Clinical Utility of Flow Cytometry for Detection of Anti-Jkb IgM in Acute Haemolytic Transfusion Reaction

Acute hemolytic transfusion reaction (AHTR) is a rare but life-threatening complication of transfusion. We herein report a case of anti-Jkb IgM-related AHTR. Two hours after an 80-year-old man with myelodysplastic syndrome received a packed red blood cell (RBC) A+/Rh-/Jkb+/c- transfusion, he developed acute respiratory failure and a fever. Although he had tested negative in routine screening tests, the 37°C normal saline test was weakly positive for Jkb. We confirmed the presence of anti-Jkb IgM in the patient's serum by flow cytometry. This case demonstrates the potential utility of flow cytometry for IgM detection.

Associated criteria used in investigating suspected septic transfusion reactions: A scoping review

BACKGROUND AND OBJECTIVES

Septic transfusion reactions (STRs) occur as a result of bacterial contamination of blood or blood products, resulting in sepsis. This scoping review aimed to identify, explore and map the available literature on the STR criteria triggering the investigation of STR.

MATERIALS AND METHODS

Four electronic databases (MEDLINE, Web of Science, Science Direct, Embase) were searched to retrieve scientific literature reporting such criteria, published from 1 January 2000 to 5 May 2022. Grey literature was also searched from open web sources.

RESULTS

Of 1052 references identified, 43 (21 peer-reviewed and 22 grey literature) met the eligibility criteria for inclusion and data extraction after full article screening. Of them, most (27/43, 62.79%) were found to report a single set of criteria, and only two reported four or more sets of criteria. The analysis of 66 sets of criteria collected from the selected references revealed 57 different sets. A few sets of criteria used only one sign and symptom (s/s) (12.12%, n = 8), whereas 16 sets used 7-15 s/s (n = 16/66; 24.24%). Of the total 319 occurrences of s/s associated with the 66 sets of criteria, post-transfusion hyperthermia, body temperature increase and hypotension were the most common s/s categories. Of all the literature available, only one study tested the diagnostic accuracy of the STR criteria.

CONCLUSION

This scoping review revealed a substantial variation in criteria used to identify suspected STR. Consequently, conducting further studies to enhance the diagnostic accuracy of these criteria, which trigger STR investigations, is imperative for advancing clinical practice.

Study protocol of associated criteria used in investigating septic transfusion reactions (STRs): A scoping review about available evidence

Background and objective

Assessment criteria for septic transfusion reactions (STRs) are variable around the world. A scoping review will be carried out to find out, explore and map existing literature on STRs associated criteria.

Methods

This scoping review will include indexed and grey literatures available in English or French language from January 1, 2000, to December 31, 2021. Literature search will be conducted using four electronic databases (i.e., MEDLINE via PubMed, Web of Science, Science Direct, and Embase via Ovid), and grey literatures accompanying the research questions and objectives. Based on the inclusion criteria, studies will be independently screened by two reviewers for title, abstract, and full text. Extracted data will be presented in tabular form followed by a narrative description of inputs corresponding to research objectives and questions.

Platelet transfusion refractoriness: how do I diagnose and manage?

Platelet refractoriness continues to be a problem for thrombocytopenic patients because the risk of a major spontaneous or life-threatening bleed significantly increases when platelet counts drop below 10 × 109/L. The majority of patients have nonimmune causes driving the refractoriness, such as bleeding, medications, or diffuse intravascular coagulation; however, this article is dedicated to the diagnosis and support of patients with immune-based platelet refractoriness. Antibodies to class I HLA molecules (A and B alleles) are responsible for most immune-based refractory cases, with antibodies to platelet antigens seen much less frequently. Patients may be supported with either crossmatch-compatible or HLA-matched/compatible platelet units. When trying to select HLA units it can be difficult to find a perfect "4 of 4" match for the patient's class IA and IB alleles. In these cases, it is better to use the antibody specificity prediction method, which identifies compatible units that lack antigens recognized by the patient's anti-HLA antibodies. For an algorithmic approach to the patient with platelet refractoriness, see Visual Abstract.

