1
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Davis AM, Rawson R, Pahn G, Daly J, Marks DC. Platelets retain function and can be stored following disruption of human leucocyte antigens. Vox Sang 2024. [PMID: 38596985 DOI: 10.1111/vox.13634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 02/15/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND AND OBJECTIVES Antibodies to human leucocyte antigen (HLA) Class-I antigens can lead to refractoriness to platelet transfusion. Although this can be overcome by transfusion of HLA-compatible platelets, they are not always available. Disruption of HLA antigens on platelets by acid treatment may be a suitable alternative when no other components are available. The aim of this study was to assess the effect of HLA disruption and subsequent storage of platelet components. MATERIALS AND METHODS Platelet components were treated with 0.9% saline or citric acid solution (pH 3.0), and then stored until expiry (Day 7). HLA and platelet glycoprotein expression, platelet viability, activation and sialylation were measured by flow cytometry. Release of soluble factors was measured by ELISA and metabolism by biochemistry analyser. Reactivity to patient anti-sera containing anti-HLA antibodies was measured using platelet immunofluorescence tests (PIFTs) and monoclonal antibody immobilization of platelet antigen (MAIPA) assays. Platelet function was measured using aggregometry and thromboelastography (TEG). RESULTS Acid treatment reduced detection of HLA Class-I on platelets by 75%, with significant reductions in reactivity to patient anti-sera. Acid treatment reduced platelet content and viability, increased platelet activation and accelerated metabolism. Glycan cleavage was increased by acid treatment. Treatment reduced platelet activation following agonist stimulation by ADP and TRAP-6, but platelets remained functional, displaying increased aggregation response and reduced time to clot formation by TEG. CONCLUSION Although HLA disruption had some detrimental effects, acid-treated platelets remained functional, retaining their capacity to respond to agonists and form clots, and with further development could be used to support refractory patients.
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Affiliation(s)
- April M Davis
- Australian Red Cross Lifeblood, Research and Development, Sydney, New South Wales, Australia
| | - Renée Rawson
- Australian Red Cross Lifeblood, Research and Development, Sydney, New South Wales, Australia
| | - Gail Pahn
- Australian Red Cross Lifeblood, Transplantation and Immunogenetics, Brisbane, Queensland, Australia
| | - James Daly
- Australian Red Cross Lifeblood, Pathology and Clinical Governance, Brisbane, Queensland, Australia
| | - Denese C Marks
- Australian Red Cross Lifeblood, Research and Development, Sydney, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia
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2
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Chiueh TS, Wang HY, Wu MH, Hsueh YS, Chen HC. Evaluation of Platelet Alloimmunization by Filtration Enzyme-Linked Immunosorbent Assay. Diagnostics (Basel) 2023; 13:diagnostics13101704. [PMID: 37238189 DOI: 10.3390/diagnostics13101704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 05/03/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
The current methods for detecting antiplatelet antibodies are mostly manual and labor-intensive. A convenient and rapid detection method is required for effectively detecting alloimmunization during platelet transfusion. In our study, to detect antiplatelet antibodies, positive and negative sera of random-donor antiplatelet antibodies were collected after completing a routine solid-phase red cell adherence test (SPRCA). Platelet concentrates from our random volunteer donors were also prepared using the ZZAP method and then used in a faster, significantly less labor-intensive process, a filtration enzyme-linked immunosorbent assay (fELISA), for detecting antibodies against platelet surface antigens. All fELISA chromogen intensities were processed using ImageJ software. By dividing the final chromogen intensity of each test serum with the background chromogen intensity of whole platelets, the reactivity ratios of fELISA can be used to differentiate positive SPRCA sera from negative sera. A sensitivity of 93.9% and a specificity of 93.3% were obtained for 50 μL of sera using fELISA. The area under the ROC curve reached 0.96 when comparing fELISA with the SPRCA test. We have successfully developed a rapid fELISA method for detecting antiplatelet antibodies.
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Affiliation(s)
- Tzong-Shi Chiueh
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan, China
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan, China
| | - Hsin-Yao Wang
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan, China
- PhD Program in Biomedical Engineering, Chang Gung University, Taoyuan City 333, Taiwan, China
| | - Min-Hsien Wu
- Graduate Institute of Biochemical and Biomedical Engineering, Chang Gung University, Taoyuan City 333, Taiwan, China
| | - Yu-Shan Hsueh
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan, China
| | - Hui-Chu Chen
- Department of Laboratory Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan City 333, Taiwan, China
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3
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Attieh M, Dent EA, Happney L, Roback JD, Alter DN, Barrette E, Then C, Sullivan HC. Three patients highlighting potential pitfalls in platelet refractory testing. Transfusion 2023; 63:888-892. [PMID: 36794568 DOI: 10.1111/trf.17280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/13/2023] [Accepted: 01/13/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND Platelet-transfusion refractory (PR) patients do not achieve expected post-transfusion platelet counts. We investigate suspected PR patients with post-transfusion platelet counts, indirect platelet antibody screens (ind-PAS), Class I HLA antibody tests (HLA-Scr), and physical platelet crossmatch (PXM) studies. STUDY DESIGN AND METHODS The three following cases describe possible pitfalls of laboratory tests used in PR workup and management. RESULTS Case #1: Antibody testing detected antibodies to only HLA-B13, corresponding to a 4% calculated panel reactive antibodies (CPRA; 96% predicted donor compatibility). However, PXM showed the patient compatible with 11/14 (79%) donors; two of the PXM-incompatible units were ABO-incompatible. Case #2: PXM revealed compatibility with 1/14 screened donors; however, the patient did not respond to the product from the compatible donor. The patient did respond to HLA-matched product. Dilution studies provided evidence of the prozone effect, which caused negative PXM despite clinically relevant antibodies. Case #3: There was a discrepancy between the ind-PAS and HLA-Scr. Ind-PAS was negative for HLA antibodies, while HLA-Scr was positive and specificity testing corresponded to 38% CPRA. Per the package insert, the sensitivity of ind-PAS is ~85% compared to HLA-Scr. DISCUSSION These cases highlight the importance of investigating incongruent results. Cases #1 and #2 demonstrate PXM pitfalls: ABO incompatibility can result in positive PXM and false-negative PXM can occur in the setting of the prozone effect. Case #3 reveals the importance of knowing a test's sensitivity. Centers that only perform ind-PAS may fail to detect HLA antibodies.
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Affiliation(s)
- Michel Attieh
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edward A Dent
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - John D Roback
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David N Alter
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Eileen Barrette
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Caroline Then
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - H Cliff Sullivan
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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4
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Couvidou A, Rojas-Jiménez G, Dupuis A, Maître B. Anti-HLA Class I alloantibodies in platelet transfusion refractoriness: From mechanisms and determinants to therapeutic prospects. Front Immunol 2023; 14:1125367. [PMID: 36845153 PMCID: PMC9947338 DOI: 10.3389/fimmu.2023.1125367] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/31/2023] [Indexed: 02/11/2023] Open
Abstract
Patients with hematological disorders and severe thrombocytopenia require extensive and iterative platelet transfusion support. In these patients, platelet transfusion refractoriness represents a serious adverse transfusion event with major outcomes for patient care. Recipient alloantibodies against the donor HLA Class I antigens expressed at the cell surface of platelets result in a rapid removal of transfused platelets from the circulation and thus, therapeutic and prophylactic transfusion failure leading to a major bleeding risk. In this case, the only way to support the patient relies on the selection of HLA Class I compatible platelets, an approach restricted by the limited number of HLA-typed donors available and the difficulty of meeting the demand in an emergency. However, not all patients with anti-HLA Class I antibodies develop refractoriness to platelet transfusions, raising the question of the intrinsic characteristics of the antibodies and the immune-mediated mechanisms of platelet clearance associated with a refractory state. In this review, we examine the current challenges in platelet transfusion refractoriness and detail the key features of the antibodies involved that should be considered. Finally, we also provide an overview of future therapeutic strategies.
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Affiliation(s)
- Adèle Couvidou
- UMR_S1255, INSERM, Strasbourg, France
- Etablissement Français du Sang-Grand Est, Strasbourg, France
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
- Université de Strasbourg, Strasbourg, France
| | - Gabriel Rojas-Jiménez
- UMR_S1255, INSERM, Strasbourg, France
- Etablissement Français du Sang-Grand Est, Strasbourg, France
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
- Université de Strasbourg, Strasbourg, France
| | - Arnaud Dupuis
- UMR_S1255, INSERM, Strasbourg, France
- Etablissement Français du Sang-Grand Est, Strasbourg, France
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
- Université de Strasbourg, Strasbourg, France
| | - Blandine Maître
- UMR_S1255, INSERM, Strasbourg, France
- Etablissement Français du Sang-Grand Est, Strasbourg, France
- Fédération de Médecine Translationnelle de Strasbourg (FMTS), Strasbourg, France
- Université de Strasbourg, Strasbourg, France
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5
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[Chinese expert consensus on the diagnosis and management of platelet transfusion refractoriness (2022)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:897-902. [PMID: 36709179 PMCID: PMC9808860 DOI: 10.3760/cma.j.issn.0253-2727.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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6
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Sinwatcharaphirom T, Apisawes K, Kittivorapart J. Evaluation of the effectiveness of platelet crossmatching by the solid‐phase red cell adherence assay in adult patients of a tertiary care hospital in Thailand: A retrospective study. Health Sci Rep 2022; 5:e769. [PMID: 35983548 PMCID: PMC9375133 DOI: 10.1002/hsr2.769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 07/07/2022] [Accepted: 07/11/2022] [Indexed: 11/17/2022] Open
Abstract
Background and Aims Platelet transfusion refractoriness is well aware to be associated with poor clinical outcomes. Patients with the alloantibody causing refractoriness required cross‐matched compatible products to improve the platelet number. This study aims to evaluate the effectiveness and availability of platelet crossmatching provided by the solid‐phase red cell adherence (SPRCA) technique in the context of a tertiary university hospital. Methods A retrospective chart review was performed of the records of 214 patients with platelet refractoriness in Siriraj Hospital, a tertiary university hospital in Thailand, between January 1, 2017, and December 31, 2020. Results The SPRCA technique successfully provided cross‐matched compatible platelets to 114 patients (69.7%). Platelet crossmatching significantly improved the platelet counts, as shown by the increased 1‐ and 24‐h corrected‐count increments (p< 0.0001). No acute transfusion reactions were observed in these patients. Of the 114 patients who received cross‐matched platelets, 82 patients (71.9%) survived at 30‐day posttransfusion; whereas, 16 patients (14.0%) died within 7‐day posttransfusion. Conclusion The SPRCA method can provide a high availability rate of cross‐matched platelets, which is effective at stopping and preventing clinical bleeding conditions. This method is appropriate to apply for platelet crossmatching in the context of a hospital blood bank.
