Erythrocyte Alloimmunity and Genetic Variance: Results from the Collaborative Study of Alloimmunity to Antigen Diversity in Asian Populations (All ADP).

As an East-Asian international study, we evaluated erythrocyte alloimmunity by gender and history of transfusion or pregnancy. In total, data from more than 1,826,000 patients were analyzed, from whom 26,170 irregular erythrocyte antibodies were detected in 22,653 cases. Antibody frequencies in these cases were as follows: anti-E, 26.8%; anti-Lea, 20.0%; anti-P1, 7.1%; anti-M, 6.4%; anti-Mia, 5.6%; anti-c + E, 5.6%; anti-Leb, 4.6%; anti-D, 2.8%; anti-Fyb, 2.6%; anti-Lea+Leb, 2.5%; anti-Dia, 2.0%; and others. For pregnant patients, anti-D (12.7%) was statistically more frequent. For transfused patients, anti-E (37.3%), anti-c + E (9.5%), anti-C + e (3.3%) and anti-Jka (3.1%) were significantly more frequent.

Recommendations Regarding Practical DEL Typing Strategies for Serologically D-Negative Asian Donors.

BACKGROUND: DEL, the weakest D variant, is mistyped as D-negative by routine serological assays. Transfusion of red blood cells expressing the DEL phenotype has the potential to elicit anti-D alloimmunization in D-negative recipients. The goal of this study was to recommend DEL typing strategies for serologically D-negative Asian donors. METHODS: RhCE phenotyping and the adsorption-elution test were performed on 674 serologically D-negative samples. RHD genotyping using real-time polymerase chain reaction and melting curve analysis were also undertaken to identify DEL alleles. Costs and turnaround time of RhCE phenotyping, the adsorption-elution test, and RHD genotyping were estimated. RESULTS: Sensitivity and specificity of the adsorption-elution test for serologically D-negative samples were 94.9% (93/98) and 91.5% (527/576), respectively. C+ phenotypes were detected in all 98 samples with DEL alleles. Despite comparable costs, RHD genotyping was more accurate and rapid than the adsorption-elution test. CONCLUSIONS: Two practical DEL typing strategies using RhCE phenotyping as an initial screening method were recommended for serologically D-negative Asian donors. Compared with DEL typing using RHD genotyping, serological DEL typing using adsorption-elution test is predicted to increase the incidence of anti-D alloimmunization and decrease the D-negative donor pool without having any cost-competitiveness but can be used in laboratories where molecular methods are not applicable.

Transplantation of human mobilized mononuclear cells improved diabetic neuropathy.

Rodent stem cells demonstrated regenerative effects in diabetic neuropathy via improvement in nerve perfusion. As a pre-clinical step, we explored if human mobilized mononuclear cells (hMNC) would have the same effects in rats. hMNC were injected into Rt. hind-limb muscles of streptozotocin-induced diabetic nude rats, and the grafts were monitored using with MRI. After 4 weeks, the effects were compared with those in the vehicle-injected Lt. hind limbs. Nerve conduction, muscle perfusion and gene expression of sciatic nerves were assessed. Induction of diabetes decreased nerve function and expression of Mpz and Met in the sciatic nerves, which are related with myelination. hMNC injection significantly improved the amplitude of compound muscle action potentials along with muscle perfusion and sciatic nerve Mpz expression. On MRI, hypointense signals were observed for 4 weeks at the graft site, but their correlation with the presence of hMNC was detectable for only 1 week. To evaluate paracrine effects of hMNC, IMS32 cells were tested with hepatocyte growth factor (HGF), which had been reported as a myelination-related factor from stem cells. We could observe that HGF enhanced Mpz expression in the IMS32 cells. Because hMNC secreted HGF, IMS32 cells were co-cultured with hMNC, and the expression of Mpz increased along with morphologic maturation. The hMNC-induced Mpz expression was abrogated by treatment of anti-HGF. These results suggest that hMNC could improve diabetic neuropathy, possibly through enhancement of myelination as well as perfusion. According to in vitro studies, HGF was involved in the hMNC-induced myelination activity, at least in part.

Establishment and Utilization of a Transfusion Recipient Registry in Korea: Estimating the Frequencies of Specific Antigen-Negative Blood Units.