Pseudomonas poae-Associated Fatal Septic Transfusion Reaction, Peoria, Illinois, USA, 2017

In the United States, fatal transfusion-transmitted infections from red blood cell units are rare. Although this pattern mostly reflects how inhospitable refrigerated red blood cell units are to contaminant growth, fatalities caused by microorganisms that can grow at storage temperature (4°C), but not in standard clinical blood cultures at 37°C, are probably underestimated. We analyzed a fatal red blood cell transfusion in Peoria, Illinois, USA, that occurred in 2017. Samples from the patient's whole blood and the red blood cell unit remained culture-negative during the investigation, despite direct visualization of gram-negative bacilli within the unit immediately after transfusion. We identified the bacteria as Pseudomonas poae, a nonpathogenic pseudomonad carrying multiple cold-shock domain protein genes, and confirmed its cold tolerance and inability to grow at 37°C. Our work indicates transfusion reaction workups need to include testing for psychrophilic organisms, which could explain the cause of other apparently culture-negative transfusion reactions.

Profound Intraoperative Hypotension Associated With Transfusion via the Belmont Fluid Management System

This retrospective observational case series conducted at 2 large academic centers over a 4-year period consists of 15 cases of profound hypotension in surgical patients immediately after initiation of the Belmont Fluid Management System for rapid transfusion of blood products. Halting the infusion and administering vasoactive agents led to resolution of hypotension. Repeat transfusion with the Belmont system resulted in repeat hypotension unless counteracted with vasopressors. No etiology was elucidated. This represents the largest documented association of acute hypotensive transfusion reaction with any rapid infusion system in surgical patients.

Clinical presentation of delayed hemolytic transfusion reactions and hyperhemolysis in sickle cell disease

Red blood cell (RBC) transfusion therapy is a key component in the comprehensive management of patients with sickle cell disease (SCD). Consequently, most adult SCD patients will receive at least one, and many will receive more than a hundred RBC transfusions in their lifetime. SCD patients develop RBC alloantibodies much more frequently than non-SCD transfused patients, which often make the selection of compatible RBCs extremely difficult, in addition to placing patients at significantly higher risk of suffering from delayed hemolytic transfusion reactions (DHTRs). Similar to alloimunization, DHTRs are much more common in patients with SCD compared to other heavily transfused populations, and are particularly consequential due to their propensity to cause hyperhemolysis, a life-threatening phenomenon in which both transfused RBCs in addition to the patient's own sickle-erythrocytes are destroyed. In this review, we highlight the incidence and pathophysiology of DHTRs; illustrate common presentations, appropriate evaluations and outcomes of DHTRs in patients with SCD; and discuss strategies for preventing or reducing the likelihood of DHTRs from occurring.

Post transfusion malaria: current state in Tunisia (new case reported in 2016)

Since the elimination of indigenous transmission of malaria in Tunisia in 1979, almost all the cases observed are imported cases related to travel. We report a recent case of highly probable post-transfusion malaria (PTM) in a 27-year-old Tunisian who has never left Tunisia. He has been allografted and has received of the globular pellets and the platelet units along with his hospitalization. The evolution was marked by the appearance of a fever resistant to antibiotics 15 days later. On day 11 of fever, a thick drop (TD) and a blood smear (BS) showed trophozoites of Plasmodium falciparum with 20% parasitaemia. The evolution was favorable under quinine. The epidemiological survey concluded that among blood donors an African donor from Ivory Coast, in Tunisia for 2 months, had a TD, a BS, a rapid test and a nested PCR for P. falciparum species were negative, only the serology was positive by indirect immunofluorescence (1/20). Real-time PCR was positive for P. falciparum, and the diagnosis of highly probable PTM was retained. Blood transfusion is a transmission pathway for Plasmodium and contamination can occur with a very few parasites. As a result, the PTM must be considered for any unexplained fever arising in the aftermath of a blood transfusion that and establish strict prevention recommendations for PTM in our country.