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Affiliation(s)
| | - Kusuma Apisawes
- Department of Transfusion Medicine, Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
| | - Janejira Kittivorapart
- Department of Transfusion Medicine, Faculty of Medicine Siriraj Hospital Mahidol University Bangkok Thailand
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7
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Chaudhary R, Das SS. Application of flow cytometry in transfusion medicine: The Sanjay Gandhi Post Graduate Institute of Medical Sciences, India experience. Asian J Transfus Sci 2022; 16:159-166. [PMID: 36687536 PMCID: PMC9855202 DOI: 10.4103/ajts.ajts_61_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 05/30/2022] [Accepted: 06/05/2022] [Indexed: 01/25/2023] Open
Abstract
The application of flow cytometry (FC) is diverse and this powerful tool in used in multiple disciplines such as molecular biology, immunology, cancer biology, virology, and infectious disease screening. FC analyzes a single cell or a particle very rapidly as they flow past single or multiple lasers while suspended in buffered solution. FC has a great impact in the field of transfusion medicine (TM) due to its ability to analyze individual cell population and cell epitopes by sensitive, reproducible, and objective methodologies. The main uses of FC in TM are detection of fetomaternal hemorrhage, diagnosis of paroxysmal nocturnal hemoglobinuria, quantification of D antigen, detection of platelet antibody, quality control of blood components, for example, residual leukocyte counts and evaluation of CD34-positive hematopoietic progenitor cells in stem cell grafts. In recent years, FC has been implemented as an alternative method for the detection and characterization of red cell autoantibodies in autoimmune hemolytic anemia. Many workers considered FC as a very good complement when aberrant expression of various erythrocyte antigens needs to be elucidated. It has been extensively used in the resolution of ABO discrepancies and chimerism study. FC has also been used successfully in various platelet immunological studies. In the recent past, FC has been used in several studies to assess the platelet storage lesions and elucidate granulocyte/monocyte integrity and immunology. FC analysis of CD34+ stem cells is now the method of choice to determine the dosage of the collected progenitor cells. The technique is vastly used to evaluate residual leukocytes in leukodepleted blood components. We conclude that flow cytometers are becoming smaller, cheaper, and more user-friendly and are available in many routine laboratories. FC represents a highly innovative technique for many common diagnostic and scientific fields in TM. Finally, it is the tool of choice to develop and optimize new cellular and immunotherapeutic trials.
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Affiliation(s)
- Rajendra Chaudhary
- Department of Transfusion Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sudipta Sekhar Das
- Department of Transfusion Medicine, Apollo Multispeciality Hospitals, Kolkata, West Bengal, India
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8
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Liu Y, Zhang Y, Chen D, Fu Y. Current Status of and Global Trends in Platelet Transfusion Refractoriness From 2004 to 2021: A Bibliometric Analysis. Front Med (Lausanne) 2022; 9:873500. [PMID: 35602482 PMCID: PMC9121734 DOI: 10.3389/fmed.2022.873500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
Abstract
Platelet transfusion refractoriness (PTR) is common in patients with hematology and oncology and is becoming an important barrier in the treatment of thrombocytopenia and hemorrhage. Bibliometrics is an effective method for identifying existing research achievements, important breakthroughs, current research hotspots, and future development trends in any given field. In recent years, research on PTR has received increasing attention, but a bibliometric analysis of this field has not yet been reported. In this study, we applied bibliometrics to analyze the existing literature on PTR research over the past 17 years. On November 1, 2021, we began a publications analysis of PTR research using the Science Citation Index Expanded of the Web of Science Core Collection with collection dates from 2004 to 2021. This research aimed to summarize the state of PTR research using Bibliometrix to identify connections between different elements (i.e., authors, institutions, countries, journals, references, and keywords) using VOS viewer analyses to visualize key topics and trends in PTR research using Cite Space and gCLUTO. The results of all 310 studies showed that the annual number of publications focused on PTR is steadily increasing, with the United States of America and Japan making significant contributions. We noted that the research group led by Dr. Sherrill J. Slichter was prominent in this field, while Estcourt Lise may become the most influential newcomer. Transfusion was the most popular journal, and Blood was the most cited journal. Using various analyses, including co-cited analysis, historiography analysis, citation burst analysis, and factorial analysis, we pointed out and discussed contributing publications. According to occurrence analysis, co-word biclustering analysis, landform map, thematic evolution, and thematic map, we believe that “activation,” “p-selection,” “CD36 deficiency,” “gene-frequencies,” “CD109,” “HPA-1,” and “beta (3) integrin” may become new trends in PTR research. The outcome of our bibliometric analyses has, for the first time, revealed profound insights into the current state and trends in PTR research. The systematic analysis provided by our study clearly demonstrates the field's significant advancements to all researchers who are interested in a quick and comprehensive introduction to the field.
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Affiliation(s)
- Ying Liu
- Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangzhou Blood Center, Guangzhou, China
| | - Yufan Zhang
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University Guangzhou, Guangzhou, China
| | - Dawei Chen
- Guangzhou Blood Center, Guangzhou, China
| | - Yongshui Fu
- Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangzhou Blood Center, Guangzhou, China
- *Correspondence: Yongshui Fu
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9
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Youk HJ, Hwang SH, Oh HB, Ko DH. Evaluation and management of platelet transfusion refractoriness. Blood Res 2022; 57:6-10. [PMID: 35483919 PMCID: PMC9057673 DOI: 10.5045/br.2022.2021229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/13/2022] [Indexed: 11/17/2022] Open
Abstract
Platelet transfusion refractoriness (PTR), in which platelet counts do not increase after transfusion, occurs in many patients receiving platelet transfusions. PTR is a clinical condition that can harm patients. The causes of PTR can be divided into two types: immune and non-immune. Most cases of PTR are non-immune. Among immune causes, the most common is human leukocyte antigen (HLA) class I molecules. PTR caused by anti-HLA antibodies is usually managed by transfusing HLA-matched platelets. Therefore, it is important, especially for hemato-oncologists who frequently perform transfusion, to accurately diagnose whether the cause of platelet transfusion failure is alloimmune or non-immunological when determining the treatment direction for the patient. In this review, we discuss the definitions, causes, countermeasures, and prevention methods of PTR.
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Affiliation(s)
- Hee-Jeong Youk
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Hyun Hwang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Heung-Bum Oh
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae-Hyun Ko
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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10
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Griffith AJ, Rose WN. Educational Case: Platelet refractoriness. Acad Pathol 2022; 9:100015. [PMID: 35600743 PMCID: PMC9115717 DOI: 10.1016/j.acpath.2022.100015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 12/28/2021] [Accepted: 01/09/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
| | - William N. Rose
- Corresponding author. Department of Pathology, University of Wisconsin Hospital, 600 Highland Ave, Madison, WI, 53792, USA.
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11
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Juskewitch JE, Zuccarelli MD, Clymer KK, Wakefield LL, Kreuter JD, Gandhi MJ. Prozone rates in the solid-phase platelet crossmatch assay and correlation with class I HLA antibody levels. Transfusion 2021; 61:3236-3246. [PMID: 34523730 DOI: 10.1111/trf.16660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/28/2021] [Accepted: 08/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Solid-phase platelet crossmatch (PXM) testing is used to help manage patients with platelet transfusion-refractoriness. Recently, we published the first report of false-negative PXM results from prozone effect that was mitigated using sample dilution. This study aimed to describe the prevalence of PXM prozone effect and the levels of class I HLA antibodies (HLA-Abs) associated with positive PXM results and with false-negative PXM results from prozone effect. STUDY DESIGN AND METHODS A cross-sectional study of patients undergoing PXM testing from July 2019 through December 2020 was performed. All PXM tests were run simultaneously using undiluted and 1:4 diluted patient plasma. Prozone effect was defined as a negative PXM result using undiluted patient plasma but a positive PXM result using 1:4 diluted patient plasma. RESULTS Among 59 patients, 830 individual ABO-compatible PXM results yielded an overall positivity rate of 25.8% (214/830) and a false-negative rate from prozone effect of 4.7% (10/214). Among the 28 patients with class I HLA-Ab testing and no other anti-platelet antibodies, maximum HLA-Ab mean fluorescence intensity (MFI) was significantly associated with a positive PXM result (p < .0001; AUC approx. 0.9) and categorized into negative (<3700), indeterminate (3700-10300), and positive (>10300) maximum HLA-Ab MFI zones. Maximum HLA-Ab MFI, however, was not associated with prozone effect (p = .17; AUC approx. 0.6). DISCUSSION While there is a strong predictive association between class I HLA-Ab levels and positive PXM results, PXM prozone effect is a common occurrence not associated with class I HLA-Ab levels, so additional testing with diluted samples should be considered.
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Affiliation(s)
- Justin E Juskewitch
- Division of Transfusion Medicine, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Micah D Zuccarelli
- Division of Transfusion Medicine, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristie K Clymer
- Division of Transfusion Medicine, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Laurie L Wakefield
- Division of Transfusion Medicine, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Justin D Kreuter
- Division of Transfusion Medicine, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manish J Gandhi
- Division of Transfusion Medicine, Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
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12
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Chenna D, Shastry S, Baliga P. Evaluation and monitoring of response to platelet transfusion therapy: experience from a tertiary care center. Acta Clin Belg 2021; 76:300-303. [PMID: 32090713 DOI: 10.1080/17843286.2020.1732568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Refractoriness to platelet transfusion is defined as Corrected Count Increment (CCI) <5000 after two sequential ABO identical transfusions. Immune causes include alloimmunization to HLA and/or platelet-specific antigens. Analysis of various factors leading to platelet refractoriness would help in the management of the patient in a timely manner.Materials and Methods: A prospective observational study on platelet transfusions from November 2013 to June 2015 was conducted. Demographic information, pre, and post-transfusion platelet counts and relevant clinical details were noted. Among patients who were considered refractory to platelet transfusions, platelet factor 3 assay was performed to detect antiplatelet antibodies. Data were analyzed using SPSS software. A P value of <0.05 was considered to be statistically significant.Results: A total of 1190 patients received platelet transfusions during the study period. Among these only 339 (28.5%) patients received transfusions on two or more occasions, of which 237 (69.91%) were considered non-refractory. Among the 102 (30.1%) refractory cases non-immune causes for refractoriness were present in 97 (95.1%) patients and antiplatelet antibody was positive in 18 (17.64%) patients. Bleeding and medication have shown to have significantly contributed to refractoriness (p = 0.025 and 0.003) respectively. Use of medication was independently associated with refractoriness.Conclusion: Non-immune causes are more profound in leading to a poor response to platelet transfusions. Recognizing the cause of poor response and treating the underlying cause would help in getting a better response.
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Affiliation(s)
- Deepika Chenna
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Shamee Shastry
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Poornima Baliga
- Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
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13
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Liu Y, Liang B, Liu Y, Wei G, Wu W, Yang L, Yang L, Huang H, Xie J, Hu Y. Cytokine Release Syndrome Is an Independent Risk Factor Associated With Platelet Transfusion Refractoriness After CAR-T Therapy for Relapsed/Refractory Acute Lymphoblastic Leukemia. Front Pharmacol 2021; 12:702152. [PMID: 34366854 PMCID: PMC8343018 DOI: 10.3389/fphar.2021.702152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Chimeric antigen receptor T cell (CAR-T) therapy is successful in improving treatment outcomes for relapsed/refractory acute lymphoblastic leukemia (R/R ALL). However, toxicities associated with CAR-T therapy are being increasingly identified. Pancytopenia is one of the most common complications after CAR-T therapy, and platelet transfusions are an essential part of its supportive care. Study Design and Methods: This study aimed to assess the effectiveness of platelet transfusions for R/R ALL patients at our single center and identify associated risk factors. Overall, 44 R/R ALL patients were enrolled in this study, of whom 26 received CAR-T therapy and 18 received salvage chemotherapy. Result: Patients in the CAR-T group had a higher incidence of platelet transfusion refractoriness (PTR) (15/26, 57.7%) than those in the chemotherapy group (3/18, 16.7%) (p = 0.007). For patients receiving CAR-T therapy, multivariate analysis showed that the grade of cytokine release syndrome (CRS) was the only independent risk factor associated with PTR (p = 0.007). Moreover, higher peak serum IL-6 and IFN-γ levels suggested a higher risk of PTR (p = 0.024 and 0.009, respectively). Patients with PTR received more platelet infusion doses than those without PTR (p = 0.0426). Patients with PTR had more grade 3-4 bleeding events than those without PTR (21.4 vs. 0%, p = 0.230), and the cumulative incidence of grade 3-4 bleeding event was different (p = 0.023). Conclusion: We found for the first time that PTR is associated with the CRS grade. Improved knowledge on the mechanisms of PTR after CAR-T therapy is needed to design a rational therapeutic strategy that aims to improve the efficiency of transfusions.
