["Gift or good?"]. / Don ou marchandise?

The European Union and many transfusion international organizations and societies held the unpaid blood donation as an imperative for enrolling donors, not always providing the means for implementing this regulation, in particular induced by the (pharmaceutical) industry's hesitations. In spite of this, all available data, whatever former or recent, prove that the unpaid blood donation has a higher transfusion safety level than the remunerated donation's. The author also stresses that blood industrialization, while considerably improving the transfusion safety, has also destroyed the past vicinity between donor and receiver within the hospital environment, detrimental to enrolling donors. He also evokes challenges to be coming up soon in transfusion centres as well as changing the role of Red Cross and Red Crescent societies to refocusing their activities on the promotion of blood donation and donor enrollment.

[The practice guideline 'Blood transfusion' (third integral revision)]. / Richtlijn 'Bloedtransfusie' (3e algehele herziening).

The revised and expanded practice guideline 'Blood transfusion' describes the whole transfusion chain within the hospital for the first time. Despite compatibility tests before transfusion (determination of the ABO and Rhesus blood groups and detection of clinically relevant antibodies (C, c, D, E, e, Fy(a), Fy(b), Jk(a), Jk(b), M, S and s)), transfusion reactions can occur. So that a transfusion reaction can be recognised in time, the patient must be observed intensively for the first 5-10 minutes after the start of any new transfusion and the vital functions must be recorded. In patients with a Hb level of 4-6 mmol/l, the decision whether or not to transfuse should be made dependent on the patient's other characteristics. Thrombocyte transfusion is not indicated in case of thrombopenia due to increased breakdown or pooling. If leukaemia, tumour infiltration or drug toxicity is the underlying cause of thrombopenia, then a platelet count of 10 x 10(9)/l or 20 x 10(9)/l should be the transfusion trigger. Reduction of the number of blood transfusions can be achieved by the administration of epoetin in case of renal insufficiency: transfusion can thus be avoided in more than 70% of the patients concerned. Autotransfusion during surgery with severe blood loss also results in a reduction of the number of allogenic blood transfusions.

WHO Expert Committee on Biological Standardization.

This report presents the recommendations of a WHO Expert Committee commissioned to coordinate activities leading to the adoption of international requirements for the production and control of vaccines and other biologicals and the establishment of international biological reference materials. The report starts with a discussion of general issues brought to the Committee's attention and provides information on the status and development of reference materials for various antibodies, antigens, blood products and related substances, cytokines, growth factors, and endocrinological substances. The second part of the report, of particular relevance to manufacturers and national regulatory authorities, contains recommendations for the production and quality control of meningococcal group C conjugate vaccines, guidelines for regulatory expectations for clinical evaluation of vaccines, guidelines for the production and quality control of inactivated oral cholera vaccines and guidelines on viral inactivation and removal procedures intended to assure the viral safety of human blood plasma products.

[Hemovigilance: a joint responsibility of hospitals and blood banks]. / Hemovigilantie: een gezamenlijke taak van ziekenhuizen en bloedbanken.

The objective of haemovigilance, a set of surveillance procedures covering the complete transfusion chain, is to collect and assess information concerning unexpected and undesirable effects arising from the therapeutic use of labile blood products, and to prevent the recurrence of such incidents. A number of guidelines and directives from national and European health authorities require hospitals to institute a haemovigilance system. Preliminary data from one blood bank region in the Netherlands reveals the various types of transfusion reactions reported. The current haemovigilance systems still have some limitations. A considerable amount of time and effort will be needed for the benefits of haemovigilance to become apparent.

['Variant of Creutzfeldt-Jacob disease and blood transfusion'; report of the Dutch Health Council]. / 'Variant van de ziekte van Creutzfeldt-Jakob en bloedtransfusie'; rapport van de Gezondheidsraad.