Reactive Blood Donor Notification; Their Responses And Perceptions: Experience From Southern Pakistan

BACKGROUND

Donor notification of reactive status is important to prevent the spread of disease. Response of reactive donors to seek confirmation and treatment is a direct reflection of their knowledge and attitudes towards transfusion transmittable infections.

METHODS

A cross sectional observational study was conducted from August 2014 to July 2015 at the blood bank of a tertiary care hospital, Karachi, Pakistan. Reactive donors' notification and responses were noted with reasons of failure. A cross-sectional analytical survey with non-probability purposive sampling was done on 350 potential consenting blood donors using a pre-tested questionnaire to assess their knowledge and attitude about disease awareness, transmission routes, financial implications and disease sensitization.

RESULTS

Out of 16660 donations, 5.57% were rejected on positive screening tests. Repeat donors (69.5%) with primary to secondary qualifications constituted the bulk of reactive donors. Donor notification rate were 54.25% whereas 28.68% donors responded to blood bank in person. The survey showed limited awareness about transfusion transmitted infections. Respondents who were ignorant of disease spread through blood transfusion comprised of 48%. 96.6% donors did not know the financial impact of treatment and 69.7% were unable to afford it. Moreover, 94.9% donors were not protected against hepatitis B. Participants with secondary education had significantly less odds of being adequately knowledgeable (OR=0.372, 95% CI: 0.203-0.681, p-value <0.01) but more likely to have a positive attitude.

CONCLUSIONS

There is need for structured pre-donation counselling to sensitize donors about transfusion related diseases in resource limited countries where treatment costs are high and out of reach for most donors..

Seroprevalence of transfusion-transmissible infections among blood donors at National Blood Transfusion Service, Eritrea: a seven-year retrospective study

BACKGROUND

Blood transfusion is associated with several risks particularly exposure to blood transfusion-transmissible infections (TTI), including: Hepatitis B virus (HBV), Hepatitis C virus (HCV), Human immunodeficiency virus (HIV) and Syphilis, among others. The threat posed by these blood-borne pathogens is disproportionately high in Sub-Saharan Africa (SSA). This fact underscores the need for continuous surveillance of TTIs in the region. Therefore, the study objectives were to evaluate the prevalence of TTIs and donor characteristics associated with positivity for TTIs at the National Blood Transfusion Center (NBTC) in Asmara, Eritrea.

METHODS

A retrospective analysis of blood donors' records covering the period from January 2010 to December 2016 was undertaken. The records were analyzed to evaluate the annualised cumulative prevalence of TTIs. Chi-square test (χ2) or Fisher's exact test was used to evaluate the relationship between serological positivity and particular donor characteristics. Logistic regression was fitted to identify factors associated with cumulative TTIs positivity. A P-value < 0.05 was considered statistically significant.

RESULT

A total of 60,236 consecutive blood donors were screened between 2010 and 2016. At least 3.6% of donated blood was positive for at least one TTI and 0.1% showed evidence of multiple infections. The sero-prevalence of HBV, HCV, HIV, syphilis and co-infection was 2.0, 0.7, 0.3 and 0.6%, respectively. Sex, type of donor and region were associated with TTI positivity. Except for donation frequency, there was a significant relationship (P < 0.005) between HBV, HCV, HIV and syphilis sero-positivity and other donor characteristics evaluated in the study.

CONCLUSION

The result demonstrates that Eritrea has relatively low TTI prevalence compared to other countries in Sub-Saharan Africa. However, the prevalence, particularly that of HCV, increased significantly in 2016. Enhancing donor screening and additional research utilizing nucleic acid based techniques should therefore be prioritized.

