I-JAMM-(I): A survey providing an insight into the practices of isoagglutinin titration in ABO incompatible kidney and liver transplantation

BACKGROUND AND OBJECTIVES

ABO-incompatible transplantations allow patients to receive timely transplants. Isoagglutinin titration to ascertain levels of incompatible antibodies in the recipient is important in determining patient selection and transplant survivability. To find out the prevalent trends in India, the largest, first of its kind survey was carried out among the transplant centers regarding their practices in isoagglutinin titration.

METHODS

The survey was drafted by a working group of Transfusion and Transplant Immunology specialists from six different centers. Data was obtained via the use of an online questionnaire.

RESULTS

Results were categorized into four categories, Hospital information, Titration methodology, Role of transfusion specialists and cut-off titers. Most centers had a well-established solid-organ transplant program with considerable number of ABO-incompatible transplantations. Most centers performed isoagglutinin titration in Transfusion Medicine department. Column Agglutination Technique (CAT) was the most common method, using EDTA blood samples and freshly-prepared in-house pooled cells. Most centers had a turn-around time of less than 12 h. While the policy for ascertaining baseline and threshold titers is well-defined in ABO-incompatible renal transplants, variations from center to center still exist for ABO-incompatible liver transplants. Most centers required a Transfusion Medicine consultation for the patients before such transplants.

CONCLUSION

With increasing ABO-incompatible kidney and liver transplants across the country, the role of Transfusion medicine specialists has become vital in pre-conditioning regimes enabling the viability and success of such transplants. This was a unique survey that provided a snapshot of current trends and practices of isoagglutinin titration for ABO-incompatible transplants in India.

Role of therapeutic plasma exchange as a desensitization therapy in human leukocyte antigen incompatible renal transplant patients: A single-center experience

OBJECTIVE

Despite an increase in the rate of successful live donor renal transplantation done annually, the number of potential recipients with acceptable donors is relegated to the ever-expanding cadaver-donor waiting list due to sensitization to human leukocyte antigen (HLA) antibodies. If not sufficiently suppressed, these preformed HLA antibodies can trigger antimicrobial resistance (AMR) and early graft loss. To ameliorate this situation, various desensitization treatments are administered to provide a survival benefit to highly sensitized patients.

METHOD

One hundred and six patients in the time frame of January 2017 to March 2019 were included in the study group. The desensitization protocol included therapeutic plasma exchange and administration of low-dose intravenous immunoglobulin (100 mg/kg per therapeutic plasma exchange (TPE) session) to highly sensitized patients (treatment group) who subsequently underwent renal transplantation after negative pre-transplant Centers for Disease Control and Prevention Luminex crossmatch (CDC/LumXM). We compared graft survival rates between the group undergoing desensitization (treatment group) and matched control group of patients that underwent HLA-compatible transplantation.

RESULTS

In the treatment group, Kaplan-Meier analysis estimates an average rate of patient graft survival of 95.2% at 3 years post-transplant, as compared with the rate of 86.9% in the same time frame for the control-matched group (p < 0.05 for both comparisons).

CONCLUSION

Desensitization treatment with TPE before live donor renal transplantation in the case of patients with HLA sensitization provides better survival benefits along with monitoring for donor-specific antibodies (DSAs) and other infections, rather than waiting for a compatible organ donor. The data lays out evidence that desensitization treatments can assist overcome HLA incompatibility barriers in live donor renal transplantation.

Efficacy of therapeutic plasma exchange in pediatric cases of acute liver failure as an extracorporeal liver support system

BACKGROUND

Acute liver failure in the pediatric population is often accompanied by deranged metabolism, severe encephalopathy and coagulopathy. A liver transplant is the most viable option for the management of such patients. Therapeutic plasma exchange (TPE) is helpful in improving the liver biochemistry profile, thereby, increasing their likelihood of undergoing a liver transplant METHOD: The study was conducted over a period of 3 years (January 2018 to December 2021). Indications mainly consisted of ALF with hepatic encephalopathy, worsening liver parameters in spite of medical management, and candidacy for undergoing a liver transplant. Plasma exchange was performed daily or alternatively until the patient recovered, succumbed, or was stable enough to undergo a transplant. Biochemical parameters serum bilirubin, ALT, AST serum ammonia serum urea, serum creatinine were recorded before and after TPE sessions.

RESULTS

The study group comprised 14 patients of which a total of 28 TPE was performed. There were a total of 5 cases of cryptogenic ALF, 4 of Wilson disease, 2 cases each of infection-related ALF and autoimmune hepatitis, and a single case of drug-induced hepatitis. A total of 5 out of 14 patients underwent a liver transplant and amongst the 9 who did not undergo a transplant, 4 patients expired due to septic shock syndrome; the remaining 5 were discharged in a stable condition following TPE sessions. The disease-free survival was 78.9% and the transplant-free survival was 35.71%.

CONCLUSION

TPE plays a crucial role in improving the biochemistry profile of the liver in children with liver failure.

Autoantibodies mimicking alloantibodies: A case series unveiling the dilemmas of transfusion

INTRODUCTION

Autoimmune hemolytic anemia is characterized by increased red cell destruction and/or decreased red cell survival due to autoantibodies directed against self-antigens on red cells. Since autoantibodies react with self and nonself red blood cells (RBCs), they tend to mask the underlying clinically significant alloantibodies and many a times mimic a specific pattern like alloantibodies.

MATERIALS AND METHODS

We discuss three immune hematological cases of warm autoantibodies. Antibody screening was performed by solid-phase red cell adherence (SPRCA) technique on a fully automated platform NEO Iris (Immucor Inc., USA). In case of a positive antibody screen, antibody identification was performed using SPRCA, NEO Iris (Immucor Inc., USA). Alloadsorption for adsorbing the autoantibodies was done using in-house prepared allogenic packed RBCs - R1R1, R2R2, and rr.

RESULTS

All cases had warm autoantibody with a broad specificity against self-Rh antigens. Anti "C" and Anti "e" antibodies were identified in case 1 and autoanti "e" antibody in cases 2 and 3. Case 3 had underlying alloanti "E" along with autoanti "e" which posed a transfusion challenge.

CONCLUSION

Our case series highlights the importance of detecting the nature of the antibody whether it is alloantibody or autoantibody with antigen specificity. This would help in selecting appropriate antigen negative blood units for transfusion purpose.

