Transfusion Group Research Articles

To transfuse or not to transfuse in upper gastrointestinal hemorrhage? That is the question

To transfuse or not to transfuse in upper gastrointestinal hemorrhage? That is the question

Transfusion practices in a neonatal intensive care unit in a city in Brazil

ObjectiveNewborn infants are the most heavily transfused population inside intensive care units. The hemoglobin level used to indicate the need of transfusions is not well established. The aim of this study was to evaluate transfusional practices in newborns in the neonatal intensive care units of one specific city.MethodsRed blood cell transfusion practices of all transfused newborns in all five of the neonatal intensive care units of the city were analyzed. Data are reported as descriptive statistics, including numbers and percentages and means and standard deviation. Univariate analysis, followed by stepwise logistic regression was performed in respect to transfusional data and outcomes.ResultsA total of 949 patients were admitted to the intensive care units during the 12-month study period with 20.9% receiving at least one transfusion, most (62.4%) of whom received more than one transfusion. The mean number of transfusions per infant was 2.7 ± 2.16; in the liberal transfusion group the mean number was 1.59 ± 1.63 and in the restrictive group it was 1.08 ± 1.51. The mean hemoglobin and hematocrit levels were 9.0 g/dL (±1.4 g/dL) and 27.4% (±4.3%), respectively. The most common indications for blood transfusions were sepsis and prematurity.ConclusionThis study shows that the characteristics and the transfusion practices for newborns admitted in the neonatal intensive care units of Juiz de Fora are similar to recent pubications. There was no significant reduction in the number of transfusions per child in the restrictive group compared to the liberal group. Restrictive transfusions are an independent risk factor for peri-intraventricular hemorrhages and death.

Pretreatment of Transfused Donor Splenocytes and Allografts With Mitomycin C Attenuates Acute Rejection in Heart Transplantation in Mice

ObjectiveThe aim of this study was to investigate the effect of pretreatment of donor splenocytes and grafts with mitomycin C (MMC) on heart allograft survival, as well as to demonstrate the mechanism of function. MethodsDonor splenocytes from Balb/C mice were incubated with MMC (40 μg/mL) in vitro and then transfused into recipients (C57BL/6 mice). The heart allograft was perfused with MMC before harvest. Graft survival and histopathology were examined. Lymphocyte activation, regulatory T cells, and donor splenocyte apoptosis were examined with the use of flow cytometry. ResultsMMC incubation in vitro induced apoptosis of donor splenocytes (15.5 ± 2.3% vs 23.2 ± 4.2%; P < .01). Either intravenous injection of MMC-treated donor splenocytes or transplantation of allograft pretreated with MMC prolonged heart allograft mean survival time from 7 ± 0.8 days to 20.5 ± 1.9 days or 10 ± 0.9 days, respectively (both P < .01). A combination of MMC-pretreated donor splenocyte transfusion and allografts showed the best effect on prolongation of graft survival (28.5 ± 1.8 days). Activation of CD4+ T cells in spleen and peripheral lymph nodes of recipients was significantly inhibited by either MMC-splenocyte transfusion or the combination treatment. Meanwhile, the percentage of CD4+CD25+Foxp3+ regulatory T cells in the spleen was increased in the MMC-splenocyte transfusion group (15.5 ± 1.1% vs 18.2 ± 0.9%; P < .05). ConclusionsBoth injection of MMC-conditioned donor splenocytes and MMC-conditioned allograft have effects on prolongation of heart allograft survival in mice, and MMC-conditioned donor splenocytes might play an essential role. MMC pretreatment induced regulatory T cells likely through induction of donor splenocyte apoptosis, and thus it inhibited T-cell activation.

Washing red cells after leucodepletion does not decrease human leukocyte antigen sensitization risk in patients with chronic kidney disease.