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Affiliation(s)
- Yadan Liu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Bin Liang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Department of Hematology, Wenzhou Medical University, Wenzhou, China
| | - Yan Liu
- Department of Blood Transfusion, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guoqing Wei
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Wenjun Wu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Luxin Yang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Li Yang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Jue Xie
- Department of Blood Transfusion, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yongxian Hu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
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14
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Catelli LF, Saad STO. Ex Vivo Manufacture of Megakaryocytes and Platelets from Stem Cells: Recent Advances Toward Transfusion in Humans. Stem Cells Dev 2021; 30:351-362. [PMID: 33622080 DOI: 10.1089/scd.2020.0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The generation of ex vivo functional megakaryocytes (MK) and platelets is an important issue in transfusion medicine as donor dependence implies in limitations, such as shortage of eligible volunteers. Indeed, platelet transfusion is still a procedure that saves the lives of patients with defective platelet production. Recent technological development has enabled the isolation and expansion of stem cells that can be used as a source for the production of functional platelets for transfusion. In this review, we discuss recent approaches of in vitro or ex vivo production of MK and platelets, suggesting that, in the near future, donor-independent sources may become a possibility. The feasibility of using these cells in the clinic may be safer, and in vitro manipulation could generate universally compatible products, solving problems related to platelet refractoriness. However, functionality and survival testing of these products in human beings are scarce; therefore, additional studies are needed to consolidate this purpose.
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Affiliation(s)
- Lucas Ferioli Catelli
- Hematology and Transfusion Medicine Center, University of Campinas, Campinas, São Paulo, Brazil
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15
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Matsui R, Hagino T, Tsuno NH, Ohtani H, Azuma F, Matsuhashi M, Saito M, Kobayashi M, Saga R, Hidai H, Tsutsumi H, Akiyama H, Motomura S. Does time of CCI measurement affect the evaluation of platelet transfusion effectiveness? Transfus Apher Sci 2021; 60:103123. [PMID: 33757699 DOI: 10.1016/j.transci.2021.103123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/05/2021] [Accepted: 03/13/2021] [Indexed: 11/25/2022]
Abstract
The measurement of corrected count increment at 1-h post-transfusion (CCI-1 h) of platelet concentrate (PC) transfusion is recommended, but in the revised Japanese Guideline (2017) it was changed to "after 10-min to 1-h", following the revision of the guidelines from Western countries. Here, we aimed to investigate on the feasibility to apply the CCI measured at 10-min or 30-min post-transfusion as the surrogate of CCI-1 h. Peripheral blood was collected at 10-min, 30-min and 1-h post-transfusion of PC and the effectiveness of the transfusion was analyzed based on the CCI. In the period from December 2017 to February 2020, 8 patients, who received multiple PC transfusion (total 208) at our institution, were analyzed. We performed the univariate analyses to examine the relationship between CCI value and the categorical variables, p-value <0.1 was obtained for gender (p = 2.91 × 10-19), fever after transfusion (p = 0.0163). The qualitative variables, namely measurement time (p = 0.0553), also showed p-value <0.1. Using these factors as covariates in the mixed effect model, we found that the measurement time (p = 0.0007) had a significant effect on the CCI value when looking at fixed effects. Although there is a tendency for decreased CCI values with time progression, the slope of the change in the mixed model was -0.00307, indicating that the CCI difference among the 3 measurements was small. Here we provide evidence that CCI measured at 10-min and 30-min post-transfusion give results comparable to those measured at 1-h post-transfusion, under the Japanese practice of platelet transfusion, which relies on 100 % single-donor apheresis PC, and ABO-identical whenever possible.
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Affiliation(s)
- Reina Matsui
- Department of Laboratory Medicine, Tama-Hokubu Medical Center, Tokyo Metropolitan Health and Medical Treatment Corporation, Tokyo, Japan
| | - Takeshi Hagino
- Department of Hematology, Tama-Hokubu Medical Center, Tokyo Metropolitan Health and Medical Treatment Corporation, Tokyo, Japan.
| | | | - Hideo Ohtani
- Department of Laboratory Medicine, Tama-Hokubu Medical Center, Tokyo Metropolitan Health and Medical Treatment Corporation, Tokyo, Japan
| | - Fumihiro Azuma
- Japanese Red Cross Kanto-Koshinetsu Block Blood Center, Tokyo, Japan
| | - Mika Matsuhashi
- Japanese Red Cross Kanto-Koshinetsu Block Blood Center, Tokyo, Japan
| | - Makoto Saito
- Clinical Research Support Center, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Maya Kobayashi
- Department of Hematology, Tama-Hokubu Medical Center, Tokyo Metropolitan Health and Medical Treatment Corporation, Tokyo, Japan
| | - Reina Saga
- Department of Hematology, Tama-Hokubu Medical Center, Tokyo Metropolitan Health and Medical Treatment Corporation, Tokyo, Japan
| | - Hiroko Hidai
- Department of Hematology, Tama-Hokubu Medical Center, Tokyo Metropolitan Health and Medical Treatment Corporation, Tokyo, Japan
| | - Hisashi Tsutsumi
- Department of Laboratory Medicine, Tama-Hokubu Medical Center, Tokyo Metropolitan Health and Medical Treatment Corporation, Tokyo, Japan
| | - Hideki Akiyama
- Department of Hematology, Tama-Hokubu Medical Center, Tokyo Metropolitan Health and Medical Treatment Corporation, Tokyo, Japan
| | - Sayuri Motomura
- Department of Hematology, Tama-Hokubu Medical Center, Tokyo Metropolitan Health and Medical Treatment Corporation, Tokyo, Japan
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16
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Laroche V, Blais‐Normandin I. Clinical Uses of Blood Components. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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17
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The HLA System in Transfusion Medicine and Transplantation. Transfus Med 2021. [DOI: 10.1002/9781119599586.ch18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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18
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Mirlashari MR, Vetlesen A, Nissen-Meyer LSH, Naper C, Tjønnfjord GE, Njerve IU, Ezligini F, Landmark BF, Meinke S, Sandgren P, Höglund P, Hetland G. HLA class I depletion by citric acid, and irradiation of apheresis platelets for transfusion of refractory patients. Transfusion 2021; 61:1222-1234. [PMID: 33580979 DOI: 10.1111/trf.16282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 12/07/2020] [Accepted: 12/17/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients can form antibodies to foreign human leukocyte antigen (HLA) Class I antigens after exposure to allogeneic cells. These anti-HLA class I antibodies can bind transfused platelets (PLTs) and mediate their destruction, thus leading to PLT refractoriness. Patients with PLT refractoriness need HLA-matched PLTs, which require expensive HLA typing of donors, antibody analyses of patient sera and/or crossmatching. An alternative approach is to reduce PLT HLA Class I expression using a brief incubation in citric acid on ice at low pH. METHODS AND MATERIALS Apheresis PLT concentrates were depleted of HLA Class I complexes by 5 minutes incubation in ice-cold citric acid, at pH 3.0. Surface expression of HLA Class I complexes, CD62P, CD63, phosphatidylserine, and complement factor C3c was analyzed by flow cytometry. PLT functionality was tested by thromboelastography (TEG). RESULTS Acid treatment reduced the expression of HLA Class I complexes by 71% and potential for C3c binding by 11.5-fold compared to untreated PLTs. Acid-treated PLTs were significantly more activated than untreated PLTs, but irrespective of this increase in steady-state activation, CD62P and CD63 were strongly upregulated on both acid-treated and untreated PLTs after stimulation with thrombin receptor agonist peptide. Acid treatment did not induce apoptosis over time. X-ray irradiation did not significantly influence the expression of HLA Class I complexes, CD62P, CD63, and TEG variables on acid treated PLTs. CONCLUSION The relatively simple acid stripping method can be used with irradiated apheresis PLTs and may prevent transfusion-associated HLA sensitization and overcome PLT refractoriness.
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Affiliation(s)
| | - Annette Vetlesen
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Christian Naper
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | - Geir Erland Tjønnfjord
- Department of Hematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ida Unhammer Njerve
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | - Farshid Ezligini
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Stephan Meinke
- Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden.,Function Area Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Per Sandgren
- Function Area Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Petter Höglund
- Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden.,Function Area Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Geir Hetland
- Department of Immunology and Transfusion Medicine, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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19
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Sung AD, Yen RC, Jiao Y, Bernanke A, Lewis DA, Miller SE, Li Z, Ross JR, Artica A, Piryani S, Zhou D, Liu Y, Vo-Dinh T, Hoffman M, Ortel TL, Chao NJ, Chen BJ. Fibrinogen-Coated Albumin Nanospheres Prevent Thrombocytopenia-Related Bleeding. Radiat Res 2020; 194:162-172. [PMID: 32845987 DOI: 10.1667/rade-20-00016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 05/07/2020] [Indexed: 11/03/2022]
Abstract
Thrombocytopenia (TCP) may cause severe and life-threatening bleeding. While this may be prevented by platelet transfusions, transfusions are associated with potential complications, do not always work (platelet refractory) and are not always available. There is an urgent need for a synthetic alternative. We evaluated the ability of fibrinogen-coated nanospheres (FCNs) to prevent TCP-related bleeding. FCNs are made of human albumin polymerized into a 100-nm sphere and coated with fibrinogen. We hypothesized that FCNs would bind to platelets through fibrinogen-GPIIb/IIIa interactions, contributing to hemostasis in the setting of TCP. We used two murine models to test these effects: in the first model, BALB/c mice received 7.25 Gy total-body irradiation (TBI); in the second model, lower dose TBI (7.0 Gy) was combined with an anti-platelet antibody (anti-CD41) to induce severe TCP. Deaths in both models were due to gastrointestinal or intracranial bleeding. Addition of antiplatelet antibody to 7.0 Gy TBI significantly worsened TCP and increased mortality compared to 7.0 Gy TBI alone. FCNs significantly improved survival compared to saline control in both models, suggesting it ameliorated TCP-related bleeding. Additionally, in a saphenous vein bleeding model of antibody-induced TCP, FCNs shortened bleeding times. There were no clinical or histological findings of thrombosis or laboratory findings of disseminated intravascular coagulation after FCN treatment. In support of safety, fluorescence microscopy suggests that FCNs bind to platelets only upon platelet activation with collagen, limiting activity to areas of endothelial damage. To our knowledge, this is the first biosynthetic agent to demonstrate a survival advantage in TCP-related bleeding.
