Therapeutic plasma exchange in HELLP syndrome: A life savior.

BACKGROUND: HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome occurs in about 0.5%-0.9% of all pregnancies, but its prevalence is higher in patients with severe preeclampsia, accounting for a substantial maternal and perinatal morbidity and mortality. According to the latest American Society for Apheresis guidelines, Therapeutic plasma exchange (TPE) performed for postpartum cases and antepartum HELLP syndrome cases fall in Categories III and IV, respectively. MATERIALS AND METHODS: Retrospective analysis was done at our tertiary care center from January 2014 to June 2019 for patients diagnosed with HELLP syndrome. Clinical data for age, gestational age at the time of diagnosis, type of delivery, outcome of pregnancy, history of preeclampsia /eclampsia, hemoglobin levels, AST, ALT, LDH, platelet counts, prothrombin time, activated partial thromboplastin time, international normalised ratio, complete blood count, was obtained from patients' electronic medical records. The TPE was initiated within 24 hrs of diagnosis. All TPE was done on Spectra Optia apheresis system (Terumo BCT, Inc, USA). Statistical testing was conducted with the statistical package for the social science system version SPSS 20.0 and R-3.2.0. Continuous variables were expressed as mean±SD and were compared between Pre and Post TPE records of patients by using the paired T test. RESULTS: Nine patients fulfilled the criteria of HELLP syndrome. Seven (77.8%) were diagnosed in the postpartum period and 2 (22.2%) during the second trimester. Out of the total nine patients, two patients (22.2%) recovered completely and were discharged on day 15 ± 7 days, whereas 4 (44.4%) patients were discharged on day 21 ± 7 days with the advice of hemodialysis. Two (22.2%) patients had an intrauterine death and were discharged 3-4 days after the demise. In all these patients (except one), the TPE was initiated within 24 h of the diagnosis. A significant increase in platelet count and decrease in the lactate dehydrogenase levels (P < 0.05) was observed post TPE. CONCLUSION: Our data showed that TPE improved the treatment outcome in patients with HELLP syndrome despite being a Category III and IV indication among postpartum and antenatal females, respectively. However, a timely diagnosis and management are of paramount importance for a favorable outcome. TPE needs to be performed within 24 h of the diagnosis postdelivery when the patient is not responsive to the usual therapies, especially in class I HELLP syndrome.

Assessing safety and efficacy of therapeutic plasma exchange in pediatric patients: A single-center experience.

INTRODUCTION: Therapeutic plasma exchange has been widely employed by clinicians for removal of the toxic constituents from plasma by filtration of whole blood and subsequent removal of plasma and reinfusion of cellular components along with a replacement fluid. It has become an accepted therapeutic modality in paediatric patients for numerous indications including but not limited to renal transplant, haemolytic uremic syndrome and Guillain Barre Syndrome. But, data on safety and efficacy are mainly derived from studies in the adult population with very limited data available in the paediatric age group. However, it is technically challenging in children due to their small circulating volume. This study discusses the clinical indications, efficacy, and safety of therapeutic plasma exchange in paediatric population. METHOD: We retrospectively reviewed the data of children (up to 18 years of age) who underwent TPE between January 2017 and March 2019 at our Hospital. Main features of the TPE procedures i.e. frequency of TPE, site of vascular access, type of replacement fluid used, instrument used, plasma volume processed, priming of the circuit, adverse events if any and outcome of the patients were analysed. RESULTS AND CONCLUSION: A total of 114 procedures were performed on these 24 patients. Fifteen patients with Category I indication showed good clinical outcome in terms of attainment of target ABO titre and/or decrease in the donor specific antibody. TPE is an effective therapeutic option in selected paediatric disorders. Our series of data on TPE procedures from paediatric perspective has shown safety and efficacy of the therapy.

ABO-incompatible granulocyte transfusion: Is ABO subgroup a barrier?

