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Across western North America (WNA), 20th-21st century anthropogenic warming has increased the prevalence and severity of concurrent drought and heat events, also termed hot droughts. However, the lack of independent spatial reconstructions of both soil moisture and temperature limits the potential to identify these events in the past and to place them in a long-term context. We develop the Western North American Temperature Atlas (WNATA), a data-independent 0.5° gridded reconstruction of summer maximum temperatures back to the 16th century. Our evaluation of the WNATA with existing hydroclimate reconstructions reveals an increasing association between maximum temperature and drought severity in recent decades, relative to the past five centuries. The synthesis of these paleo-reconstructions indicates that the amplification of the modern WNA megadrought by increased temperatures and the frequency and spatial extent of compound hot and dry conditions in the 21st century are likely unprecedented since at least the 16th century.
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CONTEXT.: Modern RHD genotyping can be used to determine when patients with serologic weak D phenotypes have RHD gene variants at risk for anti-D alloimmunization. However, serologic testing, RhD interpretations, and laboratory management of these patients are quite variable. OBJECTIVE.: To obtain interlaboratory comparisons of serologic testing, RhD interpretations, Rh immune globulin (RhIG) management, fetomaternal hemorrhage testing, and RHD genotyping for weak D-reactive specimens. DESIGN.: We devised an educational exercise in which 81 transfusion services supporting obstetrics performed tube-method RhD typing on 2 unknown red blood cell challenge specimens identified as (1) maternal and (2) newborn. Both specimens were from the same weak D-reactive donor. The exercise revealed how participants responded to these different clinical situations. RESULTS.: Of reporting laboratories, 14% (11 of 80) obtained discrepant immediate-spin reactions on the 2 specimens. Nine different reporting terms were used to interpret weak D-reactive maternal RhD types to obstetricians. In laboratories obtaining negative maternal immediate-spin reactions, 28% (16 of 57) performed unwarranted antiglobulin testing, sometimes leading to recommendations against giving RhIG. To screen for excess fetomaternal hemorrhage after a weak D-reactive newborn, 47% (34 of 73) of reporting laboratories would have employed a contraindicated fetal rosette test, risking false-negative results and inadequate RhIG coverage. Sixty percent (44 of 73) of laboratories would obtain RHD genotyping in some or all cases. CONCLUSIONS.: For obstetric and neonatal patients with serologic weak D phenotypes, we found several critical problems in transfusion service laboratory practices. We provide recommendations for appropriate testing, consistent immunohematologic terminology, and RHD genotype-guided management of Rh immune globulin therapy and RBC transfusions.
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Transfusão Feto-Materna , Sistema do Grupo Sanguíneo Rh-Hr , Gravidez , Feminino , Humanos , Sistema do Grupo Sanguíneo Rh-Hr/genética , Imunoglobulina rho(D)/uso terapêutico , Imunoglobulina rho(D)/genética , Fenótipo , Genótipo , EritrócitosRESUMO
BACKGROUND: Thrombotic thrombocytopenic purpura (TTP) patients have increased risk for allergic transfusion reactions (ATR) due to the number of plasma products they require. This study evaluated the efficacy of solvent detergent treated plasma (S/D treated plasma) to reduce ATRs. STUDY DESIGN AND METHODS: All TTP patients who presented from April 2014 to February 2015 and experienced a moderate-severe ATR to untreated plasma with TPE were switched to S/D treated plasma (Octaplas) for their remaining procedures and included in the study. Patient records were retrospectively reviewed. RESULTS: The overall ATR rate per procedure decreased from 35.0% (95% CI = 15.4%-59.2%) with untreated plasma to 1.4% ([1/73] 95% CI = 0.0%-7.4%) with S/D treated plasma. The moderate-severe ATR rate decreased from 20.0% ([4/20] 95% CI = 5.7%-43.7%) with untreated plasma to 0.0% ([0/73] 95% CI = 0.0%-4.9%) with S/D treated plasma. The overall ATR rate per plasma unit decreased from 2.6% (95%CI = 1.0%-5.1%) with untreated plasma to 0.1% (95% CI = 0.0%-0.4%) with S/D treated plasma. No patients experienced VTE while receiving untreated plasma. Four patients experienced VTE events while receiving S/D treated plasma. All patients who experienced a VTE had additional risk factors for VTE. CONCLUSION: S/D plasma has promise as an effective product to reduce the risk of ATRs in TTP patients. Given the high risk of ATR in TTP patients, consideration of S/D plasma instead of untreated plasma for TPE in these patients may be warranted, especially for patients with a history of moderate to severe ATR. More extensive studies are needed to confirm these findings.