Standard leucodepleted blood transfusions can induce the production of human leukocyte antigen (HLA)-specific antibodies, which are associated with longer transplant waiting times and poorer graft outcomes. We hypothesized that additional washing of leucodepleted red cells might reduce antigenic stimulus by removal of residual leukocytes and soluble HLA. A retrospective review of HLA antibodies in children with chronic kidney disease stage 4-5 who had ≥ two HLA antibody screens between 2000 and 2009, pre- and post-transfusion, and were HLA antibody-negative at first testing. Patients were divided according to whether they received standard leucodepleted blood or "washed cells". To assess the efficacy of washing methods, total leukocytes were enumerated pre- and post- manual and automated washing of standard leucodepleted red cells that had been supplemented with whole blood to achieve measurable leukocyte levels pre-washing. A total of 106 children were included: 23 received no blood transfusions (group 1), six had washed cells only (group 2), 59 had standard transfusions only (group 3), and 18 had both standard and washed cells (group 4). Sensitization rates were 26, 17, 44, and 44 % in groups 1-4 (p = 0.32). Patients in groups 3 and 4 had more transfusions with red cells, platelets, and plasma products. There was no difference in HLA sensitization risk with washed or standard red cells on analysis of co-variance controlling for platelets and plasma transfusions. The red cell washing study showed no significant reduction in leukocytes using manual methods. Although there was a statistically significant reduction (33 %) from baseline pre-washing using the automated method, from 6.54 ± 0.84 × 10(6) to 4.36 ± 0.67 × 10(6) leukocytes per unit, the majority of leukocytes still remained. There was no evidence that using washed leucodepleted red cells reduced patient HLA sensitization rates. Washing leucodepleted red cells is unlikely to reduce the risk of HLA sensitization due to the limited effect on residual leukocytes.

Blood Transfusion and Risk of Infection

In this issue of JAMA, Rohde and colleagues report results of a meta-analysis evaluating the association between a liberal transfusion strategy vs a restrictive strategy and risk of hospital-acquired infections.1 In the meta-analysis, which included 17 randomized trials that compared these strategies among 7456 patients, the absolute rates of serious hospital-associated infection were 12.7% in the liberal transfusion group and 10.6% in the restrictive transfusion group. The number needed to treat with a restrictive transfusion strategy to prevent serious infection was about 48 patients. Results were consistent when analyses were repeated in trials with concealed randomization and infrequent protocol violations but not for overall infections. A prior meta-analysis of liberal vs restrictive transfusion strategies and infection outcomes reported a nonstatistically significant reduction in infections.2 The current meta-analyses by Rohde et al includes several newly published trials, although these significant differences in serious infection rates may not hold up when the results of other large transfusion trials are reported. Most trials define a restrictive transfusion strategy as the administration of red blood cells (RBCs) once hemoglobin falls below either 7 or 8 g/dL, and most trials define a liberal strategy as the administration of RBCs once hemoglobin level falls below 10 g/dL.

Comparison of restrictive and liberal transfusion strategy on postoperative delirium in aged patients following total hip replacement: A preliminary study

Few studies have examined the association between perioperative blood transfusion and postoperative delirium (POD) in aged patients undergoing total hip replacement surgery. In this prospective study, 186 patients older than 65 years undergoing elective unilateral total hip replacement surgery were enrolled. Of those, 94 patients were randomly assigned to the restrictive strategy transfusion strategy group, in which red blood cells were transfused in order to maintain 10.0g/dL>hemoglobin≧8.0g/dL. Ninety-two patients were randomly assigned to the liberal transfusion strategy group, in which red blood cells were transfused in order to maintain hemoglobin≧10.0g/dL. POD was diagnosed by confusion assessment method. The baseline characteristics of patients, the length of hospital stay, the incidence of POD, myocardial infarction, stroke, wound infection, pulmonary embolism, and the transfusion volume were recorded. No difference was observed in the baseline characteristics, the length of hospital stay, and the incidence of POD, myocardial infarction, stroke, wound infection, and pulmonary embolism between the two groups (P>0.05). The proportion of patients transfused with red blood cell and frozen plasma was decreased in the restrictive transfusion group compared with the liberal transfusion group (P<0.05). In conclusion, restrictive transfusion does not influence the incidence of POD but reduces blood transfusion. Thus, restrictive transfusion may serve as an effective and safe strategy for aged patients following total hip replacement.

Association of perioperative transfusion and postoperative complications after radical gastrectomy for gastric cancer

