Transfusion Of Red Cell Concentrates Research Articles

Change in Tacrolimus Concentration Measured in Whole Blood Correlates With Changes in Red Blood Cell Parameters After Red Blood Cell Transfusion in Kidney Transplant Recipients

BackgroundTacrolimus (TAC) is a narrow therapeutic range drug that requires therapeutic drug monitoring. TAC concentration is measured using whole blood owing to its high red blood cell (RBC) transfer rate of 95%. The distribution and whole-blood TAC concentration may be affected by the transfusion of red cell concentrates (RCCs); however, this has not been studied in kidney transplant recipients (KTR). Therefore, we investigated the relationship between changes in whole-blood TAC concentration and RBC parameters before and after RCC transfusion in KTR. MethodsFifteen KTR who received TAC and RCC transfusions were enrolled. The change rates of RBC parameters (RBC count, hemoglobin [Hgb], hematocrit [Hct]), and TAC concentration/dose before and after transfusion were calculated. The correlation between each RBC parameter and the TAC rate was evaluated. ResultsThe TAC concentration and rate increased after RCC transfusion. Moreover, the TAC rate showed a significant and strong correlation with RBC count, Hgb, and Hct, with RBC count showing the highest correlation coefficient (r = 0.811, 0.766, and 0.764, respectively; p < .01). Serum creatinine and potassium levels remained stable, suggesting the absence of typical adverse effects associated with TAC, such as acute kidney injury or hyperkalemia. ConclusionChanges in whole-blood TAC concentration and RBC parameters were correlated, and whole-blood TAC concentration increased after RCC transfusion. Therefore, the TAC dose should be adjusted accordingly.

Blood transfusion in autoimmune rheumatic diseases

Autoimmune rheumatic disorders (ARD) represent a wide spectrum of disorders that affect in priority the joints, bones, muscles, and connective tissues. Examples of ARD include rheumatoid arthritis, systemic lupus erythematosus, Sjögren syndrome, polymyositis, systemic sclerosis, antiphospholipid syndrome and mixed connective tissue disease. Patients with ARD often require transfusion of red cell concentrates (RCC) or other blood-derived components. The presence of an autoimmune background, often complicated by the use of immunosuppressive medications, renders these patients quite vulnerable. Exposing them to RCC, when indicated, can trigger transfusion-related immunomodulation that can be aggravated by the role played by the donor microbiome, and the complement activation and the immune dysregulation induced by iron, leading to an amplification of the immune problems. Furthermore, patients are challenged by the transfused extracellular vesicles which could have a potentially negative role, particularly in patients with antiphospholipid syndrome. Despite the very vigorous screening, transfusion transmissible infections can still represent a risk to these patients, particularly in cytomegalovirus seronegative patients or when dormant pathogens are activated in the immunosuppressed transfusion recipient. The ARD population is also more at risk for transfusion-related reactions. One, therefore, has to consider a restrictive transfusion strategy if possible and, if needed, resort to the numerous blood bank procedures to reduce the immunogenicity of blood products or use safer, more targeted, industrial plasma-derived products subjected to purification and pathogen reduction technologies.

Noninferior Red Cell Concentrate Quality after Repeated Air Rescue Mission Transport for Prehospital Transfusion

