A review of the use of blood and blood products in HIV-infected patients.

Despite numerous publications on the appropriate use of blood and blood products, few specifically consider the role of transfusion in the management of HIV. This review is a synthesis of conditions encountered in the management of HIV-infected patients where the transfusion of blood or blood products may be indicated. A consistent message emerging from the review is that the principles of transfusion medicine do not differ between HIV-negative and -positive patients. The aim of the review is to provide clinicians with a practical and succinct overview of the haematological abnormalities and clinical circumstances most commonly encountered in the HIV setting, while focusing on the rational and appropriate use of blood and blood products for HIV patients. Important ethical considerations in dealing with both the collection and transfusion blood and blood products in the HIV era have also been addressed.

Characterization of occult hepatitis B virus strains in South African blood donors.

UNLABELLED: Since October 2005, all blood units collected in South Africa were screened individually for human immunodeficiency virus (HIV)-1, hepatitis B and C virus (HBV, HCV) genomes uncovering preseroconversion window period (WP) infections for each virus and occult HBV infections (OBIs) defined as persistent HBV DNA without detectable hepatitis B surface antigen (HBsAg). Samples identified as HBsAg-negative/DNA-positive were confirmed by combining real-time quantitative polymerase chain reaction, nested amplification, anti-HBc and anti-HBs. Amplified basic core promoter/precore, pre-S/S, and whole genome were sequenced, analyzed, and compared to 73 HBsAg+ strains. Genotype was determined by phylogenetic analysis. From 109 samples examined, 54 were classified as OBI, 14 as WP, 20 as false-positive, five as other classification, and 16 as undetermined due to lack of serological or follow-up data. OBI donors were predominantly males (67%), median age 31 years, black (54%), with normal alanine aminotransferase levels. Viral load ranged between unquantifiable and 518 IU/mL (median 5 IU/mL). Genotype A1 was more frequent (23 strains) than genotype D (seven strains). Genotype A1 strains were little mutated. In the major hydrophilic region, 56.5% strains were wild type or with few amino acid substitutions. Most important, all 13 full genome sequences presented 1 to 7 mutations known to or assumed to negatively impact viral replication. In particular, 6/13 sequences had a stop codon in the HBx gene translated into deletion of 117 or 19-25 C-terminus amino acids not found in 15 HBeAg+ HBsAg+ strains. One WP sequence with an HBx stop codon suggested infectivity. CONCLUSION: Genotype A1 OBIs are different from genotype A2 and D OBIs in that there is little evidence of immune pressure as a major factor involved in OBI genesis. Limited replication appears mostly related to genetic viral defects.

Metabolic effects occurring in irradiated and non-irradiated red blood cellular components for clinical transfusion practice: An in vitro comparison.

BACKGROUND: Storage lesions occur in red blood cell products when potassium ions, haemoglobin and lactate dehydrogenase are released into the extracellular plasma due to post-irradiation storage or cellular degeneration. The South African blood transfusion establishments do not comply with the universal leucocyte-reduction policy due to cost and the current HIV pandemic. Various studies regarding storage lesions have been completed in well-developed countries but not in Cape Town, South Africa. OBJECTIVE: This study aimed to determine cellular degeneration occurring in non-irradiated and irradiated red blood cells (RBC) by comparing the measured biochemical and haematological indices during storage of up to 42 days. METHOD: Eighty whole blood units were collected from voluntary, non-remunerated donors. Blood components tested weekly until expiry were whole blood, RBC concentrate, leucocyte-reduced RBC concentrate (pre-storage) and paediatric RBC concentrate (n = 20). Ten units per product were irradiated and 10 were not. Evaluations included potassium, sodium, glucose, lactate dehydrogenase, phosphate, haemoglobin, haematocrit, mean corpuscular haemoglobin, mean corpuscular haemoglobin concentrate, mean cell volume and plasma haemoglobin. Plasma haemolysis levels were calculated using an approved formula. RESULTS: The haemolysis levels evaluated on Day 35 and Day 42 were higher than the recommended 0.8%, whereas results for the non-irradiated components up to expiry were all below 0.8%. CONCLUSION: This study confirms that gamma irradiation aggravates the RBC storage lesions. The products tested yielded similar results to other studies in developed countries, however the South Africa transfusion medicine policy should remain unchanged.

A clinical audit of the utilisation of red cell products in elective total hip replacement surgery.