The new variant form of Creutzfeldt-Jakob Disease (vCJD), which has been diagnosed in about 100 patients--mostly in the United Kingdom (UK)--is considered to be associated with the consumption of beef contaminated with the agent bovine spongi-form encephalopathy (BSE). Although no cases of vCJD have been reported until now in the Netherlands, large quantities of beef have been imported from the UK in previous years; furthermore about 17 cattle with BSE have been detected in the Netherlands. Concern about the possible transmission of vCJD via blood and blood-products has led to a number of countries taking precautionary measures. Following questions raised by the Minister of Health, Welfare and Sport, the Health Council of the Netherlands issued a report to address the need for certain precautionary measures such as the leukodepletion of blood and the exclusion of donors at risk for vCJD. The Health Council recommends the routine leukodepletion of cellular blood components. The exclusion of donors who have resided in the UK for six or more months during the period 1980-1996, was considered to be insufficient to contribute to risk reduction. The Minister has recently decided to follow these two recommendations. However, she is of the opinion that the Health Council's recommendation to exclude all donors who have previously been transfused with cellular blood components is unnecessary. A common European position regarding such precautionary measures is deemed to be necessary. This would allow the exchange of blood components between countries and would also prevent donors, patients and the public at large from being confused or uncertain about the safety of blood components.

Relation between cell density and the secretion of von Willebrand factor and prostacyclin by human umbilical vein endothelial cells.

In this study, the relation between the density of human umbilical vein endothelial cells (HUVECs) cultured on TCPS and (crosslinked) collagen, and the secretion of von Willebrand factor (vWF) and prostacyclin (PGI2) was determined. Collagen was crosslinked using N-(3-dimethylaminopropyl)-N'-ethylcarbodiimide (EDC) in combination with N-hydroxy-succinimide (NHS), resulting in a matrix containing 14 free primary amino groups per 1000 amino acid residues after crosslinking (E/N14C). HUVECs were seeded on E/N14C, non-crosslinked collagen (N-Coll) and fibronectin-coated TCPS at densities ranging from 2500 to 50,000 cells/cm2. After 1 day of culture, both basal and A23187-stimulated secretion of vWF (expressed per 1,000,000 cells) was considerably increased at low cell densities (i.e. below 5000 cells/cm2) on all substrates. Secretion of PGI2 gradually increased with decreasing cell densities below 10,000 cells/cm2. After 10 days of proliferation, cell numbers on all substrates exceeded 50,000 cells/cm2, irrespective of the seeding density. Concomitantly, the initial higher secretion of PGI2 and vWF at the lowest seeding densities was decreased after longer times of culture, to values comparable to those obtained for higher seeding densities.

Binding and release of basic fibroblast growth factor from heparinized collagen matrices.

Endothelial cell seeding is a promising method to improve the performance of small-diameter vascular grafts. Growth of endothelial cells seeded on the luminal surface of synthetic vascular grafts, coated with a matrix suitable for cell seeding (e.g. collagen), can be accelerated by local, sustained release of basic fibroblast growth factor (bFGF). In this study two potential matrices for in vivo endothelial cell seeding were studied with respect to bFGF binding and release: collagen crosslinked using N-(3-dimethylaminopropyl)-N'-ethylcarbodiimide (EDC) and N-hydroxysuccinimide (NHS), as well as heparinized EDC/NHS-crosslinked collagen. bFGF binding was determined after incubation of circular samples (10 mm diameter) with 0.25 ml bFGF solution for 90 min. Immobilization of increasing amounts of heparin, also using EDC and NHS, to crosslinked collagen containing 14 free primary amino groups per 1000 amino acid residues (E/N14C) resulted in binding of increasing amounts of bFGF. A plateau in bFGF binding was observed for heparinized E/N14C containing approximately 2.0-3.0 wt% of immobilized heparin which was obtained using a molar ratio of EDC to heparin-carboxylic acid groups of 0.4 during heparin immobilization (E/N14C-H(0.4)). At concentrations up to 840 ng bFGF/ml, 10% of the added bFGF bound to E/N14C, while binding of bFGF to E/N14C-H(0.4) amounted to 22%. Both E/N14C and E/N14C-H(0.4) pre-loaded with bFGF showed sustained bFGF release. A burst release of 30% in endothelial cell culture medium (CM) was observed for E/N14C during the first 6 h, compared to 2% release from E/N14C-H(0.4). After 28 days, the bFGF release from E/N14C and E/N14C-H(0.4) in CM amounted to 100 and 65%, respectively. Combined results of binding and release of bFGF indicate that compared to E/N14C, E/N14C-H(0.4) is the substrate of choice for bFGF pre-loading and subsequent endothelial cell seeding.