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Transfusão de Componentes Sanguíneos/efeitos adversos , Detergentes/uso terapêutico , Hipersensibilidade/prevenção & controle , Plasma , Púrpura Trombocitopênica Trombótica/terapia , Reação Transfusional/prevenção & controle , Feminino , Humanos , Masculino , Estudos RetrospectivosRESUMO
BACKGROUND: Antibody-mediated rejection (AMR) is a major barrier to the long-term function of renal allografts. White blood cells, which may be present in red blood cell (RBC) units, and platelets (PLTs) express HLA antigens that may increase the risk of AMR by inducing or increasing humoral sensitization to HLA. STUDY DESIGN AND METHODS: A retrospective cohort study of HLA-incompatible (HLAi) renal transplant recipients between 2004 and 2015 was conducted. Data on apheresis PLT and leukoreduced RBC transfusions within 4 weeks of transplantation, demographic information, and biopsy-proven AMR were collected from medical records and the Scientific Registry of Transplant Recipients. Patients were evaluated until they showed evidence of AMR or until 1 year posttransplant, whichever came first. Multivariable analysis with Cox modeling was performed. RESULTS: Of 244 individuals, 182 (74.6%) received RBCs and 20 (8.2%) of those also received PLTs. During the first year posttransplant, 97 (39.8%) had AMR. RBC-alone or RBC and PLT transfusions were not associated with increased risk of AMR after adjustment for panel-reactive antibody, years on dialysis, HLA antibody strength, and number of therapeutic plasma exchange treatments (adjusted hazard ratio [adjHR] 1.00, 95% confidence interval [95% CI] 0.59-1.69; and adjHR 0.68, 95% CI 0.28-1.68, respectively). For each 1-unit increase in RBC transfusions, there was no association with AMR (adjHR 0.94, 95% CI 0.85-1.05). Only HLA antibody strength before transplantation was associated with AMR (adjHR 2.23, 95% CI 1.10-4.52; cytotoxic crossmatch compared to crossmatch negative but detectable donor-specific HLA antibodies). CONCLUSIONS: Patients who receive an HLAi transplant who are transfused with leukoreduced RBCs or PLTs in the peritransplant period are at no higher risk of AMR than nontransfused patients.
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Aloenxertos/imunologia , Transfusão de Sangue/métodos , Rejeição de Enxerto/imunologia , Transplante de Rim/efeitos adversos , Procedimentos de Redução de Leucócitos , Adulto , Anticorpos/imunologia , Transfusão de Eritrócitos , Feminino , Histocompatibilidade , Humanos , Imunidade Humoral , Masculino , Pessoa de Meia-Idade , Transfusão de Plaquetas , RiscoRESUMO
Thyroid storm is a potentially lethal complication of hyperthyroidism with increased thyroid hormones and exaggerated symptoms of thyrotoxicosis. First-line therapy includes methimazole (MMI) or propylthiouracil (PTU) to block production of thyroid hormones as a bridge toward definitive surgical treatment. Untreated thyroid storm has a mortality rate of up to 30%; this is particularly alarming when patients cannot tolerate or fail pharmacotherapy, especially if they cannot undergo thyroidectomy. Therapeutic plasma exchange (TPE) is an ASFA category III indication for thyroid storm, meaning the optimum role of this therapy is not established, and there are a limited number of cases in the literature. Yet TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines and cytokines and is likely beneficial for these patients. We report a patient with thyroid storm who could not tolerate PTU, subsequently failed therapy with MMI, and was not appropriate for thyroidectomy. TPE was therefore performed daily for 4 days (1.0 plasma volume with 5% albumin replacement and 2 U of plasma). Over the treatment course, the patient's thyroid hormones normalized and symptoms of thyroid storm largely resolved; his T3 decreased from 2.27 to 0.81 ng/mL (normal 0.8-2.0), T4 decreased from 4.8 to 1.7 ng/mL (0.8-1.8), heart rate normalized, altered mental status improved, and he converted to normal sinus rhythm. He was ultimately discharged in euthyroid state. He experienced no side effects from his TPE procedures. TPE is a safe and effective treatment for thyroid storm when conventional treatments are not successful or appropriate.