CONVALESCENT PLASMA- AN INSIGHT INTO A NOVEL TREATMENT OF COVID-19 ICU PATIENTS

Various therapies have been tried for Covid disease including the use of antivirals, steroids, monoclonal antibodies and convalescent plasma. Method: The study was conducted on convalescent plasma transfused ICU patients. Part A of the study involves clinical outcomes based on gender, age, comorbidities, blood group,and the average length of stay. Part B investigates clinical outcomes in patients transfused with convalescent plasma before and after the November 2021 guidelines. Part C of the study includes patients in cytokine storm and the efficacy of tocilizumab in these patients.Result: Out of the 326 ICU patients transfused with convalescent plasma the overall mortality was 152 (53.3 %). On comparing blood groups and clinical outcomes, a clinically significant result was found. A clinically significant association was also seen on comparing the clinical outcome of 18–50 years and 61–70 years age group and in female gender patients. The average number of ICU days had a positive impact on the overall patient survival. Out of the patients in ‘cytokine storm’ (n = 109), on day 20, the survival percentage in the non-Tocilizumab group showed a downward trend throughout. However, in the Tocilizumab group, the survival percentage remained stable throughout till around day 50. Conclusion: Amongst the convalescent plasma transfused ICU patients, females, having blood group B, and an average length of stay of fewer than 20 days had a better chance of survival. The patients given tocilizumab and convalescent plasma had a better chance of survival compared to tocilizumab alone.

ABO-incompatible granulocyte transfusion: Is ABO subgroup a barrier?

Granulocyte transfusion (GTx) is an efficient and compelling treatment option for patients with neutropenia following hematopoietic stem cell transplant. The donor pool for granulocyte harvest is limited to close friends and family members and the donors accepted are often of the same ABO Rh type. We report a case of ABO-incompatible prophylactic GTx, in a case of acute myeloblastic leukemia. Postcollection processing of the granulocyte product was done to reduce the red blood cell volume to <5 ml, making it safe for transfusion. The transfusion was successful in stabilizing the total leukocyte counts in the patient. The patient was monitored, and there were no adverse reactions posttransfusion.

Platelet additive solution suspended apheresis platelets in a tertiary care hospital: A step toward universal single donor platelets

BACKGROUND

Transfusion of ABO-compatible single donor platelets (SDP) is preferable for better outcomes over group switchover SDP. The use of SDP containing ABO-incompatible plasma is associated with a risk of allergic and acute hemolytic transfusion reactions. Moreover, high titer O group donors SDP impose a further threat to patient safety. Platelet additive solution (PAS) is used worldwide for the storage of platelets which reduces plasma volume available in SDP. SSP + (Macopharma) is one such PAS which can provide improved availability, logistical management, decrease wastage, and improvement in patient safety. The aim of this study was to assess the feasibility of using PAS to obtain low titer SDP units which can be utilized across a larger patient population and to study quality control parameters of these units.

MATERIALS AND METHODS

The study was performed in the department of Transfusion Medicine from June 2017 to January 2018 after clearance from the Institutional Review Board. The study design comprised two cohorts (A and B). In cohort A, the temporal trend of in-vitro changes in the quality parameters was tested and analyzed for PAS modified and unmodified products on days 1, 5 and 7. In cohort B, the original plasma from the SDP donors of all blood group donors except the AB group was tested for antibody titers before (prepreparation) and after modification (postpreparation) by PAS.

RESULTS

In cohort A, in the control group, there was a significant change in the mean platelet volume, potassium, and bicarbonate levels from day 1 to day 7, whereas no significant change in the biochemical parameters was noted in the study group where PAS was used. In cohort B, on comparing the anti-A and anti-B, before and after modification of SDP with PAS, there was a significant reduction in the median titers across all the groups studied.

CONCLUSION

PAS added SDP is an efficient strategy to reduce the ABO-antibody levels significantly. PAS added SDP also helps in the better inventory management of available groups.

Assessing safety and efficacy of therapeutic plasma exchange in pediatric patients: A single-center experience

INTRODUCTION:

Therapeutic plasma exchange has been widely employed by clinicians for removal of the toxic constituents from plasma by filtration of whole blood and subsequent removal of plasma and reinfusion of cellular components along with a replacement fluid. It has become an accepted therapeutic modality in paediatric patients for numerous indications including but not limited to renal transplant, haemolytic uremic syndrome and Guillain Barre Syndrome. But, data on safety and efficacy are mainly derived from studies in the adult population with very limited data available in the paediatric age group. However, it is technically challenging in children due to their small circulating volume. This study discusses the clinical indications, efficacy, and safety of therapeutic plasma exchange in paediatric population.

METHOD:

We retrospectively reviewed the data of children (up to 18 years of age) who underwent TPE between January 2017 and March 2019 at our Hospital. Main features of the TPE procedures i.e. frequency of TPE, site of vascular access, type of replacement fluid used, instrument used, plasma volume processed, priming of the circuit, adverse events if any and outcome of the patients were analysed.

RESULTS AND CONCLUSION:

A total of 114 procedures were performed on these 24 patients. Fifteen patients with Category I indication showed good clinical outcome in terms of attainment of target ABO titre and/or decrease in the donor specific antibody. TPE is an effective therapeutic option in selected paediatric disorders. Our series of data on TPE procedures from paediatric perspective has shown safety and efficacy of the therapy.

Therapeutic plasma exchange in HELLP syndrome: A life savior

BACKGROUND:

HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome occurs in about 0.5%–0.9% of all pregnancies, but its prevalence is higher in patients with severe preeclampsia, accounting for a substantial maternal and perinatal morbidity and mortality. According to the latest American Society for Apheresis guidelines, Therapeutic plasma exchange (TPE) performed for postpartum cases and antepartum HELLP syndrome cases fall in Categories III and IV, respectively.

MATERIALS AND METHODS:

Retrospective analysis was done at our tertiary care center from January 2014 to June 2019 for patients diagnosed with HELLP syndrome. Clinical data for age, gestational age at the time of diagnosis, type of delivery, outcome of pregnancy, history of preeclampsia /eclampsia, hemoglobin levels, AST, ALT, LDH, platelet counts, prothrombin time, activated partial thromboplastin time, international normalised ratio, complete blood count, was obtained from patients' electronic medical records. The TPE was initiated within 24 hrs of diagnosis. All TPE was done on Spectra Optia apheresis system (Terumo BCT, Inc, USA). Statistical testing was conducted with the statistical package for the social science system version SPSS 20.0 and R-3.2.0. Continuous variables were expressed as mean±SD and were compared between Pre and Post TPE records of patients by using the paired T test.

RESULTS:

Nine patients fulfilled the criteria of HELLP syndrome. Seven (77.8%) were diagnosed in the postpartum period and 2 (22.2%) during the second trimester. Out of the total nine patients, two patients (22.2%) recovered completely and were discharged on day 15 ± 7 days, whereas 4 (44.4%) patients were discharged on day 21 ± 7 days with the advice of hemodialysis. Two (22.2%) patients had an intrauterine death and were discharged 3–4 days after the demise. In all these patients (except one), the TPE was initiated within 24 h of the diagnosis. A significant increase in platelet count and decrease in the lactate dehydrogenase levels (P < 0.05) was observed post TPE.

CONCLUSION:

Our data showed that TPE improved the treatment outcome in patients with HELLP syndrome despite being a Category III and IV indication among postpartum and antenatal females, respectively. However, a timely diagnosis and management are of paramount importance for a favorable outcome. TPE needs to be performed within 24 h of the diagnosis postdelivery when the patient is not responsive to the usual therapies, especially in class I HELLP syndrome.