Improved platelet compatiblity of water vapour glow discharge treated non-woven poly(ethylene terephthalate) leukocyte-reduction filters for different types of platelet concentrates.

Non-woven poly[ethylene terephthalate] (NW-PET) filter fabric, usually used for leucocyte removal of red cells, was modified by water vapour glow discharge (WVGD) treatment to improve platelet compatibility. Modified filter material was evaluated with different kinds of platelet concentrates (PCs). In addition, modified filter materials were gamma-sterilized and tested after different time intervals at different storage conditions. Modification of the filter material resulted in an improved platelet recovery after filtration of PC from 57 to about 80%. No significant difference in platelet recovery was observed when filtering either freshly prepared (79 +/- 3.5%, mean +/- SD), overnight-stored single BC-PC (78 +/- 3.3%), overnight-stored single PRP-PC (75 +/- 8.8%) or overnight-stored pooled BC-PC (79 +/- 8.9%). However, freshly prepared pooled BC-PC gave a significantly higher platelet recovery (84 +/- 3.5%). Leukocyte depletion did not differ significantly between the different types of PC. gamma-Sterilization and subsequent storage of the modified filter material for 5, 14 and 26 weeks at 20 degrees C or 37 degrees C had no significant influence on the filtration results of overnight-stored pooled BC-PC. The results of the present study show that WVGD-treated NW-PET is platelet compatible and can be used for leucocyte removal from preferably BC-PC. It can be gamma-sterilized and stored for at least 6 months prior to filtration without affecting the platelet recovery and leucocyte removal.

In vivo biocompatibility of carbodiimide-crosslinked collagen matrices: Effects of crosslink density, heparin immobilization, and bFGF loading.

Collagen matrices, crosslinked using N-(3-dimethylaminopropyl)-N'-ethylcarbodiimide (E) and N-hydroxysuccinimide (N), were previously developed as a substrate for endothelial cell seeding of small-diameter vascular grafts. In the present study, the biocompatibility of various EN-crosslinked collagen matrices was evaluated following subcutaneous implantation in rats for periods up to 10 weeks. The effects of the crosslink density, referred to as the number of free primary amino groups per 1,000 amino acid residues (EN10, EN14, EN18, or EN22), the amount of heparin immobilized to EN14, and the effect of preloading heparinized EN14 with basic fibroblast growth factor (bFGF) on the induced tissue reaction were studied. EN-crosslinked collagen was biocompatible at both early and late time intervals, and matrices with high crosslink densities (i.e., EN14, EN10) especially demonstrated a significantly decreased antigenic response when compared to noncrosslinked collagen. Furthermore, increased crosslinking resulted in a decreased degradation rate. Immobilization of heparin onto EN14 resulted in a similar to EN14 (thus without heparin) or somewhat reduced tissue reaction, but fibrin formation and vascularization were increased with increasing quantities of immobilized heparin. Matrices preloaded with bFGF also demonstrated good biocompatibility, especially in combination with higher amounts of immobilized heparin. The latter matrices [EN14 with high heparin and bFGF, thus EN14-H (0.4)F and EN14-H(1.0)F] demonstrated significantly increased vascularization for periods up to 3 weeks. Neither heparin immobilization nor bFGF preloading induced an increased antigenic response. It is concluded that the results of this study justify further evaluation of bFGF preloaded, heparin immobilized EN14 collagen, as a matrix for endothelial cell seeding in experimental animals.

Immobilization of heparin to EDC/NHS-crosslinked collagen. Characterization and in vitro evaluation.

