Febrile Transfusion Reactions Research Articles

Transfusion transmissible malaria: seroprevalence of malaria parasitemia in blood donors in Garhwal region of Uttarakhand, India

Background and Objectives: Malaria was the first ever reported case of transfusion transmitted infection (TTI). Transfusion transmissible malaria (TTM) can result in febrile transfusion reaction in the recipient. TTM can be fatal if the blood transfu- sion recipient is from vulnerable population i.e. pregnant women or young children. Therefore, the present study was done to estimate the seroprevalence of malaria parasitemia among blood donors in Garhwal region.
 Materials and Methods: Study subjects were healthy blood donors who had passed the screening criteria for blood do- nation. Donors with a history of malaria were temporarily deferred for 3 months following full recovery. Screening of the donated blood units for malaria parasite was done using immunochromatography based rapid diagnostic test. Thin smear examination was performed for malaria parasite species identification.
 Results: A total of 1984 blood donations were screened for TTI. The seroprevalence of HBV, HCV HIV and syphilis was 0.3% (n=6), 0.25% (n=5), 0% (n=0) and 0% (n=0) respectively. The seroprevalence of malaria parasite was 0.05% (n=1). Plasmodium vivax was identified upon thin smear examination. The donor reactive for malaria parasite was a replacement donor and gave no recent history of fever or any past history of malaria.
 Conclusion: Meticulous donor screening combined with rapid diagnostic tests for malaria parasite is the most practical strategy to prevent TTM in Garhwal region of India.

The transfusion-associated dyspnea prospective observation and laboratory assessment study: a protocol for investigating and disambiguating cardiopulmonary and high-grade febrile transfusion reactions in adults

Background: Cardiorespiratory transfusion reactions drive most transfusion-related morbidity and mortality. Transfusion-associated circulatory overload and transfusion-related acute lung injury have established causes, important impacts, mitigation options, and revised definitions, while non-conforming CRTRs fall into a category known as transfusion-associated dyspnea. Though procedures to investigate high-risk febrile transfusion reactions are typically rooted in detecting incompatibility or bacterial contamination, a common standard for examining CRTRs is lacking. CRTRs are further challenged by charting limitations, confounding (or enhanced susceptibility) by comorbidities, and/or overlapping insults. Deeper profiling of CRTRs could improve categorizations, reveal best-value diagnostics, and decipher the nature of (and/or minimize) reactions coded as TAD. Methods: The primary objective of this multi-center study is to reduce uncertainty in final conclusions drawn on CRTRs (cases), defined by dyspnea with objective disturbances and/or significant hemodynamic insults, with/without fever (±F). HRFTRs (controls) represent higher-grade F (T≥39°C or chills/rigors or lower-grade F (≥38°C by +Δ1°C) with non-respiratory effects). Patients (goal: 200) consent to additional sampling (≤24h post-TR) to identify contributing factors in case/control presentations, and in diagnostic groups (TRALI, TACO±F, TAD). Mechanistic axes of interest are cardiorenal, hemolytic, leukoagglutinating, biolipid, vasoactive, and inflammatory. Secondary goals include elucidation of real-life “insult-multiplicity” in CRTRs, tests of greatest yield, and distinguishing features in TRALI/TACO/TAD. Conclusions: A deep systematic CRTR probe may not only reduce diagnostic uncertainty but frame biomarker performance and pathologic signatures in definition-specific CRTRs. The re-classifiability or biology of TAD may be better understood. High-quality, mechanistic, true-to-quantity hemovigilance better exposes burdens and management options. Trial Registration: The trial is registered with ClinicalTrials.gov. with registry number NCT04267029.

Clinical Burden of β-Thalassemia: Findings from a Multinational Medical Record Abstraction Study