BACKGROUND: Previous studies have documented a marked variation in transfusion practice for total hip replacement (THR) surgery. OBJECTIVE: To audit red cell product utilisation for THR at two Western Cape tertiary referral hospitals (HY and HG). METHODS: The folders of 207 consecutive patients undergoing elective THR surgery from January 2013 to December 2013 were reviewed. Information relating to age, sex, clinical observations, indications for surgery, pre- and postoperative haemoglobin (Hb) values, comorbidities, length of hospital stay and transfusion history was recorded. RESULTS: The transfusion rate at HY (41.6%) was significantly higher than that at HG (10.0%). The mean postoperative Hb in the transfused patients at HG was 8.3 g/dL v. 9.1 g/dL at HY. Females had a significantly higher transfusion rate (33.0%) than males (15.0%) (p<0.05), and the mean age of transfused patients was significantly greater than that of untransfused patients (p<0.005). Although patients with comorbidities had a higher transfusion rate than those without, this did not reach statistical significance. Of 120 patients with complete data, 113 (94.2%) had a blood bank order, of which the vast majority, 102/113 (90.3%), were group-and-screen (G&S) requests; 29/113 (25.7%) were converted to a full crossmatch. CONCLUSIONS: Overall, the transfusion rate for both hospitals was 25.8%, which is well within published rates. A guideline Hb trigger of 8.0 g/dL is recommended as per published guidelines, with the caveat that the clinical judgement of the attending clinician whether a transfusion is indicated is paramount. Causes of preoperative anaemia should be investigated and treated. Routine cross-matching preoperatively is unnecessary, and a G&S order is sufficient.

Characterization of occult hepatitis B virus from blood donors carrying genotype A2 or genotype D strains.

BACKGROUND/AIMS: Nucleic acid testing (NAT) for hepatitis B virus (HBV) DNA in blood donations identified occult HBV infection (OBI) as a potential threat to blood safety. METHODS: A collaborative study was undertaken to explore the molecular basis of OBIs prevalent in Europe in relation to clinical and serological data. RESULTS: Ninety-one percent of 77 donor samples of European origin HBV DNA positive but HBV surface antigen (HBsAg) negative were confirmed. Viral load ranged between unquantifiable and 5640 IU/mL (median 25 IU/mL). Fifty-two strains were genotyped (14 HBV(A2) and 38 HBV(D)). Compared to HBsAg+ samples, genotype D was significantly more frequent than genotype A2 in OBIs from Poland or Italy (P<0.04). Amino acid substitutions were concentrated in the immunologically active parts of the Pre-S/S proteins (P<0.0001) affecting both cellular CD8 T-cell epitopes and B-cell neutralizing Major Hydrophilic Region epitopes. Substitutions were more frequent in OBIs than in HBsAg+ strains of both genotype D (P<0.001) and A2 (P<0.01), in OBIs of genotype D than A2 in the 'a' region (P<0.001) but not cellular epitopes, and in anti-HBs+ than anti-HBs- OBIs (P<0.001). CONCLUSIONS: Results support the hypothesis that humoral and cellular immune pressure on the HBV envelope proteins are major mechanisms generating OBI.

Erythrocytes: Better Tolerance of Iron Polymaltose Complex Compared with Ferrous Sulphate in the Treatment of Anaemia.

BackgroundAbsolute iron deficiency, irrespective of aetiology, remains a major and worldwide cause of morbidity. After correction of the causative lesion, reconstitution of haemoglobin level and body iron stores is traditionally achieved with oral administration of ferrous salts. The latter have significant gastrointestinal tract side-effects that, in the short-term, may impair compliance. With protracted administration these products can cause lipid peroxidation which, in turn, may accelerate atherogenesis. An alternative formulation is an iron polymaltose complex where animal data supported a promoting effect of glycerophosphate. Setting and Trial Design This was a single-centre, open, randomised, multidose four treatment parallel group study. A standard dose of ferric polymaltose complex with two differing levels of glycerophosphate was compared with an equivalent amount of iron supplied as ferrous sulphate in anaemic volunteer blood donors. The endpoints were rate of haemoglobin rise and re-expansion of body iron stores reflected in blood ferritin concentration, as well as percentage saturation of transferrin. Secondary observations were changes in the proportion of hypochromic red cells during the course of treatment, erythropoietin levels and tolerability of the two formulations. Results Outcome in the rat model suggested that the utilisation of iron from polymaltose might be enhanced by glycerophosphate. However, in donors this difference was not evident and, accordingly, the data from the three polymaltose groups combined and compared to those receiving ferrous sulphate. The rate at which haemoglobin level improved, red cell indices returned to normal, and the number of hypochromic and microcytic red cells fell was not significantly different between the groups. Similarly the serum iron, percentage saturation of transferrin and red cell ferritin were comparable. In contrast the serum ferritin levels were higher for those receiving ferrous sulphate. Additionally, side-effects were significantly more frequently encountered with the latter preparation. Conclusion These data demonstrate that the addition of glycerophosphate, observed to be beneficial in rats, did not occur in humans. Secondly, in the blood donors, equivalent amounts of iron provided as the polymaltose, with or without glycerophosphate or ferrous sulphate, corrected haemoglobin concentration and morphologically abnormal erythropoiesis at comparable rates. Similarly iron stores are replenished to an equivalent extent as seen in the matching percentage saturation of transferrin and red cell ferritin levels. Interestingly, there is a discrepancy in the serum ferritin which is higher with the salt and this may reflect oxidative stress. Thirdly, corresponding efficacy can be achieved with better patient tolerance for the complex. Finally it is postulated that the iron polymaltose complex formulation more closely approximates the way in which enterocytes handle dietary iron and thus physiologic regulatory mechanisms would be expected to reciprocally slow down absorption as stores expand. Logically, therefore and, if confirmed, the latter finding suggests that this formulation may have a potential role in longer-term supplementation programmes.