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Affiliation(s)
- Anthony D Sung
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, and Duke Cancer Institute
| | | | - Yiqun Jiao
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, and Duke Cancer Institute
| | | | | | | | - Zhiguo Li
- Department of Biostatistics & Bioinformatics
| | - Joel R Ross
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, and Duke Cancer Institute
| | - Alexandra Artica
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, and Duke Cancer Institute
| | - Sadhna Piryani
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, and Duke Cancer Institute
| | - Dunhua Zhou
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, and Duke Cancer Institute
| | - Yang Liu
- Department of Biomedical Engineering, Pratt School of Engineering
| | - Tuan Vo-Dinh
- Department of Biomedical Engineering, Pratt School of Engineering.,Department of Chemistry, Duke University, Durham, North Carolina
| | | | - Thomas L Ortel
- Division of Hematology, Department of Medicine.,Department of Pathology
| | - Nelson J Chao
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, and Duke Cancer Institute
| | - Benny J Chen
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, and Duke Cancer Institute
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20
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Cohn CS. Platelet transfusion refractoriness: how do I diagnose and manage? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:527-532. [PMID: 33275694 PMCID: PMC7727584 DOI: 10.1182/hematology.2020000137] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Platelet refractoriness continues to be a problem for thrombocytopenic patients because the risk of a major spontaneous or life-threatening bleed significantly increases when platelet counts drop below 10 × 109/L. The majority of patients have nonimmune causes driving the refractoriness, such as bleeding, medications, or diffuse intravascular coagulation; however, this article is dedicated to the diagnosis and support of patients with immune-based platelet refractoriness. Antibodies to class I HLA molecules (A and B alleles) are responsible for most immune-based refractory cases, with antibodies to platelet antigens seen much less frequently. Patients may be supported with either crossmatch-compatible or HLA-matched/compatible platelet units. When trying to select HLA units it can be difficult to find a perfect "4 of 4" match for the patient's class IA and IB alleles. In these cases, it is better to use the antibody specificity prediction method, which identifies compatible units that lack antigens recognized by the patient's anti-HLA antibodies. For an algorithmic approach to the patient with platelet refractoriness, see Visual Abstract.
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21
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Inoue H, Sakamoto R, Nishimiya H, Sakamoto H, Terasu S, Aminaka R, Koh Y, Takihara Y, Hirayama F, Kuroishi A. Minor impact of patient alloantibodies against human platelet antigen (HPA)-15 in the effectiveness of platelet transfusion: A pilot study. Transfusion 2020; 61:738-743. [PMID: 33166416 DOI: 10.1111/trf.16181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/12/2020] [Accepted: 10/12/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Alloantibodies against human platelet antigen (HPA)-15 are sometimes detected in patients with platelet transfusion refractoriness (PTR); however, little is known about their impact on PTR. STUDY DESIGN AND METHODS Two patients who possessed HPA-15 alloantibodies (Patient 1, anti-HPA-15b; Patient 2, anti-HPA-15a) and human leukocyte antigen (HLA) antibodies were enrolled. The efficacy of HPA-15-compatible vs -incompatible platelet transfusion was compared by focusing on ABO- and HLA-matched transfusions on the basis of the 24-hour corrected count increment (CCI-24 hours) for platelets. The titers of HPA-15 antibodies in the patients' sera were also monitored. RESULTS The patients received 71 and 12 ABO-compatible, HLA-matched platelet transfusions, respectively, during the monitoring periods. Among these transfusions, CCI-24 hours could be calculated in 27 and 10 transfusions, respectively, and the HPA-15 genotype of the donors was determined. There were no significant differences in the CCI-24 hours between the HPA-15 compatible and incompatible transfusions in both patients (P = .30 and .56, respectively, Mann-Whitney U test). There was no significant change in the HPA-15b antibody titer in Patient 1 during the monitoring period, while the HPA-15a antibody level in Patient 2 was undetectable at the end of the monitoring period, although the titer was low at the beginning. CONCLUSION The efficacy of HPA-15-incompatible platelet transfusions was not necessarily inferior to that of HPA-15 compatible ones. Although the case number was limited, our results suggest that HPA-15 antibodies do not have a significant impact on the effects of platelet transfusion.
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Affiliation(s)
- Hiroko Inoue
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan
| | - Rumi Sakamoto
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan
| | | | - Hiroe Sakamoto
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan
| | - Shota Terasu
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan
| | - Ryota Aminaka
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan
| | - Yangsook Koh
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan
| | | | | | - Ayumu Kuroishi
- Japanese Red Cross Kinki Block Blood Center, Ibaraki, Japan
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22
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Horton RK, Zuccarelli MD, Wakefield LL, DiGuardo MA, Gandhi MJ, Juskewitch JE. False-negative solid-phase platelet crossmatch results due to prozone phenomenon. Transfusion 2020; 60:3055-3059. [PMID: 33047855 DOI: 10.1111/trf.16132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/13/2020] [Accepted: 08/25/2020] [Indexed: 11/29/2022]
Abstract
Prozone is a known phenomenon affecting immunoassays causing falsely low or negative results when excess target is present in the test system. For assays used to evaluate immune-mediated platelet (PLT) transfusion refractoriness, prozone-like phenomenon has been described in solid-phase human leukocyte antigen (HLA) antibody testing and can be mitigated by diluting samples or pretreating samples with ethylenediaminetetraacetic acid (EDTA) or dithiothreitol. Prozone phenomenon has not yet been described in solid-phase red blood cell (RBC) adherence PLT crossmatch assays. CASE REPORT: A 40-year-old female with myeloid sarcoma and PLT transfusion refractoriness underwent repeated solid-phase PLT crossmatches; however, crossmatch-compatible PLTs units did not yield adequate PLT count responses. Class I HLA antibody testing with neat, diluted, and EDTA-pretreated serum demonstrated significant prozone-like effect and the presence of numerous high strength HLA antibodies. Based on this HLA antibody profile, HLA antigen-negative PLTs gave an adequate PLT count response. It was noted that the HLA types of her crossmatch-compatible PLTs were incompatible with her HLA antibody profile (eg, HLA-A2). With ABO-identical, HLA-A2-positive PLT units, a solid-phase PLT crossmatch was repeated using undiluted and diluted EDTA plasma. Undiluted EDTA plasma demonstrated negative or weakly positive PLT crossmatches while the diluted EDTA plasma demonstrated strongly positive PLT crossmatches. CONCLUSION: The prozone phenomenon can cause false-negative results in solid-phase RBC adherence PLT crossmatch assays, which can be mitigated with sample dilution. In immune-mediated PLT transfusion-refractory patients with high-strength HLA antibodies, sample dilution should be considered to correctly identify compatible PLT inventory.
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Affiliation(s)
- Rachel K Horton
- Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Manish J Gandhi
- Division of Transfusion Medicine, Mayo Clinic, Rochester, Minnesota
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23
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Belizaire R, Makar RS. Non-Alloimmune Mechanisms of Thrombocytopenia and Refractoriness to Platelet Transfusion. Transfus Med Rev 2020; 34:242-249. [PMID: 33129606 PMCID: PMC7494440 DOI: 10.1016/j.tmrv.2020.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/24/2020] [Accepted: 09/03/2020] [Indexed: 12/11/2022]
Abstract
Refractoriness to platelet transfusion is a common clinical problem encountered by the transfusion medicine specialist. It is well recognized that most causes of refractoriness to platelet transfusion are not a consequence of alloimmunization to human leukocyte, platelet-specific, or ABO antigens, but are a consequence of platelet sequestration and consumption. This review summarizes the clinical factors that result in platelet refractoriness and highlights recent data describing novel biological mechanisms that contribute to this clinical problem.
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Affiliation(s)
- Roger Belizaire
- Associate Director, Adult Transfusion Medicine, Brigham and Women's Hospital, Boston, MA
| | - Robert S Makar
- Director, Blood Transfusion Service, Massachusetts General Hospital, Boston, MA.
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24
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Cheok KPL, Chhetri R, Wee LYA, Friel O, Pham A, Salvi A, McRae S, Bardy P, Singhal D, Roxby DJ, Wood EM, Hiwase DK. The burden of immune‐mediated refractoriness to platelet transfusions in myelodysplastic syndromes. Transfusion 2020; 60:2192-2198. [DOI: 10.1111/trf.16029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/22/2020] [Accepted: 05/25/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Kathleen P. L. Cheok
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Rakchha Chhetri
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
- Precision Medicine Theme South Australian Health and Medical Research Institute Adelaide South Australia Australia
- School of Public Health University of Adelaide Adelaide South Australia Australia
| | - Li Yan A. Wee
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
- Precision Medicine Theme South Australian Health and Medical Research Institute Adelaide South Australia Australia
| | - Oisin Friel
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Anh Pham
- Department of Haematology Blood Bank,Royal Adelaide Hospital Adelaide South Australia Australia
| | - Arabelle Salvi
- SA Pharmacy Royal Adelaide Hospital Adelaide South Australia Australia
| | - Simon McRae
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Peter Bardy
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
| | - Deepak Singhal
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
- Precision Medicine Theme South Australian Health and Medical Research Institute Adelaide South Australia Australia
- School of Medicine University of Adelaide Adelaide South Australia Australia
| | - David J. Roxby
- College of Medicine and Public Health Flinders University Bedford Park South Australia Australia
| | - Erica M. Wood
- Transfusion Research Unit Monash University Melbourne Victoria Australia
- Monash Health Melbourne Victoria Australia
| | - Devendra K. Hiwase
- Department of Haematology Royal Adelaide Hospital Adelaide South Australia Australia
- Precision Medicine Theme South Australian Health and Medical Research Institute Adelaide South Australia Australia
- School of Medicine University of Adelaide Adelaide South Australia Australia
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25
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Juskewitch JE, Gandhi MJ, Kreuter JD, Norgan AP. Development and performance characteristics of Platelet Virtual Crossmatch (PLT VXM), a software application for the evaluation and management of platelet transfusion-refractory patients. Transfusion 2020; 60:2284-2293. [PMID: 32827167 DOI: 10.1111/trf.16025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Platelet (PLT) transfusion refractoriness increases bleeding complications, hospital stays, and PLT inventory usage. Immune-mediated refractoriness can be evaluated for using a physical PLT crossmatch with ABO-compatible inventory and, if positive, managed with HLA-compatible PLT inventory and donors. Manual completion of these complex tasks can be time-consuming and potentially error-prone. This study was conducted to determine if a Web-based software application could improve process efficiency and accuracy. STUDY DESIGN AND METHODS Workflow analysis was performed to identify process, data, and analytic requirements for a software application for three PLT transfusion-refractoriness associated tasks: (a) physical PLT crossmatch inventory selection, (b) HLA-compatible inventory selection, and (c) HLA-compatible donor selection. After software application development, a comparison study was performed over 10 consecutive days, with each task performed manually and with the software application (Platelet Virtual Crossmatch [PLT VXM]) for a different unique immune-mediated PLT transfusion-refractory recipient. Task completion time, number of incompatible units/donors presented, and number of documentation errors were compared. RESULTS PLT VXM is a Web-based software application developed using R and the Shiny Web application framework. PLT VXM significantly reduced median task completion times by 4.5 (49%), 11.2 (79%), and 59.1 minutes (94%), respectively. PLT VXM did not present any incompatible PLT units or donors for user consideration. PLT VXM also had a lower number of documentation errors than the manual process, and none of these documentation errors were software generated. CONCLUSION Computer-aided evaluation and management of immune-mediated PLT transfusion-refractory recipients can significantly improve workflow and reduce manual errors in this complex process.