Changes in hematological parameters post plateletpheresis: Single center study from North India

INTRODUCTION

Increasing demand for platelet transfusion implies the need to recruit greater numbers of donors. We planned this study to evaluate donor safety issues with regards to changes in hematological values after plateletpheresis to improve donor safety and satisfaction.

MATERIALS & METHODS

The study was conducted on 1000 healthy plateletpheresis donors over a period of 24 months. Pre- and post-apheresis hematological parameters of donors were analyzed. Recovery of platelet was also observed in plateletpheresis donor who returned to after 48 h.

RESULT

We observed that the Platelet counts decreased significantly in the plateletpheresis donors (p=<0.001) after each procedure and there was a non-significant decline in Hb (p = 0.34), Hct (p = 0.44) and RBCs (p = 0.08). The hematological changes were within the normal limits with no clinical evidence of anemia or thrombocytopenia. Recovery of platelets in plateletpheresis donors after 48 h was observed in 30 donors (0.03 %).

CONCLUSION

A significant immediate post procedure decrease in platelet count was observed in our study but the recovery of platelets was adequate suggesting next platelet collection from the donor can be safely done after a period of 48 h.

A case of Bickerstaff encephalitis with overlapping Gullian Barre syndrome in a pediatric patient treated with therapeutic plasma exchange

Bickerstaff brain stem encephalitis (BBE) is a rare brainstem disorder characterized by acute onset of ophthalmoplegia, ataxia, and altered consciousness. Guillain Barre syndrome (GBS), Miller Fischer syndrome and BBE share certain similarities such as the presence of anti-ganglioside antibodies. The use of Therapeutic Plasma Exchange (TPE) has been reserved for severe to fulminant cases of BBE mostly as an 'off label' use. The role of TPE in the overlapping syndrome of BBE and GBS has not been explored much, especially in the paediatric population. Herein, we describe a case of 2-year-old male who presented with features of BBE and later evolved to an overlapping syndrome with BBE and GBS. A multi-disciplinary team managed the patient and TPE was initiated as a part of the treatment plan. Five cycles of TPE were done from day 24 after which the patient improved. In our case, TPE was used as rescue therapy in patients with BBE overlapping with GBS. The effectiveness of TPE can be further explored as a modality in such disorders.

Role of therapeutic plasma exchange in acute humoral rejection patients undergoing live-related renal transplantation: A single-center experience

BACKGROUND AND AIM:

Renal transplantation (RT) is the most successful and ideal renal replacement therapy for end-stage renal disease patients. Renal allograft rejection has always been one of the major barriers in successful RT. Our aim was to report the role of therapeutic plasma exchange (TPE) in acute humoral rejection (AHR) patients who underwent live-related RT (LRRT) and their renal allograft outcome at our center.

MATERIALS AND METHODS:

A prospective observational study was conducted from July 1, 2014, to December 31, 2016. Patients with biopsy-proven AHR and treated with TPE along with other lines of treatment after undergoing LRRT were included in the study. ABO-incompatible individuals, pediatric patients, and patients undergoing second transplants were excluded from the study. Clinical history, donor and graft details, management, and patient and graft survival were noted.

RESULTS:

Of the 1608 patients who underwent LRRT, 49 (37 males, 76%; 12 females, 24%; mean age 39.5 ± 13.3 years) had biopsy-proven AHR (3.04%) and were treated with TPE. A total of 281 TPEs were performed with an average of 5.7 TPE/patient (range 2–12). Of the 49 patients, 38 patients (78%) with favorable response underwent 213 (75.8%) TPEs (average of 5.6 TPE/patient; range: 2–12), whereas 11 patients (22%) with unfavorable response underwent 68 (24.2%) TPEs (average of 6.2 TPE/patient; range: 3–8). Blood urea (P = 0.012) and serum creatinine (P = 0.038) levels at the time of rejection were significant predictors of response to TPE therapy. The average length of stay in our study population was 33 ± 22 days. Six months posttransplant, the patient and graft survival were 93.3% and 89.5%, whereas at 12 months, they were 89.3% and 81.5%, respectively.

CONCLUSION:

TPE is a safe and effective adjunct therapy for treating AHR patients.

Daratumumab: The perplexity in immunohematology with emerging horizons in myeloma therapy

CD38 is a disulfide-linked molecule present on red blood cells (RBCs) and daratumumab; an anti-CD38 monoclonal antibody is a novel agent for treating multiple myeloma patients. It also binds to the RBC along with the plasma cells in concern, creating a menace in the immunohematology workups and requires the use of dithiothreitol-treated cells to rule out its interference. Appropriate and timely communication with the clinicians about the patient history goes a long way in solving complex looking immunohematology workups.

Implication of a positive virtual crossmatch with negative flow crossmatch: A mind-boggler

There are occasions when tests performed before considering a patient for transplant are ambiguous and require further workup. One such condition is the presence of a positive virtual crossmatch (VXm) (anti-human leukocyte antigen [HLA-A]*26: 01 antibody in this case) with a negative complement-dependent cytotoxicity, Luminex, and flow crossmatch. To ascertain the nature of the antibody, the beads used in single-antigen bead assay (SAB) were treated by acid to denature the antigens and retested with the control and test sample. The mean fluorescence intensities (MFIs) from the patient sera with acid-treated beads increased considerably as compared to the regularly untreated SAB indicating additional antigen epitopes become available by the denaturation process. The MFIs of the antibodies from that of the control sera were reduced to half on testing with the acid-treated SAB assay, indicating that HLA antigen HLA-A*26 was susceptible to acid treatment. Therefore, results of VXm should be interpreted with caution.

Role of de novo DQ donor-specific antibody in antibody-mediated rejection in renal transplant recipient: A case study

The human leukocyte antigen (HLA) matching plays an important role in determining the clinical outcome of renal transplantation. The development of donor specific antibodies (DSA) against HLA is associated with antibody mediated allograft tissue injury, poor outcome and rejection. The DQ-DSA develops in a denovo pattern and its unfavorable impact on renal transplantation has not yet been widely reported. We investigated the clinical significance of DQ-DSA in a patient diagnosed with hypertension, CKD stage V on maintenance hemodialysis (MHD) for second renal transplant. The histocompatibility workup before the first transplant included low resolution HLA-A, B, DR typing of both patient and donor. HLA type of the patient was HLA-A*29, 68, HLAB*44, 44, DRB1*07, 11. HLA type of the donor was HLA-A*03, 68, HLA-B*39, 44, DRB1*07, 10 with a 3/6 match. The HLA antibody screen and complement dependent cytotoxicity crossmatch (CDC) were found to be negative. No therapeutic plasma exchanges (TPE) were done during stay and post-transplant the patient was on triple immunosuppressant therapy. After four years the patient was diagnosed with recurrent membranoproliferative glomerulonephritis and second renal transplant was planned, therefore, histocompatibility workup was initiated. HLA antibody screen was found to be positive for HLA class II. Initially only HLA-A, B, DR typing was performed and that too only low resolution, further, high resolution HLA typing was done for HLA-DR and DQ to rule out if these antibodies are de-novo DQ/DR DSA. We analyzed that the patient had developed de-novo DSA against HLA-DRB1* 10:01 (DR10), MFI-2374 and DQB1*06:01 (DQ6), MFI-15315. This study suggests the role of DQ antibodies in determining the graft survival and to highlight the need of HLA DQ typing as a routine of the diagnostic work-up in a solid organ transplant.