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Troca Plasmática , Crise Tireóidea/terapia , Agendamento de Consultas , Humanos , Masculino , Terapia de Salvação/métodos , Resultado do TratamentoRESUMO
BACKGROUND: Hospital-wide massive transfusion protocols (MTPs) primarily designed for trauma patients may lead to excess blood products being prepared for nontrauma patients. This study characterized blood product utilization among distinct trauma and nontrauma MTPs at a large, urban academic medical center. METHODS: A retrospective study of blood product utilization was conducted in patients who required an MTP activation between January 2011 and December 2015 at an urban academic medical center. Trauma MTP containers included 6 red blood cell (RBC) units, 5 plasma units, and 1 unit of apheresis platelets. Nontrauma MTP containers included 6 RBC and 3 plasma units. RESULTS: There were 334 trauma MTP activations, 233 nontrauma MTP activations, and 77 nontrauma MTP activations that subsequently switched to a trauma MTP ("switched activations"). All nontrauma MTP activations were among bleeding patients who did not have a traumatic injury (100% [233/233]). Few patients with a nontrauma activation required ad hoc transfusion of RBC units (1.3% [95% confidence interval {CI}, 0.3%-3.7%]) or plasma (3.4% [95% CI, 1.5%-6.7%]), and only 45.5% (95% CI, 39.0%-52.1%) required ad hoc transfusion of apheresis platelets. Compared to trauma and switched activations, nontrauma activations transfused a lower median number of RBC, plasma, and apheresis platelet units (P < .001 for all comparisons). There was also a lower median number of prepared but unused plasma units for nontrauma activations (3; [interquartile range {IQR}, 3-5]) compared to trauma (7; [IQR, 5-10]; P < .001) and switched activations (8; [IQR, 5-11]; P < .001). The median number of unused apheresis platelet units was 1 (IQR, 1-2) for trauma activations and 0 (IQR, 0-1) for switched activations. There was a high proportion of trauma and switched activations in which all of the prepared apheresis platelet units were unused (28.1% [95% CI, 23.4%-33.3%] and 9.1% [95% CI, 3.7%-17.8%], respectively). CONCLUSIONS: The majority of initial nontrauma MTP activations did not require a switch to a trauma MTP. Patients remaining under a nontrauma MTP activation were associated with a lower number of transfused and unused plasma and apheresis platelet units. Future studies evaluating the use of hospital-wide nontrauma MTPs are warranted since an MTP designed for nontrauma patient populations may yield a key strategy to optimize blood product utilization in comparison to a universal MTP for both trauma and nontrauma patients.
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Centros Médicos Acadêmicos/métodos , Transfusão de Eritrócitos/métodos , Hospitais Urbanos , Troca Plasmática/métodos , Transfusão de Plaquetas/métodos , Ferimentos e Lesões/terapia , Transfusão de Sangue/métodos , Humanos , Estudos Retrospectivos , Ferimentos e Lesões/epidemiologiaRESUMO
BACKGROUND: Passenger lymphocyte syndrome occurs when donor lymphocytes are transplanted with a solid organ and produce alloantibodies that react with antigens on the recipient's red blood cells (RBCs). Typically, passenger lymphocyte syndrome presents as immunoglobulin G antibody-mediated, extravascular hemolytic anemia with reticulocytosis. Often, the donor was alloimmunized before transplantation. CASE REPORT: A 34-year-old Group O, D+ man with a negative antibody screen received a liver transplant from a Group O, D- donor. Twenty Group O, D+ RBC units were transfused on Postoperative Days (PODs) 0 through 2. On POD 7, the patient developed anemia, a weakly positive antibody screen, and a positive direct antiglobulin test with anti-D in the eluate. After POD 8, a D- transfusion protocol was initiated. Despite laboratory evidence of hemolysis, two initial peripheral blood smears showed no increase in schistocytes or spherocytes, the reticulocyte count was depressed, and a marrow biopsy revealed erythroid hyperplasia. Eventually, anemia resolved after a period of medication non-compliance; however, a positive direct antiglobulin test persisted to the last follow-up date (POD 233). RESULTS: Other potential causes of aplastic anemia were investigated, but no alternative cause was found. History excluded passive anti-D. D+, LW- cells were reactive, excluding anti-LW. Genotyping showed no evidence of a partial D genotype. Chart review revealed that the liver donor had a history of anti-D. A diagnosis of passenger lymphocyte syndrome was reached. CONCLUSION: Although antibody-mediated hemolytic anemia has been reported to cause reticulocytopenia in the presence of marrow erythroid hyperplasia, this report of passenger lymphocyte syndrome causing a similar post-transplant anemia in association with reticulocytopenia is noteworthy.