Granulocyte transfusion (GTx) is an efficient and compelling treatment option for patients with neutropenia following hematopoietic stem cell transplant. The donor pool for granulocyte harvest is limited to close friends and family members and the donors accepted are often of the same ABO Rh type. We report a case of ABO-incompatible prophylactic GTx, in a case of acute myeloblastic leukemia. Postcollection processing of the granulocyte product was done to reduce the red blood cell volume to <5 ml, making it safe for transfusion. The transfusion was successful in stabilizing the total leukocyte counts in the patient. The patient was monitored, and there were no adverse reactions posttransfusion.

Platelet additive solution suspended apheresis platelets in a tertiary care hospital: A step toward universal single donor platelets.

BACKGROUND: Transfusion of ABO-compatible single donor platelets (SDP) is preferable for better outcomes over group switchover SDP. The use of SDP containing ABO-incompatible plasma is associated with a risk of allergic and acute hemolytic transfusion reactions. Moreover, high titer O group donors SDP impose a further threat to patient safety. Platelet additive solution (PAS) is used worldwide for the storage of platelets which reduces plasma volume available in SDP. SSP + (Macopharma) is one such PAS which can provide improved availability, logistical management, decrease wastage, and improvement in patient safety. The aim of this study was to assess the feasibility of using PAS to obtain low titer SDP units which can be utilized across a larger patient population and to study quality control parameters of these units. MATERIALS AND METHODS: The study was performed in the department of Transfusion Medicine from June 2017 to January 2018 after clearance from the Institutional Review Board. The study design comprised two cohorts (A and B). In cohort A, the temporal trend of in-vitro changes in the quality parameters was tested and analyzed for PAS modified and unmodified products on days 1, 5 and 7. In cohort B, the original plasma from the SDP donors of all blood group donors except the AB group was tested for antibody titers before (prepreparation) and after modification (postpreparation) by PAS. RESULTS: In cohort A, in the control group, there was a significant change in the mean platelet volume, potassium, and bicarbonate levels from day 1 to day 7, whereas no significant change in the biochemical parameters was noted in the study group where PAS was used. In cohort B, on comparing the anti-A and anti-B, before and after modification of SDP with PAS, there was a significant reduction in the median titers across all the groups studied. CONCLUSION: PAS added SDP is an efficient strategy to reduce the ABO-antibody levels significantly. PAS added SDP also helps in the better inventory management of available groups.

A case of rare anti-Hro alloantibody in a tertiary care center in India.

Anti-Hro is an alloantibody produced in individuals with -D- phenotype after a sensitizing event. Owing to the rarity of this antigen negative unit, registration in rare donor registries helps in procuring blood components at the earliest. We had a patient of -D- with anti-Hro antibody who required 7 units of red cells which was unavailable at our center. The patients near relatives were typed in search of a similar phenotype blood. Search was made for the rare units and Japanese Red Cross Society, American Red Cross Society, and International Blood Group Reference Laboratory, United Kingdom was contacted. Patient's brother and mother were typed as -D- and one unit from each of them was collected, irradiated, and transfused to the patient. Five units were imported from the Japanese Red Cross Society, Japan. Accessibility for identification and confirmation of rare blood groups and provision of the same can be centralized and liaison with the international registries can go a long way in the provision of blood components at the earliest.

Evaluation of bacterial inactivation in random donor platelets and single-donor apheresis platelets by the INTERCEPT blood system.

BACKGROUND: Blood transfusion of contaminated components is a potential source of sepsis by a wide range of known and unknown pathogens. Collection mechanism and storage conditions of platelets make them vulnerable for bacterial contamination. Several interventions aim to reduce the transfusion of contaminated platelet units; however, data suggest that contaminated platelet transfusion remains very common. AIM: A pathogen inactivation system, "INTERCEPT", to inactivate bacteria in deliberately contaminated platelet units was implemented and evaluated. MATERIALS AND METHODS: Five single-donor platelets (SDP) and five random donor platelets (RDP) were prepared after prior consent of donors. Both SDP and RDP units were deliberately contaminated by stable stock ATCC Staphylococcus aureus and Escherichia coli, respectively, with a known concentration of stock culture. Control samples were taken from the infected units and bacterial concentrations were quantified. The units were treated for pathogen inactivation with the INTERCEPT (Cerus Corporation, Concord, CA) Blood system for platelets (Amotosalen/UVA), as per the manufacturer's instructions for use. Post illumination, test samples were analyzed for any bacterial growth. RESULTS: Post-illumination test samples did not result in any bacterial growth. A complete reduction of >6 log10 S. aureus in SDP units and >6 log10 Escherichia coli in RDP units was achieved. CONCLUSION: The INTERCEPT system has been shown to be very effective in our study for bacterial inactivation. Implementation of INTERCEPT may be used as a mitigation against any potential bacterial contamination in platelet components.