Introduction: β-thalassemias are rare genetic conditions characterized by mutations in the HBB gene, resulting in defective β-globin production and ineffective erythropoiesis. The severity of disease varies according to genotype. Periodic red blood cell transfusions (RBCTs) are the standard of care, but long-term dependence on RBCTs is associated with risk of iron overload and other clinical sequelae. As new treatment options are available, understanding the clinical burden of β-thalassemia and RBCTs is essential to optimal clinical care. Methods: This retrospective observational study analyzed anonymized medical records from adults (≥ 23 years of age) with transfusion dependent β-thalassemia (TDT) or non-transfusion dependent β-thalassemia (NTDT) who visited a participating physician on or after January 2016. Physicians in the UK, France, Germany, Spain, and Canada abstracted medical records for eligible patients with ≥ 5 years of medical history in their practice. Clinical characteristics, transfusion patterns, and RBCT utilization were analyzed descriptively. Results: A total of 214 patients were included: 118 (55%) with TDT and 96 (45%) with NTDT. Mean age was 36 years and body mass index was approximately 24 kg/m2 in both groups; 71% and 61% of patients with TDT and NTDT, respectively, were male. Mean (median) duration of patient medical history in the practice was 8.5 (7.5) and 8.6 (6.9) years for patients with TDT and NTDT, respectively. Among the TDT group, the mean (standard deviation [SD]) age at first diagnosis and first treatment of β-thalassemia was 11.1 (10.2) and 13.7 (11.2) years, respectively. The most common reasons for initiating RBCTs were: hemoglobin (Hb) levels < 8 g/dL (32%), < 7 g/dL (21%), < 6 g/dL (14%), and to maintain Hb > 10 g/dL (25%). The majority of patients (n = 87 [74%]) received β-thalassemia mutation testing; of these, 31 (36%) were β0/β0, 19 (22%) were β0/β+, and 23 (26%) were β+/β+. More than one-third (n = 41 [35%]) of patients with TDT had progressed from NTDT, at a mean (SD) age of 31.4 (11.7) years. The mean (SD) pre-transfusion Hb level in the TDT group was 6.9 g/dL (1.30) (n = 94). At the time of data abstraction, most patients with TDT (n = 90/118 [76%]) had an RBCT at least every 3 weeks (Figure 1), receiving a mean (SD) of 2.4 (0.64) RBC units (n = 101) per session. Approximately one-third (n = 43/118 [36%]) of patients with TDT received 3 RBC units per session, on average (Figure 2). Patients with TDT received their most recently reported RBCT regimen for a mean (SD) of 72.6 (72.43) months (n = 83). Adverse events (AEs) associated with the most recent transfusion regimen included allergic reactions (n = 3/118 [3%]), non-hemolytic febrile transfusion reactions (n = 2/118 [2%]), and transfusion-associated circulatory overload (n = 1/118 [1%]). Among the NTDT group, the mean (SD) age at first diagnosis and first treatment of β-thalassemia was 14.5 (11.8) and 18.8 (12.0) years, respectively. Approximately two-thirds (n = 63 [66%]) of patients with NTDT received β-thalassemia mutation testing; of these, 7 (11%) were β0/β0, 19 (30%) were β0/β+, and 20 (32%) were β+/β+. Among patients with NTDT, who had ≥ 1 RBCT (n = 81 [84%]), the mean (SD) number of RBCTs received was 15.9 (15.88) (in the physician's practice or as history noted in the medical record). The most common reasons for receiving RBCTs were: Hb levels < 8 g/dL (33%), < 7 g/dL (20%), and < 6 g/dL (14%), infection exacerbating anemia (16%), and to maintain Hb > 10 g/dL (15%). The mean (SD) pre-transfusion Hb level was 7.4 g/dL (1.18) (n = 67) and a mean (SD) of 2.2 (0.57) RBC units (n = 66) was transfused per session. AEs for patients with NTDT included allergic reactions (n = 4/96 [5%]), alloimmunization (n = 1/96 [1%]), autoimmune hemolytic anemia (n = 1/96 [1%]), and nonhemolytic febrile transfusion reaction (n = 1/96 [1%]). Conclusions: This study provides much needed insight into the real-world clinical needs of patients with β-thalassemia. About one-third of patients with TDT had progressed from NTDT. Patients with TDT had a high transfusion burden, requiring RBCTs every 2-4 weeks and 2-3 RBC units per session, on average. Additionally, patients with NTDT had low pre-transfusion Hb and required 2 RBC units per transfusion, on average. New therapeutic options are needed that can reduce RBCT dependency for patients with TDT, and improve pre-transfusion Hb levels and transfusion requirements for patients with NTDT. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Utilization of Fresh Frozen Plasma and Cryoprecipitate in Factor VIII and Factor IX Deficient Hemophilia Patient

Haemophilia is one of the most common causes of inherited bleeding disorder resulting from deficiency of coagulation factor VIII or factor IX. Ideally, replacement should be done with factor concentrate. Due to economic constraints associated with its procurement, bleeding episodes are regularly dealt with Fresh Frozen Plasma (FFP) or cryoprecipitate in low-resource countries. This study was carried out to compare the utilization profile and clinical characteristics of haemophilia patients receiving FFP and cryoprecipitate for replacing clotting factor deficiency. This cross-sectional comparative study was conducted in the day care unit of the Department of Transfusion Medicine of Bangabandhu Sheikh Mujib Medical University between 2 groups of haemophilia patients receiving either cryoprecipitate or FFP for treatment. Out of the total 100 haemophilia patients, 50 were treated with cryoprecipitate and 50 with FFP. In FFP group, the majority of patients (48% in cryoprecipitate group and 36% in FFP group) were in the age group of more than 5 to 10 years followed by 11 to 15 years age (24% versus 30%) with a mean SD of age in cryoprecipitate group and FFP group being 11.78±5.61 and 13.42±6.12 years, respectively. About 33 (66.0%) had a history of bleeding following trauma and 32 (64.0%) had a history of spontaneous bleeding among the patients in cryoprecipitate group as a cause of swelling/bleeding and in FFP group, 23 (46.0%) had history of spontaneous bleeding followed by 23 (34.0%) with history of bleeding following trauma. Regarding the type of bleeding, oral bleeding was most common, followed by soft tissue bleeding in both group (40.0% versus 38.0%). Presence of ecchymosis in both groups was statistically significant. The difference in type of haemophilia between the two groups was statistically significant (p&lt;0.001) with a prevalence of haemophilia A of about 88%. The life expectancy of haemophilia patients is increasing dramatically day by day with successful and effective treatment with the appropriate plasma component. Cryoprecipitate is better than FFP as there is less chance of volume overload minimizing leucocyte induced non-haemolytic febrile transfusion reaction and rapid correction of coagulation factor.

