Immunologic changes after transfusion of autologous or allogeneic buffy coat-poor versus WBC-reduced blood transfusions in patients undergoing arthroplasty. II. Activation of T cells, macrophages, and cell-mediated lympholysis.

BACKGROUND: To estimate the impact of RBC preparations on the status of postoperative immune activation, the soluble cytokine receptors of TNFalpha (sTNF-R) and IL-2 (sIL-2R), as well as neopterin and cell-mediated lympholysis (CML), were measured. STUDY DESIGN AND METHODS: Patients undergoing strictly standardized anesthesiologic management for elective orthopedic surgery were enrolled in a prospective study. The perioperative course (Days 0, 3, 7, and 10) of sTNF-R, sIL-2R, neopterin, and CML was compared after random assignment to allogeneic buffy coat-reduced (Group 2, n = 8) or WBC-reduced (Group 3, n = 11) RBC transfusion regimen. Recipients of autologous buffy coat-reduced RBC transfusions (Group 1, n = 15) served as controls. Patients receiving intraoperatively and postoperatively salvaged blood only (n = 10) were separately analyzed as Group 4. RESULTS: In Group 1, a short-lasting increase in soluble cytokine receptors, a diminished cytolytic response (Day 0 vs. Day 7: sTNF-R, p = 0.0001; sIL-2R, p = 0.0004; CML, p = 0. 0238), and an elevation of neopterin (Day 0 vs. Day 3: p = 0.0064) were observed. In contrast, in allogeneically transfused patients, sTNF-R (Group 2, p = 0.0469: Group 3, p = 0.0039), sIL-2R (Group 3, p = 0.002) and neopterin (Group 3, p = 0.0164) increased further from baseline to Day 10 (Day 0 vs. Day 10), and this increase was accompanied by a diminished cytolytic response (Day 0 vs. Day 10: Group 2, p = 0.05; Group 3, p = 0.0076). Patients in Group 4 showed a short-lasting increase in sIL-2R (Day 0 vs. Day 3: p = 0.0078), neopterin (Day 0 vs. Day 3: p = 0.0156) and sTNF-R (Day 0 vs. Day 7: p = 0.0781). CONCLUSION: Allogeneic transfusions seem to prolong the postoperative status of immune activation, even when WBC-filtered RBCs are used for the transfusion regimen.

Immunologic changes after transfusion of autologous or allogeneic buffy coat-poor versus white cell-reduced blood to patients undergoing arthroplasty. I. Proliferative T-cell responses and the balance of helper and suppressor T cells.

BACKGROUND: Donor white cells (WBCs) contained in red cell (RBC) transfusions are thought to provoke down-regulation of T-cell-mediated immunity. This study investigated this topic in otherwise healthy patients receiving buffy coat-depleted or WBC-filtered RBCs and undergoing standardized perioperative management. STUDY DESIGN AND METHODS: Patients undergoing elective orthopedic surgery (primary hip and knee replacement surgery) were enrolled in a prospective study. Perioperative changes in T-cell proliferation (stimulation with phytohemagglutinin and mixed lymphocyte culture) and T-cell balance (T-lymphocytes, helper T cells, and suppressor T cells) were compared after random assignment to allogeneic buffy coat-depleted (Group 2, n = 8) or WBC-reduced RBC (Group 3, n = 11) transfusion regimens. Recipients of autologous buffy coat-depleted RBC transfusions (n = 15) served as controls (Group 1). RESULTS: Compared to that in autologous transfusion recipients, alloantigen-induced T-cell proliferation was significantly reduced in recipients of allogeneic WBC-reduced RBCs (Day 3, p = 0.0274). After the transfusion of allogeneic buffy coat-depleted RBCs, a weak trend toward decreased T-cell proliferation was observed (p = 0.0933) and the numbers of CD4+ T cells were also significantly lower (Day 7, p = 0.0389). On Day 10, alloantigen-induced T-cell proliferation remained significantly below baseline after transfusion of WBC-reduced RBCs (p = 0.05), the numbers of CD3+ cells decreased in allogeneic RBC recipients (Group 2, p = 0.078; Group 3, p = 0.05), and those of CD8+ cells decreased significantly after the transfusion of allogeneic buffy coat-depleted RBCs (p = 0.0234) concomitant with an increased CD4:CD8 ratio (p = 0.0391). CONCLUSION: Results of the present study confirm the hypothesis of impaired T-cell-mediated immunity after allogeneic transfusion.

Transfusion of buffy coat-depleted blood components and risk of postoperative infection in orthopedic patients.

