The Dead Sea needs salt water… massively bleeding patients need whole blood: The evolution of blood product resuscitation

Whole blood, that is blood that is not manufactured into its component red blood cells (RBC) plasma, and platelets (PLT) units, was the mainstay of transfusion for many years until it was discovered that the component parts of a blood donation could be stored under different conditions thereby optimizing the storage length of each product. The use of low anti-A and -B titer group O whole blood (LTOWB) has recently been rediscovered for use in massively bleeding trauma patients. Whole blood has several advantages over conventional component therapy for these patients, including simplifying the logistics of the resuscitation, being more concentrated than whole blood that is reconstituted from conventional components, and providing cold-stored PLTs, amongst other benefits. While randomized controlled trials to determine the efficacy of using LTOWB in the resuscitation of massively bleeding trauma patients are currently underway, retrospective data has shown that massively bleeding recipients of LTOWB with traumatic injury do not have worse outcomes compared to patients who received conventional components and, in some cases, recipients of LTOWB have more favourable outcomes. This paper will describe some of the advantages of using LTOWB and will discuss the emerging evidence for its use in massively bleeding patients.

The effects of a data driven maximum surgical blood ordering schedule on preoperative blood ordering practices

OBJECTIVES

The maximum surgical blood ordering schedule (MSBOS) provides guidelines for pre-operative pre-transfusion testing for elective surgical procedures. This study compared blood ordering and utilization during the period when the MSBOS was created by achieving consensus between the blood bank and the various surgical specialties, and after the introduction of an MSBOS created by using department-specific red blood cell (RBC) transfusion data (data driven MSBOS, dMSBOS).

METHODS

The dMSBOS was created by analyzing 12 months of RBC transfusion data for each procedure across a regional health system. Pre-transfusion testing and the RBC crossmatch:transfusion (C:T) ratios at 8 of the hospitals were compared between the 12 month period before the dMSBOS was introduced, and the 15 months after its introduction.

RESULTS

There were significant reductions in the median monthly number of type and screens not associated with RBC crossmatches (10 714-10 061; p < 0.0001) and the median number of type and screens associated with RBC crossmatches (10 127-9 349; p = 0.0014) on surgical patients after dMSBOS implementation. There were significant decreases in the median number of monthly RBC units crossmatched (2 981-2 444; p < 0.0001) and transfused (890-791; p < 0.0001) to surgical patients after implementing the dMSBOS. The overall system-wide C:T ratio trended down after dMSBOS implementation (from 3.34 to 3.17, p = 0.067).

DISCUSSION

Crossmatching fewer RBC units facilitates more efficient management of the blood bank's inventory.

CONCLUSION

The dMSBOS was effective in reducing the extent of unnecessary pre-transfusion testing before surgery and reduced the number of RBCs that were crossmatched for specific patients.

Incidence and clinical characteristics of transfusion-associated circulatory overload using an active surveillance algorithm

BACKGROUND

The concordance of haemovigilance criteria developed for surveillance of transfusion-associated circulatory overload (TACO) with its clinical diagnosis has not been assessed. In a pilot study to evaluate an electronic screening algorithm, we sought to examine TACO incidence and application of haemovigilance criteria in patients with post-transfusion pulmonary oedema.

STUDY DESIGN AND METHODS

From June to September 2014, all transfused adult inpatients at four academic hospitals were screened with an algorithm identifying chest radiographs ordered within 12 h of blood component release. Patients with post-transfusion pulmonary oedema underwent case adjudication by an expert panel. TACO incidence was calculated, and clinical characteristics were compared with other causes of post-transfusion pulmonary oedema.

RESULTS

Among 4932 transfused patients, there were 3412 algorithm alerts, 50 cases of TACO and 47 other causes of pulmonary oedema. TACO incidence was 1 case per 100 patients transfused. TACO classification based on two sets of haemovigilance criteria (National Healthcare Safety Network and proposed revised International Society for Blood Transfusion) was concordant with expert panel diagnosis in 57% and 54% of reviewed cases, respectively. Although the majority of clinical parameters did not differentiate expert panel adjudicated TACO from other cases, improved oxygenation within 24 h of transfusion did (P = 0·01).

CONCLUSIONS

The incidence of TACO was similar to that observed in prior studies utilizing active surveillance. Case classification by haemovigilance criteria was frequently discordant with clinical diagnoses of TACO in patients with post-transfusion pulmonary oedema. Improvements in oxygenation within 24 h of transfusion merit further evaluation in the diagnosis of TACO.

Whole blood for the acutely haemorrhaging civilian trauma patient: a novel idea or rediscovery?