Red cell alloimmunization & role of advanced immunohaematological support in liver transplantation.

BACKGROUND & OBJECTIVES: Transfusion support forms an integral part of liver transplantation programme. Advanced immunohaematology services are required to deal with complex serological problems that can complicate transfusion therapy in these patients. Here, we report on red cell alloimmunization and presence of alloimmunization in donors and patients undergoing liver transplantation in a tertiary care hospital in north India. METHODS: Records of 1433 liver transplants performed from January 2009 to March 2015 were retrieved and reviewed. Antibody screening was performed both for liver donors, and recipients and antibody identification was performed for the screen-positive patients. RESULTS: Of the 1433 liver recipients, 32 (2.3%) developed antibodies. Seventeen patients had one or more alloantibodies, five had autoantibodies with an underlying alloantibody and 10 had only autoantibodies in their plasma. The overall alloimmunization rate was 1.5 per cent with 25 alloantibodies identified in 22 patients. Anti-E was the most common specificity identified. INTERPRETATION & CONCLUSIONS: The presence of alloantibodies can complicate transfusion therapy in patients undergoing liver transplantation, who are already at a high risk of being heavily transfused owing to the nature of surgery and the haemostatic dysfunction from chronic liver disease. Therefore, screening for irregular red cell alloantibodies combined with a rational blood transfusion policy may be essential for these patients.

ABO incompatible renal transplant: Transfusion medicine perspective.

INTRODUCTION: Our study presents an analysis of the trends of ABO antibody titers and the TPE (Therapeutic Plasma Exchange) procedures required pre and post ABO incompatible renal transplant. MATERIALS AND METHODS: Twenty nine patients underwent ABO incompatible renal transplant during the study period. The ABO antibody titers were done using the tube technique and titer reported was the dilution at which 1+ reaction was observed. The baseline titers of anti-A and anti-B antibodies were determined. The titer targeted was ≤8. Patients were subjected to 1 plasma volume exchange with 5% albumin and 2 units of AB group FFP (Fresh Frozen Plasma) in each sitting. TPE procedures post-transplant were decided on the basis of rising antibody titer with/ without graft dysfunction. RESULTS: The average number of TPE procedures required was 4-5 procedures/patient in the pretransplant and 2-3/patient in the post-transplant period. An average titer reduction of 1 serial dilution/procedure was noted for Anti-A and 1.1/procedure for Anti-B. Number of procedures required to reach the target titer was not significantly different for Anti-A and Anti-B (P = 0.98). Outcome of the transplant did not differ significantly by reducing titers to a level less than 8 (P = 0.32). The difference in the Anti-A and Anti-B titers at 14th day post-transplant was found to be clinically significant (P = 0.042). CONCLUSION: With an average of 4-5 TPE procedures pretransplant and 2-3 TPE procedures post transplants, ABO incompatible renal transplantations can be successfully accomplished.

Impact of antigenic exposures and role of molecular blood grouping in enhancing transfusion safety in chronically transfused thalassemics.