Exchange transfusion in neonatal hyperbilirubinemia: A single Centre experience from Northern India

OBJECTIVE

To determine the indication, efficacy and adverse events related to exchange transfusion (ET) with reconstituted blood (RB) in neonatal hyperbilirubinemia (NNH).

METHODS

Blood bank records of neonates who underwent double volume ET for NNH from January 2013 to July 2018 were retrospectively reviewed. Demographic details, cause of NNH, details of ET and ET related adverse events were recorded.

RESULTS

A total of 23 ET (average: 1.64/neonate) were performed in 14 neonates (9 males; 5 females) with a mean age of 9.8 ± 7.6 days. Ten (71.4%) neonates underwent 1 session of ET, while 4 (28.6%) underwent repeated sessions (average: 3.25/neonate). A total of 5912 ml of RB was transfused (average: 422 ml/neonate). A statistically significant reduction was noted in total serum bilirubin (TSB) level post-ET (p < 0.001) with overall TSB reduction/procedure being 46%. Of the 14 neonates with NNH, 11 (78.6%) had Rh haemolytic disease of foetus and new-born (HDFN), 2 (14.3%) had ABO HDFN and 1 (7.1%) had hyperbilirubinemia due to prematurity. Of the 11 neonates with Rh HDFN, only 5 underwent intrauterine transfusion (average: 1.8/neonate). Post-ET, top-up transfusions were noted in 8 (57.1%) neonates with packed red blood cell and/or platelet concentrate. ET related adverse were noted in 5 (21.7%) procedures only.

CONCLUSION

Rh HDFN was the most common cause of NNH in our study population.Exchange transfusion is a safe treatment modality for treating NNH, as it results in the rapid elimination of serum bilirubin, thus, lowering the risk of kernicterus in these patients.

A case report on anti-Mia antibody in a multi-transfused patient from India

GP.Mur antigen belongs to the MNSs system and the corresponding antibody is called as anti-Mia antibody. Anti-Mia antibody is a clinically significant antibody capable of causing haemolytic disease of the new born (HDFN) and intravascular haemolytic transfusion reactions. Literature on anti-Mia antibody from India is very limited. We report here a case of anti-Mia antibody in a multi-transfused patient from India.

A case study: Therapeutic plasma exchange in voltage-gated potassium channel autoimmune encephalitis

INTRODUCTION

Neurological syndromes associated with voltage-gated potassium channels (VGKC) affect the nerve and muscle physiology. Presence of antibodies to VGKC are associated with three main neurologic syndromes namely neuromyotonia (NMT), limbic encephalitis (LE) and Morvan's syndrome(MVS) LE is a variably treatable neurologic syndrome associated with high levels of antibodies to the voltage-gated potassium channel (VGKC) complex. These antibodies are directed against protein antigens that bind to the VGKC complex. These antigens are usually leucine-rich, glioma inactivated 1 (LGI1), and contactin associated protein-like 2 (CASPR2).

CASE DESCRIPTION

A 58-year-old female and with a known case of auto immune encephalitis (voltage gated potassium channel) and steroid induced diabetes mellitus presented with progressive worsening of vertigo, recurrent myoclonic jerks and post ictal confusion for last 7 days. She had memory impairment since last few months. She was on treatment with steroids which were gradually tapered off 11 months back. CSF was tested for presence of VGKC antibodies and the test was positive for LGI (leucine-rich glioma inactivated 1) antibody. Therapeutic plasma exchange (TPE) was scheduled every day for 6 consecutive days based upon the recommendations from the ASFA guidelines for the treatment of neurologic syndromes.

CONCLUSION

TPE done every day in patient diagnosed LE with VGKC antibodies had shown rapid improvement in controlling the symptoms.

A case of rare anti-Hro alloantibody in a tertiary care center in India

Anti-Hro is an alloantibody produced in individuals with -D- phenotype after a sensitizing event. Owing to the rarity of this antigen negative unit, registration in rare donor registries helps in procuring blood components at the earliest. We had a patient of -D- with anti-Hro antibody who required 7 units of red cells which was unavailable at our center. The patients near relatives were typed in search of a similar phenotype blood. Search was made for the rare units and Japanese Red Cross Society, American Red Cross Society, and International Blood Group Reference Laboratory, United Kingdom was contacted. Patient's brother and mother were typed as -D- and one unit from each of them was collected, irradiated, and transfused to the patient. Five units were imported from the Japanese Red Cross Society, Japan. Accessibility for identification and confirmation of rare blood groups and provision of the same can be centralized and liaison with the international registries can go a long way in the provision of blood components at the earliest.

Therapeutic Immunoadsorption and Conventional Plasma Exchange in ABO-incompatible Renal Transplant: An Exculpatory Evidence

Aim

The objective of this study was to compare the efficacy of immunoadsorption (IA) with conventional therapeutic plasma-exchange (cTPE) in ABO-incompatible (ABOi) renal transplant.

Methods

Data of patients from July 2015 to June 2017 (category-I, number of patients (N) = 11; IA±cTPE) on the average length of stay (ALOS), number of cTPE/IA, antibody-titers (AT), creatinine, patient and graft survival at one year were compared retrospectively with patients in period from February 2012 to June 2015 (category-II, N = 29; cTPE only). AT of patients not decreasing to less than one fold after two cTPE were shifted for IA. For patients undergoing IA, real-time AT was done and IA stopped after target titer (TT <1:8) was achieved. Post-transplant cTPE was done if, titers rebounded to ≥1:8. Intravenous immunoglobulin (IVIG) was given after every cTPE/IA. Cost comparisons were made.

Results

In category-I, seven patients (63.63%) were shifted to IA from cTPE. The mean cTPE procedures in category I and II are 3.5 ± 2.4 and 4.8 ± 2.5, respectively (p = 0.206). The mean IA procedures in category-I are 1.6 ± 0.5. The number of patients requiring post-operative TPE was less in category-I than category-II, i.e., N = 5, 45.5% vs N = 20, 69%, respectively (p = 0.171). The expense of IA in category-I vs cTPE in category-II was statistically not significant (p = 0.422) but had significant lesser ALOS (p = 0.044). Expenses, when a patient undergoes both cTPE and IA (category-I), are significantly higher to category-II (p = 0.003). The two groups were comparable in AT, creatinine value, graft and patient survival rates at one year.

Conclusion

Contrary to the general judgment of IA being expensive than cTPE, this study shows equivalent expenditures with comparable therapeutic outcomes.