The concept of whole blood (WB) as a treatment modality for trauma patients requiring transfusion therapy is not new. Successfully employed in the early 20 century, WB was the product of choice for military trauma resuscitation until the advent of component therapy changed the landscape of transfusion medicine. However, the recognition of the success of WB in the military operational setting has provided some enthusiasm to explore its revival as a cold-stored option in the civilian trauma resuscitation sector. Concerns continue to exist over potential limitations for its application in regards to the efficacy of platelets after cold storage, the risk of haemolytic transfusion reactions following the transfusion of un-cross-matched WB and the logistical issues for civilian blood banks in providing WB. This review aims to reconcile these concerns with data available in the literature, with a view to establishing that there is in vitro evidence supporting the haemostatic effects of cold-stored WB as a potential therapeutic option in both the pre-hospital and in-hospital civilian trauma resuscitation settings.

Detection of HHV-8 (human herpesvirus-8) genomes in induced peripheral blood mononuclear cells (PBMCs) from US blood donors

BACKGROUND

Human herpesvirus-8 (HHV-8) causes Kaposi's sarcoma and can be detected and induced in peripheral blood mononuclear cells (PBMCs) from infected individuals. The prevalence of viral genomes in induced/cultured PBMCs from healthy blood donors has not been systematically studied.

MATERIALS AND METHODS

PBMCs from 164 donors were purified and stored as two equal aliquots in liquid nitrogen. One aliquot was used for CD19+ B-cell purification with a fraction reserved for DNA extraction. The second aliquot was cultured for 2 or 4 days in culture media containing n-butyrate and tetradecanoyl phorbol acetate. DNA was extracted from all four cell sources: PBMCs, purified B cells, induced PBMCs harvested at days 2 and 4 of culture. A sensitive real-time PCR with a DNA equivalent of 3×10(5) cells per reaction was run in duplicate for all samples along with a quantitative HHV-8 DNA standard ranging from 1.6 to 200 copies.

RESULTS

For all 164 donors, HHV-8 genomes were not detected in the DNA equivalent of 3-6×10(5) of PBMCs and induced/cultured PBMCs with a real-time PCR assay (95% CI: 0-3.5/164). HHV-8 DNA was not detected from DNA equivalent of 1.5 (0.5-5.6)×10(5) CD19+ B cells from 139/164 donors. HHV-8 antibodies were detected in 7 of the 164 donors (4.3%).

CONCLUSIONS

HHV-8 genomes were not detected from PBMCs, induced/cultured PBMCs and CD19+ B cells from 164 blood donors. The level of detectable HHV-8 genomes in blood donors seems to be extremely low, if they exist.

Stability of lymphocytes and Epstein?Barr virus during red blood cell storage

BACKGROUND

The Epstein-Barr virus (EBV) establishes and maintains latent infection in B lymphocytes of the healthy adults. Lymphocytes remain viable during red blood cell (RBC) storage. The effect of RBC storage on the stability of EBV-infected B lymphocytes and EBV genome is not known.

STUDY DESIGN AND METHODS

Eight randomly selected non-leukoreduced AS-5 RBC units were stored for 42 days under standard blood bank refrigerated at 1-6 degrees C. Cell count and EBV genomes in CD19+ B lymphocytes were measured in fresh products and weekly for 6 weeks. Total white blood cells (CD45+), T lymphocyte (CD3+), and B lymphocyte (CD19+) were quantified by a single platform flow cytometric assay. EBV genomes were quantified by real-time polymerase chain reaction using DNA purified from CD19+ B cells.

RESULTS

Viable white blood cell, T and B lymphocytes followed a biphasic decline curve during RBC storage consisting of a steep steady decline during the first 3 weeks followed by a plateau for the remainder of the storage. At the end of the RBC shelf-life, 19% of the original T and B cells remained viable. EBV genomes per 10(5) CD19+ B lymphocytes remained constant during RBC storage. However, the total EBV genomes in the RBC units decline by more than 80% of their original value at the end of RBC storage due to loss of viable B lymphocytes.

CONCLUSIONS

The results indicate that lymphocytes and EBV latently infected B cells can survive the normal storage conditions for RBC.

The RADAR repository: a resource for studies of infectious agents and their transmissibility by transfusion

BACKGROUND

An ongoing issue in transfusion medicine is whether newly identified or emerging pathogens can be transmitted by transfusion. One method to study this question is through the use of a contemporary linked donor-recipient repository.

STUDY DESIGN AND METHODS

The Retrovirus Epidemiology Donor Study Allogeneic Donor and Recipient (RADAR) repository was established between 2000 and 2003 by seven blood centers and eight collaborating hospitals. Specimens from consented donors were collected, components from their donations were routed to participating hospitals, and recipients of these units gave enrollment and follow-up specimens for long-term storage. The repository was designed to show that zero transmissions to enrolled recipients would indicate with 95 percent confidence that the transfusion transmission rate of an agent with prevalence of 0.05 to 1 percent was lower than 25 percent.

