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Khedjat K, Lenain R, Hamroun A, Baes D, Top I, Labalette M, Lopez B, Van Triempont M, Provôt F, Frimat M, Gibier JB, Hazzan M, Maanaoui M. Post-Transplantation Early Blood Transfusion and Kidney Allograft Outcomes: A Single-Center Observational Study. Transpl Int 2022; 35:10279. [PMID: 35368637 PMCID: PMC8971186 DOI: 10.3389/ti.2022.10279] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/07/2022] [Indexed: 11/30/2022]
Abstract
The association between blood transfusion and the occurrence of de novo HLA donor specific antibodies (DSA) after kidney transplantation remains controversial. In this single-center observational study, we examined the association between early blood transfusion, i.e. before 1-month post-transplantation, and the risk of DSA occurrence, using Luminex based-methods. In total, 1,424 patients with a minimum of 1-month follow-up were evaluated between January 2007 and December 2018. During a median time of follow-up of 4.52 years, we observed 258 recipients who had at least one blood transfusion during the first month post-transplantation. At baseline, recipients in the transfused group were significant older, more sensitized against HLA class I and class II antibodies and had a higher 1-month serum creatinine. Cox proportional hazards regression analyses did not show any significant association between blood transfusion and the risk of de novo DSA occurrence (1.35 [0.86–2.11], p = 0.19), the risk of rejection (HR = 1.33 [0.94–1.89], p = 0.11), or the risk of graft loss (HR = 1.04 [0.73–1.50], p = 0.82). These data suggest then that blood transfusion may not be limited when required in the early phase of transplantation, and may not impact long-term outcomes.
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Affiliation(s)
| | - Rémi Lenain
- Department of Nephrology, CHU Lille, Lille, France.,INSERM UMR 1246 -SPHERE, Nantes University, Tours University, Nantes, France
| | - Aghilès Hamroun
- Department of Nephrology, CHU Lille, Lille, France.,Clinical Epidemiology Team, CESP, Centre for Research in Epidemiology and Population Health, Inserm, Paris-Saclay University, Versailles Saint Quentin University, Villejuif, France
| | | | - Isabelle Top
- CHU Lille, Institut d'Immunologie, Bd du Professeur Jules Leclercq, Lille, France.,Lille University, Regional and University Hospital Center of Lille, Lille, France
| | - Myriam Labalette
- CHU Lille, Institut d'Immunologie, Bd du Professeur Jules Leclercq, Lille, France.,Lille University, Regional and University Hospital Center of Lille, Lille, France
| | - Benjamin Lopez
- Laboratoire de Biologie Médicale, CH Dunkerque, Dunkerque, France
| | | | | | - Marie Frimat
- Department of Nephrology, CHU Lille, Lille, France
| | - Jean-Baptiste Gibier
- Department of Pathology, Pathology Institute, Inserm UMR-S1172 Lille, JPARC-Jean-Pierre Aubert Research Center, Team "Mucins, Epithelial Differentiation and Carcinogenesis", Lille, France
| | - Marc Hazzan
- Department of Nephrology, CHU Lille, Lille, France
| | - Mehdi Maanaoui
- Department of Nephrology, CHU Lille, Lille, France.,Univ. Lille, Inserm, CHU Lille, Institut Pasteur Lille, U1190-EGID, Lille, France
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Abstract
There remains controversy as to when patients undergoing cardiac surgery should receive a transfusion and whether a low hematocrit and its treatment with a transfusion of red cells influences outcome. The data related to this controversy are reviewed. Although the risk of known viral transmission is currently low, stored red cells do not function normally, and each unit contains activated inflammatory cells and mediators. These changes cause limited oxygen release, impaired microcirculatory flow, and immune suppression. A number of studies have observed decreased survival associated with transfusions in trauma, coronary artery bypass grafting, and intensive care unit patients. Studies that show an adverse outcome associated with low hematocrit are not definitive, because they fail to distinguish between the impact of low hematocrit per se and the possible adverse effects of transfusion, for what the low hematocrit may simply be a surrogate. The observation that a low hematocrit is associated with an adverse outcome does not necessarily prove that “treatment” of the anemia with a red cell transfusion will improve the outcome. Stored platelets contain a highly activated mixture of platelets with storage lesions and inflammatory mediators. Two retrospective post hoc multifactorial analyses suggest that platelet transfusions are associated with substantial increased morbidity and mortality. Clearly, large prospective studies are required to define the proper trigger for blood product transfusion to balance the adverse effects of anemia and platelet deficiency or dysfunction with the adverse effects of transfusion of blood products on morbidity and mortality associated with cardiac surgery and anesthesia.
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Affiliation(s)
- Bruce D Spiess
- Department of Anesthesiology and the Reanimation Engineering Shock Center, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0695, USA.
