Are we missing reverse TRALI? - A real world experience from a tertiary care oncology centre in India.

Transfusion related acute lung injury (TRALI) is a rare but potentially fatal pulmonary complication of transfusion that presents as acute hypoxemia and non-cardiogenic pulmonary oedema, developing during or within six hours of transfusion. Majority of the cases reported are due to transfusion of plasma rich blood components containing antibodies to human leukocyte antigen (anti-HLA) or human neutrophil antigen (anti-HNA). Rarely, anti-HLA or anti-HNA in recipients against transfused donor leukocyte antigens, cause TRALI by a reverse mechanism. Herein, we report three cases of suspected TRALI following transfusions of buffy coat derived granulocytes and peripheral blood stem cells. Three patients with hematological malignancies developed pulmonary symptoms after transfusions of leukocyte rich blood components. All cases showed findings of bilateral pulmonary infiltrates at chest radiography and patients were managed accordingly; however, all three expired within seven days of transfusion due to progressive respiratory deterioration. The patients were transfusion dependent for a long time and had received multiple non-leukoreduced blood components in the past. Clinical findings in all three cases indicate the possibility of reverse TRALI. Although, patients' anti-HLA or anti-HNA antibodies concordance with donors' cognate antigens (HLA and HNA) was not confirmed; yet these three cases suggest that reverse pathogenesis of TRALI is not as infrequent as reported in the literature. However, reverse TRALI has not been confirmed as the presence and nature of antibodies in the transfused recipient were not investigated due to the non availability of immunodiagnostic tests in India.

Clinical and laboratory profile of anti-M.

CONCLUSIONS: Anti-M is a frequently detected naturally occurring antibody that has been reported in various clinical settings and also in voluntary donors. We describe here the clinical and laboratory findings of 11 cases with anti-M detected at our center. This report is a retrospective study in which we reviewed our immunohematology laboratory records for cases involving anti-M. Both donor and patient data from a 28-month period (September 2014 to December 2016) were reviewed. During this period, 11 examples of anti-M were detected (8 patients, 1 voluntary whole blood donor, and 1 hematopoietic stem cell donor. Anti-M was also detected in one external quality assessment scheme sample received during this period. In conclusion, anti-M can be detected in various clinical settings. This antibody can be clinically significant; in the laboratory, it can present as a serologic problem such as an ABO group discrepancy or an incompatible crossmatch. After detection, management and course of action is determined by both the antibody characteristics and the clinical setting.

Red cell alloimmunisation in oncology patients: A study from eastern India.

BACKGROUND: Red cell alloimmunisation is an important complication in multi-transfused patients with haematologic and surgical malignancies. Antibody screening with identification is necessary to ensure transfusion safety. Data on the prevalence of alloimmunisation in oncology patients is limited. In this study we assessed multitransfused haematology-oncology patients for red cell alloimmunisation. This was a retrospective analysis undertaken to assess the alloantibody prevalence and determine the antibody specificity. MATERIALS AND METHOD: Retrospective analysis of antibody screening data was done for haematopoietic stem cell transplant (HSCT) patients as well as surgical oncology patients, from April 2013 to May 2014. This included the antibody screening done prior to surgery, antibody screening prior to HSCT and any antibody screening performed for these patients at cross match. Antibody screening was done using the three cell panel (surgiscreen) and if positive, further identification performed using the 11 cell panel (Resolve Panel A). If the antibody screen (three cell panel) was positive, an autocontrol was performed using reverse diluent (Ortho Biovue System) card. Patients with autoantibodies were excluded from this study. RESULT AND DISCUSSION: Our overall red cell alloimmunisation rate was 2.5%. Alloimmunisation rate among HSCT transplant patients was 1.6% as compared to the 2.4% in patients with solid organ malignancies. Keeping in view the low alloimmunisation rate, the justification of repeating antibody screening 72 hours post transfusion in this category of patients needs to be re-assessed.

An analysis of transfusion support in haematopoietic stem cell transplantation--report from a centre in India.