To explore the association of perioperative homologous blood transfusion (packed red blood cell, PRBC) and postoperative complications after radical gastrectomy in patients with gastric cancer. From October 2010 to July 2013, a total of 636 patients undergoing radical gastrectomy at Department of Gastric, Duodenal & Pancreatic Surgery at Hunan Provincial Tumor Hospital were divided into 2 groups according to perioperative blood transfusion (n = 170, 26.73%) or not (n = 466, 73.27%). Their clinicopathological data, such as age, gender, co-morbidities, surgical duration, intraoperative blood loss volume and pathological stage were retrospectively analyzed by case-control study model. And the transfusion group was further divided into subgroup by transfusion volume (total PRBC<3.0, 3.0-7.5 or >7.5 U) and timing (pre-, intra- or post-operative) to examine the association of transfusion volume and timing with postoperative complications by Logistic regression. Thirty-two patients suffered from complications in the transfusion group (18.82%). And it was significantly more common than that in the control group (10.09% (47/466) , P < 0.01). Moreover, the complication rate (33.33% (12/36) ) was obviously higher in the large transfusion volume group (PRBC>7.5 U) than with those in the moderate (15.53% (16/103), P = 0.02) and low groups (12.90% (4/31) , P = 0.04). Infection was more common along with the total amount of transfused blood (6.45% (2/31), 10.68% (11/103) and 19.44% (7/36) in the low, moderate and large transfusion group respectively). Yet the differences were insignificant (P = 0.22). There was no significant difference of complication rates among the pre-, intra- and post-operative transfusion group classified by transfusion time (P = 0.39). And the postoperative infection rates were also insignificantly different (P = 0.88). Further Logistic analysis revealed that perioperative transfusion (OR = 2.71, 95% CI: 1.40-5.27, P < 0.01) was an independent risk factor for postoperative complications after radical gastrectomy. Perioperative blood transfusion is significantly associated with postoperative complications after radical gastrectomy in patients with gastric cancer. And a positive correlation exists between infection and the amount of transfused blood. But there was no association between transfusion time and complications. Thus decreasing perioperative transfusion may reduce the incidence of postoperative complications and shorten the length of hospital stays.

Perioperative blood transfusion affects hepatitis C virus (HCV)-specific immune responses and outcome following liver transplantation in HCV-infected patients

ObjectivesPerioperative factors can affect outcomes of liver transplantation (LT) in recipients with hepatitis C virus (HCV) infection. This study was conducted to investigate whether the immunomodulatory effects of packed red blood cells (PRBC) and platelets administered in the perioperative period might affect immune responses to HCV and thus outcomes in LT recipients. MethodsData for a total of 257 HCV LT recipients were analysed. Data on clinical demographics including perioperative transfusion (during and within the first 24h), serum cytokine concentration, HCV-specific interferon-γ (IFN-γ) and interleukin-17 (IL-17) producing cells, and outcomes including graft and patient survival were analysed. ResultsPatient survival was higher in HCV LT recipients who did not receive transfusions (Group 1, n = 65) than in those who did (Group 2, n = 192). One-year patient survival was 95% in Group 1 and 88% in Group 2 (P = 0.02); 5-year survival was 77% in Group 1 and 66% in Group 2 (P = 0.05). Group 2 had an increased post-transplant viral load (P = 0.032) and increased incidence of advanced fibrosis at 1 year (P = 0.04). After LT, Group 2 showed increased IL-10, IL-17, IL-1β and IL-6, and decreased IFN-γ, and a significantly increased rate of IL-17 production against HCV antigen. Increasing donor age (P = 0.02), PRBC transfusion (P < 0.01) and platelets administration were associated with worse survival. ConclusionsTransfusion had a negative impact on LT recipients with HCV. The associated early increase in pro-HCV IL-17 and IL-6, with decreased IFN-γ, suggests that transfusion may be associated with the modulation of HCV-specific responses, increased fibrosis and poor transplant outcomes.

Effect of perioperative transfusion of old red blood cells on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous flap surgery for breast reconstruction

Transfusion with old red blood cells (RBCs) was associated with adverse clinical outcomes. The effect of perioperative transfusion of old RBCs on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous (TRAM) flap surgery was retrospectively investigated. Two hundred sixty-one patients undergoing breast reconstruction were assigned to two groups: no transfusion and transfusion groups. Transfused patients were further divided according to the RBC storage duration (fresh, ≤14 days; old, >14 days). Postoperative complications such as vascular thrombosis, hematoma, and flap congestion were noted. Patients who received old blood (n = 34), compared with those received fresh blood (n = 40) or no transfusion (n = 187), had a higher incidence of postoperative complications (44.1% vs. 20.0% or 12.8%, P < 0.05). Perioperative transfusion of old RBCs can be associated with an increase in postoperative complications after free muscle sparing TRAM flap surgery.