OBJECTIVES: This study was conducted to establish the Korean national registry, to evaluate the distribution of unexpected antibodies, and to determine the frequencies of specific antigen-negative blood units. METHODS: Data added to the Korean national registry between July 2013 and April 2016 were analyzed. The distribution of unexpected antibodies and frequencies of specific antigen-negative blood units were estimated. RESULTS: In total, 3,513 cases from 22 institutes were registered. The most common single alloantibodies were anti-E, anti-Lea, and anti-M. The most common multiple alloantibodies were anti-E with anti-c, anti-C with anti-e, and anti-Lea with anti-Leb. The frequencies of E-, Lea-, and M-negative units were 42.3%, 56.9%, and 20.2%, respectively. CONCLUSIONS: The distribution of unexpected antibodies and frequencies of specific antigen-negative blood units were investigated using data from the Korean national registry. The results provide useful data to predict the number of blood units to be tested to obtain compatible blood units.

Genotyping of 19 red cell antigens, including RHD, using liquid bead arrays.

BACKGROUND: Traditionally, the determination of blood group has been performed using serological techniques. Due to the drawbacks of using antisera, molecular typing of blood groups has been introduced. However, the commonly used genotyping assays in blood banks have limitations because the panels for these were based on genetic variations in Caucasians. METHODS: We developed a multiplex human erythrocyte antigen genotyping assay using allele-specific primer extensions and hybridization with bead microarrays. Single nucleotide polymorphisms (SNP) were genotyped for the 18 red cell antigens and wild-type RHD, DEL, and complete deletion were examined for RHD. The cut-off of median fluorescence intensity (MFI) for each allele was optimized. In the evaluation stage, the results of 87 samples were compared with those from other genotyping methods, and 26 serologic results were also compared. RESULTS: The cut-off values were determined using -1 and -2 standard deviation (SD) of the minimum adjusted MFI for SNP detection. Complete deletion was determined with raw MFI+2SD. In comparison with the other methods, the kappa values were 0.984 overall. Compared with serologic methods, our assay showed discrepancy in 2 S/s, 3 C/c, and 3 Dia/Dib antigens. CONCLUSIONS: Our method reliably predicts the presence or the absence of the 19 antigens.

Genotyping of 22 blood group antigen polymorphisms and establishing a national recipient registry in the Korean population.

It is often difficult for standard blood banks in Korea to supply adequate amounts of blood for patients with rare phenotype. Moreover, the definition of a blood in need is ambiguous, and much remains to be learned. In this study, we determined the prevalence of various red blood cell (RBC) antigens from a donor viewpoint and estimated the demand for specific antigen-negative blood from a patient viewpoint. Our data will aid the establishment of a Rare Blood Program in Korea (KRBP). RBC genotyping of 419 blood donors was performed using a Lifecodes RBC/RBC-R typing kit (Immucor, Norcross, GA). A national recipient registry website has been established. Each hospital-based blood bank voluntarily enters data on antibodies detected and identified and the outcomes of specific antigen testing. We calculated the availabilities of specific antigen-negative blood components based on these registry data and predicted the prevalence of RBC antigens via RBC genotyping. The prevalences of various RBC antigens in the D-negative population were determined for the first time, and the Cartwright, Scianna, Dombrock, Colton, Landsteiner-Wiener, Cromer, and Knops blood group systems were identified. The availabilities of specific antigen-negative units differed when calculations were based on serotyping or genotyping, especially in the D-negative group. Data on the prevalences of various blood antigens are essential for estimating the availabilities of blood components that are appropriate for use by patients expressing relevant antibodies. Then, blood banks would be able to efficiently supply safe blood products.

Thrombotic risk of reduced ADAMTS13 activity in patients with antiphospholipid antibodies.