Effect of platelet storage duration on clinical outcomes and incremental platelet change in critically ill children.

We performed a secondary analysis of a prospective, observational point-prevalence study. Children (3 days to 16 years of age) from 82 pediatric intensive care units in 16 countries were enrolled if they received a PLT transfusion during one of the predefined screening weeks. Outcomes (including PLT count increments, organ dysfunction, and transfusion reactions) were evaluated by PLT storage age. Data from 497 patients were analyzed. The age of the PLT transfusions ranged from 1 to 7 days but the majority were 4 (24%) or 5 (36%) days of age. Nearly two-thirds of PLT concentrates were transfused to prevent bleeding. The indication for transfusion did not differ between storage age groups (P = .610). After patient and product variables were adjusted for, there was no association between storage age and incremental change in total PLT count or organ dysfunction scoring. A significant association between fresher storage age and febrile transfusion reactions (P = .002) was observed. The results in a large, diverse cohort of critically ill children raise questions about the impact of storage age on transfusion and clinical outcomes which require further prospective evaluation.

Human Leucocyte Antigens in blood transfusion

Human Leucocyte Antigen (HLA) genes and molecules have an important role in transplantation, aetiology of many autoimmune, non‐autoimmune and infection diseases. Due to the extremely high polymorphism of HLA genes and their different frequency distributions in various populations, an increasing probability of HLA non‐compatible blood products, tissues or organs usage exists. For that reason, the aim of this paper was to give a concise overview of the role of HLA antigens and antibodies in adverse reactions caused by administration of transfusion products. The HLA system can cause detrimental immune reactions in transfusion therapy (platelet immune refractoriness, febrile transfusion reaction, transfusion‐related acute lung injury and transfusion‐associated graft versus host disease). Anti‐HLA antibodies present in the patient are responsible for some of these reactions, while anti‐HLA antibodies or HLA reactive cells present in the transfused product are accountable for immune‐reactivity in other cases. In order to avoid or reduce the development of these transfusion‐related events, anti‐HLA antibody‐negative or compatible products should be used. This is increasingly facilitated by introduction of more sensitive and specific techniques to determine anti‐HLA antibodies and gene polymorphisms. In conclusion, the most common adverse reactions related to administration of incompatible HLA transfusion products are discussed. Basic information about HLA genes and antibodies as well as methods for their detection is also provided in order to give sufficient data for safe and efficient administration of transfusion products.

Romiplostim in patients with refractory aplastic anaemia previously treated with immunosuppressive therapy: a dose-finding and long-term treatment phase 2 trial

Aplastic anaemia is a rare, life-threatening condition, characterised by pancytopenia with hypocellular bone marrow. Haematopoietic stem cells and most progenitor cells express thrombopoietin receptor (c-MPL). Romiplostim is a peptibody with c-MPL agonist activity that stimulates endogenous thrombopoietin production and leads to promoting the proliferation and differentiation of megakaryocytes in the bone marrow. In this phase 2 trial we aimed to assess the activity and safety of romiplostim in patients with aplastic anaemia who were previously treated with immunosuppressive therapy. We did an open-label, phase 2 study including a randomised, parallel, dose-finding part followed by an extension part to evaluate long-term treatment at two clinical centres in Seoul, South Korea. Eligible patients were aged 19 years or older, and had aplastic anaemia confirmed by bone marrow and cytogenetic studies and thrombocytopenia (platelet count ≤30 × 109/L), an Eastern Cooperative Oncology Group performance status score of 2 or lower, and were previously treated with immunosuppressive therapy, including at least one course of antithymocyte globulin plus cyclosporin. In the dose-finding part, patients were randomly assigned to fixed dose cohorts (1, 3, 6, or 10 μg/kg) of subcutaneous romiplostim once weekly for 8 weeks, according to a static allocation procedure after stratification by platelet count. In the extension part of the study, patients continued romiplostim titrated every 4 weeks in single steps (1, 3, 6, 10, 13, 16, and 20 μg/kg once weekly), depending on platelet response and safety up to 1 year (weeks 9-52). Patients who had a platelet response during weeks 46-53 continued dose titration in single steps (3, 6, 10, 13, 16, and 20 μg/kg once weekly) for an additional 2 years (weeks 53-156). The primary endpoint was the proportion of patients achieving a platelet response at week 9 (after completion of the dose-finding part). Activity was assessed per-protocol in all patients evaluable for response at week 9 and safety was assessed in all patients who received at least one dose of romiplostim. This trial is registered with ClinicalTrials.gov, NCT02094417. Between April 14 and Nov 24, 2014, 35 patients were enrolled and randomly assigned to one of four dose cohorts: romiplostim 1 μg/kg (n=7), 3 μg/kg (n=9), 6 μg/kg (n=9), and 10 μg/kg (n=10). Data cutoff for this final analysis was on April 14, 2018. The median duration of treatment for all patients was 53 weeks (IQR 35-155). Ten (30%) of 33 evaluable patients achieved a platelet response at week 9, including seven (70%) of ten patients in the 10 μg/kg cohort, three (33%) of nine patients in the 6 μg/kg cohort, and no patients in both the 3 μg/kg and 1 μg/kg cohorts. During the extension study, 18 (55%) of 33 evaluable patients had a platelet response during weeks 46-53 and were eligible for continued treatment. Ten (30%) patients maintained a platelet response at 2 and 3 years, of whom nine had an erythroid response and five a neutrophil response, and completed protocol treatment. Treatment-related adverse events occurred in three (9%) of 35 patients, including grade 1 or 2 myalgia, fatigue, and dizziness. 17 (49%) of 35 patients had adverse events of grade 3 or higher; seven (20%) had serious adverse events (one event of febrile neutropenia, cataract, retinal detachment, macular fibrosis, inguinal hernia, appendicitis, cellulitis, tendon injury, and transfusion reaction); and one patient died from sepsis during treatment; none of these events were related to treatment. No patients developed clonal evolution. Romiplostim seems to be active and has a favourable safety profile in patients with refractory aplastic anaemia. 10 μg/kg once weekly might be used as a recommended starting dose in future studies. These findings warrant further investigation. Kyowa Hakko Kirin Korea.

