Storage of washed or irradiated red cells in AS-7 improves their in vitro characteristics.

BACKGROUND: AS-7 is a new alkaline hypotonic red cell additive solution (AS) shown to improve red cell quality during storage compared with AS-1. We sought to compare red cells stored in AS-7 with those stored in SAGM using RCC that were either untreated, or washed or irradiated on day 14 of storage. STUDY DESIGN AND METHODS: A pooled and split study design was used to produce seven identical RCC (four in SAGM and three in AS-7). At day 14 following donation, two RCC (one in SAGM and one in AS-7) were gamma irradiated and three RCC (two in SAGM and one in AS-7) were washed and resuspended in either SAGM or AS-7. RCC were sampled for analysis throughout storage and at end of shelf life: day 28 for washed or irradiated and day 35 for untreated RCC. RESULTS: For untreated, washed or irradiated RCC, those stored in AS-7 had lower haemolysis, red cell microvesicles and supernatant potassium content than RCC in SAGM. In addition, ATP levels and pH were better maintained in AS-7 RCC than in SAGM RCC. CONCLUSION: These data suggest that the quality of these components may be improved by storage in AS-7 compared with SAGM.

Leukocyte apheresis using a centrifugal cell separator in refractory ulcerative colitis: a multicenter open label trial.

Recently, successful results of ulcerative colitis (UC) treatments with leukocyte apheresis have been reported by several institutes. To certify the efficacy of leukocyte apheresis in refractory UC patients, a multicenter open label trial was conducted, and results were analyzed. Fifty patients diagnosed with active steroid-resistant UC were enrolled in this study from 14 medical centers. Using a centrifugal cell separator (Component Collection System, Haemonetics), leukocyte apheresis was performed once a week for 5 weeks. General conditions and abdominal symptoms were recorded daily, and laboratory tests were followed weekly. Changes of colonoscopic and histological manifestations of luminal activity through the study period were evaluated. At the end of the study period, stool frequency was decreased to less than 4 times a day in 68.4% (26 of 38) and serum C-reactive protein (CRP) concentration was normalized in 56.7% (17 of 30) of the patients. Colonoscopic remission was achieved in 57.7% (26 of 45), and histological improvement was noted in 54.1% (20 of 37) of the patients tested. Improved disease activity was demonstrated in 74% (37 of 50) of the patients by general assessment criteria. Analysis of the trial data confirmed the valid clinical efficacy of leukocyte apheresis by centrifugal cell separator in refractory UC patients.

Autologous platelet-rich plasma isolated using the Haemonetics Cell Saver 5 and Haemonetics MCS+ for the preparation of platelet gel.

BACKGROUND AND OBJECTIVES: We compared three methods of isolating platelet-rich plasma (PRP) using the Haemonetics Cell Saver 5 and one method of isolating PRP by plateletpheresis using the Haemonetics MCS+. PRP contains both platelets and fibrinogen, which are used in the preparation of haemostatic agents. MATERIALS AND METHODS: When the Haemonetics Cell Saver 5 was used, 500 ml of blood from each of 30 normal volunteer donors was collected into 70 ml of citrate-phosphate-dextrose (CPD) anticoagulant. In a further 14 normal volunteers, the Haemonetics MCS+ was used to isolate PRP by plateletpheresis using an acid citrate dextrose (ACD) to blood ratio of 1 : 9. In a separate study, CPD-anticoagulated whole blood from another 30 volunteers was used for measurement of fibrinogen levels in the plasma and cryoprecipitate. RESULTS: A larger volume of PRP can be collected using the Haemonetics Cell Saver 5 than by using the Haemonetics MCS+. The platelet concentration and the total number of platelets were higher in the PRP isolated using the Haemonetics MCS+ than in the PRP isolated by the three methods used with the Haemonetics Cell Saver 5, with differences in platelet concentration and PRP volume among the four methods. The mean fibrinogen level in the plasma was 253 mg % +/- 47 (SD) and in the cryoprecipitate was 1085 mg % +/- 304 (SD). CONCLUSIONS: The most appropriate method of PRP isolation for preparation of platelet gel is dependent upon the specific surgical procedure to be undertaken and the patient's needs.

HLA class II antibodies in transfusion-related acute lung injury.