BACKGROUND: Transfusion support in haematopoietic stem cell transplantation (HSCT) can be very demanding and challenging. The conditioning regimen, stem cell dose, donor type, presence of GvHD, infection all influence transfusion therapy in haematopoietic stem cell transplantation (HSCT). We retrospectively analysed the first 100 days transfusion requirements among HSCT recipients with haematological as well as non-haematological malignancies in our centre. MATERIALS AND METHODS: Transfusion data were retrieved for 100 patients who had undergone HSCT over a period of two years. The HSCT recipients were divided into three groups: autologous, allogenic and haplo-identical. Allogenic group was subdivided into matched related donor (MRD) and matched unrelated donor (MUD). The allo and haplo groups were then classified on the basis of the ABO compatibility as major, minor, bi-directional and compatible. We analysed the mean requirement of blood components (RBC, RDP, SDP and FFP) within the first 100 days of HSCT in each category. RESULTS AND DISCUSSION: Haematologic malignancies constituted 97% of the indications for HSCT. Allo-HSCT constituted 50% of the HSCT, of which 92% were MRD. Auto and haplo-HSCT constituted 40% and 10% respectively. Mean requirement for all products--RBC, SDP, RDP and FFP--was highest in the haplo category, followed by the allo category and then the auto HSCT category. The mean product requirement in the MUD category was significantly higher than in the MRD category (p < 0.05). The mean product requirement in the major and bidirectional ABO incompatible group was significantly higher as compared to the minor and ABO compatible group (p < 0.05). Hence our data may help transfusion medicine specialists to understand the transfusion requirement in stem cell transplant settings from developing countries like India. The average number of blood donors required for each group of stem cell transplant patients can also be roughly predicted from this study.

Assessment of changes in plasma hemoglobin and potassium levels in red cell units during processing and storage.

Red cell units undergo changes during storage and processing. The study was planned to assess plasma potassium, plasma hemoglobin, percentage hemolysis during storage and to determine the effects of outdoor blood collection and processing on those parameters. Blood collection in three types of blood storage bags was done - single CPDA bag (40 outdoor and 40 in-house collection), triple CPD + SAGM bag (40 in-house collection) and quadruple CPD + SAGM bag with integral leukoreduction filter (40 in-house collection). All bags were sampled on day 0 (day of collection), day 1 (after processing), day 7, day 14 and day 28 for measurement of percentage hemolysis and potassium levels in the plasma of bag contents. There was significant increase in percentage hemolysis, plasma hemoglobin and plasma potassium level in all the groups during storage (p < 0.001). No significant difference was found between any parameter analyzed for outdoor and in-house collected single CPDA red cell units. There was significant lower percentage hemolysis (p < 0.001) and potassium (day 7 to day 14 - p < 0.05 and day 14 to day 28 - p < 0.001) in red cell units from day 7 onward until day 28 of storage in the leukoreduced quadruple bag as compared to the triple bag. The in-house single CPDA red cell units showed significantly more hemolysis (p < 0.001) as compared to the triple bags with SAGM additive solution after 28 days of storage. There is gradual increase in plasma hemoglobin and plasma potassium levels during the storage of red blood cells. Blood collection can be safely undertaken in outdoor blood donation camps even in hot summer months in monitored blood transport boxes. SAGM additive solution decreases the red cell hemolysis and allows extended storage of red cells. Prestorage leukoreduction decreases the red cell hemolysis and improves the quality of blood.

Warm autoimmune hemolytic anemia with mimicking anti-e specificity causing intravascular hemolysis in a chronic ITP patient.

A 12-year-old male child presented to the emergency room with three days history of cola-colored urine, mild icterus, dyspnea, palpitation and fatigue. He had a history of chronic ITP two years ago and had since been on steroid for maintenance of platelet count. He was subsequently diagnosed as a case of warm autoimmune hemolytic anemia. Laboratory investigations were suggestive of intravascular hemolysis, and on immuno-hematological evaluation it was diagnosed that the patient had autoantibody with mimicking anti-e specificity. The specificity of autoantibody was further confirmed by adsorption study. The patient was successfully managed by transfusion of Rh(e)-negative red cells,steroid and rituximab therapy. So an autoantibody with mimicking anti-e specificity was identified in this case, which was significant in clinical point of view.

Seroprevalence of cytomegalovirus antibodies among blood donors and Multitransfused recipients--a study from north India.