Work‐up in the case of granulocyte antibodies

Granulocyte allo‐ and autoantibodies have been implicated in a variety of clinical conditions such as primary and secondary autoimmune neutropenia (AIN), alloimmune neutropenia (NAIN), transfusion‐related acute lung injury (TRALI) as well as febrile and severe pulmonary transfusion reactions. The classic granulocyte agglutination test (GAT) in combination with the granulocyte indirect immunofluorescence test (GIFT) can detect nearly all relevant antibodies. HNA‐1, ‐2, 4, 5 and HLA class I antibodies are clearly detectable in the GIFT while HNA‐3 antibodies strongly agglutinate neutrophils in the GAT. The glycoprotein‐specific and highly sensitive monoclonal antibody‐specific immobilization of granulocyte antigens (MAIGA) test detects all human neutrophil antigen (HNA) antibodies except for HNA‐3 but is time‐consuming and requires highly skilled personnel. For TRALI diagnostics, laboratory testing is completed by the indirect lymphocyte immunofluorescence test (LIFT), and HLA class I and II ELISAs or fluorescent bead‐based assays (Luminex). The latter also enable faster and more automated HNA antibody detection but to date not all specificities, especially HNA‐3, can be reliably detected so that still the classical tests have to complete the methodological spectrum. HNA allelotyping by PCR methods is the first choice for all HNA except for HNA‐2 because the molecular reason for the HNA‐2null phenotype is not completely understood. Establishing a PCR‐SSP reaction for the main CD177*787A&gt;T polymorphism comprises the risk to miss other causes so that HNA‐2 is still typed serologically. Granulocyte serology even today is widely based on a variety of manual methods, requires experienced laboratory staff and profound knowledge of granulocyte immunobiology.

Prevalence of naturally occurring non-AB blood type incompatibilities in cats and influence of crossmatch on transfusion outcomes.

BackgroundRecognition of the feline red blood cell (RBC) antigen Mik and the presence of naturally occurring anti‐Mik antibodies resulting in acute hemolytic transfusion reactions prompted the recommendation to perform a crossmatch before a cat's first RBC transfusion, but this guideline has not yet become a standard practice.ObjectiveTo determine the prevalence of naturally occurring non‐AB alloantibodies detectable by tube crossmatch, and to compare transfusion outcomes in cats with and without a crossmatch performed.AnimalsThree hundred cats that received an RBC transfusion, with or without a major crossmatch performed.MethodsRetrospective study.ResultsMajor crossmatch incompatibilities were documented in 23 of 154 transfusion‐naive cats (14.9%) and in 15 of 55 previously transfused cats (27%; P = 0.042). Type‐specific packed RBCs (pRBCs) were administered to 167 and 82 cats with and without a crossmatch, respectively. Median volume of pRBCs administered during the first transfusion was 5.3 mL/kg (range, 2.4‐18 mL/kg). Median change in PCV scaled to dose of pRBCs was +0.8%/mL/kg; administration of crossmatch‐compatible pRBCs was not associated with a greater increase in PCV. Febrile transfusion reactions occurred more often in cats that received non‐crossmatched (10.1%) compared to crossmatched (2.5%) pRBCs (P = 0.022). Seventy‐six percent of cats that received pRBC transfusions survived to hospital discharge. A crossmatch was not associated with improved survival to discharge or at 30 or 60 days posttransfusion.Conclusions and Clinical ImportanceThe prevalence of naturally occurring non‐AB incompatibilities is sufficiently high to justify the recommendation to perform a crossmatch before all (including the first) RBC transfusions in cats.