BACKGROUND: Transfusion-related acute lung injury (TRALI) is a serious, sometimes fatal, complication of transfusion. Granulocyte and HLA class I antibodies present in blood donors have been associated with TRALI. HLA class II antibodies have recently been described in a few cases of TRALI. STUDY DESIGN AND METHODS: Donors involved in TRALI reactions reported to a blood center over an 18-month period were tested for HLA class I and II antibodies as well as granulocyte antibodies, if HLA antibodies were not identified. RESULTS: HLA class II antibodies were identified, in at least one donor, in 7 (64%) of 11 cases of TRALI. HLA class I antibodies were identified in combination with HLA class II antibodies in 5 of these 7 cases. HLA class I antibodies were exclusively identified in 2 cases. Granulocyte antibodies were identified in 1 case, and no antibodies were identified in another. CONCLUSION: In addition to HLA class I antibodies, HLA class II antibodies are associated with TRALI. Testing of donors for HLA class II antibodies as well as HLA class I and granulocyte antibodies is recommended as part of the investigation of suspected cases of TRALI.

Transfusion and lung injury.

The respiratory tree has been viewed as an infrequent site of injury arising as a complication of transfusion. In recent years, this view has changed as investigators have shown that two complications--circulatory overload and transfusion-related acute lung injury--are relatively frequent events. Circulatory overload is a result of hypertransfusion to individuals at risk, the very young or old recipient. The reaction is due to fluid infusion which overwhelms the capacity of the left ventricle, resulting in pulmonary edema. While rarely fatal, studies have shown that such incidents result in intensive care and extended hospitalization. In the setting of orthopedic surgery, 1% of elderly patients undergoing hip or knee surgery experience circulatory overload. These events are associated with autologous, as well as allogeneic red blood cells (RBC) and fresh frozen plasma. Transfusionists need to be vigilant with transfusion therapy in this population. Phlebotomy and supplemental oxygen are the key therapies. Transfusion-related acute lung injury (TRALI) is the adult respiratory distress syndrome due to transfusion. It is associated with a significant morbidity and mortality of 5-14%, making it the third most common cause of death from transfusion in developed countries. It is characterized by the onset of acute respiratory distress, bilateral pulmonary edema and hypoxemia. It occurs within 1-2 hours of transfusion of a plasma-containing blood product. All blood components have been associated with the reaction, and rarely, intravenous immune globulin. There is no recognized profile of individuals at increased risk for TRALI. There are two purported mechanisms of injury; the vast majority of cases are associated with passively transfused complement-activating antibodies. These antibodies are either HLA (Class I or II) or granulocyte-specific. These antibodies appear to act as mediators, which result in granulocyte aggregation, activation, and microvascular pulmonary injury. With appropriate respiratory intervention, 80% of patients recover within 96 hours of the original insult. There are no permanent pulmonary sequelae.

Bigger is better: maternal and neonatal predictors of hematopoietic potential of umbilical cord blood units.

Umbilical cord blood (CB) is a useful stem cell source for patients without matched family donors. CB banking is expensive, however, because only a small percentage of the cord units stored are used for transplantation. In this study, we determined whether maternal factors, such as race, age, and smoking status have an effect on laboratory parameters of hematopoietic potential, such as viability, cell counts, CD34+ cell counts, and CFU-GM. We studied the effect of neonatal characteristics such as birth order, birth weight, gestational age, and sex of the baby on the same laboratory parameters. Race and maternal age had no effect on these laboratory parameters. In multivariate analysis, babies of longer gestational age had higher cell counts, but lower CD34+ cell counts and CFU-GM. Bigger babies had higher cell counts, more CD34+ cells, and more CFU-GM. Women with fewer previous live births also produced cord units with higher cell counts, CFU-GM, and CD34+ cell counts. Specifically, each 500 g increase in birth weight contributed to a 28% increase in CD34+ cell counts, each week of gestation contributed to a 9% decrease in CD34+cell counts, and each previous birth contributed to a 17% decrease in CD34+ cell counts (all P < 0.05). These data may be used to select the optimal cord blood donors and allow CB banks efficient resource allocation.

Transfusion to blood group A and O patients of group B RBCs that have been enzymatically converted to group O.