Impact of Perioperative Allogeneic and Autologous Blood Transfusion on Acute Wound Infection Following Total Knee and Total Hip Arthroplasty

Patients undergoing total hip or knee arthroplasty frequently receive blood transfusions. The relationship between transfusion and the risk of infection following total joint arthroplasty is unclear. In this study, we sought to examine the impact of allogeneic and autologous transfusion on the risk of acute infection following total hip and total knee arthroplasty. We performed a retrospective study of consecutive primary total knee arthroplasties and total hip arthroplasties. Patients who had a reoperation for suspected infection within three months after the arthroplasty were identified. Differences in risk factors were assessed across transfusion groups: no transfusion, autologous only, and allogeneic exposure (allogeneic with or without additional autologous transfusion). Backward-stepwise logistic regression analysis was used to compare reoperations (as outcomes) between cases with and those without allogeneic exposure. Prespecified covariates were body mass index, diabetes, an American Society of Anesthesiologists (ASA) score of >2, preoperative hematocrit, and total number of units transfused perioperatively. We identified 3352 patients treated with a total hip or knee arthroplasty (1730 total knee arthroplasties and 1622 total hip arthroplasties) for inclusion in the study. Transfusion was given in 1746 cases: 836 of them had allogeneic exposure, and 910 had autologous-only transfusion. There were thirty-two reoperations (0.95%) for suspected infection. Between-group risk-factor differences were observed. The mean age and the rates of diabetes, immunosuppression, ASA scores of >2, and bilateral surgery were highest in the allogeneic group, as were estimated blood loss, surgery duration, and total number of units transfused (p < 0.001). In the unadjusted analyses, the rate of reoperations for suspected infection was higher in the cases with allogeneic exposure (1.67%) than in those without allogeneic exposure (0.72%) (p = 0.013). Autologous-only transfusion was not associated with a higher reoperation rate. However, multivariable logistic regression demonstrated that the total number of units transfused (p = 0.011) and an ASA score of >2 (p = 0.008)-but not allogeneic exposure-were significantly predictive of a reoperation. Perioperative allogeneic transfusion was associated with a higher rate of reoperations for suspected acute infection. However, patients with allogeneic exposure had increased infection risk factors. After adjustment for the total number of units transfused and an ASA score of >2, allogeneic exposure was not significantly predictive of a reoperation for infection.

Significance of prenatal joint detection of ABO antibody titers and irregular antibodies in pregnant women with type O blood

Objective: To investigate the effects of blood transfusion and number of pregnancies on ABO antibody titers and irregular antibodies in pregnant women with type O blood. Materials and Methods: The study included 4,200 pregnant women with type O blood (their husbands were with non-O type blood) that were divided into transfusion group and non-transfusion group, according to whether they had a history of blood transfusion. The both groups were respectively divided into three subgroups (the number of pregnancies was one, two, and ≥ three). The ABO antibody titers and irregular antibodies were detected at the same time. The effects of ABO antibody titers and irregular antibodies on hemolytic disease of the newborn (HDN) were discussed. Results: There was no consistency of ABO antibody titers and existence of irregular antibody. The positive rates of irregular antibody of transfusion group and of the subgroup (number of pregnancies ≥ three) were far higher than that of non-transfusion group and of the subgroups (number of pregnancies Conclusions: For pregnant women with number of pregnancies ≥ three or with history of blood transfusion, the prenatal joint detection of ABO antibody titers and irregular antibodies is helpful for accurately reflecting the in vivo antibody type and level.

Impact of warming blood transfusion and infusion toward cerebral oxygen metabolism and cognitive recovery in the perioperative period of elderly knee replacement

ObjectiveThis study aims to observe the impact of the temperature of blood transfusion and infusion toward the perioperative cerebral oxygen metabolism and the postoperative cognitive recovery.MethodsEighty patients of knee replacement under epidural and general anesthesia were randomly divided into warming blood transfusion and infusion (WBI) group (n = 40) and control group (n = 40). The changes of nasopharyngeal temperature, middle cerebral artery blood flow, CERO2, and SjVO2 of the two groups were recorded at each time point for the assessment of the postoperative overall quality of recovery and cognitive recovery situation.ResultsThe nasopharyngeal temperatures of the two groups at different time points after transfusion were significantly lower than that at T1, and there was a significant difference between the two groups (P < 0.05). The CERO2 values of the two groups at T3 were significantly higher than at T1, while the SjVO2 values were significantly decreased (P < 0.01).ConclusionThe WBI can significantly reduce the occurrence of the perioperative hypothermia, while it has no significant effect toward cerebral oxygen metabolism, postoperative overall recovery, and recovery of cognitive function.