A study on therapeutic plasma exchange using apheresis in treatment of Guillain-Barré syndrome in a tertiary care teaching hospital

Background: Therapeutic plasma exchange (TPE) is the separation and removal of plasma from whole blood with replacement by a crystalloid/colloid solution (typically albumin or plasma). The DGHS has established guidelines and recommendations for application of therapeutic apheresis in clinical practice. Guillain-Barré syndrome (GBS) is considered category I indications for TPE. This study was undertaken to establish the effectiveness and safety of therapeutic plasma exchange in GBS which is one of the common indication for TPE at our tertiary care teaching hospital.Methods: A retrospective study of 30 patients admitted to a tertiary care teaching hospital, from January 2014 to December 2016 with clinical signs of Guillain-Barre syndrome (GBS) and/or GBS variants were evaluated for performing TPE. A total of 104 procedures were performed for 30 patients. Replacement of crystalloids and plasma was used. Medical Research Council scale was used to assess the clinical improvement by measuring the grade of muscle power. Information was collected in a structured proforma and statistical analysis was performed using SPSS software (version 20). P value less than 0.05 was considered statistically significant.Results: During the study period, 104 procedures were performed on 30 patients on an average of three procedures per patient. The average age of the patients was 41.4±10.4 years. The mean period of illness at admission was 14.5±5.4 (range 4-32) days. In 23 out of 30 patients, more than three TPE procedures were done, out of which 21 patients clinically improved. The common complications during the procedure were chills (16%), hypotension (10%) and non-hemolytic febrile transfusion reaction (10%) and they were managed accordingly. Two (6.7%) patients who were not ambulatory at discharge had significantly (p &lt;0.05) lower grade of power in lower limbs at admission and all patients recovered fully on follow up.Conclusions: GBS is one of the most commonly occurring clinical paralytic disorders. 76.7% of patients underwent three or more cycles of TPE with 70% had excellent clinical improvement which was comparable with various other studies. Based on results published by various other studies, therapeutic plasma exchange is a comparatively safe and effective procedure.

Prognostic effect of different blood transfusion ratios in trauma patients with massive transfusion

Objective To evaluate the prognostic effect of different ratios of fresh frozen plasma (FFP) to packed red blood cells (PRBC) in massively transfused trauma patients. Methods A retrospective cohort study was conducted for 210 trauma patients who received more than 10 units of PRBC during the initial 24 hours from January 2007 to June 2015. The patients were divided into four groups: Group A(PRBC ∶FFP≤1, n=41), Group B (1 2, n=76). At 24 hours after admission, blood transfusion amount, blood transfusion ratios, post-transfusion adverse reactions (allergy, non-hemolytic febrile transfusion reaction, hemolysis, congestive heart failure, pulmonary edema, etc) and coagulation changes [hemoglobin (Hb), platelet count (PC), prothrombin time(PT), activated partial thromboplastin time(APTT), international normalized ratio (INR), etc] were compared among groups. Prognostic markers including sequential organ failure assessment(SOFA), hospital stay, ICU stay, 30-day mortality and causes of death were also evaluated. Results Use of PRBC was decreased significantly in Group A than in other groups (P 0.05). The coagulation indices (PT, APTT and INR) in Groups A and B were significantly decreased compared to Group D after transfusion (P 0.05). Group D was associated with higher SOFA and higher 30-day mortality than other groups(P 0.05). Meanwhile, ratio of patients died of massive hemorrhage in Group D was also higher than other groups (P<0.01). Kaplan-Meier survival analysis showed the survival interval was the shortest in Group D, while the longest in Group B and C. Conclusions Modest transfusion ratios(1. 5<PRBC ∶FFP≤2)within 24 hours can substantially improve outcomes in trauma patients. Aggressive ratios may improve coagulation indices and reduce use of PRBC, with no more benefit to the outcomes. Key words: Blood component transfusion; Wounds and injuries; Prognosis

Fibrinogen Supplementation Ex Vivo Increases Clot Firmness Comparable to Platelet Transfusion in Thrombocytopenia

(Abstracted from Br J Anaesth, 117(5):576–582, 2016) This study investigates how the use of fibrinogen concentrate ex vivo compares to the use of in vivo platelet transfusion (PT) to improve clot firmness in patients with thrombocytopenia (platelet count <150 × 109 L−1). While PT is currently first-line treatment to prevent bleeding in patients with clinically significant thrombocytopenia, PT carries significant risks, including viral or bacterial infection, febrile and nonfebrile transfusion reactions, and transfusion-related lung injury.