BACKGROUND: Red cell alloimmunization is an acknowledged complication of blood transfusion. Current transfusion practices for thalassemia do not cater to this risk. Serological phenotyping is usually not reliable in these cases unless performed before the first transfusion. Under such circumstances, molecular blood grouping is an effective alternative. AIM: To perform molecular blood group genotyping in chronically transfused thalassemia patients and assess the risk of antigenic exposure and incidence of alloimmunization with current transfusion protocols. MATERIALS AND METHODS: Molecular blood group genotyping was performed for 47 chronically transfused thalassemia patients. Their 1-year transfusion records were retrieved to assess the antigenic exposure and the frequency thereof. RESULTS: Of 47 patients, 6 were already alloimmunized (3 with anti-E and 3 with anti-K) and were receiving the corresponding antigen negative units. We observed that random selection of ABO and Rh D matched units resulted in 57.7% ±8.26% chance of Rh and Kell phenotype matching also. Forty-four patients had received one or more antigenic exposures at least once. The 6 already alloimmunized patients were further exposed to antigens other than the ones they were immunized to. During the study period, only one patient developed an alloantibody, anti-E with exposure to antigens C (92%) and/or E (32%) at each transfusion. CONCLUSION: Several factors apart from mere antigen exposure may influence the development of alloimmunization as most of our patients received antigenic exposures but not alloimmunized. Our data provide an impetus for future large-scale studies to understand the development of alloimmunization in such patients.

Separation of boron from borated paraffin wax by pyrohydrolysis and alkali extraction methods and its determination using ion chromatography.

A method based on the pyrohydrolysis extraction of boron and its quantification with ion chromatography was proposed for paraffin waxes borated with H3BO3 and B4C. The optimum pyrohydrolysis conditions were identified. Wax samples were mixed with U3O8, which prevents the sample from flare up, and also accelerates the extraction of boron. Pyrohydrolysis was carried out with moist O2 at 950°C for 60 and 90 min for wax with H3BO3 and wax with B4C, respectively. Two simple methods of separation based on alkali extraction and melting wax in alkali were also developed exclusively for wax with H3BO3. In all the separations, the recovery of B was above 98%. During IC separation, B was separated as boron-mannitol anion complex. Linear calibration was obtained it between 0.1 and 50 ppm of B, and LOD was calculated as 5 ppb (S/N = 3). The reproducibility was better than 5% (RSD).

A multivariate analysis to assess the effect of packed red cell transfusion and the unit age of transfused red cells on postoperative complications in patients undergoing cardiac surgeries.

BACKGROUND: Transfusion of blood components and age of transfused packed red cells (PRCs) are independent risk factors for morbidity and mortality in cardiac surgeries. MATERIALS AND METHODS: We retrospectively examined data of patients undergoing cardiac surgery at our institute from January 1, 2012 to September 30, 2012. Details of transfusion (autologous and allogenic), postoperative length of stay (PLOS), postoperative complications were recorded along with other relevant details. The analysis was done in two stages, in the first both transfused and nontransfused individuals and in the second only transfused individuals were considered. Age of transfused red cells as a cause of morbidity was analyzed only in the second stage. RESULTS: Of the 762 patients included in the study, 613 (80.4%) were males and 149 (19.6%) were females. Multivariate analysis revealed that factors like the number and age of transfused PRCs and age of the patient had significant bearing upon the morbidity. Morbidity was significantly higher in the patients transfused with allogenic PRCs when compared with the patients not receiving any transfusion irrespective of the age of transfused PRCs. Transfusion of PRC of over 21 days was associated with higher postoperative complications, but not with in-hospital mortality. CONCLUSION: In patients undergoing cardiac surgery, allogenic blood transfusion increases morbidity. The age of PRCs transfused has a significant bearing on morbidity, but not on in-hospital mortality. Blood transfusion services will therefore have to weigh the risks and benefits of providing blood older than 21 days in cardiac surgeries.

Antibody screening & identification in the general patient population at a tertiary care hospital in New Delhi, India.

