Unraveling the Impact of Blood Transfusion on Transcription Factors Regulating T Helper 1, 2, 17 and Regulatory T cells.

T helper 1 (TH1) and TH2 lymphocytes are the most important components of the immune system affected by blood transfusion. This study aimed`` to evaluate the effect of blood transfusion on gene expression of transcription factors related to the development of TH1, TH2, TH17 and regulatory T cells (Tregs). In this cross-sectional study, 20 patients diagnosed with abdominal aortic aneurysms requiring surgical repair were studied from January 2018 to August 2020. We utilized real-time PCR to evaluate the expression of transcription factor genes associated with TH1, TH2, TH17, and Treg, namely T-box-expressed-in-T-cells (T-bet), GATA-binding protein 3 (GATA-3), retinoid-related orphan receptor (RORγt), and fork head box protein 3 (Foxp3), respectively. The sampling occurred before anesthesia, 24- and 72 hours post-transfusion, and at the time of discharge. The results showed that the T-bet gene expression, compared to the time before transfusion, was significantly decreased 24 hours after blood transfusion and upon discharge while GATA3 genes exhibited a significant reduction both 24 and 72 hours after the transfusion, as compared to the pre-transfusion levels and the time of patient discharge. The Foxp3 gene demonstrated an increase at all study stages, with a notable surge, particularly 72 hours after red blood cell (RBC) transfusion. Conversely, the expression of RORγt gene, consistently decreased throughout all stages of the study. RBC transfusion in abdominal aortic aneurysm patients altered the balance of transcription gene expression of TH1, TH2, TH17, and Treg cells.

Blood Products Utilization Status in Off-Pump Cardiac Surgery Patients.

Background: Transfusion support has an essential role in coronary artery bypass graft (CABG). The time-honored gold standard for CABG is the on-pump procedure (ONCAB); however, off-pump coronary artery bypass (OPCAB) is also a safe, cost-benefit procedure with fewer blood transfusion requirements. This study was performed to evaluate transfusion patterns in OPCAB due to the diversity of transfusion practices. Materials and Methods: This retrospective study was performed to determine the transfusion rate and triggers in OPCAB patients. Medical files of all patients undergoing OPCAB surgery at Sanandaj Tohid Hospital in 2014 were reviewed. Patients' demographics data, preoperative laboratory tests (PT, aPTT, Hb, Hct, Platelet count), underlying medical conditions, and their possible relation to further transfusions and the ward department in which the transfusion had taken place were extracted. SPSS 16 Chicago software, T-student Test, One Way Anova, and χ2 exam were applied for data analysis. P values ≤0.05was considered significant. Results: Among 91 elective OPCAB patients: 28(30.8%) women and 63(69.2%) men with mean age of 64.80±9.02 years, 63(69.23%) received a blood product. Mean utilization of PRBC, FFP, Platelet, and Cryoprecipitate were 2.17±2.044, 2.46±2.86, 2.86±3.80 and 0.40±2.10 units, respectively. ICU revealed the highest consumption rate for all products.  Female sex (p<0.001), Hypertension (P=0.002), and low hemoglobin(P=0.004) were noted as predictive factors for transfusion.  Conclusion: This study concluded that the transfusion rate in OPCAB is still very high in Iran (regarding a study in a countryside hospital) and that the highest utilization rate is seen in the ICU.

Evaluating Preoperative Intravenous Iron and Erythropoietin Treatment and Outcomes in Cardiac Surgery Patients.

Background: Anemia is more common in cardiac surgery patients than in other people. Severe anemia before cardiac surgery strongly predicts blood transfusion. Objectives: This study aimed to evaluate the outcomes of Intravenous (IV) iron and erythropoietin (EPO) injection preoperatively in anemic patients waiting for coronary artery bypass graft (CABG) surgery. Methods: This cross-sectional study was performed between May to December 2020 at Masih Daneshvari hospital in Tehran, Iran. Anemia was described according to the WHO definition (Hb < 130 g/L in men). The study was designed in two groups of men CABG patients. Hematocrit level, platelet count, partial thromboplastin time, international normalized ratio, prothrombin time before surgery, red blood cells (RBCs) transfusion, as well as plasma and platelet units' transfusion during surgery and at the time of hospitalization were obtained from patient's files. The length of stay in the hospital and the consequences, including infection, stroke and heart attack, and mortality, were also obtained from the patient's files and recorded in the checklists. Pearson's chi-squared test, Fisher's exact test, independent samples t-test, univariate logistic regression, and odds ratio (OR) were used. All statistical analyses were performed by the SPSS software version 21. The significance level in this study was considered 0.05. Results: In this study, the data of 64 patients were gathered, among whom 16 (25%) were injected with IV iron and EPO, and the remaining 48 (75%) did not receive any medications for stimulating erythropoiesis. The mean age of patients was 64.05 ± 8.21 years, with an age range of 51 - 91 years. Infection (P = 0.258) and mortality rate (P = 0.440) in the two groups of injection and non-injection did not show a statistically significant difference. The duration of the clamp at the time of surgery (r = 0.699, P = 0.001) and the duration of hospitalization (r = 0.399, P = 0.023) had statistically significant positive relationships with the pump duration. Red blood cell consumption in the injection and non-injection groups was 2.50 ± 2.07 and 2.90 ± 1.80 (P = 0.469), respectively. Conclusions: Infection (P = 0.258), mortality rate (P = 0.440), and RBC utilization (P = 0.469) in the two groups of injection and non-injection were not significantly different.