Post-Transfusion Fevers and Post-Reaction Culture Practices at a Large Academic Hospital Transfusion Service: Quality of Information and Calculated Bacterial Contamination Event Rates

Introduction: The extent to which febrile transfusion reactions (FTRs) are investigated is the extent to which bacterial contamination (BaCon) may be ascertained; FTR rates in turn vary with policies concerned with their recognition and approach. Microbiology and serology aim to rule out contamination or incompatibility, both potentially fatal. BaCon and acute hemolytic transfusion reactions (AHTR) followed transfusion related lung injury (TRALI) as the leading causes of transfusion-related death in the US in 2013 (FDA: 59 fatalities: 38% TRALI, 15% AHTR, 10% BaCon). Timely BaCon recognition enables interdiction/examination of sister products, while highlighting contamination points in the work sequence. The quality and quantity of hemovigilance data from a large hospital transfusion service were reviewed with respect to overall component utilization, adverse events, and patient/product microbiology, so as to gain a contemporary estimate of BaCon.Methods: The blood transfusion laboratory (BTL) of the tertiary care, 767-bed university hospital is supplied by Canadian Blood Services and managed by a team of technologists, a transfusion safety officer (TSO), and transfusion medicine specialists (TM MDs). Patient Reaction Events (PRE) reported to the BTL were logged over a 5 year period alongside components transfused (red cell units [pRBC], adult dose platelet concentrates [APC], frozen plasma [FP], and cryoprecipitate [crpt]). By policy, PRE are reported and formally investigated, with quarterly analyses. Roughly 3% of product recipients experience a PRE, and 40% are febrile in nature. Patient sampling is discouraged for "lower risk" fevers (asymptomatic Tmax <39C), whereas "high risk" fevers (Tmax >39C or major symptoms and/or vital sign disturbances) call for cultures of the patient and implicated product(s), as well as AHTR testing. TSO and TM MD review ensue to conclude product imputability, event severity, and final diagnosis. Definite BaCon (Def-BaCon) is defined as product and patient positive (+) for the same microbe, Probable BaCon (Prob-BaCon) as product (+) [but patient negative or untested], and Possible BaCon (Poss-BaCon) as patient (+) [but product negative or untested]. Poss-BaCon was re-classified to high-imputability (Hi-Imp Poss-BaCon) if case review failed to discover a more likely pre-existing source.Results:Between 1/1/2010 to 31/12/2014, 1,624 PRE occurred through 290,044 components dispensed (175,542 pRBC, 43,187 APC, 58,235 FP, 13,080 crpt). Patient cultures occurred in 617 (38%) of PRE, and product cultures occurred in 406 (25%) of PRE. BaCon rates varied significantly according to concluded certainty, with significant re-scaling of poss-BaCon after careful case review (Table). Table 1rate (95% confidence interval):rate per culturerate per patient reaction event (PRE)rate per component dispensedDef-BaCon (4 cases)0.65% (0.26-1.6)0.25% (0.10-0.63)1.4 x 10^-5 (0.6-3.5) or 1 in 72,511Prob-BaCon (13 cases)3.2% (1.9-5.4) (products)0.80% (0.47-1.4)4.5 x 10^-5 (2.6-7.7) or 1 in 22,311Poss-BaCon (96 cases)15.6% (12.9-18.6)5.9% (4.9-7.2)3.3 x 10^-4 (2.7-4.0) or 1 in 3,021Hi-Imp Poss-BaCon (14 cases)2.3% (1.4-3.8)0.86% (0.52-1.4)4.8 x 10^-5 (2.9-8.1) or 1 in 20,717Discussion/Conclusions: These data illustrate practical limits to deducing BaCon rates, despite robust hemovigilance. Def-BaCon was rare (1 in 72,511), while Prob-BaCon and Hi-Imp Poss-BaCon were more frequent at ~1 in 20,000. Current as-practiced tools in FTR/BaCon investigation are flawed at various levels. Underestimates stem from under-culturing and test sensitivity, and overestimates occur with incomplete case review for true sources of bacteremia, with Poss-BaCon as high as 1 in 3000. The MD Anderson Cancer Center (Ricci, et al 2014) reported on 999 reactions, with 738 (74%) in 642 central venous catheter (CVC) patients; 606 were cultured within a week of reaction, and 60 (9.9%) were bacteremic. Fevers were concluded to more likely represent the unmasking of CVC colonization rather than BaCon. Systematically incorporating (and adjusting for) CVC data may thus help to reduce inflationary poss-BaCon rates. On the other hand, more rigorous product testing (with biofilm studies) may scale BaCon rates upwards. Clinicolaboratory studies are needed to clarify the true relationship between febrile reactions, bacterial sources, and their significance. DisclosuresNo relevant conflicts of interest to declare.

Survival Time of Cross-Match Incompatible Red Blood Cells in Adult Horses.