Antiphospholipid syndrome (APS) is an autoimmune disease in which antiphospholipid antibodies (aPLs) are generated. Previous studies show concurrence of APS and thrombotic thrombocytopenic purpura; therefore it is plausible to assume that anti-ADAMTS13 autoantibody is also involved in the pathophysiology of APS. We investigated the clinical significance of ADAMTS13 activity and anti-ADAMTS13 antibody in patients with aPLs. Two hundred and sixteen patients with positive lupus anticoagulant and/or anticardiolipin antibody were included. ADAMTS13 activity and anti-ADAMTS13 antibody were measured using fluorescence resonance energy-transfer technology and ELISA, respectively. Reduced ADAMTS13 activity was observed in 40.3% (87/216) of patients with aPLs. Although 33.8% (73/216) of patients were positive for anti-ADAMTS13 antibody, 41 of these 73 patients had normal levels of ADAMTS13 activity. Reduced ADAMTS13 activity was a significant risk factor for thrombotic events. Thrombotic events and age contributed to the reduced level of ADAMTS13 activity. Presence of anti-ADAMTS13 antibody did not show any association with the level of ADAMTS13 activity. Patients with autoimmune diseases tended to show higher levels of anti-ADAMTS13 antibody. Our findings suggest that reduced ADAMTS13 activity is a significant thrombotic risk factor in patients with aPLs irrespective of the presence of anti-ADAMTS13 antibody. Presence of anti-ADAMTS13 antibody is not seen with reduced activity and it tends to be increased in patients with autoimmune diseases.

Development of Real-time PCR and Melting Curve Analysis for the Rapid Detection of DEL with RHD (c.1222T>C) or RHD (c.1227G>A).

BACKGROUND: DEL, a variant of RhD, is difficult to detect in routine blood bank testing owing to its extremely low levels of D antigen expression. However, DEL is capable of alloimmunizing a patient when transfused into RhDnegative individuals. METHODS: In this study, we developed real-time PCR and melting curve analysis for the rapid detection of the DEL phenotype. RESULTS: Of the 325 serologically RhD-negative individuals involved in the study, 56 (17.2%) had melting temperatures distinguishable from complete RHD absence as follows: 53 RHD (c.1227G>A) DEL specimens had a plateau at 54 - 56°C and a peak at 61.95°C, while 3 RHD (c.1222T>C) DEL had a melting temperature of 62.62°C. All DEL results were identical to those obtained by multiplex single-base primer extension reactions. CONCLUSIONS: The rapid DEL genotyping method developed in this study will be useful for screening DEL in serologically RhD-negative donors and preventing the alloimmunization of RhD-negative individuals by DEL.

Protein Z efficiently depletes thrombin generation in disseminated intravascular coagulation with poor prognosis.

Disseminated intravascular coagulation (DIC) is characterized by consumption of coagulation factors and anticoagulants. Thrombin generation assay (TGA) gives useful information about global hemostatic status. We developed a new TGA system that anticoagulant addition can deplete thrombin generation in plasma, which may reflect defective anticoagulant system in DIC. TGAs were measured on the calibrated automated thrombogram with and without thrombomodulin or protein Z in 152 patients who were suspected of having DIC, yielding four parameters including lag time, endogenous thrombin potential, peak thrombin and time-to-peak in each experiment. Nonsurvivors showed significantly prolonged lag time and time-to-peak in TGA-protein Z system, which was performed with added protein Z. In multivariate Cox regression analysis, lag time and time-to-peak in TGA system were significant independent prognostic factors. In TGA-protein Z system, lag time and time-to-peak were revealed as independent prognostic factors of DIC. Protein Z addition could potentiate its anticoagulant effect in DIC with poor prognosis, suggesting the presence of defective protein Z system. The prolonged lag time and time-to-peak in both TGA and TGA-protein Z systems are expected to be used as independent prognostic factors of DIC.

Therapeutic Plasmapheresis Enabling Radioactive Iodine Treatment in a Patient with Thyrotoxicosis.

Therapeutic plasma exchange (TPE) is one possible treatment for patients resistant to conventional antithyroid drugs or requiring urgent attention for thyrotoxicosis. We report a 35-yr-old man with thyrotoxicosis, ultimately attributed to Graves' disease in whom antithyroid drug used initially was soon discontinued, due to abnormal liver function, and replaced by Lugol's solution. Three weeks later, an escape phenomenon (to Lugol's solution) was apparent, so we performed TPE to control the thyrotoxicosis. Two courses of TPE by a centrifugal type machine resulted in diminished levels of thyroid hormone levels, which then rebounded after another two courses of membrane filtration type TPE. However, the patient could be treated with radioactive iodine therapy without any complications at present.

Occult hepatitis B virus infection and blood transfusion.