Background: Transfusion of red cell concentrates (RCCs) is an integral therapy after severe hemorrhage or trauma. Prehospital transfusion offers an immediate intervention in emergency cases. Air ambulance-based prehospital transfusion, already used in different countries, is currently established in Germany. Limited information is available for regulatory-compliant transport logistics of RCCs and their quality after repeated air rescue missions. Thus, the aim of this study was (i) to validate regulatory-compliant logistics and (ii) to assess product quality, analyzing biochemical parameters and RBC morphology. Study Design and Methods: Due to regulatory requirements, we adapted a rotation system of 1 day transport, 1 day quarantine storage and 1 day storage over the entire RCC shelf life. RCCs transported on air rescue missions (flight group) were compared against a control group, treated identically except for helicopter transport. RCCs were visually inspected, and their temperature was documented throughout the entire rotation cycles. RCCs at the end of shelf life (end point samples) were assessed for levels of hemoglobin, hematocrit, free hemoglobin, hemolysis, mean corpuscular volume, potassium and pH. In addition, morphological changes were assessed using flow morphometry. Results: In total 81 RCCs were assessed in the flight group and 50 in the control group. Within the flight group, 30 RCCs were transfused. RCCs were dispatched on average 11 times (7–13 times). The average flight time was 18.3 h (6.6–28.8 h). The rotation system ensured adherence to regulatory guidelines, especially compliance to storage conditions of +2 to +6°C of intermediate storage. Biochemical and morphological quality parameters did not exhibit any changes upon repeated air rescue missions. A correlation with respect to the flight time was not observed either. Discussion: The quality of RCCs after repeated air rescue missions is noninferior to control samples regarding biochemical and morphological parameters. The product quality is within German regulations for up to 42 days of storage. The logistics and maintenance of the thermal conditions are safe and feasible. Thus, a rotation system of RCCs offers a regulatory-compliant option to supply air rescue missions with RCCs to allow life-saving prehospital transfusions at the incident scene.

Stratégie transfusionnelle restrictive : unique choix en Afrique subsaharienne, une revue générale

Transfusion of red cell concentrates (RMCs) is the administration of red blood cells from a donor to a recipient to correct anemia. Despite improvements in blood preservation and treatment techniques in developed countries, the risk of transfusion-related adverse reactions remains significant. In Sub-Saharan Africa (SSA), while haemovigilance is not well organized and the majority of health institutions do not always screen for irregular agglutinins before each blood transfusion. Therefore, the restrictive transfusion policy defined by a transfusion threshold of blood haemoglobin concentration between 7 and 8 g/dl should be in place. Received: March 10th, 2021 Accepted: July 21st, 2021

Hemoglobin Utilization in Asplenic and Non-Splenectomized Transfusion Dependent Thalassemia Patients Supported with Pathogen Reduced Red Blood Cell Concentrates in a Phase 3 Study (SPARC)