Relationship between perioperative blood transfusion and surgical site infections in pediatric general and thoracic surgical patients

BACKGROUND

Recently, perioperative transfusions were demonstrated to be associated with higher rate of surgical site infections (SSIs) in neonates. We sought to examine whether a similar relationship exists between perioperative blood transfusions and SSI among non-neonatal pediatric general surgical patients.

METHODS

We conducted an IRB-approved retrospective study reviewing non-neonatal patients (age greater than 28days and less than 18years) who underwent a general or thoracic surgical procedure in 2012, 2013, 2014, in the American College of Surgeons National Safety and Quality Improvement Project-Pediatric (ACS-NSQIP-P) Participant User Files. We used Chi-square analyses to perform a bivariate analysis comparing proportions of SSI's between patients who received blood transfusion to those who did not. Multiple logistic regression analyses compared the odds of SSIs in transfused versus nontransfused patients controlling for organ failure, steroid use, nutritional status, current infection, American Society of Anesthesiologists (ASA) Physical Status classification, and wound classification.

RESULTS

There were 55,133 patients with 1779 patients who received blood transfusion (≥25ml/kg body weight) during or within 72h of surgery. Bivariate analysis showed at least twice the rate of infection in transfused patients compared to nontransfused patients (p<0.01): superficial SSI 3.5% vs 1.5%; deep SSI 0.8% vs 0.2%, organ space SSI 3.8% vs 1.6%; deep dehiscence 2% vs 0.3%. Total wound infections and dehiscence for transfused patients were 10.5% vs 3.8% in nontransfused patients (p<0.01). Multiple regression analysis showed that nutritional issue, current infection, and wounds not classified as "clean" have statistically significant correlation with SSI. Although there was significant interaction between ASA and transfusion (p<0.0001), we found statistically significant associations between transfusions and SSI for ASA class 1-2 (OR=5.51, 95% CI 3.47-7.52), ASA class 3 (OR=2.06, 95% CI 1.63-2.61), and ASA class 4-5 (OR=1.67, 95% CI 1.15-2.42).

CONCLUSION

In non-newborn pediatric general and thoracic surgery patients, transfusions were associated with higher risk of SSI or wound dehiscence. Although there was a significant interaction between ASA and transfusion, OR for SSI was stronger for lower ASA classes.

TYPE OF STUDY

Retrospective Review.

LEVEL OF EVIDENCE

II.

Reversible splenial lesion syndrome after blood transfusion presents callosal disconnection syndrome: A case report

RATIONALE

Reversible splenial lesion syndrome (RESLES) is a reversible condition with an excellent prognosis in most patients. The clinical features include altered states of consciousness, delirium, headache, and seizures, but no callosal disconnection syndromes have been described in RESLES.

PATIENT CONCERNS

We presented a 57-year-old patient with alien hand syndrome, autotopagnosia, gait disorders, and left ideomotor apraxia after blood transfusion. The brain magnetic resonance imaging (MRI) showed a few regions with high signal intensity in the genu, body, and splenium of the right corpus callosum on diffusion weighted images. Cerebrovascular examination was unremarkable.

DIAGNOSES

He was diagnosed with RESLES and callosal disconnection syndrome.

INTERVENTIONS

The patient received symptomatic and supportive treatment in our hospital.

OUTCOMES

He recovered to baseline on following up of 6 months and abnormalities on brain MRI completely disappeared.

LESSONS

Neurologists should be aware of the symptoms of callosal disconnection syndrome in RESLES. In addition, caution should be taken when transfusing blood products in patients with gastrointestinal bleeding.

Role of heme in lung bacterial infection after trauma hemorrhage and stored red blood cell transfusion: A preclinical experimental study

BACKGROUND

Trauma is the leading cause of death and disability in patients aged 1-46 y. Severely injured patients experience considerable blood loss and hemorrhagic shock requiring treatment with massive transfusion of red blood cells (RBCs). Preclinical and retrospective human studies in trauma patients have suggested that poorer therapeutic efficacy, increased severity of organ injury, and increased bacterial infection are associated with transfusion of large volumes of stored RBCs, although the mechanisms are not fully understood.