A case report of successful renal transplantation in an ABO incompatible patient with a preformed donor-specific antibody and negative CDC human leukocyte antigens crossmatch

ABO incompatibility and preformed antibodies against the human leukocyte antigen (HLA) are two impermissible barriers to a successful renal transplantation, especially in highly sensitized patient population. With the availability of effective desensitization regimens, good patient and graft outcomes have been reported. As transfusion medicine specialists we report our experience, where patient presented with dual histocompatibility barriers i.e. ABO incompatibility along with preformed donor-specific antibodies (DSA) and negative complement dependent lymphocytotoxicity (CDC) HLA crossmatch. The desensitization strategy followed for our patient included rituximab (375 mg/m²), bortezomib (1.3 mg/m²) and eleven pre-transplant therapeutic plasma exchange (TPE) followed by intravenous immunoglobulin (100 mg/kg per TPE session). Anti-B titer of 1:1 and negative Luminex crossmatch (LumXm) class II DSA (less than 1000 mean fluorescence intensity; MFI), was achieved prior to renal transplantation. Fifteen months post-transplant, patient is doing well with serum creatinine level of 0.8 mg/dL with repeat LumXm class II DSA negative (891 MFI). The desensitization regimen followed proved to be effective in our case.

A positive complement dependent cytotoxicity immunoglobulin G crossmatch due to auto-antibodies with a negative luminex bead assays in a renal transplant recipient: A Diagnostic dilemma

Transplant recipients are always at a risk of developing anti-human leukocyte antigen (HLA) antibodies due to prior sensitizing events such as blood transfusions, multiple pregnancies, or transplantation. Unexpected positive outcomes can be seen in complement dependent cytotoxicity (CDC) based assays due to underlying autoimmune disorders or pharmacological treatment (rituximab/intravenous immunoglobulin/anti-thymocyte globulin administration), therefore, limiting its value. CDC based assay results strongly depend on the vitality of the donor lymphocytes, highlighting another major limitation of this assay. Thus, as an alternative approach, solid phase based crossmatch assays were introduced which function independently of the cell quality and have higher sensitivity and specificity in detecting anti-HLA antibodies. We describe a case where the patient awaiting renal transplantation from living related donor was evaluated by pretransplant histocompatibility testing for the detection of anti-HLA antibodies. The histocompatibility testing revealed positive CDC anti-human globulin and flow crossmatch along with negative Luminex based assays (HLA antibody screen, luminex crossmatch, and luminex single bead assay). Detailed histocompatibility workup revealed immunoglobulin G autoantibodies which were complement activating and lympocytoxic in nature.

Role of Anti-MICA Antibodies in Graft Survival of Renal Transplant Recipients of India

INTRODUCTION

The MIC (MHC class I chain-related) genes are a group of nonclassical MHC genes, located in the MHC class 1 region of chromosome 6. The aim of the present study was to find the prevalence of MHC class 1 chain-related (MICA) alloantibodies in patients undergoing live-related donor renal transplantation and its role in short-term graft survival. The role of blood transfusion in the formation of these antibodies was also studied.

MATERIALS AND METHODS

Pretransplant samples of patients undergoing renal allograft transplantation were tested for anti-MICA antibodies. Association of various demographics, HLA-A + B + DRB1 mismatches, anti-HLA antibody screen, and anti-MICA antibodies was assessed using Pearson's chi-square test.

RESULTS

Out of 646 serum samples, 94 (14.6%) were positive and 552 (85.4%) were negative for anti-MICA antibodies. Patients with anti-MICA antibody had a graft survival 89.3% as compared to 94.7% in patients without anti-MICA antibody (P < 0.05). The hazard ratio for all patients was 3.0701 (P < 0.05). Out of the 340 patients with no HLA antibodies, the presence of anti-MICA antibodies without any HLA antibodies (n = 43) was associated with poor outcome in the patients (hazard ratio of 2.768, P < 0.05). The presence of MICA antibodies with HLA antibodies did not decrease the graft survival (hazards ratio of 1.3750, P > 0.05).

CONCLUSION

Preformed MICA antibodies independently increase the risk of kidney rejection and therefore recommend that guidelines should be formed for mandatory testing of these antibodies prior to renal transplant.

The good, the bad, and the ugly of luminex donor-specific crossmatch

The presence of donor-specific antibodies directed against human leukocyte antigen significantly influences renal transplant because of antibody-mediated rejection. We performed the screening of pre-renal transplant patients for preformed anti-HLA antibodies using anti-human globulin augmented-complement-dependent lymphocytotoxicity crossmatch (AHG-CDCXm), luminex donor-specific crossmatch (LumXm) and HLA antibody screening. Seven hundred and fifty-four patients were assessed for LumXm. HLA antibody screening was possible in 325 out of 754 cases. All the three investigations viz. CDCXm, HLA antibody screening and LumXm was performed in 325 patients. All CDCXm positive patients (10/325, 3.08%) were also positive with LumXm and HLA antibody screen whereas 14 cases (4.31%) with CDCXm negative were positive with luminex-based assays. LumXm and HLA antibody screening were both positive in 24 (7.38%) cases, LumXm and HLA antibody screening were both negative in 275 (84.63%) cases and LumXm negative and HLA antibody screening was positive in 22 (6.76%) cases. However, there were four cases (1.23%) which were positive in LumXm in spite of being negative in HLA antibody testing. Single Antigen Bead (SAB) assay was performed in all patients positive for HLA antibody test. We suggest that LumXm is a useful and sensitive technique for the detection of anti-HLA antibodies in pre-transplant renal patients. However, other measures such as luminex antibody screen, SAB assay, history of the donor, and the class of antibodies involved should be taken into consideration for pre-transplant work up of renal patients.

Prevalence of irregular red cell antibody in healthy blood donors attending a tertiary care hospital in North India

BACKGROUND:

Alloantibodies may be detected in blood donors who have either been transfused previously or female donors with previous obstetric events. These antibodies can occasionally cause severe transfusion reaction, if a large amount of plasma or whole blood is transfused, as in massive transfusions and pediatric patients.

AIMS:

The present study aims to assess the prevalence of red cell antibodies in healthy blood donors at a tertiary care hospital-based blood bank in India.

MATERIALS AND METHODS:

A total of 82,153 donor samples were screened for irregular red cell antibodies between January 2012 and December 2015 at the Department of Transfusion Medicine, Indraprastha Apollo Hospitals, New Delhi. Antibody screening was performed by solid phase method using Immucor Capture–R ready screen (pooled cells) on fully automated immunohematology analyzer Galileo Neo (Immucor Inc., Norcross, GA, USA). Positive tests were further confirmed using Capture-R ready screen (4 cell panel). Advanced investigations to identify the antibody/ies were performed on confirmed positive samples. Antibody identification was conducted using various cell panels (Immucor Capture-R Ready-ID, Panocell-10, Ficin Treated). An advanced technique such as adsorption and elution was performed as per requirement.

RESULTS:

Screening with pooled cells and 4 cell panel was positive in 227 donors (0.27%), 150 of these donors had autoantibodies, 1 had autoantibodies with underlying alloantibody anti-Jk^a (0.001%), and 76 had alloantibodies (0.09%) alone in their plasma. Anti-M was the most common antibody (43 donors) identified, followed by anti-D (21 donors). Anti-N was detected in 4; anti-Jk^a, anti-C, and anti-E in two donors each followed by anti-P1 and anti-Le^b in 1 donor.