RESULTS

The repository contains pre- and posttransfusion specimens from 3,575 cardiac, vascular, and orthopedic surgery patients, linked to 13,201 donation specimens. The mean number of RADAR donation exposures per recipient is 3.85. The distribution of components transfused is 77 percent red cells, 13 percent whole blood-derived platelet concentrates, and 10 percent fresh frozen plasma. A supplementary unlinked donation repository containing 99,906 specimens from 84,339 donors was also established and can be used to evaluate the prevalence of an agent and validate assay(s) performance before accessing the donor-recipient-linked repository. Recipient testing conducted during the establishment of RADAR revealed no transmissions of human immunodeficiency virus, hepatitis C virus, or human T-lymphotropic virus.

CONCLUSIONS

RADAR is a contemporary donor-recipient repository that can be accessed to study the transfusion transmissibility of emerging agents.

Number of RBC units and rate of transfusionto anemic HIV-positive patients assigned to receiveWBC-reduced or non-WBC-reduced RBCs: the viral activation transfusion study experience

BACKGROUND

It is known that the use of filtration to reduce WBCs in RBC units is associated with a 6- to 15-percent loss of RBCs. It is not known if the use of such WBC-reduced RBCs results in an increased need for RBC units or in the transfusion of more units per year to patients with anemia.

STUDY DESIGN AND METHODS

In the multicenter Viral Activation Transfusion Study (VATS), anemic HIV-positive patients were randomly assigned to receive either WBC-reduced or non-WBC-reduced RBCs. The number of RBC units transfused per patient and the rate of RBC use were studied. All RBC units given after the enrollment transfusion were counted, until the end of follow-up or the occurrence of bleeding (receiving >5 RBCs within 2 consecutive days).

RESULTS

As expected, the WBC-reduced RBC units in VATS were lighter in weight than the non-WBC-reduced units (median weight: WBC-reduced, 300 g; non-WBC-reduced, 330 g; p<0.0001). After the enrollment transfusion, 258 WBC-reduced arm patients received 1279 units of RBCs (average, 5.0 units/patient, median, 2 units) while 262 patients in the non-WBC-reduced arm received 1111 RBCs (4.2 units/patient; median, 2 units). The number of units transfused for anemia was slightly greater in the WBC-reduced arm, but the difference was not significant (p = 0.41). Similarly, the rate of RBC use was somewhat higher in the WBC-reduced arm, but the difference was not significant (p = 0.14). The median was 2.3 units per patient per year of follow-up in the WBC-reduced arm; the median in the non-WBC-reduced arm was 1.2 units.

CONCLUSION

This study confirms that WBC-reduced RBC units are significantly lighter in weight than non-WBC-reduced RBCs. However, in the setting of a large, randomized, blinded study of transfusion for anemia, the smaller size of the WBC-reduced RBC units had no significant effect on the number of RBC units transfused or on the rate at which RBC units were used. In this study, the frequency of blood transfusion may have had a greater relationship to the frequency of routine, scheduled appointments or transfusion orders for a specified Hb trigger than to the actual Hb content of the unit.

Microchimerism, GVHD, and tolerance in solid organ transplantation

The phenomenon of microchimerism and its relationship to long-term graft tolerance is an area of active study. The ability to establish a tolerant state has been enhanced with current immunosuppressive drugs and emerging therapies such as donor HPC infusions. An undesirable outcome of host-donor WBC interaction is GVHD. GVHD is a rare complication reported most frequently in liver transplantation. Two cases of GVHD reported in recipients of organs from donors homozygous for a shared HLA haplotype would support a policy of avoiding the use of these donors. TA-GVHD is very rare in solid organ transplant recipients, with only four published cases; only two had convincing supportive evidence and one of these had an underlying hematologic abnormality. These few cases do not support a policy of routine irradiation of cellular blood components for all solid organ transplant recipients. The use of donor HPC infusions to enhance chimerism and graft tolerance has increased the number of GVHD cases observed (usually mild) and decreased the severity and number of rejection episodes. The long-term effects of donor HPC infusions on graft survival is under investigation.

WBC subset analysis of WBC-reduced platelet components

BACKGROUND

WBC-reduced platelet components may be prepared by filtration or apheresis processing. Both methods have previously been shown to result in a residual total WBC content <5 x 10(6) per component. However, there may be differences in the efficacy of these techniques for removing certain WBC subsets.

STUDY DESIGN AND METHODS

Two multiparameter flow cytometric assays were developed and validated to perform WBC analysis on WBC-reduced platelets collected with two apheresis instruments (Amicus and COBE Spectra) and on 6 units of filtered pooled random-donor platelet concentrates.