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Affiliation(s)
- Justin E Juskewitch
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manish J Gandhi
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Justin D Kreuter
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew P Norgan
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
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26
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Nagelkerke SQ, Porcelijn L, Geissler J, Tanck MWT, Huiskes E, van Bruggen R, van den Berg TK, de Haas M, Kuijpers TW. The association and functional relevance of genetic variation in low-to-medium-affinity Fc-gamma receptors with clinical platelet transfusion refractoriness. J Thromb Haemost 2020; 18:2047-2053. [PMID: 32588549 DOI: 10.1111/jth.14892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Inadequate responses to platelet transfusions (i.e., platelet transfusion refractoriness [PLT refractoriness]) are a serious problem. Multiple factors contribute to low yields upon platelet transfusion, among which are platelet-reactive allo-antibodies. Platelet-reactive allo-antibodies occur in up to 30% of patients receiving multiple transfusions, and presumably lead to rapid destruction of the transfused platelets via receptors for IgG, the Fc-gamma receptors (FcγRs). Genetic variation in FcγRs is associated with susceptibility to immune thrombocytopenia, in which autoantibodies against platelets cause thrombocytopenia. OBJECTIVES We hypothesized that genetic variation in FcγRs may also influence PLT refractoriness in allo-immunized patients and could help in identifying the patients at risk. PATIENTS/METHODS Patients with severe PLT refractoriness for whom diagnostic testing for allo-immunization was requested in the period of 2005 to 2013 were retrospectively included. A case-control study was performed comparing patients in whom platelet-reactive antibodies were detected (n = 181) with ethnically matched healthy controls (n = 180) to determine differences in all known functional copy number variations and single nucleotide polymorphisms in FcγRs. RESULTS AND CONCLUSIONS None of the tested FcγR genetic variations seemed associated with the development of severe PLT refractoriness. In contrast to observations in immune thrombocytopenia, genetic variation in FcγRs does not seem to influence the chance to develop PLT refractoriness. Our results do not support determination of FcγR genetic background as a means to identify patients most at risk for PLT refractoriness.
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Affiliation(s)
- Sietse Q Nagelkerke
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Leendert Porcelijn
- Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Judy Geissler
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael W T Tanck
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Elly Huiskes
- Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands
| | - Robin van Bruggen
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Timo K van den Berg
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Masja de Haas
- Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, The Netherlands
- Center for Clinical Transfusion Research, Sanquin Research, Amsterdam, The Netherlands
- Department of Immunohematology and Blood Transfusion, LUMC, Leiden, The Netherlands
| | - Taco W Kuijpers
- Department of Blood Cell Research, Sanquin Research and Landsteiner Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Pediatric Hematology, Immunology & Infectious Diseases, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Vo P, Purev E, West KA, McDuffee E, Worthy T, Cook L, Hawks G, Wells B, Shalabi R, Flegel WA, Adams SD, Reger R, Aue G, Tian X, Childs R. A pilot trial of complement inhibition using eculizumab to overcome platelet transfusion refractoriness in human leukocyte antigen allo-immunized patients. Br J Haematol 2020; 189:551-558. [PMID: 32086819 DOI: 10.1111/bjh.16385] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 10/11/2019] [Indexed: 02/06/2023]
Abstract
Heavily transfused patients frequently develop human leukocyte antigen (HLA) allo-immunization resulting in platelet transfusion refractoriness and a high risk for life-threatening thrombocytopenia. Data suggest complement activation leading to the destruction of platelets bound by HLA allo-antibodies may play a pathophysiologic role in platelet refractoriness. Here we conducted a pilot trial to investigate the use of eculizumab, a monoclonal antibody that binds and inhibits C5 complement, to treat platelet transfusion refractoriness in allo-immunized patients with severe thrombocytopenia. A single eculizumab infusion was administered to 10 eligible patients, with four (40%) patients overcoming platelet refractories assessed measuring the corrected platelet count increment (CCI) 10-60 min and 18-24 h post transfusion. Responding patients had a reduction in the requirement for subsequent platelet transfusions and had higher post-transfusion platelet increments for 14 days following eculizumab administration. Remarkably, three of the four responders met CCI criteria for response despite receiving HLA-incompatible platelets. Our results suggest that eculizumab has the ability to overcome platelet transfusion refractoriness in patients with broad HLA allo-immunization. This study establishes proof of principle that complement inhibition can treat platelet transfusion refractoriness, laying the foundation for a large multicentre trial to assess the overall efficacy of this approach (ClinicalTrials.gov, identifier: NCT02298933).
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Affiliation(s)
- Phuong Vo
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | | | - Kamille A West
- Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Emily McDuffee
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Tatyana Worthy
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lisa Cook
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Geri Hawks
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Brian Wells
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Reem Shalabi
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Willy A Flegel
- Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Sharon D Adams
- Department of Transfusion Medicine, NIH Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Robert Reger
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Georg Aue
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Xin Tian
- Office of Biostatistics Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Richard Childs
- Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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28
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Seike K, Fujii N, Asano N, Ohkuma S, Hirata Y, Fujii K, Sando Y, Nakamura M, Naito K, Saeki K, Meguri Y, Asada N, Ennishi D, Nishimori H, Matsuoka KI, Tsubaki K, Otsuka F, Maeda Y. Efficacy of HLA virtual cross-matched platelet transfusions for platelet transfusion refractoriness in hematopoietic stem cell transplantation. Transfusion 2020; 60:473-478. [PMID: 31970799 DOI: 10.1111/trf.15664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 11/21/2019] [Accepted: 11/27/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Cross-matched platelet (cross-matched PLT) transfusion is effective for immune-mediated platelet transfusion refractoriness (PTR), but is more costly and time-consuming for physical cross-match than using standard PLT units. Recent studies have reported the utility of human leucocyte antigens (HLA) virtual cross-matched PLT (HLA-matched PLT) that is defined as HLA-A/B matched or no antibody against donor-specific antigen. Here, we evaluated the effect of HLA-matched PLTs for PTR in post hematopoietic stem cell transplant (HSCT) recipients. STUDY DESIGN AND METHODS Our study included a total of 241 PLTs in 16 patients who underwent HSCT at Okayama University Hospital between 2010 and 2017, receiving either HLA-matched or cross-matched PLTs. We calculated the 24-hour corrected count increments (CCI-24) to evaluate the effect of PLTs. A CCI-24 ≥ 4500 was considered to be a successful transfusion. RESULTS We analyzed 139 cross-matched PLTs and 102 HLA-matched PLTs. In the immune-mediated PTR, the rate of successful transfusion was 60.5% for cross-matched PLT and 63.4% for HLA-matched PLT (p = 0.825). On the other hand, the median CCI-24 for cross-matched PLT transfusions and HLA-matched PLT transfusions were 1856 and 5824 (p < 0.001), with a success rate of 28.1 and 54.1% in cases with non-immune-mediated PTR, respectively (p = 0.001). CONCLUSION The effectiveness of HLA-matched PLT is not inferior to cross-matched PLT. This result indicates that physical cross-match can be omitted in post HSCT PTR.
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Affiliation(s)
- Keisuke Seike
- Division of Transfusion, Okayama University Hospital, Okayama, Japan.,Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Nobuharu Fujii
- Division of Transfusion, Okayama University Hospital, Okayama, Japan.,Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Naomi Asano
- Division of Transfusion, Okayama University Hospital, Okayama, Japan
| | - Shigenori Ohkuma
- Japanese Red Cross Chugoku-Shikoku Block Blood Center, Hiroshima, Japan
| | - Yasushi Hirata
- Japanese Red Cross Chugoku-Shikoku Block Blood Center, Hiroshima, Japan
| | - Keiko Fujii
- Division of Transfusion, Okayama University Hospital, Okayama, Japan.,Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Yasuhisa Sando
- Division of Transfusion, Okayama University Hospital, Okayama, Japan.,Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Makoto Nakamura
- Division of Transfusion, Okayama University Hospital, Okayama, Japan.,Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | | | - Kyosuke Saeki
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Yusuke Meguri
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Noboru Asada
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Daisuke Ennishi
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Hisakazu Nishimori
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Ken-Ichi Matsuoka
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
| | - Kazuo Tsubaki
- Japanese Red Cross Chugoku-Shikoku Block Blood Center, Hiroshima, Japan
| | - Fumio Otsuka
- Division of Transfusion, Okayama University Hospital, Okayama, Japan.,Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshinobu Maeda
- Department of Hematology and Oncology, Okayama University Hospital, Okayama, Japan
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29
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Wade J, Dean CL, Krummey SM, Roback JD, Sullivan HC. How do I … implement diagnostic management teams in transfusion medicine? Transfusion 2019; 60:237-244. [PMID: 31820453 DOI: 10.1111/trf.15618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 10/18/2019] [Indexed: 11/27/2022]
Abstract
Diagnostic management teams (DMTs) were conceptualized approximately twenty years ago in response to increasing subspecialization in medicine. DMTs are a collaboration between diagnostic experts and clinicians that aim to improve accurate and timely diagnosis and treatment of disease. Diagnostic experts provide their expertise in the increasingly complex realm of laboratory testing and interpretation of those test results to guide appropriate test utilization for individual patients. Not only can this approach improve patient care and safety, but DMTs also decrease healthcare costs by reducing unnecessary testing and potential diagnostic errors. Following the DMT construct and principles along with the 2015 National Academy of Medicine recommendations, our transfusion medicine (TM) service streamlined the workup and management of platelet refractory (PR) patients by developing and implementing a formal PR laboratory consult. The goals of this DMT and consult are to improve diagnostic management of PR patients and to decrease delays in providing these patients with appropriate and compatible platelet units. A comprehensive interpretation of test results is directly uploaded to the patient's electronic medical record (EMR), which is associated with a CPT code allowing for compensation for the PR evaluation. Herein we describe the development of and experience with the DMT since its implementation.
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Affiliation(s)
- Jenna Wade
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Christina L Dean
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Scott M Krummey
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - John D Roback
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Harold C Sullivan
- Center for Transfusion and Cellular Therapy, Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
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30
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Prodger CF, Rampotas A, Estcourt LJ, Stanworth SJ, Murphy MF. Platelet transfusion: Alloimmunization and refractoriness. Semin Hematol 2019; 57:92-99. [PMID: 32892848 DOI: 10.1053/j.seminhematol.2019.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/14/2019] [Indexed: 12/28/2022]
Abstract
The transfusion of platelets for both prophylaxis and treatment of bleeding is relevant to all areas of medicine and surgery. Historically, guidance regarding platelet transfusion has been limited by a lack of good quality clinical trials and so has been based largely on expert opinion. In recent years however there has been renewed interest in methods to prevent and treat hemorrhage, and the field has benefited from a number of large clinical trials. Some studies, such as platelet transfusion versus standard care after acute stroke due to spontaneous cerebral haemorrhage associated with antiplatelet therapy (PATCH) and platelets for neonatal transfusion Study 2 (PLANET-2), have reported an increased risk of harm with platelet transfusion in specific patient groups. These studies suggest a wider role of platelets beyond hemostasis, and highlight the need for further clinical trials to better understand the risks and benefits of platelet transfusions. This review evaluates the indications for platelet transfusion, both prophylactic and therapeutic, in the light of recent studies and clinical trials. It highlights new developments in the fields of platelet storage and platelet substitutes, and novel ways to avoid complications associated with platelet transfusions. Lastly, it reviews initiatives designed to reduce inappropriate use of platelet transfusions and to preserve this valuable resource for situations where there is evidence for their beneficial effect.
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Affiliation(s)
- Catherine F Prodger
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford; UK
| | - Alexandros Rampotas
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford; UK
| | - Lise J Estcourt
- NHS Blood and Transplant, Oxford; UK; National Institute of Health Research Biomedical Research Centre Haematology Theme, Oxford; UK
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford; UK; NHS Blood and Transplant, Oxford; UK; National Institute of Health Research Biomedical Research Centre Haematology Theme, Oxford; UK
| | - Michael F Murphy
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford; UK; NHS Blood and Transplant, Oxford; UK; National Institute of Health Research Biomedical Research Centre Haematology Theme, Oxford; UK.