In the present study, heparin immobilization to a non-cytotoxic crosslinked collagen substrate for endothelial cell seeding was investigated. Crosslinking of collagen using N-(3-dimethylaminopropyl)-N'-ethylcarbodiimide (EDC) and N-hydroxysuccinimide (NHS) resulted in a material containing 14 free primary amino groups per 1000 amino acid residues (E/N14C). At a fixed molar ratio NHS:EDC of 0.6, the amount of heparin covalently immobilized to E/N14C increased with increasing molar ratios of EDC to heparin carboxylic acid groups (Hep-COOH), to a maximum of approximately 5-5.5 wt% at a ratio of 2. Upon incubation in cell culture medium of endothelial cells, 4 to 7% of the immobilized heparin was released during 11 days. Immobilization of increasing amounts of heparin to E/N14C progressively reduced activation of contact activation proteases. Optimal anticoagulant activity, as measured by thrombin inhibition, was obtained after heparin immobilization using a ratio of EDC to Hep-COOH of 0.2-0.4 (14-20 mg heparin immobilized per gram of collagen). Platelets deposited to (heparinized) E/N14C showed only minor spreading and aggregation, although heparin immobilization slightly increased the number of adherent platelets. The results of this study suggest that heparin immobilization to EDC/NHS-crosslinked collagen may improve the in vivo blood compatibility of this material.

Endothelial cell seeding on crosslinked collagen: effects of crosslinking on endothelial cell proliferation and functional parameters.

Endothelial cell seeding, a promising method to improve the performance of small-diameter vascular grafts, requires a suitable substrate, such as crosslinked collagen. Commonly used crosslinking agents such as glutaraldehyde and formaldehyde cause, however, cytotoxic reactions and thereby hamper endothelialization of currently available collagen-coated vascular graft materials. The aim of this study was to investigate the effects of an alternative method for crosslinking of collagen, using N-(3-dimethylaminopropyl)-N'-ethylcarbodiimide (EDC) in combination with N-hydroxysuccinimide (NHS), on various cellular functions of human umbilical vein endothelial cells (HUVECs) in vitro. Compared to non-crosslinked type I collagen, proliferation of seeded endothelial cells was significantly increased on EDC/NHS-crosslinked collagen. Furthermore, higher cell numbers were found with increasing crosslink densities. Neither the morphology of the cells nor the secretion of prostacyclin (PGI2), von Willebrand factor (vWF), tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI-1) was affected by the crosslink density of the collagen substrate. Therefore, EDC/NHS-crosslinked collagen is candidate substrate for in vivo application such as endothelial cell seeding of collagen-coated vascular grafts.

[Leukodepletion of blood products: a requirement for improvement of quality and safety]. / Leukodepletie van bloedproducten: een maatregel ten behoeve van kwaliteit en veiligheid.

The presence of leukocytes in blood products has no beneficial effect on the recipient, except in special situations such as for patients being prepared to receive an organ transplantation. On the other hand the leukocytes have a number of untoward side effects such as HLA immunisation, non haemolytic febrile transfusion reactions, virus transmission and postoperative infections. In response to a request of the Minister of Health, Welfare and Sports, the Health Council of the Netherlands prepared a recommendation on the need of routine leukodepletion by filtration of blood. Although the introduction of leukodepletion of blood products is favoured, it is emphasized that only data from selected patient groups are available while the costs of leukodepletion are considerable. Therefore, an evaluation of the benefits and cost effectiveness of blood filtration is recommended. It is argued that leukodepletion, already introduced in a number of countries, is now considered to be 'state of the art'. Furthermore product liability, public opinion about blood safety and the precaution duty of manufacturers should be taken into account.

Endothelial cell seeding of (heparinized) collagen matrices: effects of bFGF pre-loading on proliferation (after low density seeding) and pro-coagulant factors.

Endothelial cell seeding to improve the performance of small-diameter vascular grafts requires a suitable substrate, such as crosslinked collagen. In addition to providing a suitable substrate for adhesion and growth of endothelial cells, proliferation of seeded endothelial cells can be enhanced by local, sustained release of basic fibroblast growth factor (bFGF, a heparin-binding growth factor for endothelial cells). We have previously shown that collagen crosslinked using N-(3-dimethylaminopropyl)-N'-ethylcarbodiimide (EDC) and N-hydroxysuccinimide (NHS) supports adhesion and proliferation of human umbilical vein endothelial cells (HUVECs). In the present study, HUVECs were seeded on (heparinized) EDC/NHS-crosslinked collagen, pre-loaded with bFGF. Proliferation of HUVECs on (heparinized) crosslinked collagen increased with increasing amounts of pre-loaded bFGF. The minimal cell-seeding density required for proliferation proved to be very low after pre-loading the substrates with bFGF, and was 4-fold lower for heparinized crosslinked collagen compared to crosslinked collagen (250 versus 1000 cells/cm(2)). Pro-coagulant properties (von Willebrand factor secretion and tissue factor expression) of HUVECs seeded on (heparinized) crosslinked collagen, with or without pre-loading of bFGF, were comparable to those of HUVECs on TCPS. It is concluded that heparinized, EDC/NHS-crosslinked collagen pre-loaded with bFGF is a candidate matrix for in vivo endothelial cell seeding of synthetic vascular graft materials.