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Anemia Hemolítica/etiologia , Incompatibilidade de Grupos Sanguíneos/imunologia , Transplante de Fígado/efeitos adversos , Linfócitos/imunologia , Sistema ABO de Grupos Sanguíneos , Adulto , Humanos , Masculino , Contagem de Reticulócitos , Sistema do Grupo Sanguíneo Rh-Hr/imunologia , Imunoglobulina rho(D)/imunologia , Doadores de TecidosRESUMO
The required intensity of monitoring for antibody-mediated rejection (AMR) after of ABO-incompatible (ABOi) kidney transplantation is not clearly formulized. We retrospectively evaluated a single-center cohort of 115 ABO-incompatible (ABOi) kidney transplant recipients, of which 32% were also HLA incompatible (ABOi/HLAi) with their donors. We used an adjusted negative binomial model to evaluate risk factors for late AMR. Using this model, we risk-stratified patients into high- and low-risk groups for the development of late AMR; 26% of patients had at least one AMR episode; 49% of AMR episodes occurred within 30-days after transplant and were considered early AMR. Patients with an early AMR episode had a 5.5-fold greater incidence of developing late AMR [IRR = 5.5, (95% CI: 1.5-19.3), P = 0.01]. ABOi/HLAi recipients trended toward increased late AMR risk [IRR = 1.9, (95% CI: 0.5-6.6), P = 0.3]. High-risk recipients (those with an early AMR or those who were ABOi/HLAi) had a sixfold increased incidence of late AMR [IRR = 6.3, (95% CI: 1.6-24.6), P = 0.008] versus low-risk recipients. The overall incidence of late AMR was 20.8% vs. 1.5% in low-risk recipients. Changes in anti-A/B titer did not correlate with late AMR (IRR = 0.9 per log titer increase, P = 0.7). This risk-stratification scheme uses information available within 30 days of ABOi transplantation to determine risk for late AMR and can help direct longitudinal follow-up for individual patients.
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Sistema ABO de Grupos Sanguíneos/imunologia , Incompatibilidade de Grupos Sanguíneos/imunologia , Rejeição de Enxerto/imunologia , Isoanticorpos/imunologia , Transplante de Rim , Adulto , Idoso , Feminino , Seguimentos , Rejeição de Enxerto/epidemiologia , Antígenos HLA/imunologia , Humanos , Incidência , Doadores Vivos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: Upper-extremity transplantation (UET) is a reality. Immunologic, functional, and graft survival outcomes have been encouraging. However, these complex reconstructions have unique considerations that pose distinct challenges. Transplant programs have reported morbidity and mortality due to significant intraoperative blood losses, but similar data are scant during other phases of recovery. We report experience from two centers on complete blood component demands and utilization with UET. STUDY DESIGN AND METHODS: Inpatient medical records of UET recipients from intraoperative (time from initiation of transplant surgery to exit from the operative suite) and postoperative (exit from the operative suite to discharge from the hospital) phases were retrospectively reviewed. RESULTS: Six patients received various UETs and mean (±SD) postoperative hospital stay was 46 (±14.4) days. Mean (±SD) intraoperative blood unit utilization was 14.8 (±10.2) red blood cells (RBCs), 10.5 (±11.8) plasma, 0.8 (±1.2) platelets (PLTs), and 0.3 (±0.8) cryoprecipitate units. Mean postoperative blood unit utilization was 9.3 (±10.4) RBCs, 5.3 (±6.7) plasma, 1.2 (±2.0) PLTs, and 0.7 (±1.6) cryoprecipitate units. Both intraoperative and postoperative blood utilization for unilateral versus bilateral transplant were different, but not significantly so. However, total inpatient blood use in bilateral transplants was significantly greater than in unilateral transplants. CONCLUSION: Substantial blood loss may occur in UET and require transfusion of many blood components, primarily RBCs and plasma. We propose an UET transfusion protocol and suggest that centers preparing to perform these transplants should actively engage the transfusion medicine service to ensure availability and access to appropriate blood components for the entire hospitalizations of these unique patients.