CONCLUSION:

Antibodies against red cells can be present in healthy donors detection of which is important in providing safe blood to the patient. The prevalence of red blood cell antibody in healthy donors in this study was found to be 0.27%, while the prevalence of alloantibodies was 0.09%. The majority of alloantibodies were anti-M (56.57%) and anti-D (27.63%).

Evaluation of bacterial inactivation in random donor platelets and single-donor apheresis platelets by the INTERCEPT blood system

BACKGROUND:

Blood transfusion of contaminated components is a potential source of sepsis by a wide range of known and unknown pathogens. Collection mechanism and storage conditions of platelets make them vulnerable for bacterial contamination. Several interventions aim to reduce the transfusion of contaminated platelet units; however, data suggest that contaminated platelet transfusion remains very common.

AIM:

A pathogen inactivation system, “INTERCEPT”, to inactivate bacteria in deliberately contaminated platelet units was implemented and evaluated.

MATERIALS AND METHODS:

Five single-donor platelets (SDP) and five random donor platelets (RDP) were prepared after prior consent of donors. Both SDP and RDP units were deliberately contaminated by stable stock ATCC Staphylococcus aureus and Escherichia coli, respectively, with a known concentration of stock culture. Control samples were taken from the infected units and bacterial concentrations were quantified. The units were treated for pathogen inactivation with the INTERCEPT (Cerus Corporation, Concord, CA) Blood system for platelets (Amotosalen/UVA), as per the manufacturer's instructions for use. Post illumination, test samples were analyzed for any bacterial growth.

RESULTS:

Post-illumination test samples did not result in any bacterial growth. A complete reduction of >6 log₁₀S. aureus in SDP units and >6 log₁₀Escherichia coli in RDP units was achieved.

CONCLUSION:

The INTERCEPT system has been shown to be very effective in our study for bacterial inactivation. Implementation of INTERCEPT may be used as a mitigation against any potential bacterial contamination in platelet components.

Red cell alloimmunization & role of advanced immunohaematological support in liver transplantation

Background & objectives:

Transfusion support forms an integral part of liver transplantation programme. Advanced immunohaematology services are required to deal with complex serological problems that can complicate transfusion therapy in these patients. Here, we report on red cell alloimmunization and presence of alloimmunization in donors and patients undergoing liver transplantation in a tertiary care hospital in north India.

Methods:

Records of 1433 liver transplants performed from January 2009 to March 2015 were retrieved and reviewed. Antibody screening was performed both for liver donors, and recipients and antibody identification was performed for the screen-positive patients.

Results:

Of the 1433 liver recipients, 32 (2.3%) developed antibodies. Seventeen patients had one or more alloantibodies, five had autoantibodies with an underlying alloantibody and 10 had only autoantibodies in their plasma. The overall alloimmunization rate was 1.5 per cent with 25 alloantibodies identified in 22 patients. Anti-E was the most common specificity identified.

Interpretation & conclusions:

The presence of alloantibodies can complicate transfusion therapy in patients undergoing liver transplantation, who are already at a high risk of being heavily transfused owing to the nature of surgery and the haemostatic dysfunction from chronic liver disease. Therefore, screening for irregular red cell alloantibodies combined with a rational blood transfusion policy may be essential for these patients.

Facts and Fallacies of Kidd Antibodies: Experience in a Tertiary Care Hospital in North India

We have analyzed the method used in our laboratory to detect the most elusive, clinically significant alloantibody: the Kidd alloantibodies and find the most convenient procedure. A retrospective analysis of the method used in our laboratory for determining Kidd alloantibodies from January 2013 to May 2015 was conducted. The details of the event that sensitized the patient for red cell antibody formation and procedure used to detect the alloantibody were retrieved from the departmental records. Of 405 red cell antibody identification cases, 24 (5.9 %) had Kidd antibody (anti-Jka in 12: 50 % cases; anti-Jkb in 4: 16.7 % cases; multiple antibodies in 8: 32 % cases). Thirteen of 24 patients (54.2 %) had autocontrol positive of which 6 cases needed adsorption procedures whereas antibody/ies could be identified without adsorption procedure in the remaining 7 cases. All the 7 cases had autocontrol of 1+ strength. Of the 11 patients (45.8 %) with autocontrol negative, the antibody was identified using solid phase in 7 cases whereas tube panels were also used in the remaining 4 cases. Kidd alloantibodies though deceptive can be identified by sensitive techniques like the solid phase and simple but laborious techniques using the tube cell panels. Depending upon the reaction strength of the autocontrol, the routine autoadsorption process may be skipped and tube cell enzyme treated cells or solid phase techniques be used to get the results.

Rh and Kell Phenotype Matched Blood Versus Randomly Selected and Conventionally Cross Matched Blood on Incidence of Alloimmunization

There is paucity of literature regarding efficacy of transfusion of Rh and Kell matched blood in reducing alloimmunization risk among non-chronically transfused patients. A prospective study to compare efficacy of Rh and Kell phenotype matched blood over randomly selected and conventionally cross-matched blood on the incidence of alloimmunization in patients undergoing cardiac surgery was carried out in the Department of Transfusion Medicine at Indraprastha Apollo Hospitals, New Delhi, from 1st September, 2013 to 31st December, 2014. Two groups, A and B of 250 each were studied. Group A received ABO, Rh and Kell phenotype matched units. Group B received units matched only for ABO and Rh D. Retrospective analysis for antigenic exposures was done. Alloimmunization rate was evaluated for both groups after 72 h and 4 weeks and compared. A p value ≤0.05 was considered statistically significant. None of the patients in Group A were alloimmunized. In Group B, 119 patients received antigenic stimulus (single antigen stimuli- 93; multiple- 26). The probability of a patient being exposed was 52.4 %. At 6 weeks post transfusion, one patient developed 'Anti-E' and had received 'E' stimulus once. The rate of alloimmunization was 0.4 % in group B, 0.8 % overall and the risk of alloimmunization per unit transfused was 0.17 %. Non responders were 99.16 %. The study did not reach statistical significance (p = 0.238). Majority of our population are non-responders therefore, the resources and time can be reserved for providing Rh and Kell matched units for multiply transfused patients.

ABO incompatible renal transplant: Transfusion medicine perspective

INTRODUCTION:

Our study presents an analysis of the trends of ABO antibody titers and the TPE (Therapeutic Plasma Exchange) procedures required pre and post ABO incompatible renal transplant.

MATERIALS AND METHODS:

Twenty nine patients underwent ABO incompatible renal transplant during the study period. The ABO antibody titers were done using the tube technique and titer reported was the dilution at which 1+ reaction was observed. The baseline titers of anti-A and anti-B antibodies were determined. The titer targeted was ≤8. Patients were subjected to 1 plasma volume exchange with 5% albumin and 2 units of AB group FFP (Fresh Frozen Plasma) in each sitting. TPE procedures post-transplant were decided on the basis of rising antibody titer with/ without graft dysfunction.