Assessment of RBC transfusion volume and its effect on postoperative pulmonary complications in on-pump CABG patients

This study was purposed to investigate the effect of the transfused RBC amount on pulmonary complications after on-pump CABG surgery, and to explore the influencing factors on RBC transfusion volume. 292 adult patients receiving on-pump CABG surgery were divided into non-RBC transfusion group (n = 71), 1-4 U RBC transfusion group (n = 144) and >4 U RBC transfusion group (n = 77). Adjusted multivariable regression analysis was performed to examine the correlation between transfused RBC amount and the odds of pulmonary complications, and multivariable linear regression was used to analyze the influencing factors on RBC transfusion volume. The results showed that compared the three groups, there was the significant difference in postoperative pulmonary complications (1.4% vs 14.6% vs 24.7%, P < 0.001). A stronger and graded correlation was found between transfused RBC amount and pulmonary complications in on-pump CABG patients, the adjusted odds were increased to 1.251 (95% CI: 1.120-1.398, P < 0.001), and influencing factors on RBC transfusion volume were as follows: age (B:0.102; 95% CI: 0.046-0.157, P < 0.001), sex (B:1.825; 95% CI: 0.692-2.957, P = 0.002), preoperative Hct (B:-36.044; 95% CI:-47.724--25.163, P < 0.001), CPB time (B: 0.031; 95% CI:0.013-0.050, P = 0.001) and acute myocardiac infarction (B:2.769; 95% CI: 1.295-4.243, P < 0.001). It is concluded that the transfused RBC amount is related with postoperative pulmonary complications, and the influencing factors on RBC transfusion volume include preoperative Hct, age, acute myocardiac infarction, sex and CPB time.

Impact of Allogenic and Autologous Transfusion on Immune Function in Patients with Tumors

To observe the effects of allogeneic and autologous transfusion on cellular immunity, humoral immunity and secretion of serum inflammatory factors and perforin during the perioperative period in patients with malignant tumors. A total of 80 patients (age: 38-69 years; body weight: 40-78 kg; ASA I - II) receiving radical operation for gastro-intestinal cancer under general anesthesia were selected. All the patients were divided into four groups based on the methods of infusion and blood transfusion: blank control group (Group C), allogeneic transfusion group (group A), hemodiluted autotransfusion Group (Group H) and hemodiluted autotransfusion + allogenic transfusion Group (A+H group). Venous blood was collected when entering into the surgery room (T0), immediately after surgery (T1) and 24h (T2), 3d (T3) and 7d (T4) after surgery, respectively. Moreover, flow cytometry was applied to assess changes of peripheral blood T cell subpopulations and NK cells. Enzyme linked immunosorbent assays were performed to determine levels of IL-2, IL-10, TNF-α and perforin. Immune turbidimetry was employed to determine the changes in serum immunoglobulin. Both CD3+ and NK cells showed a decrease at T1 and T2 in each group, among which, in group A, CD3+ decreased significantly at T2 (P<0.05) compared with other groups, and CD3+ and NK cell reduced obviously only in group A at T3 and T4 (P<0.05). CD4+ cells and the ratio of D4+/CD8+ were decreased in groups A, C and A+H at T1 and T2 (P<0.05). No significant intra- and inter-group differences were observed in CD8+ of the four groups (P<0.05). IL-2 declined in group C at T1 and T2 (P<0.05) and showed a decrease in group A at each time point (P<0.05). Moreover, IL-2 decreased in group A + H only at T1. No significant difference was found in each group at T1 (P<0.05). More significant decrease in group C at T2, T3 and T4 compared with group A (P<0.05), and there were no significant differences among other groups (P>0.05). IL-10 increased at T1 and T2 in each group (P<0.05), in which it had an obvious increase in group A, and increase of IL-10 occurred only in group A at T3 and T4 (P<0.05). TNF-α level rose at T1 (P<0.05), no inter- and intra-group difference was found in perforin in all groups (P<0.05). Compared with the preoperation, both IgG and IgA level decreased at T1 in each group (P<0.05), and they declined only in Group A at T2 and T3 (P<0.05), and these parameters were back to the preoperative levels in other groups. No significant differences were observed between preoperative and postoperative IgG and IgA levels in each group at T4 (P>0.05). No obvious inter- and intra-group changes were found in IgM in the four groups (P>0.05). Allogeneic transfusion during the perioperative period could obviously decrease the number of T cell subpopulations and NK cells and the secretion of stimulating cytokines and increase the secretion of inhibiting cytokines in patients with malignant tumors, thus causing a Th1/Th2 imbalance and transient decreasing in the content of plasma immune globulin. Autologous transfusion has little impact and may even bring about some improvement of postoperative immune function in patients with tumors. Therefore, cancer patients should receive active autologous transfusion during the perioperative period in place of allogeneic transfusion.