Improved endothelialization of vascular grafts by local release of growth factor from heparinized collagen matrices.

Endothelial cell seeding, a promising method to improve the performance of small-diameter vascular grafts, requires a suitable substrate, e.g. crosslinked collagen. In addition, the growth of seeded endothelial cells can be improved by local release of a heparin-binding protein, basic fibroblast growth factor (bFGF). In this study, the influence of immobilization of heparin to collagen, crosslinked using N-(3-dimethylaminopropyl)-N'-ethylcarbodiimide (EDC) in combination with N-hydroxysuccinimide (NHS), on the binding and release of bFGF was determined. Heparin was immobilized also using EDC and NHS. Furthermore, the effects of the release of bFGF from (heparinized) EDC/NHS-crosslinked collagen on the proliferation of seeded endothelial cells was studied in vitro. Immobilization of increasing amounts of heparin to EDC/NHS-crosslinked collagen (containing 14 free epsilon-amino groups per 1000 amino acid residues, E/N14C) resulted in binding of increasing amounts of bFGF to the material. Maximal bFGF binding was observed for E/N14C containing 20-30 mg heparin immobilized per gram of collagen which was obtained using a molar ratio of EDC to heparin-carboxylic acid groups of 0.4 for heparin immobilization (E/N14C-H(0.4)). Up to concentrations of 320 ng bFGF/ml, 10% of the added bFGF bound to E/N14C, while binding of bFGF to E/N14C-H(0.4) was 22%. The initial release rate of bFGF bound to E/N14C was much higher compared to bFGF bound to E/N14C-H(0.4): respectively, 30 vs. 2% in the first 6 h. After 10 days, the bFGF release from E/N14C and E/N14C-H(0.4) amounted to 83 vs. 42%, respectively. Binding of increasing amounts of bFGF resulted in increased growth of human umbilical vein endothelial cells (HUVECs) seeded on both E/N14C and E/N14C-H(0.4). Nevertheless, after 6 and 10 days of proliferation cell numbers on E/N14C-H(0.4) where higher than cell numbers on E/N14C, irrespective of the bFGF concentration used for loading of the matrix. It is concluded that heparinized, EDC/NHS-crosslinked collagen is a good synthetic vascular graft coating for in vivo endothelial cell seeding.

Endothelialization of crosslinked albumin-heparin gels.

Crosslinked gels of albumin as well as heparinized albumin gels, potential sealants of prosthetic vascular grafts, were studied with regard to in vitro stability, binding of basic fibroblast growth factor (bFGF) and cellular interactions. A small percentage of the heparin present in these gels, was released during storage in SDS solution. During storage in cell culture medium at 37 degrees C, heparin release was 21-25 percent. Release of albumin did not occur. Human umbilical vein endothelial cells (HUVECs) rapidly adhered and subsequently spread on (heparinized) albumin gels, but proliferation was only observed if heparin was present in the gel. Binding of 125I-bFGF to heparinized albumin gel was 35 percent higher than to non-heparinized albumin gel. Growth of HUVECs occurred only on heparinized albumin gel loaded with bFGF and not on bFGF-loaded albumin gel. The number of platelets deposited under stationary conditions onto heparinized albumin gel was about twice the number found on nonheparinized albumin gel. Seeding of HUVECs on heparinized albumin gel, significantly reduced the number of platelets adhering to this surface. Moreover, no spreading of platelets was observed on substrates seeded with HUVECs. It can be concluded that crosslinked gels of albumin to which heparin is immobilized, are candidate sealants for prosthetic vascular grafts and suitable substrates for endothelial cell seeding.