RESULTS

All components contained <1 x 10(5) WBCs. The COBE Spectra and Amicus apheresis platelet components contained more WBCs than did filtered pooled platelets (p<0.05). Lymphocytes (T and B), monocytes, and granulocytes were identified in all components. Granulocyte content was lowest in the Amicus components and filtered pools. Monocytes were lowest in filtered pools. Amicus platelet components had fewer granulocytes and monocytes than the COBE Spectra platelets. Amicus and COBE Spectra components contained more lymphocytes than the filtered pools.

CONCLUSION

Multiparameter flow cytometry can be used to quantify and characterize WBCs in WBC-reduced platelet components. WBC reduction by filtration or apheresis was highly effective. WBCs from each subset were identified in all components. Although filtered pools had the lowest numbers of WBCs, the very low numbers observed in all components suggests that the absolute quantitative differences in WBC subset content are of questionable clinical significance.

The utility of < or =3-day-old whole-blood platelets in reducing the incidence of febrile nonhemolytic transfusion reactions

BACKGROUND

Febrile nonhemolytic transfusion reactions (FNHTRs) to platelet transfusions have been linked to the presence of cytokines in supernatant plasma. Cytokine concentration is directly related to WBC content and storage time. This study evaluated the effect of limiting the storage time of random-donor platelet concentrates on the FNHTR rate.

STUDY DESIGN AND METHODS

FNHTR rates were calculated retrospectively for single-donor apheresis platelet (SDP) and pooled random-donor platelet (PP) transfusions given during three consecutive 5-month study periods (November 1995 to February 1997) to patients on a single hematology/oncology/bone marrow transplant unit. Transfusion practice policies were: Baseline Period, SDPs preferred; Study Period A, PPs preferred; and Study Period B, < or =3-day-old PPs preferred. FNHTR rates were calculated from physicians' interpretations of reported reactions and the total number of SDP and PP transfusions in each period. SDPs were collected on two cell separators. All platelet components were filtered at issue in the laboratory by WBC-reduction filters.

RESULTS

FNHTR rates for PP transfusions were: baseline, 11.1 percent (3/27); Study Period A, 4.6 percent (22/481); and Study Period B, 1.1 percent (3/282). The rates for SDP transfusions were 0. 15 percent (1/650), 0.75 percent (2/267), and 0.36 percent (1/273), respectively. The FNHTR rate for < or =3-day-old PPs was significantly less than the rate for older PPs (p = 0.0086 for Study Period A vs. Study Period B), and was not significantly different than that for SDPs (p = 0.33 for PPs vs. SDPs in Study Period B).

CONCLUSION

Limiting transfusion of PPs to those stored </=3 days is an effective strategy in reducing the rate of FNHTR and results in an FNHTR rate comparable to that seen with SDPs.

The cost-effectiveness of reducing donor exposures with single-donor versus pooled random-donor platelets

BACKGROUND

Single-donor platelets (SDPs) are frequently preferred over pooled random-donor platelets (RDPs) to reduce donor exposures and the risk for virus transmission or HLA alloimmunization. Transfusion-associated virus-transmission risks have significantly decreased, which suggests that white cell reduction by filtration eliminates any difference in the risk of alloimmunization in transfused leukemic patients. Health care reform pressures of make it appropriate to examine the cost-effectiveness of SDPs versus RDPs in reducing donor exposures.

STUDY DESIGN AND METHODS

A decision analysis model was developed and sensitivity analyses were used to assess the incremental cost (dollars/quality-adjusted life-year) associated with the use of SDPs versus RDPs for adult patients undergoing hematopoietic progenitor cell transplantation or primary coronary artery bypass grafting (CABG).

RESULTS

Among transplant patients, the incremental cost of choosing SDPs as opposed to RDPs ranged from $168,700 to $519,822 per quality-adjusted life-year. For patients undergoing primary CABG, the incremental cost was $192,415 (females) and $216,280 (males). Variations in the cost differential between SDPs and RDPs, the number of random-donor platelets in the RDP, and the risk of bacterial sepsis markedly influenced cost-effectiveness. The model was minimally affected by variations in the risks of transmission of HIV and hepatitis B and C, and human T-lymphotropic viruses.

CONCLUSION

In comparison with other accepted medical interventions, the use of SDPs as opposed to RDPs may not be a cost-effective method of reducing donor exposures in the adult patient populations studied. SDPs were more cost-effective in patients undergoing primary CABG than in leukemia patients undergoing hematopoietic progenitor cell transplantation. Regardless of diagnosis, decreasing the acquisition cost differential would have the greatest impact on improving the cost-effectiveness of SDPs, as opposed to RDPs, to decrease donor exposures.

Blood usage in lung transplantation

BACKGROUND

Few published data are available regarding perioperative blood usage in lung transplantation.

STUDY DESIGN AND METHODS

The medical records of all patients undergoing lung transplantation at a university medical center in 1994 and 1995 were reviewed.