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Abstract
The transfusion of allogeneic red blood cells (RBCs) and other blood components is ingrained in modern medical practice. The rationale for administering transfusions is based on key assumptions that efficacy is established and risks are acceptable and minimized. Despite the cliché that, "the blood supply is safer than ever," data about risks and lack of efficacy of RBC transfusions in several clinical settings have steadily accumulated. Frequentist statisticians and clinicians demand evidence from randomized clinical trials (RCTs); however, causation for the recognized serious hazards of allogeneic transfusion has never been established in this manner. On the other hand, the preponderance of evidence implicating RBC transfusions in adverse clinical outcomes related to immunomodulation and the storage lesion comes from observational studies, and a broad and critical analysis to evaluate causation is overdue. It is suggested in several circumstances that this cannot wait for the design, execution, and conduct of rigorous RCTs. We begin by examining the nature and definition of causation with relevant examples from transfusion medicine. Deductive deterministic methods may be applied to most of the well-accepted and understood serious hazards of transfusion, with modified Koch's postulates being fulfilled in most circumstances. On the other hand, when several possible interacting risk factors exist and RBC transfusions are associated with adverse clinical outcomes, establishing causation requires inferential probabilistic methodology. In the latter circumstances, the case for RBC transfusions being causal for adverse clinical outcomes can be strengthened by applying modified Bradford Hill criteria to the plethora of existing observational studies. This being the case, a greater precautionary approach to RBC transfusion is necessary and equipoise that justifying RCTs may become problematic.
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Affiliation(s)
- James P Isbister
- Society for the Advancement of Blood Management, Department of Haematology, University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales, Australia.
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Abstract
Considerable progress has been made in recognizing microvesicles as important mediators of intercellular communication rather than irrelevant cell debris. Microvesicles released by budding directly from the cell membrane surface (i.e., ectocytosis) either spontaneously or in response to various stimuli are called shed vesicles or ectosomes. Ectosomes are rightside-out vesicles with cytosolic content, and they expose phosphatidylserine in the outer leaflet of their membrane. Depending on their cellular origin, ectosomes have been associated with a broad spectrum of biological activities. In the light of recent findings, we now know that ectosomes derived from polymorphonuclear leukocytes, erythrocytes, platelets, and tumor cells have profound effects on the innate immune system, as well as on the induction of the adaptive immunity, globally reprogramming cells such as macrophages or dendritic cells toward an immunosuppressive and possibly tolerogenic phenotype. Although the effects observed in the circulation are mainly procoagulant and pro-inflammatory, ectosomes might be anti-inflammatory/immunosuppressive in local inflammation.
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Affiliation(s)
- Salima Sadallah
- Immunonephrology Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
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Almeida RMVR, Infantosi AFC, Suassuna JHR, Costa JCGD. Multiple correspondence analysis in predictive logistic modelling: application to a living-donor kidney transplantation data. Comput Methods Programs Biomed 2009; 95:116-128. [PMID: 19328584 DOI: 10.1016/j.cmpb.2009.02.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Revised: 01/10/2009] [Accepted: 02/04/2009] [Indexed: 05/27/2023]
Abstract
This work deals with the use of multiple correspondence analysis (MCA) and a weighted Euclidean distance (the tolerance distance) as an exploratory tool in developing predictive logistic models. The method was applied to a living-donor kidney transplant data set with 109 cases and 13 predictors. This approach, followed by backward and forward selection procedures, yielded two models, one with four and another with two predictors. These models were compared to two other models, ordinarily built by backward and forward stepwise selection, which yielded, respectively, five and two predictors. After internal validation, the models performance statistics showed similar results. Likelihood ratio tests suggested that backward approach achieved a better fit than the forward modelling in both methods and the Vuong's non-nested test between backward-built models suggested that these were undistinguishable. We conclude that the tolerance distance, in combination with MCA, could be a feasible method for variable selection in logistic modelling, when there are several categorical predictors.
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Affiliation(s)
- Renan Moritz Varnier R Almeida
- Biomedical Engineering Program - COPPE, Federal University of Rio de Janeiro, P.O. Box 68510, Rio de Janeiro, RJ 21941-972, Brazil.