Comparison mitochondrial DNA DAMPs changes in platelet prepared by apheresis and PRP.

INTRODUCTION: Mt DNA (DAMPs) plays a key modulatory role in immune cells and may also mediate a variety of adverse transfusion reactions. MATERIAL AND METHOD: The cross-sectional study was performed on 22 (PRP) and 14 (SDP) between February 2019 and 2020. mtDNA DAMPs by quantitative real-time PCR was assessed on days 1, 3, and 5 of platelets storage. The data was entered in REST 2009 software, and the amount of fold change was calculated. Multiple t tests were also used. RESULTS: The mtDNA DAMPs fold change in SDP on days 1-3, 1.3 times, on days 3-5, 1.5 times, and on days 1-5, 2.1 times increased. The fold change on days 1-3, 0.8 times, on days 3-5, 0.6 times, and on days 1-5, 0.49 times decreased in PRP products. CONCLUSION: The method of preparation and processing can affect mtDNA DAMPs fold changes.

The effect of platelet apheresis collection on some immunological factors in donors using two different apheresis devices.

INTRODUCTION: The aim of this study was to evaluate and compare two different apheresis and changes in some immunological factors in donors. MATERIAL AND METHODS: The cross-sectional study was performed from January 2017 to September 2018. Fifty six male blood donors were randomly divided into two groups. CD4, CD8, and CD25 markers by flow cytometry, and TGFBeta by real-time polymerase chain reaction (RT-PCR) method were done before and 7 days after the apheresis procedure. Independent Sample t-test, Mann-Whitney U Test, Wilcoxon signed ranked test, and Fisher exact test were used. RESULTS: WBC in MCS+ group after donation is significantly higher than before donation (P < 0.05) but no significant difference was seen between MCS+ and Trima groups in these two indicators. But in CD4, CD25, and TGFBeta, there was no significant difference between the two groups. CONCLUSION: There was no significant difference on CD4, CD25, and TGFBeta gene 7 days after donation.

Evaluating the Importance of Patient Blood Management During COVID-19 Pandemic.

Due to the COVID-19 pandemic, the demand for blood products may decrease as the health care system shifts toward treating the increased number of patients afflicted with COVID-19 and delaying selective surgeries and emergency procedures. One of the most important problems for blood transfusion services during COVID-19 pandemic is the reduction in the number of donors and a decrease in blood stocks. This happens due to the limitations of attendance of donors in blood centers, lack of awareness, misinformation, fear of being infected while donating blood, and restricting the freedom of blood collection teams to attend public places. Blood transfusion services should be prepared and well-responded in a timely manner. In this regard, appropriate use of blood, diminishing unnecessary transfusions, and implementation of patient blood management (PBM) principles are considered as significant measurements. PBM can help maintain blood supply throughout the crisis and reduce the pressure on blood demand. As a result, blood products can be saved for patients who need it urgently. PBM focuses on the patient, as well as the conditions that make patients transfuse blood, such as blood loss, coagulopathy, platelet dysfunction, and anemia. Thus, the majority of health systems in different countries have made recommendations to the PBM in hospitals.

Heparin-Induced Thrombocytopenia in Iranian Cardiac Surgery Patients Using the 4Ts Clinical Scoring System and Laboratory Methods.