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Transfusão de Componentes Sanguíneos , Transplante de Órgãos , Cuidados Pós-Operatórios , Extremidade Superior/cirurgia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
BACKGROUND: Hydroxyethyl starch (HES) is reportedly associated with an increased risk of renal failure and death when used for fluid resuscitation in critically ill patients. HES can be used during therapeutic leukocytapheresis (TL) procedures to enhance cell separation. The purpose of this study was to evaluate the occurrence of adverse events associated with HES during TL procedures. STUDY DESIGN AND METHODS: We performed a retrospective review of patients who underwent TL with and without HES in the period 2009 to 2013 at six academic medical institutions. RESULTS: A difference-in-difference regression analysis was used to estimate the mean change before and after TL in selected outcomes in the HES group relative to the average change in the non-HES group. Selected outcomes included serum creatinine, estimated glomerular filtration rate (eGFR), and white blood cell (WBC) count. A total of 195 patients who underwent 278 TL procedures were studied. We found no significant differences in serum creatinine levels and eGFR on Days 1 and 7 after TL procedure between patients who received and those who did not receive HES. The rate of adverse events and overall and early mortality were similar in both groups. Patients with acute myeloid leukemia who received HES had greater WBC reduction when HES was used. Additionally, patients who received HES had improvement in pulmonary leukostasis symptoms. CONCLUSION: HES, used at low doses during TL procedures, was not associated with adverse events previously ascribed to its use as a volume expander.
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Injúria Renal Aguda/etiologia , Derivados de Hidroxietil Amido/efeitos adversos , Leucaférese/métodos , Creatinina/sangue , Feminino , Taxa de Filtração Glomerular , Humanos , Leucemia Mieloide Aguda/terapia , Contagem de Leucócitos , Leucostasia , Masculino , Pessoa de Meia-Idade , Substitutos do Plasma/efeitos adversos , Estudos RetrospectivosRESUMO
BACKGROUND: Automated blood collection platforms use different technological systems to isolate and collect individual blood components. These unique systems could potentially result in differences in platelet in vivo viability, as measured by the corrected count increment (CCI). STUDY DESIGN AND METHODS: This retrospective study evaluated CCI data of platelet transfusions among oncology patients who received multiple unmanipulated apheresis platelets between January 1, 2006 and December 31, 2009. Apheresis platelets were collected from our community blood center by standard procedures using two different collection systems and were transfused to patients in a blinded manner. RESULTS: The CCI of the platelet recipient was significantly higher at 0-2 hours post-transfusion among the individuals who received platelets collected on Trima Accel (Terumo BCT) (mean = 6281, standard deviation = 3650) compared to the platelets collected by the Amicus system (Fresenius Kabi) (mean = 5251, standard deviation = 3311, p = 0.004). CONCLUSIONS: These hypothesis-generating data suggesting improved recovery and survival of Trima Accel platelets demonstrate the need for the investigation and implementation of the best collection methods to provide better platelet transfusion support.
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Plaquetas/citologia , Plaquetoferese/instrumentação , Automação , Sobrevivência Celular , Humanos , Contagem de Plaquetas/métodos , Transfusão de Plaquetas/métodos , Transfusão de Plaquetas/normas , Plaquetoferese/métodos , Plaquetoferese/normas , Estudos RetrospectivosRESUMO
OBJECTIVE: Use of high-dose cyclophosphamide without hematopoietic stem cell transplant to treat severe aplastic anemia (SAA) has been controversial due to concern for increased infectious toxicity as compared with antithymocyte globulin and cyclosporine A. As children often tolerate dose-intensive therapy better than adults, we sought to perform a detailed retrospective analysis of both treatment response and toxicity in 28 patients younger than 22 years of age treated with 29 courses of high-dose cyclophosphamide as the sole form of immunosuppression. STUDY DESIGN: Children and adolescents with SAA who lacked an human leukocyte antigen-matched sibling donor were treated with cyclophosphamide 50 mg/kg/d for 4 consecutive days then received daily granulocyte colony stimulating factor until neutrophil recovery, transfusion support, and antimicrobial prophylaxis. RESULTS: Overall survival was 85%, with hematologic response of 79% and complete response of 66%. Cumulative incidences of bacterial infection (86%) and fungal infection (62%) were high but deaths due to infection were rare, as were clonal evolution (1/28), clinically relevant paroxysmal nocturnal (1/28), and relapse (2/28). CONCLUSIONS: Response rates and survival following high-dose cyclophosphamide in pediatric patients with SAA exceed those seen in adults and compare favorably to antithymocyte globulin/cyclosporine A with manageable infectious toxicity.