Transfusion-transmitted infections including hepatitis B virus (HBV) have been a major concern in transfusion medicine. Implementation of HBV nucleic acid testing (NAT) has revealed occult HBV infection (OBI) in blood donors. In the mid-1980s, hepatitis B core antibody (HBc) testing was introduced to screen blood donors in HBV non-endemic countries to prevent transmission of non-A and non-B hepatitis. That test remains in use for preventing of potential transmission of HBV from hepatitis B surface antigen (HBsAg)-negative blood donors, even though anti-hepatitis C virus tests have been introduced. Studies of anti-HBc-positive donors have revealed an HBV DNA positivity rate of 0%-15%. As of 2012, 30 countries have implemented HBV NAT. The prevalence of OBI in blood donors was estimated to be 8.55 per 1 million donations, according to a 2008 international survey. OBI is transmissible by blood transfusion. The clinical outcome of occult HBV transmission primarily depends on recipient immune status and the number of HBV DNA copies present in the blood products. The presence of donor anti-HBs reduces the risk of HBV infection by approximately five-fold. The risk of HBV transmission may be lower in endemic areas than in non-endemic areas, because most recipients have already been exposed to HBV. Blood safety for HBV, including OBI, has substantially improved, but the possibility for OBI transmission remains.

Prominent protein Z-induced thrombin inhibition in cirrhosis: a new functional assay for hypercoagulability assessment.

BACKGROUND AND AIMS: Protein Z (PZ) is an anticoagulant that accelerates the inhibitory effect of PZ-dependent protease inhibitor (ZPI) on coagulation factor Xa. We assessed functional status of PZ system in 158 patients with liver cirrhosis and 59 healthy controls. METHODS: Plasma PZ and ZPI levels were measured by enzyme immunoassay. Thrombin generation assays (TGA) were performed with and without thrombomodulin (TM) or PZ, and the ratios were calculated by dividing TGA values with TM or PZ by values without TM or PZ. RESULTS: PZ and ZPI levels were reduced and elevated in advanced cirrhosis, respectively. The lag time ratio-PZ was significantly higher in cirrhosis patients than controls and correlated with the model for end-stage liver disease score. The peak thrombin ratio-PZ and endogenous thrombin potential (ETP) ratio-PZ were significantly lower in cirrhosis patients than controls and correlated with the severity of liver cirrhosis. The peak thrombin ratio-PZ was dramatically reduced in advanced cirrhosis. Cirrhosis patients had a significantly higher ETP ratio-TM than the controls, although the ratio was not correlated with cirrhosis severity. The lag time ratio-PZ and peak time ratio-PZ were significantly correlated with the levels of all coagulation and anticoagulation factors. Interestingly, the lag time ratio-PZ and peak thrombin ratio-PZ were significantly associated with thrombotic events. CONCLUSION: The anticoagulant role of PZ is insufficient in advanced stages of cirrhosis. Our newly developed functional assay for measuring the PZ system is expected to reflect the ongoing hypercoagulability of cirrhosis.

Attached segment has higher CD34+ cells and CFU-GM than the main bag after thawing.

A contiguous segment attached to the cord blood unit (CBU) is required for verifying HLA types, cell viability, and, possibly, potency before transplantation since such a segment is considered to be representative of the CBU. However, little is known regarding the characteristics of contiguous segments in comparison to main bag units due to the difficulty experienced in accessing a large number of cryopreserved CBUs. In this study, we used 245 nonconforming CBUs for allogeneic transplantation. After thawing the cryopreserved CBU, the number of total nucleated cells (TNCs), CD34(+) cells, and CFUs in CB from main bags and segments, as well as cell viability and apoptosis, were examined. The comparative analysis showed that the number of TNCs was significantly higher in CB from main bags, whereas the numbers of CD34(+) cells and CFU-GM were significantly higher in CB from segments. While the cell viability of TNCs in segments was higher, the proportion of apoptotic TNCs was also higher. In contrast, no difference was observed between the proportion of apoptotic CD34(+) cells in main bags and segments. In the correlation analysis, the numbers of TNCs, CD34(+) cells, and CFU-GM in main bags were highly correlated with those in segments, indicating that CB from segments is indeed representative of CB in main bags. Taken together, we conclude that segments have higher CD34(+) cells and CFU-GM and lower TNCs than the main cryopreserved bag, although the two compartments are highly correlated with each other.

Presence of antiheparin/platelet factor 4 immunoglobulin g is associated with poor prognosis in patients with suspected disseminated intravascular coagulation.