RESULTS

Ninety patients underwent lung transplantation during this period. Six patients were excluded: two received a living related-donor lung, three underwent retransplantation and one underwent concomitant repair of a tetralogy of Fallot. Of the 84 evaluable patients, 59 underwent single lung transplantation and 25 double lung transplantation. Double-lung recipients used more red cells (6.4 vs. 1.7 units, p = 0.0002) and were more likely to receive red cells, platelets, plasma, or any component (92 vs. 32%, p< or =0.0001) than were single-lung recipients. Double-lung recipients were more likely to require cardiopulmonary bypass (40 vs. 12%, p = 0.003), and cardiopulmonary bypass was associated with greater transfusion requirements (p< or =0.0001). However, among patients requiring cardiopulmonary bypass, blood use did not differ between those undergoing double lung transplantation and those undergoing single lung transplantation. In the subset of patients not requiring cardiopulmonary bypass, double-lung recipients received more red cells (4.5 vs. 0.7 units, p< or =0.0001) and more plasma (2.0 vs. 0.2 units, p = 0.006).

CONCLUSION

Double-lung recipients require more perioperative transfusions than single-lung recipients. The greater transfusion requirement is due to the more frequent need for cardiopulmonary bypass as well as the greater complexity of the procedure. These data are useful for developing surgical blood ordering guidelines for lung transplantation.

Advantages of outsourcing the transfusion service

Pressures to reduce costs are forcing hospitals to examine alternative delivery systems for transfusion services. An outsourcing arrangement for the transfusion service can be an attractive option, providing benefits not only in terms of economics, but also in terms of quality and medical support. Successful centralized testing models in Pittsburgh and Seattle have demonstrated the feasibility of this approach. When properly implemented, an outsourcing arrangement for transfusion services can improve patient care and reduce costs.

Transfusion-related acute lung injury following random donor platelet transfusion: a report of two cases

OBJECTIVES

Transfusion-related acute lung injury (TRALI) following random donor platelet (RDP) transfusion is a rare complication of transfusion without any well-documented case reported in the English language literature. We describe 2 patients in whom TRALI occurred following RDP transfusion.

METHODS

Conventional clinical and laboratory methods.

RESULTS

Both patients developed acute shortness of breath 30-60 min after completion of RDP transfusion and required mechanical ventilatory support. Chest X-ray (CXR) in both cases revealed bilateral pulmonary infiltrates. Patient 1 required vasopressors for hypotension. Right heart catheterization ruled out fluid overload. Patient 2 remained hemodynamically stable. Both patients improved rapidly with continued respiratory support and were extubated within 48 h. CXR at this time showed clearing of infiltrates. In both cases a granulocyte antibody was identified in the plasma of a platelet donor supporting the diagnosis of TRALI.

CONCLUSIONS

In suspected cases of TRALI. HLA and granulocyte antibody testing is indicated for the recipients and for donors of implicated components. Implicated donors need not be excluded from the donor pool, but can be used for fractionated plasma and plasma-free components.

The reemergence of the hospital-based laboratory

The Reference Laboratory Alliance (RLA) in Pittsburgh is an example of multiple hospital laboratories integrated for the purpose of delivering competitive outpatient laboratory services in a managed-care environment. Developed in 1994, the RLA model includes a "virtual" core laboratory (comprising four tertiary care centers of excellence) and a distributed network of more than 30 community hospitals. Linked through information systems, logistics, and an extensive committee structure, the RLA is capable of delivering a "seamless" service to the region's managed-care organizations. In its first full year of operation, the RLA is expected to shift between $12 and $15 million worth of laboratory activity back into the community's hospitals. Through its pathology component, the RLA is now actively engaged in redefining the role of the clinical laboratory in the managed-care environment.

Transfusion and cytomegalovirus-associated AIDS-defining disease in hemophiliacs. Hemophilia Malignancy Study

BACKGROUND

Whether transfusion increases the risk of AIDS-defining cytomegalovirus (CMV) infection (CMV AIDS) in immunosuppressed patients is not known. Because of concerns about the risk of transfusion transmission of CMV and potential exposure to multiple strains of CMV through transfusion, the National Hemophilia Foundation recently recommended that CMV-negative blood be used in human immunodeficiency virus-positive hemophiliacs, regardless of their CMV serologic status. Although the multiple strains of CMV cause different CMV disease manifestations in transplant recipients, there are no data on CMV disease in human immunodeficiency virus-positive hemophiliacs.

STUDY DESIGN AND METHODS

It was hypothesized that if the transmission of CMV through transfusion causes CMV disease in human immunodeficiency virus-positive hemophiliacs, then hemophiliacs with CMV AIDS would be more likely to have received transfusions than those with AIDS-defining disease not caused by CMV (non-CMV AIDS). The number and type of transfusions were evaluated in 334 hemophiliacs with AIDS (35 with CMV AIDS and 299 with non-CMV AIDS) enrolled in the multicenter Hemophilia Malignancy Study.