BackgroundThere is a markedly reduced half‐life of transfused RBCs when donor and recipient cats or humans are cross‐match incompatible. Only 10–20% of horses have naturally occurring alloantibodies. Therefore, cross‐match testing before blood transfusion is not always performed.HypothesisCross‐match incompatibility predicts shortened RBC survival time as compared to that of compatible or autologous blood.AnimalsTwenty healthy adult horses.MethodsProspective trial. Blood type, anti‐RBC antibody screen (before and 1 month after transfusion) and major and minor cross‐match determined 10 donor‐recipient pairs. Two pairs were cross‐match compatible, the remainder incompatible. Donor blood (4 L) was collected into citrate phosphate dextrose adenine‐1, labeled with NHS‐biotin, and transfused into recipients. Samples were collected at 1 hour and 1, 2, 3, 5, 7, 14, 21, 28, and 35 days after transfusion, and biotinylated RBCs were detected by flow cytometry. Horses were monitored for transfusion reaction during transfusion and daily for 5 days.ResultsCross‐match incompatibility was significantly associated with decreased RBC survival time (P < .001). The half‐life of transfused incompatible (cross‐match >1+) allogenic equine RBCs was 4.7 (95% CI, 3.2–6.2) days versus 33.5 (24–43) days for compatible pairings. Cross‐match incompatibility was associated with acute febrile transfusion reaction (P = .0083). At day 30, only 1 horse had developed novel anti‐RBC antibodies.Conclusions and Clinical ImportanceCross‐match incompatibility was predictive of febrile transfusion reaction and shortened transfused RBC survival, but did not result in production of anti‐RBC antibodies at 30 days. Cross‐match testing before transfusion is recommended.

A rapid, accurate and robust particle-based assay for the simultaneous screening of plasma samples for the presence of five different anti-cytokine autoantibodies

PurposeTo establish and validate a rapid, cost-effective and accurate screening assay for the simultaneous testing of human naturally occurring anti-cytokine autoantibodies (c-aAb) targeting interleukin-1α (IL-1α), interleukin-6 (IL-6), interleukin-10 (IL-10), granulocyte–macrophage colony-stimulating factor (GM-CSF), and interferon α (IFNα). Because the c-aAbs can be transferred to patients through blood transfusion, the assay was used to assess c-aAb levels in a cohort of patients who were receiving blood transfusions and subsequently presented with or without febrile reactions. Materials and methodsThe microsphere-based Luminex platform was used. Recombinant forms of human IL-1α, IL-6, IL-10, GM-CSF, and IFNα were gently coupled to MAG-PLEX beads. Plasma IgG binding was measured with phycoerythrin (PE)-labeled secondary antibodies. Previously confirmed c-aAb positive and negative donor plasma samples and pooled normal immunoglobulin preparations were used to validate the assay. Plasma samples from 98 transfusion recipients, half of whom presented with febrile reactions, were tested by the assay. ResultsThe assay detected specific and saturable immunoglobulin G (IgG) binding to each of the tested cytokines in previously confirmed c-aAb positive plasmas and in preparations of pooled normal immunoglobulin. Confirmed c-aAb negative plasmas gave no saturable binding. The detection limit of the cytokine autoantibodies was estimated to be between 1pM and 10pM. The recovery of confirmed cytokine autoantibodies quantities in the negative plasma samples ranged between 80% and 125%. The analytical intra- and inter-assay variations were 4% and 11%, respectively. Varying c-aAb levels were detectable in the transfusion recipients. There was no difference in c-aAb frequency between the patients with or without febrile transfusion reactions. The c-aAb level before and after the blood transfusions varied only slightly and in an irregular manner. ConclusionThis assay simultaneously detected up to five different c-aAbs in pooled human IgG and in plasma from individual blood donors, and it was deemed suitable for larger screenings. Based on confirmed antibody binding characteristics and the resultant reactivity in this multiplex assay, a classification of the c-aAb levels was suggested. The screening results of the recipients who received blood transfusions indicate that more studies are needed to clarify the role of antibodies, if any, in transfusion medicine and in high-dose immunoglobulin treatment.

Limitations of component therapy for massive haemorrhage: is whole blood the whole solution?

Limitations of component therapy for massive haemorrhage: is whole blood the whole solution?

Allelic Discrimination by TaqMan-PCR for Genotyping of Human Neutrophil Antigens.

Neutrophil antigens are implicated in a variety of clinical conditions, including neonatal immune neutropenia, transfusion-related acute lung injury, refractoriness to granulocyte transfusions, febrile transfusion reactions, and autoimmune neutropenia. In this report, we describe simultaneous genotyping of human neutrophil antigens (HNA)-1, -3, -4, and -5 using PCR with allele-specific TaqMan probes and end-point fluorescence detection, which is a robust, rapid, and reproducible method, allowing for high-throughput genotyping.

Neutrophil Expression of HNA-2 and mPR3 As Biomarkers for the Development of Preeclampsia