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Anemia Aplástica/tratamento farmacológico , Ciclofosfamida/administração & dosagem , Adolescente , Anemia Aplástica/complicações , Anemia Aplástica/mortalidade , Criança , Pré-Escolar , Evolução Clonal , Ciclofosfamida/toxicidade , Esquema de Medicação , Feminino , Fator Estimulador de Colônias de Granulócitos/administração & dosagem , Humanos , Infecções/induzido quimicamente , Masculino , Recidiva , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Red blood cell (RBC) transfusion thresholds have yet to be examined in large randomized trials in hematologic malignancies. This pilot study in acute leukemia uses a restrictive compared to a liberal transfusion strategy. STUDY DESIGN AND METHODS: A randomized (2:1) study was conducted of restrictive (LOW) hemoglobin (Hb) trigger (7 g/dL) compared to higher (HIGH) Hb trigger (8 g/dL). The primary outcome was feasibility of conducting a larger trial. The four requirements for success required that more than 50% of the eligible patients could be consented, more than 75% of the patients randomized to the LOW arm tolerated the transfusion trigger, fewer than 15% of patients crossed over from the LOW arm to the HIGH arm, and no indication for the need to pause the study for safety concerns. Secondary outcomes included fatigue, bleeding, and RBCs and platelets transfused. RESULTS: Ninety patients were consented and randomly assigned to LOW to HIGH. The four criteria for the primary objective of feasibility were met. When the number of units transfused was compared, adjusting for baseline Hb, the LOW arm was transfused on average 8.0 (95% confidence interval [CI], 6.9-9.1) units/patient while the HIGH arm received 11.7 (95% CI, 10.1-13.2) units (p = 0.0003). There was no significant difference in bleeding events or neutropenic fevers between study arms. CONCLUSION: This study establishes feasibility for trial of Hb thresholds in leukemia through demonstration of success in all primary outcome metrics and a favorable safety profile. This population requires further study to evaluate the equivalence of liberal and restrictive transfusion thresholds in this unique clinical setting.
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Transfusão de Eritrócitos , Leucemia/terapia , Doença Aguda , Idoso , Feminino , Hemoglobinas/análise , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Guias de Prática Clínica como Assunto/normasRESUMO
BACKGROUND: Despite proven efficacy and increased availability of therapeutic plasma exchange (TPE), mortality for patients with thrombotic thrombocytopenic purpura (TTP) remains high with a limited understanding of those at highest risk of death. STUDY DESIGN AND METHODS: This study utilized the Nationwide Inpatient Sample (2007-2012) to derive a prognostic score for mortality in hospitalized TTP patients. Odds ratios of death with various putative risk factors adjusted for age, sex, and race were calculated (adjOR). Weighted mean of adjOR estimates were incorporated in a risk-stratified score. RESULTS: Among 8203 hospitalizations with TTP as primary admission diagnosis who underwent TPE, 613 deaths were identified (all-cause mortality, 7.5%; median time-to-death, 9 days; interquartile range, 4-14 days). In multivariable logistic regression, arterial thrombosis (adjOR 6.7, 95% confidence interval [CI], 1.1-40.9), intracranial hemorrhage (adjOR, 6.1; 95% CI, 1.6-23.2), age at least 60 years (adjOR, 3.5; 95% CI, 2.1-5.6), renal failure (adjOR, 2.6; 95% CI, 1.5-4.5), ischemic stroke (adjOR, 2.4; 95% CI, 1.2-5.0), platelet (PLT) transfusions (adjOR, 2.2; 95% CI, 1.2-4.1), and myocardial infarction (adjOR, 2.3; 95% CI, 1.2-4.6) were significant independent predictors of mortality in TTP patients who underwent TPE. A prognostic weighted mortality prediction scoring system incorporating arterial thrombosis, intracranial hemorrhage, age, renal failure, ischemic stroke, PLT transfusion, and myocardial infarction showed very good discrimination and was predictive of 78.6% deaths. CONCLUSIONS: Early and targeted therapy for high-risk individuals should be used to guide management of TTP patients for improved survival outcomes.