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31
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Weinstock C, Schnaidt M. Human Leucocyte Antigen Sensitisation and Its Impact on Transfusion Practice. Transfus Med Hemother 2019; 46:356-369. [PMID: 31832061 DOI: 10.1159/000502158] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/13/2019] [Indexed: 01/25/2023] Open
Abstract
Human leucocyte antigen (HLA) sensitisation, including the formation of antibodies against HLA, can cause serious effects in patients receiving blood. Under certain circumstances, donor HLA antibodies in the blood product can trigger the patient's granulocytes to release mediators that cause transfusion-associated lung injury (TRALI), a serious complication of transfusion. The HLA systems of both donor and patient are involved in transfusion-associated graft-versus-host disease, which is a rare disease with a high mortality. Patient HLA antibodies can destroy incompatible platelets and may cause refractoriness to platelet transfusion. Identification of a patient's HLA antibody specificities is necessary for issuing compatible platelets to overcome refractoriness. Many techniques for the detection and identification of HLA antibodies have been developed, including complement-dependent cytotoxicity assay, bead-based assays, the platelet adhesion immunofluorescence test, and the monoclonal antibody-specific immobilisation of platelet antigens assay. Different strategies for the selection of HLA-compatible platelets are applied. These strategies depend on the breadth of antibody reactivity and range from avoiding single HLA antigens in the platelet concentrates issued to apheresis of platelets from HLA-identical donors. The mechanisms of HLA sensitisation and the efforts made to provide compatible blood products to sensitised patients are reviewed in this article from the perspective of clinical transfusion medicine.
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Affiliation(s)
- Christof Weinstock
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Service Baden-Württemberg-Hessen, Institute Ulm, Institute of Transfusion Medicine, Ulm University, Ulm, Germany
| | - Martina Schnaidt
- Centre for Clinical Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
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32
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Fontaine MJ. Role of complement in patients with autoimmune hemolytic anemia and platelet transfusion refractoriness. Transfus Clin Biol 2019; 26:152-154. [PMID: 31277985 DOI: 10.1016/j.tracli.2019.06.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 06/15/2019] [Indexed: 11/28/2022]
Abstract
The complement is a key player of the innate immune response. It provides defense mechanisms that are not specific, but very efficient at neutralizing any invader, accounting for 4% of the proteins in the peripheral blood. Nevertheless, there is a dark side to the complement system, as it may activate its machinery against healthy cells such as peripheral blood red blood cells and platelets resulting in undesired hemolysis and thrombocytopenia, respectively. Understanding and identifying the role of complement in these settings allow physicians to adjust their diagnostic and therapeutic modalities accordingly. The role of complement in the pathophysiology and management of autoimmune hemolytic anemia and of alloimmune-mediated thrombocytopenia is under investigation and discussed.
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Affiliation(s)
- Magali J Fontaine
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MA, USA.
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33
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Garraud O, Cognasse F, Moncharmont P. Immunological Features in the Process of Blood Platelet-Induced Alloimmunisation, with a Focus on Platelet Component Transfusion. Diseases 2019; 7:E7. [PMID: 30646515 PMCID: PMC6473846 DOI: 10.3390/diseases7010007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 01/06/2019] [Accepted: 01/09/2019] [Indexed: 12/12/2022] Open
Abstract
Alloimmunisation to platelet antigens is not uncommon; a large number of females, having had pregnancies, developed antibodies to Human Leukocyte Antigen (HLA) moieties harboured on their foetuses' cells (inherited from the father(s)) that may conflict with further pregnancies and transfused Platelet Components occasionally. This is possible since platelets constitutionally express HLA class I molecules (though in copy numbers that consistently differ among individuals). Platelets also express HPA moieties that are variants of naturally expressed adhesion and aggregation molecules; HPA differences between mothers and foetuses and between donors and recipients explain alloimmune conflicts and consequences. Lastly, platelets express ABO blood group antigens, which are rarely immunising, however transfusion mismatches in ABO groups seem to be related to immunisation in other blood and tissue groups. Transfusion also brings residual leukocytes that may also immunise through their copious copy numbers of HLA class I (rarely class II on activated T lymphocytes, B cells, and dendritic cells). In addition, residual red blood cells in platelet concentrates may induce anti-red blood cell allo-antibodies. This short review aims to present the main mechanisms that are commonly reported in alloimmunisation. It also critically endeavours to examine paths to either dampen alloimmunisation occurrences or to prevent them.
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Affiliation(s)
- Olivier Garraud
- EA_3064, Faculty of Medicine of Saint-Etienne, University of Lyon, 42023 Saint-Etienne, France.
- Institut National de la Transfusion Sanguine, 75015 Paris, France.
| | - Fabrice Cognasse
- EA_3064, Faculty of Medicine of Saint-Etienne, University of Lyon, 42023 Saint-Etienne, France.
- Établissement Français du Sang Auvergne-Rhône-Alpes, 69150 Décines, France.
| | - Pierre Moncharmont
- Établissement Français du Sang Auvergne-Rhône-Alpes, 69150 Décines, France.
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Revelli N, Villa MA, Olivero B, Bresciani S, Flores M, Marini M, Pizzi MN, Prati D, Rebulla P. A real-life evaluation of two platelet cross-matching programmes for the treatment of patients refractory to platelet transfusions. Vox Sang 2018; 114:73-78. [PMID: 30523641 DOI: 10.1111/vox.12736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 10/03/2018] [Accepted: 11/11/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVES Strategies for overcoming alloimmune refractoriness to random donor platelets are based on the use of compatible platelets selected from large panels of HLA-typed donors or cross-matching (XM). The aim of this study was to review the effectiveness of a platelet XM programme for treating refractory haematological patients at Milan's Policlinico Hospital (PHM) 2002-2014 and Spedali Civili in Brescia (SCB) 2013-2016. MATERIALS AND METHODS A commercially available solid-phase antibody detection system was used for platelet antibody detection and XM. Forty-nine alloimmune refractory patients at PHM and 13 at SCB, respectively, received a median [IQR] of 12 [6-13] and 18 [13-15] XM compatible platelet transfusions after the detection of refractoriness. The absolute increases in post-transfusion platelet counts obtained using random, and XM platelets were retrieved from the patients' hospital records. RESULTS The critical review at SCB showed that the median [IQR] 1 h post-transfusion increase in platelet counts was 3 × 109 /L [1-5] after 47/47 random platelet transfusions, and 10 × 109 /L [2-25] after 325/326 XM compatible platelet transfusions. The documentation concerning the outcomes of XM platelet transfusions at PHM was incomplete, and so the findings of the review were inconclusive. CONCLUSION This retrospective analysis confirmed the effectiveness of the XM programme at SCB, but revealed defective data collection and retrieval methods at PHM, thus underlining the importance of such methods. The literature review accompanying this retrospective analysis identified a recently described algorithm for ensuring platelet support in refractory patients that optimally integrates the combined use of XM and HLA typing.
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Affiliation(s)
- Nicoletta Revelli
- Department of Transfusion Medicine and Hematology, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Antonietta Villa
- Department of Transfusion Medicine and Hematology, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Olivero
- Department of Transfusion Medicine and Hematology, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Marco Flores
- Department of Transfusion Medicine and Hematology, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mirella Marini
- Blood Transfusion Service, Spedali Civili, Brescia, Italy
| | - Mara Nicoletta Pizzi
- Department of Transfusion Medicine and Hematology, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Prati
- Department of Transfusion Medicine and Hematology, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Paolo Rebulla
- Department of Transfusion Medicine and Hematology, IRCCS Foundation Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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35
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Ferreira MG, De Vito FB, Ferreira AA, Bub CB, Santos FAVD, Filho AB, Silva SS, Moraes-Souza H. Applicability of an instrument to identify human leukocyte antigen-compatible donors for platelet transfusions. Hematol Transfus Cell Ther 2018; 40:298-304. [PMID: 30370406 PMCID: PMC6200671 DOI: 10.1016/j.htct.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 03/21/2018] [Indexed: 11/19/2022] Open
Abstract
Background The selection of compatible human leukocyte antigen platelets has been associated with improved platelet increments. Therefore, an effective strategy would be the selection of donors who are genetically compatible according to the human leukocyte antigen system. Nonetheless, this is costly as it concerns a highly polymorphic system, which requires a large bank of genotyped donors. Methods This study evaluated the feasibility of virtual crossmatching using EpVix software, which simplifies the identification of compatible donors or donors with acceptable incompatibilities. Results Forty-three oncohematological patients were evaluated, in 96 platelet transfusion episodes with 16.3% of the patients being found to be refractory to platelet transfusions. Eight alloimmunized, multitransfused patients were selected to evaluate human leukocyte antigen compatibility against a bank of 336 platelet donors. At least partially compatible donors were found for all patients. The number of compatible donors was found to be inversely proportional to the human leukocyte antigen-panel reactive antibody score of each patient. It was noted that five patients with scores of 15% or less had at least 190 compatible donors; four fully compatible donors were found for two other patients with scores greater than 80% and only one patient (score of 93%) did not have a fully compatible donor. However, for this last patient, 40 donors were partially compatible according to the software. Conclusion The results showed the effectiveness of the use of the EpVix tool to identify potential platelet donors for multitransfused and/or alloimmunized patients, even with a small number of human leukocyte antigen genotyped donors available.
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Affiliation(s)
| | | | - Aline Aparecida Ferreira
- Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil.,Hemocentro Regional de Uberaba, Uberaba, MG, Brazil
| | | | | | | | - Sheila Soares Silva
- Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil.,Hemocentro Regional de Uberaba, Uberaba, MG, Brazil
| | - Helio Moraes-Souza
- Universidade Federal do Triângulo Mineiro (UFTM), Uberaba, MG, Brazil.,Hemococentro Regional de Uberlândia, Uberlandia, MG, Brazil.,Universidade Federal de Uberlândia (UFU), Uberlândia, MG, Brazil
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36
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Rijkers M, Saris A, Heidt S, Mulder A, Porcelijn L, Claas FHJ, Bierings R, Leebeek FWG, Jansen AJG, Vidarsson G, Voorberg J, de Haas M. A subset of anti-HLA antibodies induces FcγRIIa-dependent platelet activation. Haematologica 2018; 103:1741-1752. [PMID: 29858387 PMCID: PMC6165798 DOI: 10.3324/haematol.2018.189365] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/30/2018] [Indexed: 12/22/2022] Open
Abstract
HLA antibodies are associated with refractoriness to platelet transfusion, leading to rapid platelet clearance, sometimes coinciding with clinical side effects such as fever and chills. The presence of HLA antibodies is not always manifested by clinical symptoms. It is currently unclear why refractoriness to platelet transfusion is only observed in a subset of patients. Here, we utilized the availability of a unique panel of human monoclonal antibodies to study whether these were capable of activating platelets. Three out of eight human HLA-specific monoclonal antibodies induced activation of HLA-matched platelets from healthy donors as evidenced by enhanced α-granule release, aggregation, and αIIbb3 activation. The propensity of HLA monoclonal antibodies to activate platelets was independent of the HLA subtype to which they were directed, but was dependent on the recognized epitope. Activation was fully inhibited either by blocking FcγRIIa, or by blocking FcγRIIa-dependent signaling with Syk inhibitor IV. Furthermore, activation required the presence of the IgG-Fc part, as F(ab’)2 fragments of HLA monoclonal antibodies were unable to induce platelet activation. Mixing experiments revealed that activation of platelets occurred in an intra-platelet dependent manner. Accordingly, a proportion of sera from refractory patients with HLA antibodies induced FcγRIIa-dependent platelet activation. Our data show that a subset of HLA antibodies is capable of crosslinking HLA and FcγRIIa thereby promoting platelet activation and enhancing these cells’ phagocytosis by macrophages. Based on these findings we suggest that FcγRIIa-dependent platelet activation may contribute to the decreased platelet survival in platelet-transfusion-dependent patients with HLA antibodies.