Introduction: The human neutrophil antigen-2 (HNA-2) is clinically important for being involved in immune neutropenias, febrile transfusion reactions and transfusion related acute lung injury (TRALI). HNA-2 is located on the glycoprotein CD177 (NB1) and is expressed on subpopulations of neutrophils, ranging from 0 to 100%. It has been suggested that the HNA-2 is the receptor to the membrane fraction of Proteinase 3 (mPR3), as they are co-expressed in the same subpopulation of neutrophils. Furthermore, HNA-2 binds to PECAM-1 on endothelial cells, facilitating the transendothelial migration of neutrophils. The preeclampsia (PE) is characterized by a neutrophil activation and production of pro-inflammatory cytokines, migration of neutrophils to human umbilical vein, and metabolic and phenotypic changes of neutrophils leading to endothelial dysfunction. The aim of this study was to determine the expression of HNA-2 and mPR3 into three different groups of individuals: nonpregnant women, healthy pregnant women and women with PE in order to investigate the role of these molecules in the pathogenesis of PE.Methods: A cross-sectional study included samples from 81 nonpregnant women, 75 healthy pregnant women, and 45 women with PE. Blood samples from nonpregnant women were collected at the Blood Center, while blood samples from pregnant women during the 2nd trimester of gestation were collected at 2 obstetric hospitals. The HNA-2 and mPR3 expression was determined by flow cytometry (FACSCalibur, Becton Dickinson) using the monoclonal antibodies MEM166 conjugated to PE and WGM2 conjugated to FITC, respectively (Abcam, Cambridge, UK). Mouse IgG1 was used as isotype control (Abcam, Cambridge, UK). The data acquisition and analysis was performed by CellQuest® software (Becton Dickinson). The fluorescence intensity was classified as low (≤ 60%), medium (61-80%) and high (> 80%). Subjects were considered HNA-2 or PR3-negative if less than 5% of their neutrophils reacted with the monoclonal antibodies.Results: The median percentage of neutrophils expressing HNA-2 and mPR3 was significantly higher in women with PE (88%), compared with the expression in healthy pregnant (70%) and nonpregnant women (72%) (p<0.0001; ANOVA). Analyzing the results according to the degree of HNA-2 and mPR3 expression, a higher expression (> 80%) was observed in 64% (29/45) of woman with PE compared to 33% (25/75) of healthy pregnant and 26% (21/81) of nonpregnant women (p=0.0009 and p<0.0001; respectively). Interestingly, we observed that two healthy pregnant women who initially presented increased antigens coexpression (median of 96%), developed PE at the 35th week of gestation. In addition, historical obstetric analysis of the healthy pregnant women group revealed three other women who had a previous clinical and laboratory diagnosis of PE showed in this study a high expression of antigens HNA-2 and mPR3 (median of 98%).Conclusion: The present study indicates that the expression of HNA-2 and mPR3 in neutrophils is significantly increased in women with PE. Such antigens overexpression may be associated to the increased migration of activated neutrophils to human umbilical vein endothelium in addition to the local inflammation and tissue destruction, factors already described to be involved in the etiology of PE. In conclusion, the present data suggest that high expressions of HNA-2 and mPR3 measured early in the 2nd trimester of the pregnancy may be possible biomarkers for the development of PE. DisclosuresNo relevant conflicts of interest to declare.

Novel platelet storage conditions: additive solutions, gas, and cold.

Platelets are a frequently requested blood product today and are often in limited supply because of a shelf life of 5-7 days, depending on the country. Room temperature storage is associated with an increased risk of transfusion-transmitted infection. Plasma used for platelet storage is unavailable for other uses, and allogeneic plasma carries with it risks for adverse transfusion reactions. This review looks at recent activities evaluating alternative conditions for the storage of platelets. New-generation platelet additive solutions are being evaluated and applied as a strategy to reduce the volume of allogeneic plasma transfused and to support storage following pathogen reduction treatments. There is a renewed interest in refrigerator temperature and frozen storage of platelets to improve availability, to reduce septic transfusion risk, and to enhance hemostatic efficacy in the bleeding patient. Use of platelet additive solutions has been shown to reduce the incidence of allergic and nonhemolytic febrile transfusion reactions in two large studies. Results of ongoing research and new clinical trials in cold storage methods will be forthcoming and may present solutions for platelet availability problems and new choices for therapeutic transfusion of the bleeding patient.

P.1.a.019 Genetic association of LMAN2L with bipolar disorder and schizophrenia and gene–gene interaction with ANK3 gene polymorphism

Leukoreduction of blood used for transfusion alleviates febrile transfusion reactions, graft versus host disease and alloimmunization to leukocyte antigen. However, the actual clinical benefit of leukoreduction in terms of microcirculatory tissue O2 delivery after packed red blood cell (pRBC) transfusion has not been investigated. As such, the aim of this study was to determine the effects of non-leukoreduced (NLR) and leukoreduced (LR) fresh pRBC transfusion on interstitial oxygenation in anesthetized male Sprague–Dawley rats. Interstitial fluid PO2 and arteriolar diameters in spinotrapezius muscle preparations were monitored before and after transfusion with NLR- or LR-pRBCs. The major findings were that (1) transfusion of NLR-pRBCs significantly decreased interstitial oxygenation whereas transfusion of LR-pRBCs did not, and (2) transfusion with LR-pRBCs elicited a substantially greater increase in arterial blood pressure (ABP) than did transfusion with NLR-pRBCs. These changes in PO2 and ABP were not associated with changes in the diameters of resistance arterioles in the spinotrapezius muscle. These data suggest that transfusion of fresh NLR-pRBCs may negatively affect tissue oxygenation via enhanced leukocyte influx and decreased O2 delivery. They also suggest that leukocytes diminish the capability of transfused pRBCs to increase cardiac output. As such, transfusion of LR-pRBCs may be less deleterious on tissue PO2 levels than NLR-pRBCs although a concomitantly greater increase in ABP may accompany transfusion of LR-pRBCs.