Background: Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction. HIT diagnosis needs an algorithmic approach including clinical evaluation and laboratory tests (screening and confirmatory). Few studies have been conducted on HIT in Iran, and most existing research has been general and based on clinical evaluations alone. The present study was conducted to determine the prevalence of HIT among cardiac surgery patients using an algorithmic approach. Materials and Methods: A cross-sectional study was carried out over a period of 10 months, at Modares Hospital (Tehran, Iran) on 92 patients who were candidates for cardiac surgery. For the clinical evaluation, the 4Ts scoring system was used; in cases with 4Ts scores ≥4, a laboratory evaluation of anti-PF4/heparin antibody (Ab) was performed by enzyme-linked immunosorbent assay (ELISA) and a HIPA test too as a functional confirmatory method. The patients with 4Ts scores ≥4 who were ELISA positive (OD ≥0.2) and HIPA positive were taken as a definite case of HIT. Results: Of the 92 patients who had undergone cardiac surgery, 14 (15%) had 4Ts scores ≥4. Anti- PF4/heparin Ab was detected in eight patients using the ELISA and in six patients using the HIPA. Ultimately, definite HIT was confirmed in five of the patients. Conclusion: The prevalence of HIT was 5.4% among the cardiac surgery patients assessed in the present study. To the researchers' knowledge, this is the first time that HIT has been evaluated in Iran using a comprehensive algorithmic approach including clinical history-taking and both immunological and functional laboratory tests, and the findings showed a slightly higher HIT frequency in this single-center study in comparison with the other studies carried out in other countries.

Therapeutic Plasma Exchange in Tehran Between 2011 and 2014.

The goal of therapeutic plasma exchange (TPE) is to remove autoantibodies, pathogenic molecules, immune complexes, toxins, high concentration lipoproteins, and pathological proteins. We aimed to present the most common indication of TPE and rate of admission to the intensive care unit. From 2011 to 2014, our retrospective study was conducted including 1069 inpatients from the Tehran Blood Transfusion Center, which was responsible for performing therapeutic apheresis in all 122 hospitals of Tehran. The patients, based on their TPE indication, were classified into five groups: hematological and oncological, neurological, renal, rheumatological diseases, and all the remaining diseases. We performed 6329 procedures of TPE on 1069 inpatients. Of the patients, 479 (44.8%) were male and 590 (55.2%) female. Their age varied from a minimum of 2 years to the maximum of 93 years. Overall, the mean of TPE sessions for each patient was 5.92 ± 3.9; 415 (38.8%) patients were admitted to the intensive care unit (ICU). ASFA categories I/II indications were considered an appropriate request for TPE, and 82.97% (887) of all TPE were suitable. The most frequent categories of TPE indications are as follows: neurological, hematological, and renal diseases. Class I/II indications in the neurological diseases, myasthenia gravis (21.7%), Guillain-Barré disease (21%), and multiple sclerosis (13.3%), were the most prevalent. In the hematological category, thrombotic thrombocytopenic purpura (TTP) (14.1%) was observed to be greater than the other indications. We observed that the most prevalent illnesses are neurological (myasthenia gravis), hematological (TTP), and renal.

Therapeutic apheresis in neurological, nephrological and gastrointestinal diseases.

Therapeutic plasma exchange (TPE) is a process in which plasma containing antibodies, immune complexes, inflammatory moderators, paraproteins and other toxins which are believed to be the cause of disease is removed from a patient. TPE is the first-line treatment (category I, level 1A) in all forms of Acute inflammatory demyelinating polyradiculoneuropathy disease (axonal, demyelinating and miller-fisher variant) as well as in acute myasthenic crisis, chronic inflammatory demyelinating polyradiculoneuropathy and Paraproteinemic neuropathies (category I, level 1B). Moreover, TPE in kidney diseases, for instance: desensitization in renal transplantation(ABO compatible) (living donor)and desensitization in deceased donor, desensitization in renal transplantation(ABO incompatible) (living donor), thrombotic microangiopathy complement Mediated (Factor H autoantibodies), Focal segmental glomerulosclerosis(recurrent in transplanted kidney), ANCA-associated rapidly progressive glomerulonephritis(Dialysis dependence, DAH), Anti-Glomerular basement membrane disease Goodpasture's syndrome)(DAH,Dialysis-independence,) has been utilized as an initial treatment. (category I) TPE has been used as the key therapeutic modality to reduce anti-A or anti-B antibody titers in the liver peri-transplant period with the goal of preventing rejection and facilitating graft survival. Also, plasma exchange is the first-line therapy in Wilson's disease (category I, level1C).

Therapeutic Plasma Exchange in a rare case myasthenic crisis after Botox injection.