RESULTS:

The average number of TPE procedures required was 4-5 procedures/patient in the pretransplant and 2-3/patient in the post-transplant period. An average titer reduction of 1 serial dilution/procedure was noted for Anti-A and 1.1/procedure for Anti-B. Number of procedures required to reach the target titer was not significantly different for Anti-A and Anti-B (P = 0.98). Outcome of the transplant did not differ significantly by reducing titers to a level less than 8 (P = 0.32). The difference in the Anti-A and Anti-B titers at 14th day post-transplant was found to be clinically significant (P = 0.042).

CONCLUSION:

With an average of 4-5 TPE procedures pretransplant and 2-3 TPE procedures post transplants, ABO incompatible renal transplantations can be successfully accomplished.

Human leucocyte antigen Class I and II alleles associated with anti-hepatitis C virus-positive patients of North India

PURPOSE

Humans are the only known natural hosts of hepatitis C virus (HCV). This study was undertaken to examine the frequencies of human leucocyte antigens (HLAs) Class I and Class II genotype profiles in anti-HCV-infected patients of Northern India.

MATERIALS AND METHODS

From a period of January 2013 to August 2014, 148 anti-HCV-positive patients of North India referred to the Department of Molecular Biology and Transplant Immunology, Indraprastha Apollo Hospitals, New Delhi, for performing HLA typing were included in the study.

RESULTS

AFNx0102, AFNx0131 allele frequency decreased significantly in anti-HCV-positive patients. Frequencies for HLA-B loci did not reach any statistical significance. Among the Class II alleles, HLA-DRB1FNx0103 and HLA-DRB1FNx0110 were significantly higher in the patient population, and HLA-DRB1FNx0115 was significantly decreased in the patient population as compared to the controls.

CONCLUSION

HLA-AFNx0133 was significantly increased as compared to control population and showed geographic variation in HCV-infected individuals of India.

Therapeutic leukapheresis in a tertiary care hospital: A case series

Patients presenting with hyperleukocytosis secondary to acute leukemia, with total leukocyte count or blast count more than 100,000/μL are often considered for leukapheresis, especially if clinical signs of leukostasis are present. Leukostasis is often associated with high morbidity and mortality in patients with leukemic processes. The main goal of management of hyperleukocytosis and/or leukostasis is to reduce the blast count before initiation of chemotherapy. Leukapheresis is often used prophylactically to prevent leukostasis or to provide symptomatic relief. We, as transfusion medicine specialists, present our experience of doing therapeutic leukapheresis in patients presenting with hyperleukocytosis with or without presenting features of leukostasis.

Impact of antigenic exposures and role of molecular blood grouping in enhancing transfusion safety in chronically transfused thalassemics

Background:

Red cell alloimmunization is an acknowledged complication of blood transfusion. Current transfusion practices for thalassemia do not cater to this risk. Serological phenotyping is usually not reliable in these cases unless performed before the first transfusion. Under such circumstances, molecular blood grouping is an effective alternative.

Aim:

To perform molecular blood group genotyping in chronically transfused thalassemia patients and assess the risk of antigenic exposure and incidence of alloimmunization with current transfusion protocols.

Materials and Methods:

Molecular blood group genotyping was performed for 47 chronically transfused thalassemia patients. Their 1-year transfusion records were retrieved to assess the antigenic exposure and the frequency thereof.

Results:

Of 47 patients, 6 were already alloimmunized (3 with anti-E and 3 with anti-K) and were receiving the corresponding antigen negative units. We observed that random selection of ABO and Rh D matched units resulted in 57.7% ±8.26% chance of Rh and Kell phenotype matching also. Forty-four patients had received one or more antigenic exposures at least once. The 6 already alloimmunized patients were further exposed to antigens other than the ones they were immunized to. During the study period, only one patient developed an alloantibody, anti-E with exposure to antigens C (92%) and/or E (32%) at each transfusion.

Conclusion:

Several factors apart from mere antigen exposure may influence the development of alloimmunization as most of our patients received antigenic exposures but not alloimmunized. Our data provide an impetus for future large-scale studies to understand the development of alloimmunization in such patients.

Frequency of Mi(a) antigen: A pilot study among blood donors

The Miltenberger (Mi) classes represent a group of phenotypes for red cells that carry low frequency antigens associated with the MNSs blood group system. This pilot study was aimed at determining the Mia antigen positivity in the blood donor population in a tertiary care hospital in New Delhi, India. The study was performed between June to August 2014 on eligible blood donors willing to participate. Antigen typing was performed using monoclonal anti-Mia antiserum by tube technique. Only one of the 1000 blood donors (0.1%) tested was found to be Mia antigen positive. the Mia antigen can, therefore, be considered as being rare in the Indian blood donor population.

Seroprevalence of infectious markers & their trends in blood donors in a hospital based blood bank in north India

Background & objectives:

Hepatitis B virus (HBV), human immunodeficiency virus (HIV), hepatitis C virus (HCV) and syphilis infections pose a great threat to blood safety. This study was undertaken to investigate the seroprevalence of serologic markers for transfusion transmitted infections (TTIs) among blood donors at a hospital based blood centre in north India over a period of nine years.

Methods:

The results of serologic markers for TTIs (HBsAg, anti-HCV, anti-HIV and syphilis) of all blood donations (both voluntary and replacement) at our hospital from January 2005 to December 2013 were screened. Additional analysis was conducted to examine the prevalence trends associated with each of the positive marker.

Results:

The data of 180,477 donors [173,019 (95.86%) males and 7,458 (4.13%) females] were analyzed. Replacement donations [174,939 (96.93%)] represented the majority whereas, only 5,538 (3.06%) donations were from the voluntary donors. The risk of blood being reactive was three times higher in male donors when compared with the female donors. The risk of blood being reactive for one or more infectious markers was 2.1 times higher in replacement donors when compared with the voluntary donors. Seropositivity of HIV, HBsAg, HBcAb, syphilis showed a significant decreasing trend (P<0.05) while there was an increasing trend in HCV infection which was insignificant.

Interpretation & conclusions:

This study reflects that the risk of TTIs has been decreased over time with respect to HIV, HBV and syphilis, but the trends for HCV remains almost the same in blood donors. Blood transfusion remains a risk factor for the spread of blood-borne infections. Therefore, improvements are needed to strengthen both safety and availability of blood.

Retrospective analysis of perioperative transfusion requirements in living donor renal transplantation

BACKGROUND

Extensive bleeding in solid organ transplantation is a major challenge faced by transplant surgeons. Our aim was to audit the peri-operative transfusion requirements in our patients.

MATERIALS AND METHODS

A retrospective analysis of living donor renal transplant surgeries performed from 1st May 2014 to 31st December 2014 was done. The blood/blood component usage during the peri-operative period was obtained. Univariate analysis was performed and the significant factors identified were further analyzed through multivariate regression analysis.