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Púrpura Trombocitopênica Trombótica/mortalidade , Púrpura Trombocitopênica Trombótica/terapia , Medição de Risco/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Troca Plasmática/mortalidade , Valor Preditivo dos Testes , Prognóstico , Púrpura Trombocitopênica Trombótica/diagnóstico , Estudos Retrospectivos , Fatores de Risco , Adulto JovemRESUMO
High-dose granulocyte transfusion therapy has been available for 20 years, yet its clinical efficacy has never been conclusively demonstrated. We report here the results of RING (Resolving Infection in Neutropenia with Granulocytes), a multicenter randomized controlled trial designed to address this question. Eligible subjects were those with neutropenia (absolute neutrophil count <500/µL) and proven/probable/presumed infection. Subjects were randomized to receive either (1) standard antimicrobial therapy or (2) standard antimicrobial therapy plus daily granulocyte transfusions from donors stimulated with granulocyte colony-stimulating factor (G-CSF) and dexamethasone. The primary end point was a composite of survival plus microbial response, at 42 days after randomization. Microbial response was determined by a blinded adjudication panel. Fifty-six subjects were randomized to the granulocyte arm and 58 to the control arm. Transfused subjects received a median of 5 transfusions. Mean transfusion dose was 54.9 × 10(9) granulocytes. Overall success rates were 42% and 43% for the granulocyte and control groups, respectively (P > .99), and 49% and 41%, respectively, for subjects who received their assigned treatments (P = .64). Success rates for granulocyte and control arms did not differ within any infection type. In a post hoc analysis, subjects who received an average dose per transfusion of ≥0.6 × 10(9) granulocytes per kilogram tended to have better outcomes than those receiving a lower dose. In conclusion, there was no overall effect of granulocyte transfusion on the primary outcome, but because enrollment was half that planned, power to detect a true beneficial effect was low. RING was registered at www.clinicaltrials.gov as #NCT00627393.
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Granulócitos/citologia , Infecções/complicações , Transfusão de Leucócitos/métodos , Neutropenia/complicações , Neutropenia/terapia , Anti-Infecciosos/uso terapêutico , Dexametasona/farmacologia , Glucocorticoides/farmacologia , Fator Estimulador de Colônias de Granulócitos/farmacologia , Granulócitos/efeitos dos fármacos , Humanos , Infecções/tratamento farmacológico , Contagem de Leucócitos , Resultado do TratamentoRESUMO
Radiation (RT), temozolomide (TMZ), and dexamethasone in newly diagnosed high grade gliomas (HGG) produces severe treatment-related lymphopenia (TRL) that is associated with early cancer-related deaths. This TRL may result from inadvertent radiation to circulating lymphocytes. This study reinfused lymphocytes, harvested before chemo-radiation, and assessed safety, feasibility, and trends in lymphocyte counts. Patients with newly diagnosed HGG and total lymphocyte counts (TLC) ≥ 1000 cells/mm(3) underwent apheresis. Cryopreserved autologous lymphocytes were reinfused once radiation was completed. Safety, feasibility, and trends in TLC, T cell subsets and cytokines were studied. Serial TLC were also compared with an unreinfused matched control group. Ten patients were harvested (median values: age 56 years, dexamethasone 3 mg/day, TLC/CD4 1980/772 cells/mm(3)). After 6 weeks of RT/TMZ, TLC fell 69 % (p < 0.0001) with similar reductions in CD4, CD8 and NK cells but not Tregs. Eight patients received lymphocyte reinfusions (median = 7.0 × 10(7) lymphocytes/kg) without adverse events. A post-reinfusion TLC rise of ≥300 cells/mm(3) was noted in 3/8 patients at 4 weeks and 7/8 at 14 weeks which was similar to 23 matched controls. The reduced CD4/CD8 ratio was not restored by lymphocyte reinfusion. Severe lymphopenia was not accompanied by elevated serum interleukin-7 (IL-7) levels. This study confirms that severe TRL is common in HGG and is not associated with high plasma IL-7 levels. Although lymphocyte harvesting/reinfusion is feasible and safe, serial lymphocyte counts are similar to unreinfused matched controls. Studies administering higher lymphocyte doses and/or IL-7 should be considered to restore severe treatment-related lymphopenia in HGG.