The indication for perioperative red blood cell transfusions is a predictive risk factor for severe postoperative morbidity and mortality in children undergoing cardiac surgery

In paediatric cardiac surgery, red blood cell (RBC) transfusions are given to treat haemorrhage or to increase oxygen delivery (therapeutic transfusion). Sometimes, RBCs are added to the prime solution to avoid a too low haematocrit on bypass (CPB-driven transfusion). Our study investigated whether the reason for RBC transfusion might affect severe postoperative morbidity or mortality. This retrospective cohort study was conducted in a tertiary care level, children's hospital. The charts of all patients admitted between 2006 and 2009 were reviewed. Among transfused patients, children receiving a therapeutic transfusion were compared with those receiving a CPB-driven transfusion. The primary outcome was severe postoperative morbidity or mortality. Statistically significant variables founded with univariate analysis were incorporated in the multivariable logistic regression analysis to build a model that predicts severe postoperative morbidity or mortality. This model was then adjusted for clinically relevant variables that may interfere with 'indication for transfusion'. One hundred and one (48%) patients in the therapeutic and 92 (26%) patients in the CPB-driven transfusion group developed severe postoperative morbidity or died (P < 0.001). A multivariable logistic regression showed that weight, ASA, calculated blood loss, intraoperative fluid balance, duration of CPB time and the indication group for transfusion [1.64 (1.03-2.62); P = 0.039] were independent risk factors for severe postoperative morbidity or mortality. The indication group for transfusion remained significant [2.0 (1.16-3.45); P = 0.013] after adjustment for significant predictors of indication for transfusion. Number of patients with infections, or neurological deficit, and length of mechanical ventilation, PICU and hospital length of stay, were significantly higher in the therapeutic compared with the CPB-driven transfusion group one. The indication group for transfusion has an impact on the occurrence of severe postoperative morbidity or mortality in children undergoing cardiac surgery.

Effect of allogeneic blood transfusion on clinical outcomes of patients undergoing colorectal cancer surgery: a meta-analysis

Objective To evaluate the effects of allogeneic blood transfusion(ABT)on long-term prognosis in colorectal cancer(CRC)patients undergoing surgery.Methods PubMed,EMbase,The Cochrane Library and China Biology Medicine disc(CBMdisc)were searched for studies on the correlation between ABT and clinical outcomes of colorectal cancer patients,and relevant articles were also retrieved from references.All the searches were done from inception to March,2014.Two reviewers independently screened the literature,extracted the data and evaluated the quality of the data.Then the meta-analysis was performed by using Stata12.0software.Results Finally 8studies involving 5 479 patients were included.The results of metaanalysis showed that,compared with non-transfusion group,the transfusion group had significantly increased risks of overall survival(by 21%,HR=1.21;95% CI:1.09-1.33;P0.001)and disease-specific survival(by 47%,HR=1.47;95% CI:1.17-1.84;P=0.001);whereas the risks of disease free survival,local recurrence or distant metastasis were not significantly different between the 2groups.Conclusion ABT can increase the risks of overall survival and disease-specific survival in CRC patients undergoing surgery;therefore,it is of great clinical significance to take active perioperative blood conservation strategies to decrease ABT rate.

The Impact of Two Different Transfusion Strategies on Patient Immune Response during Major Abdominal Surgery: A Preliminary Report

Blood transfusion is associated with well-known risks. We investigated the difference between a restrictive versus a liberal transfusion strategy on the immune response, as expressed by the production of inflammatory mediators, in patients subjected to major abdominal surgery procedures. Fifty-eight patients undergoing major abdominal surgery were randomized preoperatively to either a restrictive transfusion protocol or a liberal transfusion protocol (with transfusion if hemoglobin dropped below 7.7 g dL−1 or 9.9 g dL−1, respectively). In a subgroup of 20 patients randomly selected from the original allocation groups, blood was sampled for measurement of IL-6, IL-10, and TNFα. Postoperative levels of IL-10 were higher in the liberal transfusion group on the first postoperative day (49.82 ± 29.07 vs. 15.83 ± 13.22 pg mL−1, P < 0.05). Peak postoperative IL-10 levels correlated with the units of blood transfused as well as the mean duration of storage and the storage time of the oldest unit transfused (r 2 = 0.38, P = 0.032, r 2 = 0.52, P = 0.007, and r 2 = 0.68, P<0.001, respectively). IL-10 levels were elevated in patients with a more liberal red blood cell transfusion strategy. The strength of the association between anti-inflammatory IL-10 and transfusion variables indicates that IL-10 may be an important factor in transfusion-associated immunomodulation. This trial is registered under ClinicalTrials.gov Identifier: NCT02020525.