The underlying inflammatory or infectious condition in disseminated intravascular coagulation (DIC) may stimulate the formation of antiheparin/platelet factor 4 (PF4) antibody, and the resulting antibody may affect the clinical course of DIC. We investigated the prognosis of antiheparin/PF4 antibodies in patients with suspected DIC. We measured heparin/PF4 immunoglobulin G (IgG) and total antibody levels using an automated chemiluminescence system in 118 patients with DIC. Of the 118 patients, 13 (11.0%) patients were positive for total antiheparin/PF4, and 6 (5.1%) patients were positive for antiheparin/PF4 IgG. These 13 patients were negative for platelet-activating antibody and had low-heparin-induced thrombocytopenia probability scores. Patients with antiheparin/PF4 IgG were older and had lower antithrombin levels than patients without antiheparin/PF4 IgG. Patients with antiheparin/PF4 IgG had a higher risk of mortality than those without antiheparin/PF4 IgG. The presence of antiheparin/PF4 IgG in old age or low antithrombin level patients with DIC with old age or low antithrombin level suggests a poor prognosis.

Influence of ABO type on global coagulation assay results: effect of coagulation factor VIII.

BACKGROUND: As ABO blood type influences the plasma level of coagulation factor VIII (FVIII), it likely also affects activated partial thromboplastin time (aPTT) and thrombin generation assay (TGA) values. Here, we aimed to investigate the effect of ABO type on the normal values of three global coagulation assays: prothrombin time (PT), aPTT, and TGA. METHODS: PT, aPTT, TGA [1 or 5 pmol/L tissue factor (TF)], coagulation factors, anticoagulation factors, and ABO type were measured in 200 healthy adults. RESULTS: aPTT was significantly prolonged in those with type O compared with those with type non-O, whereas PT was not significantly different between those with type O and type non-O. The time to peak induced by 5 pmol/L TF was significantly prolonged, and the peak thrombin level was decreased in those with type O compared with those with type non-O. FVIII was a major contributor to the ABO-specific reference range of aPTT, 5 pmol/L TF-induced time to peak, and peak thrombin level. CONCLUSIONS: The reference ranges of aPTT and TGA (time to peak and peak thrombin level) differed by ABO type. FVIII level is considered a major contributor to ABO type-specific differences with respect to aPTT and TGA.

Association between red blood cell storage duration and clinical outcome in patients undergoing off-pump coronary artery bypass surgery: a retrospective study.

BACKGROUND: Prolonged storage of red blood cells (RBCs) leads to fundamental changes in both the RBCs and the storage media. We retrospectively evaluated the relationship between the RBC age and in-hospital and long-term postoperative outcomes in patients undergoing off-pump coronary artery bypass. METHODS: The electronic medical records of 1,072 OPCAB patients were reviewed and information on the transfused RBCs and clinical data were collected. The effects of RBCs age (mean age, oldest age of transfused RBCs, any RBCs older than 14 days) on various in-hospital postoperative complications and long-term major adverse cardiovascular and cerebral events over a mean follow-up of 31 months were investigated. Correlations between RBCs age and duration of intubation, intensive care unit, or hospital stay, and base excess at the first postoperative morning were also analyzed. RESULTS: After adjusting for confounders, there was no relationship between the RBCs age and in-hospital and long-term clinical outcomes except for postoperative wound complications. A significant linear trend was observed between the oldest age quartiles of transfused RBCs and the postoperative wound complications (quartile 1 vs. 2, 3 and 4: OR, 8.92, 12.01 and 13.79, respectively; P for trend = 0.009). The oldest transfused RBCs showed significant relationships with a first postoperative day negative base excess (P = 0.021), postoperative wound complications (P = 0.001), and length of hospital stay (P = 0.008). CONCLUSIONS: In patients undergoing off-pump coronary artery bypass, the oldest age of transfused RBCs were associated with a postoperative negative base excess, increased wound complications, and a longer hospital stay, but not with the other in-hospital or long-term outcomes.

Differential expression of leukocyte receptors in disseminated intravascular coagulation: prognostic value of low protein C receptor expression.