Assuntos
Astrocitoma/terapia , Glioblastoma/terapia , Transfusão de Linfócitos/métodos , Adulto , Astrocitoma/sangue , Transfusão de Sangue Autóloga/efeitos adversos , Transfusão de Sangue Autóloga/métodos , Quimiorradioterapia/efeitos adversos , Quimiorradioterapia/métodos , Estudos de Viabilidade , Feminino , Glioblastoma/sangue , Humanos , Interleucina-7/sangue , Contagem de Linfócitos , Transfusão de Linfócitos/efeitos adversos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fator de Crescimento Transformador beta/sangue , Resultado do TratamentoRESUMO
BACKGROUND: Clinical characteristics of hypotensive transfusion reactions (HyTRs) have not been evaluated in the context of universal prestorage leukoreduction. STUDY DESIGN AND METHODS: A retrospective review of medical records of patients with HyTRs during the years 2011 and 2012 was performed at two academic medical institutions. RESULTS: Thirty-five patients with 35 HyTRs were identified, with an incidence of 1.33 per 10,000 transfusions. Red blood cells (RBCs) were implicated in 21 (60.0%) reactions and platelets (PLTs) and plasma (PL) in 11 (31.4%) and three (8.6%), respectively. The HyTR rate per blood component was 0.019% for PLTs, 0.015% for RBCs, and 0.006% for PL. Mean patient age was 65 years (range, 2 months-87 years), five (14.3%) were pediatric (<18 years), and 20 (57.1%) were male. The most frequent clinical settings associated with HyTRs were cardiac surgery (n=13; 37.1%), hematology-oncology diseases (n=11; 31.4%), and general surgery (n=7; 20.0%). Extracorporeal circuits were used within 24 hours before the reaction in 16 patients (45.7%), including nine patients on cardiopulmonary bypass, four on dialysis or continuous venous-venous hemodialysis, and three on extracorporeal membrane oxygenation. Four patients (11.4%) received an angiotensin-converting enzyme inhibitor within 24 hours before the HyTR. Seventeen patients (48.6%) responded to stopping the transfusion and supportive treatment. Thirteen patients (37.1%) had severe reactions. No HyTR resulted in death. CONCLUSION: In the absence of bedside leukoreduction filters, several medical situations are associated with HyTRs. The pathophysiology of HyTRs is yet to be defined. The US hemovigilance system allows for standardization of transfusion reactions, which facilitates their classification and study.
Assuntos
Preservação de Sangue , Transfusão de Eritrócitos/efeitos adversos , Hipotensão , Leucaférese , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Pré-Escolar , Feminino , Humanos , Hipotensão/epidemiologia , Hipotensão/etiologia , Incidência , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores Sexuais , Procedimentos Cirúrgicos OperatóriosRESUMO
While platelets are primary mediators of hemostasis, there is emerging evidence to show that they may also mediate pathologic thrombogenesis. Little data are available on risks and benefits associated with platelet transfusions in thrombotic thrombocytopenic purpura (TTP), heparin-induced thrombocytopenia (HIT) and immune thrombocytopenic purpura (ITP). This study utilized the Nationwide Inpatient Sample to evaluate the current in-hospital platelet transfusion practices and their association with arterial/venous thrombosis, acute myocardial infarction (AMI), stroke, and in-hospital mortality over 5 years (2007-2011). Age and gender-adjusted odds ratios (adjOR) associated with platelet transfusions were calculated. There were 10 624 hospitalizations with TTP; 6332 with HIT and 79 980 with ITP. Platelet transfusions were reported in 10.1% TTP, 7.1% HIT, and 25.8% ITP admissions. Platelet transfusions in TTP were associated with higher odds of arterial thrombosis (adjOR = 5.8, 95%CI = 1.3-26.6), AMI (adjOR = 2.0, 95%CI = 1.2-3.3) and mortality (adjOR = 2.0,95%CI = 1.3-3.0), but not venous thrombosis. Platelet transfusions in HIT were associated with higher odds of arterial thrombosis (adjOR = 3.4, 95%CI = 1.2-9.5) and mortality (adjOR = 5.2, 95%CI = 2.6-10.5) but not venous thrombosis. Except for AMI, all relationships remained significant after adjusting for clinical severity and acuity. No associations were significant for ITP. Platelet transfusions are associated with higher odds of arterial thrombosis and mortality among TTP and HIT patients.