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Affiliation(s)
- Maaike Rijkers
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Anno Saris
- Department of Immunopathology, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Sebastiaan Heidt
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, the Netherlands
| | - Arend Mulder
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, the Netherlands
| | - Leendert Porcelijn
- Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands
| | - Frans H J Claas
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, the Netherlands
| | - Ruben Bierings
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - A J Gerard Jansen
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands.,Department of Hematology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gestur Vidarsson
- Department of Experimental Immunohematology, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands
| | - Jan Voorberg
- Department of Plasma Proteins, Sanquin-AMC Landsteiner Laboratory, Amsterdam, the Netherlands.,Department of Vascular Medicine, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Masja de Haas
- Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, the Netherlands.,Department of Immunohaematology Diagnostics, Sanquin Diagnostic Services, Amsterdam, the Netherlands.,Center for Clinical Transfusion Research, Sanquin, Leiden, the Netherlands
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37
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Moncharmont P. Platelet component transfusion and alloimmunization: Where do we stand? Transfus Clin Biol 2018; 25:172-178. [PMID: 29478960 DOI: 10.1016/j.tracli.2018.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 01/23/2018] [Indexed: 11/27/2022]
Abstract
Platelet transfusion in patients, particularly in onco-haematology, is frequent and can become chronic in some cases. Post-transfusion alloimmunization is often seen, in practice. The risk of this is significantly improved in multitransfused patients. Several classes of antigens binding on platelets (HLA and HPA) are involved and also red blood cell antigens (residual red blood cells in platelet concentrates). Platelet alloimmunization causes a poor transfusion response, refractoriness and, more rarely, post-transfusion purpura. In an alloimmunized recipient, the efficiency of platelet transfusion is based on the selection of compatible products. Significant technical progress means that several methods are currently available to ensure a good post-transfusion platelet count and a satisfactory clinical outcome for the patient.
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Affiliation(s)
- P Moncharmont
- Hémovigilance, département des vigilances, site de Décines, Établissement français du sang Auvergne-Rhône-Alpes, 111, rue Élisée-Reclus CS 20617, 69153 Décines-Charpieu cedex, France.
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38
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Norris PJ, Kaidarova Z, Maiorana E, Milani S, Lebedeva M, Busch MP, Custer B, Rebulla P. Ultraviolet light-based pathogen inactivation and alloimmunization after platelet transfusion: results from a randomized trial. Transfusion 2018; 58:1210-1217. [PMID: 29473173 DOI: 10.1111/trf.14534] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 01/03/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The current study explored whether pathogen-reduction treatment of platelet components before transfusion would decrease the risk of alloimmunization. STUDY DESIGN AND METHODS Study participants were patients with hematologic cancer who were included in two parallel, randomized clinical trials testing pathogen-reduction treatment versus conventional platelets using the Mirasol or Intercept pathogen-reduction systems. Patients who had a baseline, pretransfusion sample and a follow-up, posttransfusion sample were included in the study (n = 179 patients in each study arm). Human leukocyte antigen antibody levels were determined using a commercial multianalyte, bead-based assay. RESULTS The rate of human leukocyte antigen Class I alloimmunization at the clinical sites in recipients of conventional platelets was low at the highest assay cutoff (range, 1.2%-5.9%). Consistent with prior studies, human leukocyte antigen antibodies were first detected from 3 to 35 days after transfusion. There were no statistically significant differences between alloimmunization rates in patients who received pathogen-reduction treatment versus conventional platelet transfusions. Although he difference was not statistically significant, the effect size for protection from alloimmunization was greatest for high-level human leukocyte antigen Class I antibodies (approximately threefold) in the Intercept-treated patients compared with those who received conventional platelets. In the Mirasol study, only two patients and one patient in the control group developed medium-level or high-level antibodies, respectively, so it was impossible to determine an effect size for potential protection. CONCLUSIONS The current study was not sufficiently powered to determine whether pathogen-reduction treatment provides protection from human leukocyte antigen alloimmunization in platelet transfusion recipients. The data presented will be useful in the design of future trials and endpoints powered to detect a protective effect.
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Affiliation(s)
- Philip J Norris
- Blood Systems Research Institute.,Department of Laboratory Medicine, University of California-San Francisco.,Department of Medicine, University of California-San Francisco, San Francisco, California
| | | | | | - Silvano Milani
- Laboratory of Medical Statistics and Biometry, Department of Clinical Sciences and Community Health, University of Milan
| | | | - Michael P Busch
- Blood Systems Research Institute.,Department of Laboratory Medicine, University of California-San Francisco
| | - Brian Custer
- Blood Systems Research Institute.,Department of Laboratory Medicine, University of California-San Francisco
| | - Paolo Rebulla
- Department of Regenerative Medicine, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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39
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Millar D, Murphy L, Labrie A, Maurer-Spurej E. Routine Screening Method for Microparticles in Platelet Transfusions. J Vis Exp 2018. [PMID: 29443045 PMCID: PMC5912315 DOI: 10.3791/56893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Platelet inventory management based on screening microparticle content in platelet concentrates is a new quality improvement initiative for hospital blood banks. Cells fragment off microparticles (MP) when they are stressed. Blood and blood components may contain cellular fragments from a variety of cells, most notably from activated platelets. When performing their roles as innate immune cells and major players in coagulation and hemostasis, platelets change shape and generate microparticles. With dynamic light scattering (DLS)-based microparticle detection, it is possible to differentiate activated (high microparticle) from non-activated (low microparticle) platelets in transfusions, and optimize the use of this scarce blood product. Previous research suggests that providing non-activated platelets for prophylactic use in hematology-oncology patients could reduce their risk of becoming refractory and improve patient care. The goal of this screening method is to routinely differentiate activated from non-activated platelets. The method described here outlines the steps to be performed for routine platelet inventory management in a hospital blood bank: obtaining a sample from a platelet transfusion, loading the sample into the capillary for DLS measurement, performing the DLS test to identify microparticles, and using the reported microparticle content to identify activated platelets.
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Affiliation(s)
| | - Larry Murphy
- Quality Engineering & Regulatory, LightIntegra Technology Inc
| | | | - Elisabeth Maurer-Spurej
- Research & Development, LightIntegra Technology Inc.; Department of Pathology and Laboratory Medicine; Center for Blood Research, University of British Columbia; Canadian Blood Services;
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40
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Caram-Deelder C, van der Bom JG, Putter H, Leyte A, Kerkhof DVD, Evers D, Beckers EA, Weerkamp F, Hudig F, Zwaginga JJ, Rondeel JMM, de Vooght KMK, Péquériaux NCV, Visser O, Wallis JP, Middelburg RA. Age of platelet concentrates and time to the next transfusion. Transfusion 2017; 58:121-131. [PMID: 29090466 DOI: 10.1111/trf.14388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 08/18/2017] [Accepted: 08/18/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Storage time of platelet (PLT) concentrates has been negatively associated with clinical efficacy outcomes. The aim of this study was to quantify the association between storage time of PLT concentrates and interval to the next PLT transfusion for different types of PLT components, stored for up to 7 days and transfused to transfusion-dependent hematooncology patients with thrombocytopenia. STUDY DESIGN AND METHODS From a cohort of patients from 10 major Dutch hospitals, patients were selected whose transfusion patterns were compatible with PLT transfusion dependency due to hematooncologic disease. Mean time to the next transfusion and mean differences in time to the next transfusion for different storage time categories (i.e., fresh, <4 days; intermediate, 4-5 days; and old, >5 days) were estimated, per component type, using multilevel mixed-effects linear models. RESULTS Among a cohort of 29,761 patients who received 140,896 PLT transfusions we selected 4441 hematooncology patients who had received 12,724 PLT transfusions during periods of PLT transfusion dependency. Transfusion of fresh, compared to old, buffy coat-derived PLTs in plasma was associated with a delay to the next transfusion of 6.2 hours (95% confidence interval [CI], 4.5-8.0 hr). For buffy coat-derived PLTs in PAS-B and -C this difference was 7.7 hours (95% CI, 2.2-13.3 hr) and 3.9 hours (95% CI, -2.1 to 9.9 hr) while for apheresis PLTs in plasma it was only 1.8 hours (95% CI, -3.5 to 7.1 hr). CONCLUSION Our results indicate that the time to the next transfusion shortens with increasing age of transfused buffy coat-derived PLT concentrates. This association was not observed for apheresis PLTs.
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Affiliation(s)
- Camila Caram-Deelder
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Johanna G van der Bom
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hein Putter
- Department of Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
| | - Anja Leyte
- Departments of Hematology and Clinical Chemistry, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Daan van de Kerkhof
- Department of Clinical Chemistry and Hematology, Catharina Hospital, Eindhoven, the Netherlands
| | - Dorothea Evers
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik A Beckers
- Department of Internal Medicine-Hematology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Floor Weerkamp
- Department of Clinical Chemistry, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | | | - Jaap Jan Zwaginga
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Immunohaematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan M M Rondeel
- Department of Clinical Chemistry, Isala, Zwolle, the Netherlands
| | - Karen M K de Vooght
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Nathalie C V Péquériaux
- Department of Clinical Chemistry and Hematology, Jeroen Bosch Hospital, 's Hertogenbosch, the Netherlands
| | - Otto Visser
- Department of Hematology, VU Medical Center, Amsterdam, the Netherlands
| | - Jonathan P Wallis
- Department of Hematology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Rutger A Middelburg
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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41
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Juskewitch JE, Norgan AP, De Goey SR, Duellman PM, Wakefield LL, Gandhi MJ, Stubbs JR, Kreuter JD. How do I … manage the platelet transfusion-refractory patient? Transfusion 2017; 57:2828-2835. [PMID: 28960321 DOI: 10.1111/trf.14316] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 06/27/2017] [Accepted: 07/29/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Platelet transfusion-refractoriness is a challenging and expensive clinical scenario seen most often in patients with hematologic malignancies. Although the majority of platelet transfusion-refractory cases are due to nonimmune causes, a significant minority are caused by alloimmunization against Class I human leukocyte antigens (HLAs) or human platelet antigens (HPAs). Such platelet transfusion-refractory patients can be effectively managed with appropriate antigen-negative products. STUDY DESIGN AND METHODS Our institution has developed a diagnostic and management algorithm for the platelet transfusion-refractory patient with an early focus on identifying those cases caused by immune-mediated factors. Using physical platelet cross-matches to initially classify platelet transfusion-refractory patients as immune-mediated or not, cross-match-compatible inventory is then provided to immune-mediated patients, whereas subsequent HLA (with or without HPA) testing is performed. RESULTS Our blood donor program performs Class I HLA typing of all repeat platelet donors to facilitate the identification of antigen-negative platelet units (virtual cross-matching) as well as the recruitment of HLA-matched donors. The platelet transfusion-refractoriness algorithm realizes an initial net cost savings once two apheresis platelets are saved from use for each newly identified, immune-mediated platelet transfusion-refractory patient. CONCLUSION An algorithm utilizing physical platelet cross-matches, Class I HLA and HPA antibody testing, and upfront Class I HLA typing of platelet donors leads to overall resource savings and improved clinical management for platelet transfusion-refractory patients.