Modified laparoscopic splenectomy and azygoportal disconnection combined with cell salvage is feasible and might reduce the need for blood transfusion.

To investigate perioperative outcomes in patients undergoing modified laparoscopic splenectomy and azygoportal disconnection (MLSD) with intraoperative autologous cell salvage. We retrospectively evaluated outcomes in 79 patients admitted to the Clinical Medical College of Yangzhou University with cirrhosis, portal hypertensive bleeding and secondary hypersplenism who underwent MLSD without (n = 46) or with intraoperative cell salvage and autologous blood transfusion, including splenic blood and operative hemorrhage (n = 33), between February 2012 and January 2014. Their intraoperative and postoperative variables were compared. These variables mainly included: operation time; estimated intraoperative blood loss; volume of allogeneic blood transfused; visual analog scale for pain on the first postoperative day; time to first oral intake; initial passage of flatus and off-bed activity; perioperative hemoglobin (Hb) concentration; and red blood cell concentration. There were no significant differences between the groups in terms of duration of surgery, estimated intraoperative blood loss and overall perioperative complication rate. In those receiving salvaged autologous blood, Hb concentration increased by an average of 11.2 ± 4.8 g/L (P < 0.05) from preoperative levels by the first postoperative day, but it had fallen by 9.8 ± 6.45 g/L (P < 0.05) in the group in which cell salvage was not used. Preoperative Hb was similar in the two groups (P > 0.05), but Hb on the first postoperative day was significantly higher in the autologous blood transfusion group (118.5 ± 15.8 g/L vs 102.7 ± 15.6 g/L, P < 0.05). The autologous blood transfusion group experienced significantly fewer postoperative days of temperature > 38.0°C (P < 0.05). Intraoperative cell salvage during MLSD is feasible and safe and may become the gold standard for liver cirrhosis with portal hypertensive bleeding and hypersplenism.

Prevalence Of Nocurnal Enuresis and Proteinuria In Children With Sickle Cell Disease and Its Relation To Severity Of Painful Crises

Nocturnal enuresis and albuminuria or proteinuria are markers of renal damage in sickle cell disease (SCD) and commonly develop early on in life. Proteinuria progresses with age, leading to chronic kidney disease in adulthood. The aims of this study were to identify the prevalence of enuresis and albuminuria/proteinuria in paediatric patients with SCD in London and to determine the relationship between these and various demographic and clinical variables. Methods A cross sectional, single centre study was conducted. Questionnaire-based interviews themed on nocturnal enuresis were undertaken for patients between the ages of 6 and 17. Urinalysis was performed for the presence of albuminuria or proteinuria. Hospital patient records were accessed for clinical data. Results A total of 56 patients were recruited to the study, of which 27 (51.8%) were female. Twenty patients (35.7%) had a history of enuresis and met the DSM IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) criteria for nocturnal enuresis compared to 5% prevalence in children in the general population1. There was a statistically significant association between enuresis and age, overactive bladder (OAB) symptoms, sleep-disordered breathing (SDB), painful crises and regular transfusions (Table 1). Fourteen out of 29 patients (48.3%) with OAB symptoms reported nocturnal enuresis compared to six out of 27 patients (22.2%) who did not (p&lt;0.05). Of the patients reporting SDB, 48.6% were enuretic compared to 14.3% who did not (p&lt;0.01). Incidence of painful crises per month was higher for the enuretic group (2.29 vs. 0.88, p&lt;0.05) but the mean number of emergency admissions in the preceding 18 months was similar. Of the 14 regular blood transfusion patients, only one (7.1%) was currently enuretic compared to 14 out of 32 (40.6%) who were not receiving any treatment (p&lt;0.05). Seven patients (13.4%) had albuminuria/proteinuria. (Table 2) There was no difference in albuminuria/proteinuria prevalence between the hydroxycarbamide or blood transfusion group compared to the non-treatment group. There was no difference in HbF percentage, systolic BP, frequency of emergency admissions, painful crises per month, haemoglobin levels and estimated glomerular filtration rates (eGFR) in patients with albuminuria/proteinuria and those without. The prevalence of haematuria increased with age; 6.7% in the 6-9 age category compared to 36.4% in the 16 to 17 age category (p=&lt;0.05). Conclusions Nocturnal enuresis and albuminuria or proteinuria is prevalent at an early age in many children with SCD. Early identification and initiation of treatment such as Angiotensin Converting Enzyme inhibitors2 may delay onset of complications especially alongside beneficial sickle cell treatments such as hydroxycarbamide and regular blood transfusions. Questioning parents on enuresis, OAB and SDB sumptoms and undertaking regular urinalysis on younger age groups is a practical and cost-effective surveillance method.