Introduction: Transfusion dependent thalassemia (TDT) requires regular transfusion of red cell concentrates (RBCC) to prevent the complications of anemia and excessive erythroid expansion. Despite donor testing, long-term transfusion has a substantial cumulative risk of transfusion-transmitted infection (TTI) due to undetected viruses, bacteria, and protozoa. Splenectomized (-S) TDT patients may have greater TTI morbidity than patients with spleens (+S); but may benefit from reduced use of red blood cell concentrates (RBCC) and reduced transfusion iron (Fe) loading. Pathogen reduction (PR) of RBCC with amustaline-glutathione (A-GSH) offers potential to reduce the risk of TTI. Objectives: To determine, the impact of PR-RBCC on hemoglobin (Hb) use, transfused Fe burden, incidence of RBC antibodies, and safety in -S and +S TDT patients. Methods: TDT patients at 3 sites, not stratified by spleen status, were prospectively enrolled in a two- period cross-over study randomized by sequence for RBCC preparation. Leukocyte reduced PR-RBCC (Test) were treated with 0.2mM amustaline and 20 mM GSH, re-suspended in saline-adenine-glucose mannitol (SAGM), and stored up to 35 days at 4°C. Leukocyte reduced conventional RBCC (Control) were suspended in SAGM and stored for up to 35 days at 4°C. Patients received 6 transfusions in each treatment sequence of Test or Control RBCC over ~ 5 months. Clinicians, blinded to RBCC Hb content and treatment sequence, ordered RBCC to maintain targeted pre-transfusion Hb thresholds of ~ 9-10 g/dL. Transfusion intervals or number of RBCC transfused were adjusted for clinical management. The primary efficacy outcome was assessed by non-inferiority (NI) analysis for Hb use (expressed as g/kg body weight/ day) using a pre-specified NI margin (≤ 15% of the observed Control mean). Results: Overall, mean (SD) Hb content (g) of 1024 Test RBCC = 54.6±5.9 (range: 39-73) and of 1008 Control RBCC = 55.6 ± 5.9 (range: 35-74) and varied widely. By intent-to-treat (ITT), 80 patients (40 +S and 40 -S) were transfused. For ITT patients (Table), the baseline Hb level (BL-Hb, g/dL) at first transfusion of Control periods was significantly lower than at Test periods; but the mean number of RBCC transfused, RBCC storage days, total Hb dose (g), and transfusion intervals were not significantly different for Test and Control. ITT analysis for all transfusion episodes showed Hb use for Test RBCC (0.110 g/kg/d) was not different from Control RBCC (0.112 g/kg/day). Non-inferiority was demonstrated (T-C = - 0.002 g/kg/d: 95% CI: -0.005, 0.001). ITT Test patients received a slightly lower mean total Hb dose (- 14g), and mean pre-transfusion Hb levels declined after 6 transfusions (9.4 to 8.8 g/dL). -S patients had lower BL-Hb levels (g/dL) than S+ patients in Test (9.2 vs 9.7) and Control (8.8 vs 9.2) periods (Table). -S patients received a lower mean total Hb dose of Test than Control RBCC (p=0.019); and had a decline in mean pre-transfusion Hb levels during Test periods (from 9.2 to 8.7 g/dL). Transfusion intervals were significantly longer for -S patients than +S patients with both Test and Control RBCC (p Conclusions: Amustaline-GSH PR treatment of RBCCs offers the potential to reduce TTI risk without impacting Hb use or Fe burden in TDT. However, Hb content of Test and Control RBCC varies widely and may contribute to unexpected changes in pre-transfusion Hb levels. Spleen status affected Hb use comparably for PR-RBCC and Control RBCC, and remains an important factor in assessing transfusion requirements and Fe loading. Disclosures Aydinok:TERUMO: Research Funding; Cerus: Honoraria, Research Funding; CRISPR Tech: Other: DMC; Protagonist: Other: SSC; La Jolla Pharmaceuticals: Research Funding; Celgene: Research Funding; Novartis: Research Funding, Speakers Bureau. Piga:Apopharma: Honoraria, Research Funding; Celgene Corp: Membership on an entity9s Board of Directors or advisory committees, Research Funding; La Jolla: Membership on an entity9s Board of Directors or advisory committees, Research Funding; Bluebird Bio: Honoraria; Acceleron: Research Funding; Novartis: Research Funding. Origa:Novartis: Honoraria; Bluebird Bio: Consultancy; Cerus Corporation: Research Funding; Apopharma: Honoraria. Mufti:Cerus Corporation: Employment, Equity Ownership. Erikson:Cerus Corporation: Employment, Equity Ownership. North:Cerus Corporation: Employment, Equity Ownership. Waldhaus:Cerus Corporation: Employment, Equity Ownership. Ernst:Cerus Corporation: Employment, Equity Ownership. Lin:Cerus Corporation: Employment, Equity Ownership. Huang:Cerus Corporation: Employment, Equity Ownership. Benjamin:Cerus Corporation: Employment, Equity Ownership. Corash:Cerus Corporation: Employment, Equity Ownership.

Usefulness of aspartate aminotransferase to platelet ratio index as a prognostic factor following hepatic resection for hepatocellular carcinoma.