BACKGROUND: The protein C receptor (PROCR), toll-like receptor (TLR) and L-selectin leukocyte receptor play roles in systemic inflammatory response including disseminated intravascular coagulation (DIC). Expression of these receptors, which mediate systemic immune or coagulation responses, is tightly regulated by physiologic or pathologic signals. We investigated whether the expressions of 3 leukocyte receptors (PROCR, TLR4, L-selectin) was related to clinical outcomes in patients suggestive of having DIC. METHODS: RNA was extracted from the peripheral blood buffy coats of patients suggestive of having DIC. After reverse transcription, mRNA expression levels of PROCR, TLR4, and L-selectin were measured using Taqman Gene Expression Assays. The 28-day hospital mortality rate was used as a clinical outcome. RESULTS: The expression level of PROCR mRNA in leukocytes was lower in those with overt-DIC as compared to those without overt-DIC, however, this difference was not statistically significant. As for TLR4 and L-selectin mRNA expression, there were no significant differences observed between those with and without overt-DIC. A Kaplan-Meier survival analysis revealed that patients with low PROCR mRNA expression levels showed significantly lower survival rates than those with high expression levels. On multivariate cox regression analysis, low levels of PROCR mRNA expression were an independent prognostic marker. However, expression levels of TLR4 and L-selectin mRNA were not associated with any prognostic value. CONCLUSION: Considering that the PROCR is an important anticoagulant receptor, low PROCR mRNA expression levels associated with a poor prognosis in patients with DIC represents an exhaustion of the natural anticoagulant system, and reflects the final decompensate stage of DIC. The leukocyte PROCR may contribute to a dampening of florid activation of coagulation reactions in vivo.

Significance of Lewis phenotyping using saliva and gastric tissue: comparison with the Lewis phenotype inferred from Lewis and secretor genotypes.

Lewis phenotypes using various types of specimen were compared with the Lewis phenotype predicted from Lewis and Secretor genotypes. This is the first logical step in explaining the association between the Lewis expression and Helicobacter pylori. We performed a study of the followings on 209 patients who underwent routine gastroscopy: erythrocyte and saliva Lewis phenotyping, gastric Lewis phenotyping by the tissue array, and the Lewis and Secretor genes genotyping. The results of phenotyping were as follows [Le(a-b-), Le(a+b-), Le(a-b+), and Le(a+b+), respectively, in order]: erythrocyte (12.4%, 25.8%, 61.2%, and 0.5%); saliva (2.4%, 27.3%, 70.3%, and 0.0%); gastric mucosa (8.1%, 6.7%, 45.5%, and 39.7%). The frequency of Le, le (59/508) , le (59/1067) , and le (59) alleles was 74.6%, 21.3%, 3.1%, and 1.0%, respectively, among 418 alleles. The saliva Lewis phenotype was completely consistent with the Lewis phenotype inferred from Lewis and Secretor genotypes, but that of gastric mucosa could not be predicted from genotypes. Lewis phenotyping using erythrocytes is only adequate for transfusion needs. Saliva testing for the Lewis phenotype is a more reliable method for determining the peripheral Lewis phenotype of an individual and the gastric Lewis phenotype must be used for the study on the association between Helicobacter pylori and the Lewis phenotype.

Proposal of standardized guidelines for the production and quality control of autologous serum eye drops in Korea: based on a nationwide survey.

BACKGROUND: Autologous serum eye drops (ASEDs) have been used to treat many eye diseases. However, there are no standardized guidelines for the production and quality control (QC) of ASEDs in Korea. Our aim was to propose standardized guidelines for the production and QC of ASEDs. STUDY DESIGN AND METHODS: We conducted a nationwide survey consisting of questions regarding the methods used in each hospital for the production and QC of ASEDs. The survey was sent by e-mail to 89 doctors responsible for the blood banks at different hospitals. RESULTS: Thirty-two hospitals replied, and 13 hospitals reported using the ASEDs in the treatment of patients with eye diseases. The screening test for patients, amount of blood sampling, type of bottle used for blood collection, details about the production of the eye drops, and storage methods and shelf life of unopened and opened bottles of eye drops varied between hospitals. CONCLUSION: Based on an analysis of the survey results and a review of the standard operating procedures and protocols for ASEDs used in Japan, Germany, England and Wales, and the United States, we proposed standardized guidelines for the production and QC of ASEDs in Korea. ASEDs are not cell therapy products in the strictest sense. However, because eye drops are composed of serum isolated from blood and are used in patients, we consider ASEDs to be the basis for cell therapy products. Therefore, ASEDs should be produced and stored according to standardized guidelines based on the Good Manufacturing Practice guidelines.