RESULTS

There were no differences between hemophiliacs with CMV AIDS and those with non-CMV AIDS in age, type, and severity of hemophilia; the proportion receiving transfusions; or the mean number of units transfused. These findings persisted after correction for transfusion practice, (i.e., CMV-unscreened blood vs. CMV-negative and/or white cell-reduced blood). There was no difference between the groups in CMV lgG titers or in the proportion who were CMV seropositive, and there was no difference between these parameters in those who had received transfusion(s) and those who had not.

CONCLUSION

Transfusion appears to have little, if any, effect on the development of CMV AIDS or CMV lgG seroprevalence in patients with hemophilia.

Red cell compatibility testing in baboon xenotransplantation

BACKGROUND

Although baboon ABO group and human anti-baboon heteroagglutinin (HA) titers have been considered in the selection of baboon donors for clinical hepatic xenotransplantation, the biologic role of these antibodies is not yet known. However, because of the potential importance of ABO hemagglutinins, a method for baboon ABO group determination is described, as are the titers of HA observed in both baboons and normal human donors.

STUDY DESIGN AND METHODS

The ABO group of 62 baboons was determined by modified reverse typing. Baboon sera were heated and absorbed with human group O red cells. Reverse typing was then performed by standard techniques. HA titers at room temperature (RT) and in the antiglobulin test (AGT) were assessed in 10 baboons by using human red cells and in 33 normal donors by using baboon red cells.

RESULTS

Ten (16%) baboons were group A, 29 (47%) were group B, 23 (37%) were group AB, and none were group O. In tests using human group O red cells, HA titers in 10 baboons ranged from 1 to 32 at RT and from negative to 64 in the AGT. All 33 normal human sera contained anti-baboon HA. Under a hemagglutination scoring system, group A persons had the lowest HA scores (17 +/- 15 at RT, 31 +/- 19 in the AGT), and group B persons had the highest HA scores (67 +/- 4 at RT, 85 +/- 9 in the AGT).

CONCLUSION

Baboon ABO group can be easily determined by modified reverse serum typing. Both baboons and humans possess HAs of variable titer. Among humans, titers appear to be highest in group B individuals and lowest in group A. Additional studies are needed to determine the clinical significance of these antibodies.

Efficacy of autologous fresh whole blood or platelet-rich plasma in adult cardiac surgery

BACKGROUND

Transfusing fresh autologous blood during cardiac surgery may improve hemostasis and decrease the need for transfusion.

STUDY DESIGN AND METHODS

A prospective randomized study was performed with fresh whole blood (WB) obtained by intraoperative hemodilution (IH) and with platelet-rich plasma (PRP) obtained by perioperative apheresis from adult cardiac surgery patients.

RESULTS

Seventy patients were randomly assigned to three arms: 24 to the PRP arm, 18 to the IH arm, and 28 to serve as controls. A mean of 924 +/- 130 mL of WB was collected from the IH group, and a mean of 650 +/- 124 mL of PRP was collected from the PRP group (mean, 1.42 +/- 0.74 x 10(11) platelets); these components were transfused after bypass. Preoperative measures were similar among groups. Intraoperatively, the groups did not differ in bypass time, estimated blood loss, number of transfusions, or proportion receiving transfusion(s). Postoperatively, control patients had more mediastinal drainage (736 mL vs. 476 mL [IH] and 463 mL [PRP]; p = 0.014), but there was no difference in the proportion of patients requiring red cell transfusion (p = 0.87), the hemoglobin at discharge (p = 0.20), or the length of hospitalization (p = 0.57).

CONCLUSION

Although a hemostatic benefit manifested as reduced postoperative bleeding was observed, this study does not support the use of fresh blood components obtained by IH or PRP collection during low-risk cardiac surgery. Additional studies are needed to assess whether more aggressive component collection or the use of these techniques in high-risk cases may have a greater impact on clinical outcome variables, including transfusion.

Heteroagglutinins and their significance in baboon hepatic xenotransplantation

The role of preformed xenoreactive antibodies in xenograft recipients is unknown. Humans and baboons possess red cell agglutinating activity associated with isohemagglutinins and heteroagglutinins (HA). We examined the role of HA in two patients who received ABO-identical baboon livers. Human antibaboon HA were assessed by correlating serial titers with studies for rejection. Serial direct antiglobulin testing (DAT) was used to detect baboon antihuman HA, potentially produced by transplanted passenger lymphocytes. Patient 1 survived 70 days. The human antibaboon HA titers remained essentially unchanged from preoperative values. Although hyperacute rejection did not occur, and there was only mild cellular rejection, liver function was suboptimal. Postreperfusion immunoglobulin and complement deposition and histologic changes suggested complement-mediated injury. DAT testing was negative except for passively acquired anti-A from transfusion. At autopsy there was marked bile stasis, but no rejection. Patient 2 survived 26 days with essentially unchanged HA titers until preterminal. Although there was no hyperacute rejection and only mild humoral rejection (without cellular rejection), suboptimal liver function and bile stasis were again noted. Postreperfusion immunoglobulin and complement deposition again suggested complement-mediated injury. DAT testing was negative. At autopsy there was no rejection. Human antibaboon HA do not appear to be associated with hyperacute or cellular rejection, but their role in the complement-mediated injury, suspected in both cases, cannot be definitively excluded. Baboon antihuman HA were not detected in either patient.