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Aalten J, Bemelman FJ, van den Berg-Loonen EM, Claas FH, Christiaans MH, de Fijter JW, Hepkema BG, Hené RJ, van der Heide JJH, van Hooff JP, Lardy NM, Lems SP, Otten HG, Weimar W, Allebes WA, Hoitsma AJ. Pre-kidney-transplant blood transfusions do not improve transplantation outcome: a Dutch national study. Nephrol Dial Transplant 2009; 24:2559-66. [PMID: 19474284 DOI: 10.1093/ndt/gfp233] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Female renal transplant candidates are prone to be sensitized by prior pregnancies, and undetected historical sensitization might decrease transplantation outcome. Hypothesis of our study was that pre-transplant blood transfusions (PTFs) can elucidate historical sensitization and that the avoidance of the associated antigens can improve transplantation outcome. METHODS Data from all female non-immunized renal transplant candidates who received a random PTF (rPTF) (n = 620), matched PTF (mPTF) (one HLA-A and B and one HLA-DR match) (n = 86) or donor-specific blood transfusion (DST) (n = 100) between 1996 and 2006 were collected. Complement-dependent cytoxicity was used to detect anti-HLA antibodies. Sensitization and transplantation outcomes after a PTF were analyzed. Non-immunized female renal transplant recipients who did not receive a PTF were used as the control group. RESULTS In 165 patients, anti-HLA antibodies (IgG) were detected after the PTF. Both historical and primary sensitizations were found. A DST induced donor-specific anti-HLA antibodies in 25% of the DST recipients. Our policy did not improve transplantation outcome in recipients of a kidney from a deceased donor (n = 368) or in recipients of a living donor [DST (n = 49) and mPTF (n = 66)]. CONCLUSIONS A PTF did elucidate historical sensitization but induce primary sensitization as well. No beneficial effect of PTFs on transplantation outcome was found, and PTFs with the intention to detect historical sensitization are therefore not suggested.
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Affiliation(s)
- Jeroen Aalten
- Department of Nephrology, University Medical Center Radboud, Postbus 9101, 6500 HB Nijmegen, The Netherlands.
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Costa JCGD, Almeida RMVR, Infantosi AFC, Suassuna JHR. A heuristic index for selecting similar categories in multiple correspondence analysis applied to living donor kidney transplantation. Comput Methods Programs Biomed 2008; 90:217-229. [PMID: 18420302 DOI: 10.1016/j.cmpb.2008.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2007] [Revised: 12/15/2007] [Accepted: 01/16/2008] [Indexed: 05/26/2023]
Abstract
This work introduces a heuristic index (the "tolerance distance") to define the "closeness" of two variable categories in multiple correspondence analysis (MCA). This index is a weighted Euclidean distance where weightings are based on the "importance" of each MCA axis, and variable categories were considered to be associated when their distances were below the tolerance distance. This approach was applied to a renal transplantation data. The analysed variables were allograft survival and 13 of its putative predictors. A bootstrap-based stability analysis was employed for assessing result reliability. The method identified previously detected associations within the database, such as that between race of donors and recipients, and that between HLA match and Cyclosporine use. A hierarchical clustering algorithm was also applied to the same data, allowing for interpretations similar to those based on MCA. The defined tolerance distance could thus be used as an index of "closeness" in MCA, hence decreasing the subjectivity of interpreting MCA results.
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Affiliation(s)
- João Carlos G D Costa
- Biomedical Engineering Program-COPPE, Federal University of Rio de Janeiro, Rio de Janeiro ZIP Code 21941-972, RJ, Brazil
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Yeh JJ, Gonen M, Tomlinson JS, Idrees K, Brennan MF, Fong Y. Effect of blood transfusion on outcome after pancreaticoduodenectomy for exocrine tumour of the pancreas. Br J Surg 2007; 94:466-72. [PMID: 17330243 DOI: 10.1002/bjs.5488] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Blood transfusion is thought to have an immunosuppressive effect. The aims of this study were to examine survival in patients with pancreatic cancer receiving blood transfusion in association with pancreaticoduodenectomy, and to define preoperative risk factors for subsequent transfusion. METHODS A retrospective review was performed of a prospective database of patients with exocrine tumours of the head of the pancreas who had undergone pancreaticoduodenectomy between 1998 and 2003. Clinical data, transfusion records and preoperative laboratory values were recorded. RESULTS A total of 294 patients underwent pancreaticoduodenectomy for exocrine tumours in the pancreatic head. Of these, 140 (47.6 per cent) received a blood transfusion. Their median survival was 18 months, compared with 24 months for those who did not have a transfusion (P = 0.036). Postoperative transfusion, margin status and node stage were independent predictors of survival. Age and preoperative total bilirubin and haemoglobin levels were the only preoperative factors that correlated with transfusion. CONCLUSION In patients with exocrine tumours of the pancreas, blood transfusion should be avoided when possible. Preoperative risk factors can identify patients who are likely to require transfusion and would therefore benefit most from blood conservation methods.
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Affiliation(s)
- J J Yeh
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York 10021, USA
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Abstract
Blood transfusion utilization continues to rise, yet it has never undergone prospective safety and efficacy testing. Recent data regarding oxygen delivery, microcirculation, and inflammation all point toward potential problems with allogeneic transfusion. Outcome data from retrospective data bases are sobering, calling to question the present practices of red cell transfusion.
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Affiliation(s)
- Bruce D Spiess
- Department of Anesthesiology, Virginia Commonwealth University Medical Center, 1200 East Broad Street, Richmond, VA 23298-0695, USA.
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