BACKGROUND: The transfusion of ABO-incompatible RBCs is the leading cause of fatal transfusion reactions. Group O RBCs, lacking terminal immunodominant A and B sugars to which humans are immunized, are safe for transfusion to persons of any ABO blood group. With the use of a recombinant alpha-galactosidase to remove terminal galactose from group B RBCs, the safety and efficacy of enzyme-converted group-B-to-group-O (ECO) RBC components were studied in transfusion-dependent patients. STUDY DESIGN AND METHODS: Twenty-four patients (blood groups A and O) were randomly assigned to receive transfusion(s) of either ECO or control group O RBCs. If a second transfusion was given, the other blood component was administered. RESULTS: Twenty-one patients were given ECO RBCs; 18 also underwent control transfusions. One patient received only a small aliquot for RBC survival studies, instead of a full-unit transfusion, because his serum was incompatible with ECO RBCs. No adverse events occurred. Both ECO and control transfusions resulted in appropriate Hb increments and comparable (51)Cr-labeled RBC survival studies. One patient developed a transient, weak-positive DAT, without hemolysis. Two weeks after transfusion, 5 of 19 evaluable ECO RBC recipients had increases in anti-B titers. CONCLUSION: ECO RBCs were comparable to group O cells for safety and efficacy in this study. The clinical significance of the increase in anti-B and of occasional serologic incompatibilities with ECO RBCs is unclear. If strategies can be developed to remove A epitopes, enzymatic conversion could be used to create a universal (group O) donor blood supply.

Transfusion-related acute lung injury.

Transfusion-related acute lung injury is a life-threatening complication of hemotherapy associated with the transfusion of plasma-containing blood products. It is characterized by acute respiratory distress, pulmonary edema and hypoxemia. Although its frequency is unknown, Food and Drug Administration data suggest that it is the third most common cause of transfusion-associated deaths, representing 9% of reported cases. Males and females of all ages are at equal risk. To date, there is no recognized profile of individuals who are at increased risk for this complication. Although there are two purported mechanisms of injury, the preponderance of evidence suggests that passively transfused complement-activating antibodies (either granulocyte or HLA-specific) act as mediators, which result in granulocyte aggregation, activation, and microvascular pulmonary injury. With appropriate respiratory intervention, most patients recover within 96 hours of the original insult and without permanent pulmonary sequelae.

Further characterization of transfusion-related acute lung injury: demographics, clinical and laboratory features, and morbidity.

According to Food and Drug Administration data, transfusion-related acute lung injury (TRALI) is the third most frequent cause of transfusion-associated death in the United States and is characterized by an acute respiratory distress syndrome-like clinical picture following transfusion of plasma-containing blood components. It may be underdiagnosed due to unfamiliarity of clinicians with the syndrome. This report describes the largest series to date, 46 cases, occurring between 1992 and 1998. The male-to-female ratio was approximately 1:1. The mean age at diagnosis was 54 years. The most frequent presenting symptom or signs were acute respiratory distress, hypotension, and hypertension. Antibodies to human leukocyte antigens or granulocytes were identified in 61 percent of cases, with 50 percent associated with antibodies in a donor whose blood had been transfused to a patient developing TRALI. Clinical recovery occurred in 87 percent of patients, but TRALI contributed to deaths in 13 percent. Clinicians need to recognize and diagnose this syndrome in order to respond with appropriate interventions.

A case-controlled multicenter study of vasovagal reactions in blood donors: influence of sex, age, donation status, weight, blood pressure, and pulse.

BACKGROUND: Vasovagal reactions occur in a small, but significant number of blood donors. These reactions may decrease return donation and disrupt blood collection activities. The purpose of this study was to define the contributory role of sex, age, weight, blood pressure, and pulse in vasovagal reactions with syncope in blood donors. STUDY DESIGN AND METHODS: A retrospective case-control study involved 1890 blood donors with syncope from three large United States blood centers during 1994 and 1995. Case controls and random population controls were used in a logistic regression analysis to determine the significance of individual variables to syncopal reactions. RESULTS: Female donors, young donors, first-time donors, low-weight donors, and donors with low predonation blood pressure had higher absolute donation reaction rates than other donors. When each variable was adjusted for other variables by regression analysis, age, weight, and donation status (first-time or repeat donor) were significant (p<0.0001), and sex, predonation blood pressure, and predonation pulse were not. The most important variables, in descending order, were age, weight, and donation status (first-time or repeat donor). CONCLUSIONS: Donation-related vasovagal syncopal reactions are a multifactorial process determined largely by age, weight, and first-time donor status.

Transfusion-associated graft-versus-host disease in an immunocompetent patient following cardiac surgery.