Liver function is a major prognostic factor following hepatic resection for hepatocellular carcinoma (HCC), which is well correlated with the degree of fibrosis. On the other hand, the presence of liver cirrhosis itself leads to a higher incidence of HCC than chronic hepatitis. Therefore, preoperative noninvasive markers of fibrosis are important for the assessment of prognosis for treatment of HCC. The present study aimed to analyze whether aspartate aminotransferase to platelet ratio index (APRI) could predict prognosis following hepatic resection for HCC. The subjects were 162 patients who underwent hepatic resection for HCC between January 2000 and December 2011. The relationship between APRI and disease-free and overall survival were retrospectively investigated. In multivariate analysis, indocyanine green at 15 min (ICG-R15) ≥15% (P=0.0306), APRI ≥0.45 (P=0.0184), perioperative blood transfusion of red cell concentrates (RCC; P=0.0034) and TNM stage II, III or IV (P=0.0184) were significant predictors in disease-free survival. For overall survival, ICG-R15 ≥15% (P=0.0454), APRI ≥0.45 (P=0.0417), perioperative blood transfusion of RCC (P=0.0036) and TNM stage II, III or IV (P=0.0033) were significant predictors. In addition, higher APRI values were positively correlated with hepatitis C virus infection and preoperative liver function. In conclusion, APRI is an independent risk factor for disease-free and overall survival following hepatic resection for HCC.

Prehospital transfusion of red cell concentrates in a paramedic-staffed helicopter emergency medical service.

The optimal volume and type of intravenous fluid for the treatment of blood loss in the prehospital setting is controversial. The use of red cell concentrates (RCCs) may be associated with improved outcomes; however, the administration of blood products is limited to physicians in many jurisdictions. We sought to describe the characteristics of RCC transfusions in a paramedic-staffed helicopter emergency medical system in Victoria, Australia. We performed a retrospective analysis of all cases where paramedics consulted the responsible physician for approval of RCC transfusion between July 2011 and December 2015 in Victoria, Australia. Ambulance data was retrieved from electronic patient care records and hospital and outcome data was retrieved from a state-wide trauma registry. A total of 180 primary missions was identified where paramedics requested approval for transfusion of RCCs during the study period. A total of 150 patients received prehospital RCCs, of which 136 had suffered trauma. The majority of these patients were male (66.7%) and were involved in a car accident (62.5%). Most (97.4%) patients had an Injury Severity Score ≥12. There were improvements in median systolic blood pressure (80 mmHg vs 94 mmHg, P < 0.001) and shock index (1.50 vs 1.23, P < 0.001) between time of consultation and arrival at hospital. Overall, mortality for trauma patients was 37.7%. There were no transfusion-related complications identified. Prehospital transfusion of RCC by paramedics is feasible. Future studies should compare the outcomes of patients receiving prehospital RCCs with outcomes for patients in which RCCs are administered in hospital.

Cost-effectiveness of post-operative cell salvage in total knee arthroplasty. Should we continue to recommend its use today?

ObjectivesTotal knee arthroplasty (TKA) has a high transfusion rate. In our protocol, the use of postoperative cell salvage is indicated in patients with contraindications to tranexamic acid (TA). An analysis was performed on the effect of post-operative cell salvage (POCS) regarding transfusion rate and costs in patients undergoing TKA. Material and methodsA prospective analysis was conducted on 518 patients, of whom 434 received TA, and 84 were contraindicated. The red cell mass, blood volume, and the percentage of lost blood volume were calculated. Incidents associated with the use of post-operative re-perfusion of drained blood and the rate of transfusion were recorded. An analysis was performed on the costs associated with allogeneic transfusion prevention methods. ResultsA POCS drain was not inserted in 10 out of the 84 patients not candidates for TA. In the 74 in which it was placed, 158±72ml of red cell mass was reinfused. The allogeneic transfusion rate was 36%, and was 52% in those with no drain inserted. Relative risk of transfusion using POCS was 0.69 (0.41 to 1.16) with an absolute risk reduction of 16% (−8 to 40%). The number needed to treat to avoid allogeneic transfusion was 7. The direct costs to avoid allogeneic transfusion were €1610. No complications associated with blood re-infusion were observed. ConclusionsThe use of POCS would be required in 7 patients after TKA to avoid one allogeneic transfusion with a cost over 10 times that of a transfusion of red cell concentrates.