Centralized transfusion service: a novel approach to the delivery of transfusion services

The development and expansion of the CTS in Pittsburgh shows the feasibility of this transfusion medicine delivery system. Few of the changes driven by health care reform both improve patient care and reduce costs. When properly implemented, a CTS achieves these objectives, benefits the community as a whole, and enhances the role of transfusion medicine specialists and the blood center in the region.

Intraoperative hemodilution and autologous platelet rich plasma collection: two techniques for collecting fresh autologous blood

Intraoperative hemodilution (IH) and autologous platelet rich plasma (APRP) collection are two techniques used to obtain autologous blood in the operating room. They have been used to reduce allogeneic blood exposure in patients undergoing both cardiac and non-cardiac surgery. Both components have the advantage of providing fresh blood not subject to the storage lesion. Whole blood (IH) or platelet rich plasma is removed from the patient as anesthesia is induced and replaced with acellular fluid. The blood is transfused back after bypass or major bleeding has ceased. Although used commonly, the data supporting the use of either technique are controversial. Methodologic problems which have confounded studies evaluating their utility include: poorly defined transfusion criteria, concommitant use of other blood conservation techniques (i.e. cell salvage, pharmacologic agents, hypothermia, controlled hypotension) and changing transfusion practices with greater tolerance of normovolemic anemia. Randomized controlled studies with well defined up to date transfusion criteria are needed to identify patients likely to benefit from these techniques.

Immunohematologic complications of ABO-unmatched liver transplants

Transplantation of ABO-unmatched livers has been associated with the development of donor-derived antibody (DDAb) and hemolysis. Nine (22%) of 41 consecutive patients undergoing liver transplantation at our institution received 10 ABO-unmatched livers. Five (56%) of nine patients developed DDAbs and hemolysis. All five patients were group A1 and received group O livers. DDAbs appeared a mean of 9.2 +/- 2.8 (1 SD) days after surgery and persisted for 15.2 +/- 10.3 days. All patients with DDAbs developed hemolysis. During the period when DDAbs were demonstrable, the hemoglobin dropped by a mean of 4.8 g per dL (48 g/L), and the patients were transfused with a mean of 7.8 +/- 2.3 units of group O red cells. One patient with hemolysis underwent exchange transfusion for acute renal failure. Patients with hemolysis required significantly more red cells postoperatively (15.0 vs. 6.9 units, p = 0.04) than did ABO-matched patients. None of the parameters examined (age, recipient or donor gender, secretor status, rejection, or donor isoagglutinin titers) were predictive of DDAb or hemolysis, although hemolysis occurred in three of four cases in which donor serum IgG anti-A titers were > or = 128, as opposed to one of four cases in which titers were < 128. Because recipients of ABO-unmatched livers are at high risk for transiently developing DDAb and hemolysis with associated morbidity, the prophylactic use of donor-type red cells for surgery and after operation is justified.

Detection and significance of alpha granule membrane protein 140 expression on platelets collected by apheresis

Activation of platelets may be measured by using the monoclonal antibody S12 to detect alpha granule membrane protein 140 (GMP-140) antigen expressed only on activated platelets. S12 was used to measure activation of apheresis platelet concentrates by flow cytometry. Eleven platelet concentrates obtained by one method and nine obtained by another were analyzed 4 hours after collection. Means +/- 1SD of 25.3 +/- 14.8 percent and 28.9 +/- 11.6 percent, respectively, of platelets were found to be activated (range, 4.8-53.1%). Six of the platelet concentrates obtained by the second method were filtered. There was a drop of 17.8 percent (range, 10-25%) in the mean total number of platelets recovered after filtration, but there was no difference in the proportion of activated platelets measured immediately before and after filtration. The 1-hour posttransfusion platelet count increment was obtained after 12 of these apheresis platelet concentrates were transfused to eight patients who were not refractory from either a clinical or alloimmune standpoint. There was a significant inverse correlation between the platelet count increment and the proportion of activated platelets in the component (p less than 0.05, r = -.58). These data suggest that apheresis platelet concentrates with more activated platelets have a reduced 1-hour recovery. Filtration did not enhance activation or selectively remove activated platelets. Expression of GMP-140 may serve as a useful quality control measurement.

