 156 (10.9%) procedures respectively. Only 14 procedures reported adverse effects. DISCUSSION: Increasing effectiveness of TPE in a number of procedures and a variety of indications has broadened its scope, while the small number of adverse events, when supervised by trained Transfusion Medicine physicians has made TPE a more viable and safer alternative to other treatment modalities.

Detection of donor-specific HLA antibodies: A retrospective observation in 350 renal transplant cases.

BACKGROUND: The main objective of this study was to determine the results of the cell-based assay (CDC-XM and FC-XM), and correlate with the results of solid phase assay (L-SAB). METHODS: In this retrospective study, 350 prospective renal transplant recipients were tested for the presence of HLA antibodies by CDC-XM, FC-XM and L-SAB screening with their corresponding donor. RESULTS: T-cell-FC-XM showed a sensitivity of 71.43% and a specificity of 91.50% for detecting class I L-SAB (+), while B-cell-FCXM showed a sensitivity of 94.94% and a specificity of 61.99% for detecting class II L-SAB (+). On the other hand, T-CDC-XM showed a sensitivity of 32.14% and a specificity of 98.64% for detecting class I L-SAB (+), while B-CDC-XM showed a sensitivity of 44.30% and a specificity of 94.83% for detecting class II L-SAB (+). In this study, the results indicated that DSA class I MFI value of 2845 and above significantly (p ≤0.001) correlated with T-cell-FC-XM positivity, while MFI value of 4585 and above (p ≤0.001) showed strong predictive accuracy of a positive T-cell-CDC-XM. However, DSA class II MFI cut-off of 1988 and above significantly (p ≤0.001) correlated with B-cell-FC-XM positivity, while MFI value of 5986 and above (p ≤0.001) showed strong predictive accuracy of a positive B-cell-CDC-XM. CONCLUSIONS: Our study showed that CDC-XM has poor sensitivity, while FC-XM has poor specificity to detect DSA. L-SAB has good correlation with T-cell-FC-XM (p < 0.0001) but not with B-cell-FC-XM (P = 0.31). DSA strength >2845 and > 1988 significantly correlated with T-cell-FC-XM positivity and B-cell-FC-XM positivity, respectively. While, a MFI value of >4585 and > 5986 significantly correlated with T-cell-CDC-XM positivity and B-cell-CDC-XM positivity, respectively. These MFI cut-off values could serve as a surrogate marker for CDC-XM and FC-XM tests and may help in resolving the limitations of cell-based techniques. In conclusion, we found that L-SAB is more sensitive and specific than CDC-XM and FC-XM and therefore may be used as a test of choice.

Reference interval of platelet counts and other platelet indices in apparently healthy blood donors in North India according to Clinical and Laboratory Standards Institute guidelines: Need to redefine the platelet count cutoffs for repeat plateletpheresis donation?

BACKGROUND: In clinical practice, laboratory results are of great importance for the diagnosis and treatment. Reference intervals of different parameters aid health-care professionals in the interpretation of results. There are very few studies on reference intervals from India. This prospective study was conducted to determine the reference intervals for platelet count (PLT) and PLT indices; mean PLT volume (MPV), PLT distribution width (PDW), and PLT large cell ratio (P-LCR). These values can be obtained as a part of a routine complete blood count (CBC) and have diagnostic and prognostic significance in certain diseases. PLT count is an important criterion for the selection of donors for repeat plateletpheresis donation. MATERIALS AND METHODS: Sixteen hundred and thirty-four first-time healthy volunteer plateletpheresis donors were enrolled for the study. CBC was done, values of PLT, MPV, PDW, and P-LCR were noted, and the results were analyzed. The 95% of the reference distribution was estimated using the 2.5th and 97.5th percentiles following Clinical and Laboratory Standards Institute guidelines. Adverse donor reactions, if any and quality parameters of single donor PLTs (SDP) were also studied. RESULTS: Reference range values of PLT, MPV, PDW, and P-LCR were 137,825-355,175/µl, 8.1-13.9/fl, 9.1-22.5/fl, and 11.7%-52.9%, respectively, and compared well with other published studies from India. It was observed that reference values of PLT count obtained in the study were lower than reference values that are currently used in most laboratories (150,000-450,000/µl) in India. CONCLUSION: Based on our results, we are of the opinion that the PLT count cutoffs for repeat plateletpheresis donation may need to be revised downwards for our country which would also mitigate the scarcity of apheresis donors.