BACKGROUND AND OBJECTIVES: Primary Cytomegalovirus infection caused by transfusion is a major problem for immunocompromised CMV seronegative patients. Documentation of the status of antibodies to cytomegalovirus in the blood donor pool population is vital to the understanding of the potential likelihood of transmission through donor blood and for determining the best transfusion practices to prevent TT-CMV infection. The present study was conducted to determine the prevalence of CMV infection among blood donors and Multitransfused recipients of north Indian population. MATERIAL AND METHODS: A prospective study was done on 2100 donors' samples and 200 patients sample for CMV antibodies using the ELISA technique. RESULTS: Out of 2100 donors recruited, 93.8% males and 6.2% females. 98.6% were positive for anti CMV IgG antibodies and only one donor was positive for anti CMV IgM antibody. In Multitransfused patients, out of 200 patients, seroprevalence for anti CMV IgG antibodies was in 100% patients and only one patient was positive for anti CMV IgM antibody. CONCLUSION: The study did not demonstrate statistical significant influence of age and gender on prevalence of anti CMV IgG and IgM antibodies. Other preventive strategies such as universal leucodepletion may be implemented to prevent transmission of CMV in immunocompromised patients.

Anti S enigma in a pregnant patient.

Among the antibodies of the MNS blood group system, anti S antibody is generally IgG antibody reacting at 37 °C. It is rarely implicated in hemolytic transfusion reaction; however, it can lead to potentially severe transfusion reactions. Anti S is also capable of causing mild to severe fatal hemolytic disease of newborn. We report a case of anti S antibody in a pregnant patient with complicated falciparum malaria.

Donor notification and counseling--experience and challenges.

BACKGROUND AND OBJECTIVES: In India, screening of blood for human immunodeficiency virus, hepatitis B surface antigen, and hepatitis C virus is mandatory before issue for transfusion, but donors are not informed of their reactive status. Advising donors who have reactive test results of viral markers is an essential adjunct to blood donor testing and is part of donor care. We realized that donor disclosure is an important public health issue. Therefore, we took the initiative of posttest counseling of blood donors. MATERIALS AND METHODS: The donors reactive for any transfusion transmitted diseases by enzyme linked immunosorbent assay in duplicate as well as by rapid tests, were notified of their reactive test results and called for counseling. We tried to maintain confidentiality at each step. Counseling and information about confirmation, evaluation, early treatment and prevention of transmission were given to responding donors. RESULTS: The results were analyzed for the period from 1st April 2011 to 30th June 2012. Among 15,844 donors, 172 were found to be reactive for various infectious markers. Letters were sent to all reactive donors. Only 60 donors responded and were counseled. The counseling rate was 49%, 45.5%, 50% and 17% for HBsAg, HCV, HIV and syphilis respectively. CONCLUSION: This study describes our experience and challenges faced in implementing the program of donor counseling in a resource poor setting.

Clinically significant anti M antibodies--a report of two cases.

INTRODUCTION: Most anti-M antibodies are not active at 37°C and are thus of no clinical significance. Occasionally these antibodies have a wide thermal range and can lead to hemolytic transfusion reactions or hemolytic disease of the new born. PATIENT AND METHODS: We describe two cases of anti-M antibodies, both of which were clinically significant. RESULTS: The first case was detected due to crossmatch incompatibility and the second presented as a blood group discrepancy. CONCLUSION: When the antibody is active at 37°C, M antigen negative red cell units should be issued.

Autoimmune hemolytic anemia due to auto anti-N in a patient with sepsis.

We describe a case of autoimmune hemolytic anemia (AIHA) due to anti-N in a young male patient with cellulitis. There have been several reports of anti-N in N positive individuals. But in all these reports, auto anti-N was mostly associated with underlying immunological conditions. We report here a case of auto anti-N in a patient of bacterial sepsis without any underlying immune disorder.

Importance and results of sterility testing of various products in a microbiology laboratory of eastern India.

Components of blood products from Blood bank, stem cells products from Haemotapoietic Stem Cell Transplant unit, CSSD (Central Sterile Supply Department) items, and pharrrmaceutical products, were sterility tested by liquid culture. 2.91% of the total 3122 samples sent for sterility testing from various departments were positive (i.e. showing contamination). CSSD products showed no contamination (0/37); products from blood bank and bone marrow transplant unit showed a contamination rate of 2.03% (47/2307) and 4.64% (31/667) respectively. The average cost of sterility test was Rs. 302 (INR). Sterility test requires stringent aseptic precautions which is resource intensive.

Comparison of Quality and Efficacy of Apheresis Platelets Stored in Platelet Additive Solution Vis a Vis Plasma.