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Affiliation(s)
- Justin E Juskewitch
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Andrew P Norgan
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Steven R De Goey
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Patti M Duellman
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Laurie L Wakefield
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Manish J Gandhi
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - James R Stubbs
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Justin D Kreuter
- Division of Transfusion Medicine, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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42
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Comont T, Tavitian S, Bardiaux L, Fort M, Debiol B, Morère D, Bérard E, Delabesse E, Luquet I, Martinez S, Huguet F, Récher C, Bertoli S. Platelet transfusion refractoriness in patients with acute myeloid leukemia treated by intensive chemotherapy. Leuk Res 2017; 61:62-67. [PMID: 28910610 DOI: 10.1016/j.leukres.2017.08.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 08/11/2017] [Accepted: 08/28/2017] [Indexed: 01/13/2023]
Abstract
Platelet transfusion refractoriness (PTR) is a major adverse event in the management of acute myeloid leukemia (AML). In a series of 897 adult patients with AML receiving intensive chemotherapy, we identified 41 patients (4.8%) with PTR. PTR was more frequently observed in parous women, patients with extra-medullary disease, a low white blood cell count, an infection, or hemophagocytic syndrome. Among the 31 patients with anti-human leucocyte antigen (HLA) antibodies, an HLA-matched donor was identified for 18 patients (58.1%). Median time between diagnosis of PTR and the first HLA-matched transfusion was 12.5days. HLA-matched transfusions induced a significant increment in platelet counts in 37% of cases. Thrombopoietin receptor agonists were given to 10 patients but did not shorten the duration of thrombocytopenia, reduce severe bleeding, or early death. Grade 3-4 bleeding events during induction, early death caused by bleeding, and death caused by bleeding at any time were significantly greater in patients that had platelet transfusion refractoriness (22% vs. 4.1%, P<0.0001; 12.2% vs. 1.4%, P=0.0006; and 24.4% vs. 5.3%, P<0.0001; respectively). PTR during chemotherapy for AML significantly increased the risk of early and late deaths caused by a severe bleeding event. Improved understanding of platelet destruction is needed to design mechanism-based therapeutic strategies.
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Affiliation(s)
- Thibault Comont
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France; Université Toulouse III Paul Sabatier, Toulouse, France
| | - Suzanne Tavitian
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Laurent Bardiaux
- Etablissement Français du Sang Pyrénées-Méditerranée, Toulouse, France
| | - Marylise Fort
- Laboratoire d'Immunologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Bénédicte Debiol
- Etablissement Français du Sang Pyrénées-Méditerranée, Toulouse, France
| | - Danièle Morère
- Etablissement Français du Sang Pyrénées-Méditerranée, Toulouse, France
| | - Emilie Bérard
- Service d'Epidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France; UMR 1027, INSERM-Université de Toulouse III, Toulouse, France
| | - Eric Delabesse
- Université Toulouse III Paul Sabatier, Toulouse, France; Laboratoire d'Hématologie Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France; Centre de Recherches en Cancérologie de Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France
| | - Isabelle Luquet
- Université Toulouse III Paul Sabatier, Toulouse, France; Laboratoire d'Hématologie Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France; Centre de Recherches en Cancérologie de Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France
| | - Salima Martinez
- Unité d'hémovigilance, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Françoise Huguet
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Christian Récher
- Université Toulouse III Paul Sabatier, Toulouse, France; Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France; Centre de Recherches en Cancérologie de Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France.
| | - Sarah Bertoli
- Université Toulouse III Paul Sabatier, Toulouse, France; Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France; Centre de Recherches en Cancérologie de Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France
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43
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Gurevich-Shapiro A, Tzadok S, Rosenberg A, Inbal A, Bar-Natan M, Wolach O, Raanani P. Extended Small-Dose Platelet Transfusions in Multitransfused Hemato-Oncological Patients: A Single-Center Experience. Acta Haematol 2017; 137:183-190. [PMID: 28419992 DOI: 10.1159/000465510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 02/26/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Refractoriness to platelet transfusion, prevalent among 15-20% of hemato-oncological patients, is associated with multitransfusions and inferior outcomes. We evaluated the effectiveness of extended slow-dose transfusion (ESDT) in increasing platelet increments in multitransfused patients. METHODS Patients treated after the implementation of ESDT were compared with historical controls treated with standard single-donor platelet (SDP) transfusions. Cohorts of early and late recipients were assembled for comparison, i.e. the 8th or 9th and 11th platelet unit per patient, respectively. Patients in the ESDT group received transfusions equal to half an SDP unit, administered over 4 h. Effectiveness was defined as a higher corrected count increment (CCI) at 1, 12, and 24 h after transfusion. RESULTS In the early-recipients cohort, 24-h-posttransfusion increments were available for 29 ESDT patients and 6 standard patients, and did not differ significantly between the groups (p = 0.078). The 24-h-posttransfusion increment was available for 20 ESDT patients and 7 standard patients in the late-recipients cohort. The CCI was significantly higher in the ESDT group (p = 0.042). ABO compatibility improved the CCI (p = 0.01). CONCLUSIONS ESDT demonstrated slightly higher increments at 24 h after transfusion in late recipients, suggesting this could be a cost-effective approach for the treatment of thrombocytopenic multitransfused hemato-oncological patients.
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44
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Estcourt LJ, Birchall J, Allard S, Bassey SJ, Hersey P, Kerr JP, Mumford AD, Stanworth SJ, Tinegate H. Guidelines for the use of platelet transfusions. Br J Haematol 2016; 176:365-394. [DOI: 10.1111/bjh.14423] [Citation(s) in RCA: 266] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Lise J. Estcourt
- NHSBT and Radcliffe Department of Medicine; University of Oxford; Oxford UK
| | - Janet Birchall
- NHSBT and Department of Haematology; North Bristol NHS Trust; Bristol UK
| | - Shubha Allard
- NHSBT and Department of Haematology; Royal London Hospital; London UK
| | - Stephen J. Bassey
- Department of Haematology; Royal Cornwall Hospital Trust; Cornwall UK
| | - Peter Hersey
- Department of Critical Care Medicine & Anaesthesia; City Hospitals Sunderland NHS Foundation Trust; Sunderland UK
| | - Jonathan Paul Kerr
- Department of Haematology; Royal Devon & Exeter NHS Foundation Trust; Exeter UK
| | - Andrew D. Mumford
- School of Cellular and Molecular Medicine; University of Bristol; Bristol UK
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45
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Abstract
Platelet transfusions play an important role in the treatment of critically ill patients. Like any blood component, however, there are various aspects of platelet transfusion therapy that need be considered by the intensivist. These include the proper dose and type of platelet component to infuse, as well as the route and method of administration. Methods to reduce the volume of the transfused platelets, for example, must ensure that the infused platelets will be functional and viable, posttransfusion. Treatment and diagnosis of the HLA alloimmunized recipient can pose a serious challenge to the clinician and an obstacle to adequate platelet therapy. An ICU patient for whom an adequate posttransfusion platelet increment cannot be achieved is at great risk of suffering a fatal hemorrhage. The ICU physician should be aware of the techniques used in modern transfusion practice to avoid having to deal with this complication. Adverse reactions to platelet transfusion include not only serologic ones, but those related to febrile and allergic complications, as well as infectious complications. The latter group includes diseases caused by infection with cytomegalovirus, bacteria, and a cadre of viruses including HIV and hepatitis. The clinical approach to thrombocytopenia in the ICU will be covered in some detail in an effort to review many of the conditions associated with recipient thrombocytopenia, including ITP, TTP, dilutional thrombocytopenia, DIC, surgery, HELLP syndrome, and drug-induced thrombocytopenia. Unfortunately the treatment approaches traditionally used are not always derived from evidence-based studies. This review covers many of these topics in an attempt to help physicians become better able to manage thrombocytopenia in the ICU and thus provide the best transfusion therapy for their patients.
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Affiliation(s)
- Jean-Pierre Gelinas
- Department of Anesthesiology and Critical Care, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, CT
| | - Lanu V. Stoddart
- Blood Bank/Apheresis Service, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, CT
| | - Edward L. Snyder
- Department of Laboratory Medicine, Yale University School of Medicine, Yale-New Haven Hospital, New Haven, CT.
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46
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Clinical Uses of Blood Components. Transfus Med 2016. [DOI: 10.1002/9781119236504.ch11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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47
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The HLA System in Transfusion Medicine and Transplantation. Transfus Med 2016. [DOI: 10.1002/9781119236504.ch16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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48
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49
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Vassallo RR, Norris PJ. Can we "terminate" alloimmune platelet transfusion refractoriness? Transfusion 2016; 56:19-22. [PMID: 26756708 DOI: 10.1111/trf.13411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 10/14/2015] [Indexed: 12/16/2022]
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50
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Meinke S, Sandgren P, Mörtberg A, Karlström C, Kadri N, Wikman A, Höglund P. Platelets made HLA deficient by acid treatment aggregate normally and escape destruction by complement and phagocytes in the presence of HLA antibodies. Transfusion 2015; 56:370-82; quiz 369. [PMID: 26442787 DOI: 10.1111/trf.13350] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 08/12/2015] [Accepted: 08/16/2015] [Indexed: 01/23/2023]
Abstract
BACKGROUND The presence of antibodies against HLA Class I can lead to platelet (PLT) transfusion refractoriness, that is, the repeated failure to achieve adequate posttransfusion PLT count increments. PLT refractoriness can be overcome by transfusion of HLA-matched donor PLTs. A different approach is to remove HLA from the PLT surface using low pH. Previous case studies using HLA-stripped PLTs showed encouraging but inconsistent results and lacked information on the biologic effects of acid treatment on PLT function as well as sensitivity to PLT destruction in the presence of HLA antibodies. STUDY DESIGN AND METHODS PLTs prepared from buffy coats were stripped from HLA Class I using a brief incubation at pH 2.9. Kinetics of acid stripping, viability, phenotypic alterations, and sensitivity to complement-mediated lysis and phagocytosis were determined by flow cytometry. Functional potential was evaluated using a multiplate analyzer. RESULTS Acid-treated PLTs were viable, upregulated activation markers normally and aggregated to a similar extent as untreated PLTs in response to stimulation with three natural agonists. Acid treatment removed 70% to 90% of HLA Class I complexes from the PLT surface, which led to complete protection from HLA antibody-mediated complement lysis and reduced monocyte-mediated phagocytosis in the presence of anti-HLA in vitro. CONCLUSION Our study fills an important knowledge gap in how acid treatment affects PLT function and interactions with immune cells, paving the way for controlled clinical trials to evaluate acid-treated PLTs as an alternative to HLA-matched donors in PLT refractoriness.
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Affiliation(s)
- Stephan Meinke
- Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Clinic for Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Per Sandgren
- Clinic for Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Anette Mörtberg
- Clinic for Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Cecilia Karlström
- Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Clinic for Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Nadir Kadri
- Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Wikman
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinic for Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Petter Höglund
- Center for Hematology and Regenerative Medicine (HERM), Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden.,Clinic for Clinical Immunology and Transfusion Medicine, Karolinska University Hospital, Stockholm, Sweden
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