OBJECTIVES: We determined which of the 22 blood components obtained from unrelated donors and transfused to an apparently immunocompetent patient following open heart surgery caused transfusion-associated graft-versus-host disease (TA-GVHD). METHODS: Serologic and molecular methods were used to type the donors, the patient's family members, and the patient's postmortem tissues for HLA and a genetic marker on chromosome 17. RESULTS: Two donors were homozygous for the HLA class I antigens A1 B8, for which the patient was heterozygous. Both donors were heterozygous, not homozygous as expected, for the class II alleles. One of them had the same class II alleles as the patient (DRB1*0301, DRB3*0101/DRB1*0404, DRB4*0103). The patient's tissues were chimeric for restriction fragments at 17p13 of this donor. CONCLUSION: One-way HLA match leading to TA-GVHD can be caused by donor blood that is homozygous for class I and heterozygous for class II alleles. Two blood components given to our patient had such one-way HLA match. Class II alleles of the lymphocytes in one component were identical with those of the recipient and caused TA-GVHD. Class II alleles of the lymphocytes in the other component differed from those of the recipient and were eliminated either by the immune system of the patient or the lymphocytes that caused the TA-GVHD (graft versus graft).

Predictive value of past and current screening tests for syphilis in blood donors: changing from a rapid plasma reagin test to an automated specific treponemal test for screening.

BACKGROUND: This study evaluated the change from a rapid plasma reagin (RPR) test to an automated specific treponemal test (PK-TP) in screening for syphilis in blood donors. STUDY DESIGN AND METHODS: A cross-sectional seroprevalence analysis was performed on 4,878,215 allogeneic blood donations from 19 American Red Cross Blood Services regions from May 1993 through September 1995. Positive predictive values relative to the confirmatory fluorescent treponemal antibody absorption test (FTA-ABS) were calculated. Differences in seroprevalence were compared in RPR and PK-TP tests for 1) unconfirmed and confirmed tests, 2) first-time and repeat donors, and 3) "recent" versus "past" infections. Donation data from three additional Red Cross regions were evaluated for repeat donation patterns of blood donors who had a donation that was positive in a serologic screening test for syphilis. The value of RPR and PK-TP tests as surrogate markers for HIV infection was compared. RESULTS: Reactive rates were lower but the positive predictive values was higher for the PK-TP test than for the RPR test. Initially, donors screened by PK-TP were more likely to be confirmed as positive than were donors screened by RPR, but these rates became comparable. It is estimated that a single HIV window-period donation was removed by serologic testing for syphilis each year of this study period. CONCLUSIONS: The change to the PK-TP test resulted in a lower repeatedly reactive rate, better prediction that a confirmed-positive test for syphilis would occur in testing in the FTA-ABS, fewer donations lost, and comparable deferral rates. Because of the high rate of reactivity to serologic testing for syphilis among donors previously confirmed positive for syphilis, indefinite deferral after a confirmed-positive index donation may be warranted. Serologic testing for syphilis is ineffective as a marker of HIV-infectious window-period donations.

Red blood cell transfusion practices in patients undergoing orthopedic surgery: a multi-institutional analysis.

This retrospective review analyzed and compared transfusion practices in patients undergoing orthopedic surgery in five Massachusetts hospitals with current practice guidelines; opportunities for improvement were identified. Patient-specific clinical information and data about transfusion practices were obtained from the medical records of 384 Medicare patients undergoing orthopedic surgery between January 1992 and December 1993. The number of patients who donated autologous blood preoperatively differed significantly among hospitals as did the number of autologous units that were unused. The number of blood units transfused at each transfusion event also differed significantly; some surgeons transfused > or =2 units in the majority of their patients, while others transfused 1 unit at a time. This variation in practice was not explained by differences in patients' clinical status. The mean pretransfusion hematocrit was higher for autologous versus allogeneic blood, suggesting more liberal criteria to transfuse autologous blood. Nearly half of all transfusion events were determined to have been potentially avoidable. Avoidable transfusions were also three to seven times more likely with autologous than with allogeneic blood. Significant inter-hospital differences existed in the number of elective surgery patients exposed to allogeneic blood. The major determinant of allogeneic blood use in these patients was the availability of autologous blood. Each additional autologous blood unit available decreased the odds of allogeneic blood exposure twofold. Differences in intraoperative and postoperative blood salvage use also were noted. These findings indicate that significant variations in practice exist. Comparative data enabled hospitals to identify and target specific areas for improvement.