PAS, by replacing part of the plasma in the platelet storage bag, reduces post transfusion allergic reactions and DHTR in the recipient. In this study we compared quality and efficacy of PAS and usual plasma stored platelets. Platelet concentration, content, MPV, pH, swirling, LDH and glucose concentration were tested in SDPs after preparation and on the day of transfusion; and compared between control (plasma-stored SDP) and study (PAS-stored SDP) groups. CCI was compared between the two groups. Transfusion reactions were also noted. In both groups quality parameters were similar except glucose [significantly decreased (p < 0.001) in plasma] and LDH [increased significantly (p: -0.005) in PAS]. CCI was similar in both groups. Transfusion reaction rate were 0.012% and 0.049% in both groups respectively. Quality and post-transfusion efficacy in both groups were similar. PAS stored platelets may be transfused in multi-transfused patients with allergic manifestations and in minor ABO incompatible transfusions.

Patterns of infections among blood donors in a tertiary care centre: a retrospective study.

BACKGROUND: Transfusion-transmitted infections continue to be a threat to safe transfusion practices. We analysed the prevalence and patterns of co-infections among voluntary and replacement donors. METHODS: Blood donations collected over a 5-year period were studied for the type of donation (voluntary or replacement), number of seroreactive cases and the number, type and distribution of co-infections. RESULTS: Of the 42 439 units of blood collected over a 5-year period, 19 118 (45%) were from voluntary and 23 321 (55%) from replacement donors. There were 1603 seroreactive cases (3.8%). These included 250 with HIV (0.6%), 734 with hepatitis B surface antigen (HBsAg; 1.7%), 337 with hepatitis C virus (HCV; 0.8%) and 282 (0.7%) with VDRL (Venereal Diseases Research Laboratory) reactivity. Twenty-three (0.05%) of these had > or = 2 seroreactive infections; 20 of these were in replacement donors and only 3 in voluntary donors and the difference was statistically significant (p < 0.005). Among HIV seropositive donors, there were 4 seroreactive for syphilis and 5 for HBsAg. Among HIV seronegative donors, 5 were seroreactive for HBsAg and VDRL, 4 for HCV and VDRL, and 2 for HBsAg and HCV. One person was seroreactive for HIV, HBsAg and VDRL. The multiple infection rate showed a decreasing trend over the years. CONCLUSION: Multiple infections pose a small but definite risk to the recipients of blood products. Voluntary donations are safer as compared with replacement ones and need to be encouraged.

Fresh Frozen Plasma and Platelet Transfusion Practices in Neonatal Intensive Care Unit of a Tertiary Care Hospital.

Blood transfusion is an indispensable part of modern medical and surgical practices. More than 35% of critically ill patients receive transfusion of blood components during their intensive care unit stay. The aim of study is to obtain an information regarding the relationship of platelet concentrate (PC) and fresh frozen plasma (FFP) transfusion on clinical outcome of neonates admitted in neonatal ICU (NICU). This prospective cohort study was conducted from 1st November 2011 to 30th April 2013. The clinical history, blood component details and laboratory parameters were evaluated with clinical outcome. The neonates requiring PC and FFP transfusion were followed up in blood bank for laboratory parameters. Clinical parameters were noted from case file. During the study period, 291 neonates were admitted in NICU. 2 neonates had congenital malformations and thus, were excluded from the study. Of the remaining 289 neonates, 49 neonates received transfusion of platelets and/or FFP. The combined mean donor exposure for all components was found to be 1.48. The mean volume of PC and FFP transfused was 20 ml and 30 ml respectively. The mean pre- and post-transfusion platelet count was 34,000 µl and 42,000 µl respectively. The mean pre- and post-transfusion INR was 2.37 and 1.53 respectively. There was a significant increase in platelet count and decrease in INR in transfused neonates. However, no clinical benefit of PC and FFP transfusion seen on bleeding. Transfusion of PC and FFP has significant effect on laboratory parameters as compared to clinical parameter.

Challenges in transfusion and the role of Thalidomide in E-ß-Thalassemia-A case report.

Hemoglobin E-ß-thalassemia is a common ß-thalassemia that has a variable presentation from mild to severe life-threatening anemia. We describe such a case, who presented with severe anemia and multiple allo-antibodies. Our case illustrates the role of thalidomide in transfusion-sparing therapies in patients with transfusion-dependent thalassemia and challenges in the blood bank.

Transient cold agglutinin disease with mycoplasma infection.

Cold agglutinins are autoantibodies and are often present in the sera of healthy individuals. They assume importance when the thermal reactivity of these antibodies approaches body temperature. This communication describes a case of cold hemagglutinin disease with Mycoplasma pneumoniae infection detected during routine laboratory investigations. The patient was managed conservatively.