METHODS AND FINDINGS

We developed a murine model of trauma hemorrhage (TH) followed by resuscitation with plasma and leukoreduced RBCs (in a 1:1 ratio) that were banked for 0 (fresh) or 14 (stored) days. Two days later, lungs were infected with Pseudomonas aeruginosa K-strain (PAK). Resuscitation with stored RBCs significantly increased the severity of lung injury caused by P. aeruginosa, as demonstrated by higher mortality (median survival 35 h for fresh RBC group and 8 h for stored RBC group; p < 0.001), increased pulmonary edema (mean [95% CI] 106.4 μl [88.5-124.3] for fresh RBCs and 192.5 μl [140.9-244.0] for stored RBCs; p = 0.003), and higher bacterial numbers in the lung (mean [95% CI] 1.2 × 10(7) [-1.0 × 10(7) to 2.5 × 10(7)] for fresh RBCs and 3.6 × 10(7) [2.5 × 10(7) to 4.7 × 10(7)] for stored RBCs; p = 0.014). The mechanism underlying this increased infection susceptibility and severity was free-heme-dependent, as recombinant hemopexin or pharmacological inhibition or genetic deletion of toll-like receptor 4 (TLR4) during TH and resuscitation completely prevented P. aeruginosa-induced mortality after stored RBC transfusion (p < 0.001 for all groups relative to stored RBC group). Evidence from studies transfusing fresh and stored RBCs mixed with stored and fresh RBC supernatants, respectively, indicated that heme arising both during storage and from RBC hemolysis post-resuscitation plays a role in increased mortality after PAK (p < 0.001). Heme also increased endothelial permeability and inhibited macrophage-dependent phagocytosis in cultured cells. Stored RBCs also increased circulating high mobility group box 1 (HMGB1; mean [95% CI] 15.4 ng/ml [6.7-24.0] for fresh RBCs and 50.3 ng/ml [12.3-88.2] for stored RBCs), and anti-HMGB1 blocking antibody protected against PAK-induced mortality in vivo (p = 0.001) and restored macrophage-dependent phagocytosis of P. aeruginosa in vitro. Finally, we showed that TH patients, admitted to the University of Alabama at Birmingham ER between 1 January 2015 and 30 April 2016 (n = 50), received high micromolar-millimolar levels of heme proportional to the number of units transfused, sufficient to overwhelm endogenous hemopexin levels early after TH and resuscitation. Limitations of the study include lack of assessment of temporal changes in different products of hemolysis after resuscitation and the small sample size precluding testing of associations between heme levels and adverse outcomes in resuscitated TH patients.

CONCLUSIONS

We provide evidence that large volume resuscitation with stored blood, compared to fresh blood, in mice increases mortality from subsequent pneumonia, which occurs via mechanisms sensitive to hemopexin and TLR4 and HMGB1 inhibition.

An acute transfusion reaction

We present the case of a 67-year-old man who suffered an acute anaphylactic reaction during red cell transfusion due to the presence of anti-IgA antibodies. The incidence and clinical relevance of anti-IgA antibodies in IgA deficiency is reviewed, and the wider investigation and management of acute transfusion reactions is also discussed. This case highlights the need to consider the potential risks of blood component transfusion against the purported benefit.

Transfusion reactions: prevention, diagnosis, and treatment

Blood transfusion is one of the most common procedures in patients in hospital so it is imperative that clinicians are knowledgeable about appropriate blood product administration, as well as the signs, symptoms, and management of transfusion reactions. In this Review, we, an international panel, provide a synopsis of the pathophysiology, treatment, and management of each diagnostic category of transfusion reaction using evidence-based recommendations whenever available.