BACKGROUND & OBJECTIVES: The development of alloantibodies can significantly complicate transfusion therapy and results in difficulties in cross-matching of blood. Most literature on alloimmunization is limited to multitransfused individuals, with very few studies on the general hospital patients. This study was aimed at assessing the frequency and type of unexpected red cell antibodies in the general patient population at a multispecialty tertiary care centre in New Delhi, India. METHODS: The results of 49,077 antibody screening tests carried out on patients, from January 2009 to December 2012 were analyzed. The clinical and transfusion records were reviewed. The data were compiled and statistically analysed. RESULTS: A total of 49,077 (29,917; 60.96% males and 19,160; 39.04% females) patient samples were screened for the presence of unexpected antibodies. Antibody screening was positive in 403 patients (0.82%). In the serum samples of 164 patients only autoantibodies were identified, 27 revealed autoantibodies with one or more underlying alloantibodies, while 212 patients had only alloantibody/ies in their serum. The overall alloimmunization rate was 0.49 per cent. Antibodies against the Rh system were the most frequent (64.1%), the most common alloantibody identified being anti E (37.2%), followed by anti D (19.2%). INTERPRETATION & CONCLUSIONS: Since clinically significant antibodies are frequently detected in our patient population, antibody screening and if required, identification is the need of the hour. Since antibodies against the common Rh and Kell blood group antigens are the most frequent, provision of Rh and Kell matched red cells may be of protective value.

Red cell alloimmunization and infectious marker status (human immunodeficiency virus, hepatitis B virus and hepatitis C virus) in multiply transfused thalassemia patients of North India.

BACKGROUND: Patients with thalassemia major are largely transfusion dependent and are thus exposed to a variety of risks such as transmission of infectious diseases, iron overload and alloimmunization. This study was performed to determine the prevalence of human immune deficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and red cell antibodies among multiple-transfused thalassemic patients in and around the national capital region. MATERIALS AND METHODS: The Department of Transfusion Medicine, Indraprastha Apollo Hospitals, conducted this study in collaboration with the National Thalassemia Welfare Society over a period of 1 year starting February2011. Blood samples from the patients were tested for blood group, red cell alloantibody/ies, anti-HIV, anti-HCV and hepatitis B surface antigen (HBsAg) by ELISA and for the respective viral ribonucleic acid (RNA) or deoxyribonucleic acid (DNA) by nucleic acid testing (NAT). RESULTS: A total of 462 thalassemics which consists of 290 males and 172 females were tested. The overall alloimmunization rate was 4.1% and anti-Kell was the most common antibody identified. Thirteen cases (2.8%) were positive for HBsAg by ELISA, 107 (23.1%) were reactive for anti HCV and 11 (2.38%) for anti HIV antibodies. Further screening and discriminatory assays by NAT confirmed the presence of HBV DNA in 11 cases, HIV RNA in 7 cases and HCV RNA in 48 cases. CONCLUSION: In spite of advances in Immunohematology and infectious marker testing in recent years, the rates of alloimmunization and infectious marker positivity remains high among multiply transfused patients like thalassemics. Provision of safe and adequate blood supply to these patients is a key to improving their quality-of-life and longevity.

Evaluation of the red cell hemolysis in packed red cells during processing and storage.

INTRODUCTION: Storage of red cells causes a progressive increase in hemolysis. In spite of the use of additive solutions for storage and filters for leucoreduction, some amount of hemolysis is still inevitable. The extent of hemolysis, however, should not exceed the permissible threshold for hemolysis even on the 42(nd) day of storage. STUDY DESIGN AND METHODS: Eighty units of packed red cells, 40 stored in SAGM post leucoreduction and 40 in ADSOL without leucoreduction filters, were evaluated for plasma hemoglobin by HemoCue Plasma Hemoglobin analyzer on the day of collection and on the 7(th), 14(th), 21(st), 28(th), 35(th) and 42(nd) days thereafter. The hemoglobin and hematocrit were also noted for all these units by the Beckman and Coulter analyzer. Percentage hemolysis was then calculated. OBSERVATIONS: Hemolysis progressively increased with the storage period in all the stored red cell units (SAGM as well ADSOL). However, on day 42(nd) of storage, free hemoglobin in all the red cell units was within the permissible level (which is 0.8% according to the Council of Europe guidelines and 1% as per the US FDA guidelines). The mean percentage hemolysis was slightly higher in the SAGM-containing bags with an integral leucoreduction filter as compared to the bags containing ADSOL. However this difference was marginal and not statistically significant. CONCLUSION: Hemolysis of the red cells increases with storage. However, maximum hemolysis does not exceed the permissible limits at any time thereby indicating the effect of optimum processing and storage conditions on red cell hemolysis.