RESULTS

A total of 510 patients (398 males: 78%, and 112 females: 22%) ranging from 18 to 77 years in age were included in the study. Of these, 269 (52.7%) patients were not transfused, while 241 (47.3%) patients received a total of 845 units of blood/blood components. The mean pre-operative hemoglobin in the transfused group was 8.7g/dl while in the non-transfused group it was 10.3g/dl. Leukoreduced packed red blood cell (PRBC) was the major blood component transfused during the peri-operative period. Multivariate regression analysis revealed that pre-operative hemoglobin was a major predictor of intra-operative PRBC transfusion (p = <0.001). Average post-operative length of stay (PLOS) was 10 ± 6 days. There was no significant difference in the PLOS between the transfused and non-transfused groups of patients; however, a statistical significant increase in utilization for both PRBC (p = 0.044) and fresh frozen plasma (p = 0.002) was observed with increased PLOS.

CONCLUSION

Nearly 47.3% of patients undergoing living donor renal transplant received transfusion. PRBC was the most common product transfused and pre-operative hemoglobin was identified as strong predictor of blood consumption.

Genetic diversity through human leukocyte antigen typing in end-stage renal disease patients and prospective donors of North India

As the incidence of end-stage renal disease (ESRD) is rapidly increasing, the demand for dialysis and transplantation has dramatically increased, which has led to concerns about the availability and equitable allocation of kidneys for transplantation. The distribution of HLA-A, B and DR alleles in 148 renal transplant recipients and 191 live related prospective donors from 2009 to 2010 were analyzed. Allele frequencies and haplotype frequencies were calculated in recipients and donors. The prospective donors were further analyzed on the basis of their relationship to the patients and according to the sex ratio. A significant female preponderance was noted in the prospective donor population, most of whom were either siblings or parents of the recipients. On the contrary, the recipient population predominantly comprised of males. The most frequent HLA-A, HLA-B, HLA-DRB1 alleles in renal transplant patients were HLA-AFNx0111, AFNx0102, AFNx0101, AFNx0124; HLA-BFNx0135, BFNx0140, BFNx0144, BFNx0115, BFNx0152, and HLA-DRB1FNx0115, DRB1FNx0107, DRB1FNx0113, DRB1FNx0111 respectively. The most frequent HLA-A, HLA-B, HLA-DRB1 alleles in prospective donors were HLA-AFNx0102, AFNx0111, AFNx0133, AFNx0124; HLA-BFNx0135, BFNx0144, BFNx0140, BFNx0115 and HLA-DRB1FNx0115, DRB1FNx0107, DRB1FNx0111, DRB1FNx0113 respectively. AFNx0111-BFNx0135, AFNx0102-DRB1FNx0115, BFNx0140-DRB1FNx0115 were the most common HLA A-B , HLA A-DR, HLA B-DR haplotypes respectively in renal transplant patients, whereas, AFNx0111-BFNx0135, AFNx0111-DRB1FNx0115, BFNx0144-DRB1FNx0107 were the most common haplotypes in renal donors. In three locus haplotype, HLA-AFNx0102-BFNx0140-DRB1FNx0115 was the most frequent haplotype in patients, whereas, in prospective renal donors HLA-AFNx0133-BFNx0144-DRB1FNx0107 was the most frequent haplotype.

Low incidence of complications in computer assisted total knee arthroplasty--A retrospective review of 1596 cases

BACKGROUND

Computer assisted total knee arthroplasty (CATKA) has its own unique complications. The aim of this study was to present our experience of early complications in a large consecutive series of CATKA.

METHOD

We investigated retrospective data on the complications specific to computer navigation that were encountered with a consecutive series of 1596 CATKA.

RESULTS

Intraoperatively, eight episodes of software failure occurred, two requiring conversion to conventional jig based TKA. There were four broken drill bits when positioning the pins for data entry. Repeat cuts of bone due to malalignment were required on two occasions. There were 17 episodes of superficial pin site infections at the tibial pin-site managed conservatively with antibiotics. One tibial fracture occurred through an old tibial tracker pin site hole.

CONCLUSION

This large study shows a low complication rate related to CATKA which is reassuring to the orthopaedic community.

CLINICAL RELEVANCE

Level of evidence: III.

Evaluation of the Procleix Ultrio Plus ID NAT assay for detection of HIV 1, HBV and HCV in blood donors

Introduction:

The Procleix Ultrio Plusassay is a new-generation qualitative in vitro nucleic acid amplification test used to screen for human immunodeficiency virus type 1 (HIV-1) RNA, hepatitis C virus (HCV) RNA and hepatitis B virus (HBV) DNA in blood donors. This study was performed to compare the Procleix Ultrio assay with the new-generation Procleix Ultrio Plus Nucleic Acid Test (NAT) assays.

Materials and Methods:

Ten thousand three hundred and two donor samples were run in parallel for ID NAT using the Procleix Ultrio and the Procleix Ultrio Plus assay. Simultaneously, enzyme-linked immunosorbent assay testing was performed on an EVOLIS Walk away System for HIV, HCV, HBsAg and anti-HBc. Reactive samples were confirmed using polymerase chain reaction.

Results:

In the 10,302 samples tested during the study period, we identified 15 NAT yields, and all these revealed HBV DNA in the discriminatory assays. Eight of these were exclusive yields from the Ultrio Plus assay and the remaining seven cases were determined as HBV NAT yield, both by the Procleix Ultrio as well as the Ultrio Plus assays, i.e. “Combined” yields. No HCV or HIV 1 yields were detected during the study period by either of two assays.

Conclusion:

With an overall yield rate of 1 in 687 and an exclusive yield rate of 1 in 1287, the Procleix Ultrio Plus assay proved to be highly sensitive in detecting occult HBV infections.

A multivariate analysis to assess the effect of packed red cell transfusion and the unit age of transfused red cells on postoperative complications in patients undergoing cardiac surgeries

BACKGROUND

Transfusion of blood components and age of transfused packed red cells (PRCs) are independent risk factors for morbidity and mortality in cardiac surgeries.

MATERIALS AND METHODS

We retrospectively examined data of patients undergoing cardiac surgery at our institute from January 1, 2012 to September 30, 2012. Details of transfusion (autologous and allogenic), postoperative length of stay (PLOS), postoperative complications were recorded along with other relevant details. The analysis was done in two stages, in the first both transfused and nontransfused individuals and in the second only transfused individuals were considered. Age of transfused red cells as a cause of morbidity was analyzed only in the second stage.

RESULTS

Of the 762 patients included in the study, 613 (80.4%) were males and 149 (19.6%) were females. Multivariate analysis revealed that factors like the number and age of transfused PRCs and age of the patient had significant bearing upon the morbidity. Morbidity was significantly higher in the patients transfused with allogenic PRCs when compared with the patients not receiving any transfusion irrespective of the age of transfused PRCs. Transfusion of PRC of over 21 days was associated with higher postoperative complications, but not with in-hospital mortality.

CONCLUSION

In patients undergoing cardiac surgery, allogenic blood transfusion increases morbidity. The age of PRCs transfused has a significant bearing on morbidity, but not on in-hospital mortality. Blood transfusion services will therefore have to weigh the risks and benefits of providing blood older than 21 days in cardiac surgeries.