Alloimmunization To HLA Class I Antigens But Not H-Y Antigens Is Associated With Transfusion In Children With Sickle Cell Disease

IntroductionPatients with sickle cell disease (SCD) are at high risk for graft rejection after hematopoietic stem cell transplant (HSCT) especially when using reduced intensity conditioning (RIC). Alloimmunization from red blood cell (RBC) transfusions, critical to the management of SCD, may predispose these patients to HSCT rejection. Alloimmunization to major or minor histocompatibility antigens (mHA) may occur after RBC transfusion due to residual white blood cells or platelets present in RBC units even after leukoreduction. In mice, despite extensive leukoreduction, RBC transfusions caused alloimmunization and subsequent HSCT rejection after RIC.We conducted a cross-sectional study to determine if RBC transfusions are associated with alloantibody formation to human leukocyte antigens (HLA) and mHA, the target of the host versus graft rejection in HLA-identical transplantation. For mHA, we assessed immunity to H-Y antigens, mHA encoded on the Y chromosome. We have previously demonstrated the importance of H-Y antibodies in a variety of settings including chronic graft versus host disease (in male recipients of female grafts) and rejection of renal transplants (in female recipients of male grafts). MethodsWe enrolled 114 nulliparous pediatric SCD (SS or Sβ0) patients: 58 females on chronic transfusion, 32 males on chronic transfusion, and 24 females who had never been transfused. Serum was evaluated for HLA antibodies using the FlowPRA® (panel reactive antibody) screening test which detects IgG antibodies to the majority of HLA class I and II antigens. Serum was also tested for IgG antibodies against 5 H-Y antigens (DDX3Y [DBY], EIF1AY, RPS4Y1, UTY, ZFY) using protein microarray technology with each H-Y-seropositive threshold determined as a microarray mean fluorescence intensity (MFI) > the median MFI + 2.5 quartiles measured in 60 adult healthy males. ResultsChronically transfused patients had a higher prevalence of HLA class I antibodies than never transfused patients (33.3% vs. 12.5%, p=0.074). This increased prevalence of HLA class I antibodies in the chronic transfusion group was significant when examining the number of patients who tested positive to more than 25% of the panel (17.8% vs. 0%, p=0.022). Few patients had detectable HLA class II antibodies with no significant differences between chronically transfused and non-transfused patients.Few SCD patients had detectable H-Y alloantibodies with no significant differences in chronically transfused females, chronically transfused males, and non-transfused females.Chronic Transfusion (n=90)Never Transfused (n=24)PHLA class I PRA >3%30 (33.3%)3 (12.5%)0.074HLA class I PRA >25%16 (17.8%)0 (0%)0.022*HLA class II PRA >3%6 (6.7%)3 (12.5%)0.39HLA class II PRA >25%3 (3.3%)1 (4.2%)1.00HLA class I or II PRA >3%33 (36.7%)6 (25.0%)0.34H-Y antigenChronic Transfusion Female (n=58)Chronic Transfusion Male (n=32)Never Transfused Female (n=24)DBY1 (1.7%)0 (0%)0 (0%)EIF1AY0 (0%)0 (0%)0 (0%)RPS4Y12 (3.4%)0 (0%)0 (0%)UTY2 (3.4%)2 (6.3%)1 (4.2%)ZFY1 (1.7%)0 (0%)0 (0%)Any H-Y4 (6.9%) [p= 0.90]2 (6.3%)1 (4.2%) ConclusionsLeukocyte-reduced RBC transfusions appear to engender immunization to class I HLA but not class II HLA or H-Y antigens in pediatric SCD patients. Since hematopoietic progenitor cells express class I HLA, transfusion-related immunity to these antigens could pose a barrier to engraftment in HLA-disparate transplants. Since these antigens are also expressed on platelets, class I HLA antibodies in SCD could have important implications for platelet transfusion support during HSCT. While RBC transfusion does not appear to be an adequate stimulus for H-Y alloantibody formation, it is possible that exposure to mHA during transfusion could cause a cellular rather than a humoral immune response that may contribute to future HSCT graft rejection. Our result that few (6%) nulliparous female children with SCD had detectable H-Y alloantibodies is also a significant finding considering that 19-41% of healthy adult females had antibodies to at least one H-Y antigen in previous studies. Finally our finding that 25% of never transfused children with SCD had a positive HLA PRA is unexpected for an “unsensitized” group; its significance is being further investigated. Disclosures:No relevant conflicts of interest to declare.