Análisis de coste-eficacia del recuperador postoperatorio de sangre de drenajes en cirugía protésica primaria de rodilla. ¿Debemos seguir recomendando su empleo en la actualidad?

ObjectivesTotal knee arthroplasty (TKA) has a high transfusion rate. In our protocol, the use of postoperative cell salvage is indicated in patients with contraindications to tranexamic acid (TA). An analysis was performed on the effect of post-operative cell salvage (POCS) regarding transfusion rate and costs in patients undergoing TKA. Material and methodsA prospective analysis was conducted on 518 patients, of whom 434 received TA, and 84 were contraindicated. The red cell mass, blood volume, and the percentage of lost blood volume were calculated. Incidents associated with the use of post-operative re-perfusion of drained blood and the rate of transfusion were recorded. An analysis was performed on the costs associated with allogeneic transfusion prevention methods. ResultsA POCS drain was not inserted in 10 out of the 84 patients not candidates for TA. In the 74 in which it was placed, 158±72ml of red cell mass was reinfused. The allogeneic transfusion rate was 36%, and was 52% in those with no drain inserted. Relative risk of transfusion using POCS was 0.69 (0.41 to 1.16) with an absolute risk reduction of 16% (−8 to 40%). The number needed to treat to avoid allogeneic transfusion was 7. The direct costs to avoid allogeneic transfusion were €1,610. No complications associated with blood re-infusion were observed. ConclusionsThe use of POCS would be required in 7 patients after TKA to avoid one allogeneic transfusion with a cost over 10 times that of a transfusion of red cell concentrates

Abstract 17541: Impact of Therapeutic Hypothermia on Hemodynamics and Prognosis of Acute Coronary Syndrome After Resuscitation From Out-of-hospital Cardiac Arrest

Backgrounds: Although therapeutic hypothermia is recommended for neurologically unconscious patients after resuscitation from cardiac arrest, few data exist regarding clinical management during therapeutic hypothermia in acute coronary syndrome (ACS), requiring emergent coronary intervention. Therefore, we analyzed the impact of hypothermia on hemodynamics and prognosis of unconscious ACS patients. Methods and Results: We investigated consecutive 21 ACS patients (16 men, mean age 62.8±9.1) who were unconscious and induced hypothermia after resuscitation from out-of-hospital cardiac arrest between April 2009 to March 2014. Invasive hemodynamic monitoring with a pulmonary artery catheter was used during hypothermia with the target body temperature 34°C. ACS was diagnosed with emergent coronary angiography before or during cooling in all cases, and 18 patients had underwent emergent percutaneous coronary intervention. Average required time for the target body temperature from cardiac arrest were 6.8±2.6 hours. During hypothermia, mean blood pressure and cardiac index decreased significantly from 91.3 to 72.7 mmHg and 2.5 to 1.5 l/min/m2, respectively (p&lt;0.05), except for 5 patients with percutaneous cardiopulmonary support (PCPS). Under these conditions, 14 patients had hypokalemia and required potassium replacement and 7 patients had anemia and required a transfusion of red cell concentrates. Therapeutic hypothermia was discontinued early in 8 patients (fatal arrhythmia or circulatory instability in 5 patients, death in 3 patients with PCPS). Average length of stay in our hospital was 26.9 days (1-75 days). Importantly, 8 patients had a good functional outcome as defined by a cerebral performance category scale (CPC) 1-2, 7 patients had CPC 4 at the time of discharge, although there were still 6 death cases. Interestingly, of 8 patients with hypothermia early discontinued, 6 patients (75%) had a good functional outcome (CPC 1-2). Shorter time until return of spontaneous circulation was the most significant factor for a good neurological outcome. Conclusions: These results demonstrate that with hypothermia the outcome of ACS was favorable as far as maintaining hemodynamic state, probably due to less occurrence of fatal arrhythmias.