A clinical and immunologic study of blood transfusion and postoperative bacterial infection in spinal surgery

Allogeneic blood transfusion has been implicated as an independent risk factor for postoperative bacterial infection in clinical and animal studies. The association among transfusion, quantitative immunologic factors, and infection was examined in 102 patients undergoing 109 spinal fusion procedures. In 60 procedures, patients received autologous blood only; in 24 procedures, they received at least 1 unit of allogeneic blood, and in 25 procedures, they received no transfusions. Twenty-two patients developed bacterial infections, in 8 cases while in hospital and in 14 cases after discharge. Univariate analysis revealed that patients who received any allogeneic blood and those who received no allogeneic blood differed significantly in the rate of hospital-acquired infection (20.8 vs. 3.5%), length of stay (12.3 vs. 9.7 days), days of fever greater than or equal to 38 degrees C (4.0 vs. 2.9), days on antibiotics (3.9 vs. 2.5), duration of surgery (309 vs. 231 min), blood loss (1343 vs. 887 mL), surgeon, and postoperative drop in natural killer (NK) cells (-174 vs. -42/microL). Multivariate logistic and linear regressions revealed that the number of allogeneic units transfused was the only significant predictor of in-hospital infection (p = 0.016) or days on antibiotics and length of stay. None of the clinical, surgical, or transfusion variables was significantly associated with posthospital infection, although a significantly greater drop in NK cells had occurred in patients who developed infection (p = 0.0035). These data strongly implicate allogeneic transfusion as a risk factor for in-hospital postoperative bacterial infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Transfusion-induced immunomodulation and its clinical consequences

The bulk of experimental and clinical data support the theory that homologous transfusion causes significant down-regulation of immunologic functions in a number of settings. These changes in immune function may account for the beneficial associations of transfusion with increased renal allograft survival, and decreased recurrence in Crohn's disease. Conversely, these transfusion-induced effects may be responsible in part for the deleterious association of homologous transfusion with increased cancer recurrence, and increased posttransfusion bacterial and viral infection rates. Host defenses against malignancy and infection may in some instances be severely compromised by transfusions of homologous blood, but the circumstances under which this occurs need to be better defined. Likewise, the hypothesis that modification of blood components to contain fewer leukocytes or less plasma might ameliorate these effects is attractive, but little or no data exist to support or refute it. Future clinical studies will no doubt address these issues.

Variability in response to cryoprecipitate treatment for hemostatic defects in uremia

Cryoprecipitate is frequently administered as treatment for hemostatic defects in patients with uremia. The only published data supporting this approach however, involves seven patients described by Janson and colleagues in whom bleeding times were shortened and bleeding complications reduced after cryoprecipitate infusion. We retrospectively reviewed our institution's experience with cryoprecipitate in this setting. Five patients had sufficiently complete data for evaluation of the efficacy of therapy with cryoprecipitate, including pretreatment bleeding time greater than 15 minutes, normal coagulation studies, and platelet count greater than 100,000/microliters. Two patients had normalization of their bleeding time and a favorable clinical outcome after cryoprecipitate infusion. Three patients failed to shorten their bleeding time after cryoprecipitate infusion or, in one case, multiple infusions. One of these latter patients had correction of his abnormal bleeding time after subsequent administration of deamino-8-D-arginine vasopressin (DDAVP). We conclude that the hemostatic response to cryoprecipitate therapy is variable, and that cryoprecipitate therapy does not achieve restoration of normal hemostasis in some patients with uremic bleeding.

Association of transfusion with postoperative bacterial infection

Homologous blood transfusion has been implicated as a modulator of the host immune system in a number of clinical settings. Improved renal allograft survival is observed in patients receiving pretransplant transfusions. Decreased recurrence of active inflammatory bowel disease has been recently reported in transfused patients with Crohn's disease. Conversely, deleterious immunomodulatory effects of transfusion may explain the association between transfusion and increased susceptibility to cancer recurrence and bacterial and viral infection. Clinical studies regarding cancer recurrence and transfusion are retrospective and conflicting. There is epidemiologic evidence for more rapid progression of HIV-1 infection in heavily transfused patients. Studies on transfused surgical patients have shown transfusion to be associated with an increased frequency of postoperative bacterial infections. Some studies have come to different conclusions. These investigators have suggested that transfusion may represent a surrogate marker for other risk factors for infection. Animal models designed to control for confounding factors have supported an association between transfusion and bacterial infection severity in most, but not all, reports. Attempts to define the immunologic alterations associated with transfusion have revealed a generalized impairment of cellular immunity in both humans and animals. Although the preponderance of data supports an association between perioperative transfusion and increased susceptibility to postoperative bacterial infection, it is not certain to what extent this relationship constitutes cause and effect.