BACKGROUND AND AIMS: Botulinum toxin (Botox) injections are used as a cosmetic treatment to decrease wrinkles in face and chin. Being a neurotoxic agent it minimizes muscle activity, while side effects are usually rare. This article subsequently presents one case of these rare effects. CASE: A 30-year-old woman presenting with ptosis, diplopia, dysarthria, dysphagia and muscle weakness was admitted to our hospital. She had no history of disease. For cosmetic reasons, she had three Botox injections during the preceding months. On physical examination, muscle weakness 4/5 (cervical extensor, ocular and pharynx) was detected and a diagnosis of myasthenia gravis was made. Protective artificial ventilation was necessary. As a consequence, eight sessions of 2.5 L volume Therapeutic Plasma Exchange (TPE) were applied using normal saline/albumin as substitute. Due to TPE, her muscle force and clinical condition improved. Artificial ventilation could be stopped. CONCLUSIONS: Clinical symptoms of myasthenia gravis and systemic Botox effects are very similar. This should be taken into consideration during medical history taking. The injection of high doses of Botox (more than 200 units in every injection) or boostering within less than one month is dangerous. (Botox BCC2024). Systemic side effects can be treated using TPE to lower the circulating dose of Botox.

A successful experience of the Iranian blood transfusion organization in improving accessibility and affordability of plasma derived medicine.

Plasma is the liquid part of blood. It is estimated 21.6 million liters of plasma collect from Whole blood annually. From these plasma, 4.2 million liters transfuse, 8.1 million liters fractionate, 9.3 million liters waste. Nowadays, blood products and PDM (plasma derived medicine) consider as essential medicine in modern health care and transfusion medicine. Iranian blood transfusion organization as a non-profit organization was established in 1974 in order to centralize all blood transfusion activities from donor recruitment to distribution of blood components to hospitals. Iran is the only country in EMR region with the rate of 20-29.9 blood donations per 1000 population and reached 100% voluntary non-remunerated blood donation in 2007. RBCs and platelets demand are much more than FFPs so the IBTO was faced the surplus plasma that could cause surplus plasma wastage. Simultaneously, hospitals need more plasma derived medicine especially albumin, IVIG, factor VIII, factor IX. IBTO was faced the challenges such as Fractionators selection, Plasma volume shipment, Contract duration, Product profile, Multiple External audits, Cold chain maintenance, Transporting plasma across international borders, NAT test. To overcome plasma wastage and storage of PDM. IBTO involved toll manufacturing in 2005 and not only prevents plasma wastage but also save MOH (ministry of health) budget.

Pre-operative blood donation versus acute normovolemic hemodilution in cardiac surgery.

INTRODUCTION: Acute normovolemic hemodilution (ANH) and preoperative autologous blood donation (PABD) have questionable efficacy, viral and bacterial infection risks, intermittent blood shortages as homeostasis problem, electrolyte and hemodynamic disturbances. MATERIALS AND METHODS: In this cross sectional survey, we studied 70 patients undergoing open heart coronary artery bypass grafts [CABG] and different valvular replacement 1 ml surgery (35 in ANH, 35 in PABD) in Shaheed Modares - Hospital. We measured electrolytes and homeostatic factors to evaluate the influence of two transfusion methods on homeostatic function and hemodynamic balance. RESULTS: We compared 70 patients (38 male [54.3%] and 32 female [45.7%]) with mean age 54.8 years undergoing open heart surgery (CABG and valvular). In ANH group, significant decrease was detected in Na (28.5%) K (2.5%), prothrombin time (PT) (88.57%), partial thromboplastin time (PTT) (94.28%), creatine phosphokinase (CPK) (11.4%), lactic dehydrogenase (LDH) (11.43%), albumin (Alb) (17.14%), globulin (91.43%) and total protein (80%). Mean initial and post-operative hemoglobin was 14.12 ± 1.06 versus 11.97 ± 0.98, hematocrit 42.22 ± 3.45 versus 35.40 ± 2.88, systolic blood pressure 124.1 ± 14.4 versus 110.88 ± 15.6 (reduction 22.86%) diastolic blood pressure 76.02 ± 10 versus 69.26 ± 11 (reduction 3%) and pulse rate was 75.45 ± 10 versus 84.45 ± 12 (12%) in this case difference between two groups was strongly significant (P = 0.001). In PABD group, significant decrease was detected in Na (20%), K (2.5%), PT (91.43%) PTT (80%), CPK (8.57%), LDH (5.72%), Alb (57.15%), globulin (71.43%) and total-protein (62.85%), the value of hemodynamic changes were in normal range. CONCLUSION: Though autologous blood transfusion (ANH and PABD) was preferable to allogeneic transfusion in cardiac surgical patients; but PABD offers more advantages in homeostasis, hemodynamic stability and electrolyte balance.