Effect of prolonged storage at 2°C-6°C for 120 h on the coagulation factors of thawed cryoprecipitate: Can we extend its shelf life post thaw beyond 4 h?

BACKGROUND: Cryoprecipitate helps in replenishing important coagulation factors like fibrinogen, Factor VIII and von Willebrand factor without running the risk of volume overload. It is very useful in the treatment of trauma patients with active bleeding and works best when administered early. Extending the shelf life of thawed cryoprecipitate beyond 4 hours enables us to manage inventory better, reduces the burden of demand vs supply as well as minimizes wastage. It can also help in logistically supporting the transfusion services in making cryoprecipitate readily available in mass casualty scenarios (war, natural calamity) in remote locations by reducing the time required for thawing cryoprecipitate and the need for costly storage equipment. AIM: The aim of this study was to compare the levels of Factor VIII, Fibrinogen and von Willebrand factor on thawed cryoprecipitate after prolonged storage for 5 days at a temperature of 2-6°C. METHODOLOGY: The above mentioned coagulation factors were analyzed in cryoprecipitate at the time of product thaw and again after 120 hours of 2 to 6°C storage using fully automated coagulation analyser (STA Compact Max). All parameters were expressed as Mean ± Standard deviation and were analyzed using paired t-test with level of significance, P < 0.05. RESULTS: There was a significant decrease in the level of Factor VIII, whereas the levels of fibrinogen and von Willebrand Factor remained stable during the storage period. All the cryoprecipitate units retained factor activities above therapeutic range even after 5 days of storage at 2-6°C. CONCLUSION: Although the levels of clotting factors are reduced during storage, they are still maintained above the therapeutic range. In scenarios where maintaining frozen cryoprecipitate inventory is a logistical challenge and emergency massive demands of cryoprecipitate are foreseen, the use of pre-thawed cryoprecipitate can be considered as a viable option.

Comparison of in-vitro and in-vivo parameters of whole blood derived random donor platelets (RDP) after over-night hold with RDP prepared after 2-h hold: Single centre report from India.

BACKGROUND: Random Donor Platelet (RDP) derived from whole blood is the major source of platelets in India. At our centre, we prepare RDPs by buffy coat method after a holding period of 2-hours (THRDP) as per current regulatory guidelines. Overnight hold of buffy coats before RDP preparation (OHRDP) would logistically optimise the manpower usage at our centre. The aim of this study was to compare both in-vitro as well as in-vivo parameters of OHRDPs with THRDPs. METHODOLOGY: Hematological (Platelet, leucocyte counts), physical (pH and Swirling) and biochemical parameters (pO2, pCO2, lactate, bicarbonate and glucose) as well as platelet activation markers were tested in THRDPs and OHRDPs each at Day-1 and Day-5 as in-vitro studies. Separately, in-vivo study was done where Corrected count increment (CCI) and percentage platelet recovery (PPR) were considered. All parameters were expressed as Mean ± Standard deviation and were analysed using paired t-test with level of significance, p < 0.05. RESULTS: OHRDPs had higher platelet counts and lower leucocytes and CD62 P expression than THRDPs. All other markers were well within the quality control range in both groups. No significant differences were seen in the two groups when comparing CCI and PPR. CONCLUSION: OHRDPs were found to be as good or better as compared to the THRDPs in the in-vitro part of our study. Additionally, there were no significant differences between the two groups when they were compared in vivo. This makes us conclude that overnight hold of buffy coats may be implemented at our center.