Blood compatibility of surfaces with immobilized albumin-heparin conjugate and effect of endothelial cell seeding on platelet adhesion.

Endothelial cell (EC) seeding significantly improves the blood compatibility of artificial surfaces. Although a coating consisting of albumin and heparin (alb-hep) is a suitable substrate for seeded ECs, binding of ECs to the substrate further improves when small amounts of fibronectin are present in the alb-hep coating. Alb-hep conjugate was immobilized on carbon dioxide gas plasma-treated polystyrene (PS-CO(2)), thereby significantly increasing the recalcification time of blood plasma exposed to this surface. Furthermore, surface-immobilized alb-hep conjugate inhibited exogenous thrombin. Heparin activity was reduced by adding fibronectin on top of a monolayer of alb-hep conjugate, but not by simultaneous coating of fibronectin and alb-hep conjugate. Coating of PS-CO(2) with alb-hep conjugate significantly decreased contact activation (FXII activation). The number of platelets deposited from blood plasma on PS-CO(2) coated with alb-hep conjugate was twice as high as on PS-CO(2) coated with albumin. Addition of fibronectin to alb-hep conjugate-coated PS-CO(2) had no significant effect on the number of adhered platelets. Seeding of the substrates with ECs significantly reduced the number of adhered platelets under stationary conditions. Platelets deposited onto endothelialized surfaces were primarily found on endothelial cell edges, and sparingly on areas between ECs. In conclusion, alb-hep conjugate-coated surfaces display anticoagulant activity. ECs adhering to and proliferating on this coating significantly decrease the number of platelets which adhere to the surface. Therefore, alb-hep conjugate-coated surfaces form a suitable substrate for seeding of ECs in low density. Although application of fibronectin on top of the coating decreases the anticoagulant activity to some extent, it might be useful in view of the improved adherence of ECs to the coating.

Proliferation of endothelial cells on surface-immobilized albumin-heparin conjugate loaded with basic fibroblast growth factor.

Seeding of endothelial cells (ECs) on the luminal surface of small-diameter vascular grafts is a promising method to avoid occlusion of these prostheses. Immobilization of basic fibroblast growth factor (bFGF) to substrates used to coat or fill porous prostheses may enhance the formation of a confluent monolayer of ECs. Human umbilical vein endothelial cells (HUVECs) were grown on bFGF-loaded albumin-heparin conjugate bound to CO2 gas-plasma-treated polystyrene. In the order of 2-3 ng/cm2 bFGF had to be immobilized to form a confluent monolayer of HUVECs. The most prominent effect of surface-immobilized bFGF was stimulation of the proliferation shortly after seeding, resulting within 3 days in confluent cell monolayers with high density. In contrast, in cultures with 0.3 ng/mL bFGF in the medium instead of bFGF bound to the surface, it took almost a week before the cell layers reached confluency. Binding of bFGF to heparin and the biological activity of bFGF towards ECs were not influenced by the (radio-)labeling of bFGF with iodine. However, only a minor part of the bFGF used in this study displayed heparin affinity. Furthermore, degradation and multimerization of labeled bFGF in time occurred when the growth factor was stored at 20 degrees -37 degrees C. This limits the use of labeled bFGF to short-term (hours) experiments. In conclusion, bFGF loading of vascular graft surfaces through complexation of bFGF with a heparin-containing matrix probably will lead to more rapid formation of a confluent monolayer of ECs on graft surfaces upon seeding of the cells.

[Prevention, diagnosis and treatment of blood group immunization during pregnancy]. / Preventie, diagnostiek en behandeling van bloedgroepimmunisatie tijdens de zwangerschap.

In the Netherlands last year two important policy changes were introduced to prevent haemolytic disease of the newborn: antenatal administration of anti RhD immunoglobulin and screening for antibodies against irregular erythrocyte antigens in all pregnant women. As the predictive value of such antibodies for the detection of hemolytic disease of the newborn is limited, it is uncertain if this measure is really cost-effective. Because blood transfusion is the most important probable cause of the immunization, and because of the clinical severity of anti-K antibodies, it is advised to give exclusively K negative blood to girls and women under the age of 45 years. In addition there is a need for a uniform protocol to deal with women who have been exposed to immunization.