BACKGROUND: Allogeneic blood transfusions have been reported to increase susceptibility to postoperative infection, but the findings were inconclusive. This study was designed to investigate the effect of buffy coat-depleted allogeneic and autologous transfusion on postoperative infection in patients undergoing orthopedic surgery. STUDY DESIGN AND METHODS: Patients (n = 385) undergoing elective orthopedic surgery (primary and revision joint replacement, spinal, or pelvic surgery) were included in a prospective observational study of the incidence of postoperative infection between April and December 1996. Infection rates in patients who received allogeneic buffy coat-depleted blood transfusions were compared with those in patients who received no transfusion or only autologous (buffy coat-depleted) blood. RESULTS: Patients without exposure to allogeneic blood (no blood or only autologous blood) had an infection rate of 3.9 percent, as compared to a rate of 12.2 percent for those with exposure to allogeneic blood (allogeneic blood, autologous plus allogeneic blood) (odds ratio 3.442; 95% CI, 1.349-10.40; p = 0.006). Of the 385 study patients, 309 underwent primary hip or knee replacement surgery. In this homogeneous subgroup, the postoperative infection rate was 4.6 percent after no transfusion or autologous transfusion and 11.9 percent after allogeneic transfusion (odds ratio 2.827; 95% CI 1.059-8.799; p = 0.036). Multivariate regression analysis confirmed buffy coat-depleted allogeneic blood transfusion as an independent variable associated with high risk for postoperative infection. CONCLUSION: Buffy coat-depleted allogeneic blood transfusion increases the incidence of postoperative infection in patients undergoing uncontaminated orthopedic surgery.

Preoperative autologous blood donation in orthognathic surgery: a follow-up study of 179 patients.

Although there have been recent advances in maxillofacial surgery and anaesthetic techniques, blood replacement is still common in orthognathic surgery. 179 patients underwent elective orthognathic surgery and donated autologous blood preoperatively. Standardized questionnaires about the preoperative blood donation were distributed to the patients. Haemoglobin, haematocrit, red blood cells and platelets were measured before blood donation, presurgically and postsurgically, as well as one year after surgery. Nearly all patients (98%) would recommend preoperative autologous blood donation. 97% of the patients saw the benefits of autologous blood donation in avoiding transfusion-transmitted infectious diseases such as acquired immune deficiency syndrome (AIDS) and hepatitis. No serious side-effects have been observed after blood donation. In patients with bimaxillary osteotomies (65% of the predeposited autologous blood units) 41% were in cases having upper jaw osteotomies and only 22% of the preoperatively donated units were retransfused in patients having lower jaw osteotomies. After a postsurgical decrease, the mean haemoglobin and mean haematocrit levels regained the levels determined prior to the donation. Preoperative autologous blood donation of 2 to 3 units (900-1350 ml +/- 10%) of blood is recommended in bimaxillary osteotomies and 1 to 2 units (450-900 ml +/- 10%) of blood for upper jaw osteotomies. In lower jaw surgery, the acute isovolaemic haemodilution should be considered.

[Degree of patient education retardation preoperative autologous blood donation at a university clinic]. / Aufklärungsgrad von zur präoperativen Eigenblutabnahme vorgesehenen Patienten an einer Universitätsklinik.

OBJECTIVE: Uncovering the low degree of information in autologous blood donors for the purpose of implementation of corrective measures. DESIGN: Questionnaire for autologous blood donors. SETTING: Department for Transfusion Medicine of a University Clinic. PARTICIPANTS: 174 autologous blood donors, selected by their responsible physician between June 1, 1995 and August 1, 1995. RESULTS: 64 (36.8%) of 174 patients who were admitted for withdrawal of autologous blood units had been informed by their treating physician, 100 (57.5%) of them came without any information and 10 (5.7%) on their own initiative. Of the 110 patients who had not been informed by their physician 16 declared to be sufficiently informed on risks or alternatives of allogeneic blood transfusion by mass media. Within the group of informed patients the percentage of those who did not fear allogeneic blood transfusions was clearly lower (23.4%) than within the group of uninformed patients (35.5%). Irrational fears were found less in informed than in uninformed patients (12.2% vs. 16.9%, informed vs. uninformed). CONCLUSIONS: Increasing numbers of patients are enrolled in allogeneic blood-saving programs, but still the degree of information does not seem to be sufficient. Because of the fact that information has to be given before the admission of the patient to the transfusion department, an enforced educational program on legal and medical issues of allogeneic blood transfusion for all medical disciplines involved is urgently required.