Recommendations for the transfusion of red blood cells.

The transfusion of red cell concentrates (RCC) is indicated in order to achieve a fast increase in the supply of oxygen to the tissues, when the concentration of haemoglobin (Hb) is low and/or the oxygen carrying capacity is reduced, in the presence of inadequate physiological mechanisms of compensation (table I)1–14. Table I Mechanisms of adaptation to anaemia Tissue oxygenation depends on various factors - the concentration of Hb; - the saturation of Hb, which, in turn, depends on the O2 tension and the affinity of the Hb for O2; - the O2 requirement, that is, the volume of oxygen needed by the tissues to carry out their aerobic function. Clinical factors that affect the physiological mechanisms of adaptation to anaemia5–8,15–19 - a reduced increase in cardiac output: hypovolaemia, coronary artery disease, disorders of heart valves, congestive heart disease, negative inotropic drugs; - decreased capacity to increase the extraction of O2: acute respiratory distress syndrome (ARDS), sepsis, systemic inflammatory response syndrome (SIRS), traumatic ischaemia-reperfusion damage syndrome; - altered gas exchange: chronic obstructive pulmonary disease (COPD), ARDS; - increased consumption of O2: fever, pain, stress, sepsis, SIRS, hyperventilation syndromes. When there is an indication to correct anaemia, but the situation is not urgent, strategies other than transfusion are preferred, such as the use of haematopoietic drugs (iron, vitamin B12, folic acid, recombinant erythropoietin)5–8,20. In order to reduce perioperative bleeding, it is important to suspend treatment with platelet anti-aggregants, adapt/neutralise anticoagulant therapy and use drugs such as antifibrinolytics and desmopressin9,20–23. Autotransfusion, carried out according to the criteria set out in the appropriate pre-operative request schemes (maximum surgical blood order schedule -MSBOS), and surgical and anaesthetic techniques to limit blood loss are useful strategies for decreasing the use of homologous blood (Grade of recommendation: 1C+)5,6,13,14,20–24.

CABG-procedures in patients with pretreatment with the GPIIb/IIIa-receptor antagonist tirofiban (Aggrastat ©): Modification of perioperative management?

In order to investigate the effects of tirofiban administration in cardiac surgery all patients undergoing coronary artery bypass grafting (CABG) which received this drug preoperatively between 1/2002 and 6/2005 ( n = 232) were studied. Three groups regarding the perioperative administration of antifibrinolytic drugs were compared: group A = controls ( n = 70), group B = aprotinin ( n = 110), group C = tranexamic acid ( n = 52) Furthermore we could differ the patients depending on the time when tirofiban was stopped (< 2 h, 2–4 h, > 4 h preoperatively). The postoperative blood loss was significantly higher in all tirofiban-patients (A–C) compared to a group of CABG-patients without tirofiban. The best results concerning blood loss, transfusion of red cell concentrates (rcc), fresh frozen plasma (ffp) and incidence of re-sternotomy could be found in patients with aprotinin. A further significant improvement could be seen in patients who received platelets, intraoperative hemofiltration and in which tirofiban was stopped > 4 h preoperatively. We conclude that by early presurgical discontinuing of tirofiban-therapy and slight modifications of the perioperative management bleeding complications can significantly be reduced.

Pall leukotrap affinity prion‐reduction filter removes exogenous infectious prions and endogenous infectivity from red cell concentrates

Three recent probable cases of transmission of a variant of human Creutzfeldt-Jakob disease (vCJD) through blood transfusion suggest that the disease can be transmitted through transfusion of blood components from presymptomatic blood donors. In this study, we investigated the performance of a new filter for reducing the levels of infectious prions (PrP(Sc)) from red cell concentrates (RCC). Endogenous Infectivity: A pool of 500 ml of whole blood was collected from 263K-strain scrapie-infected hamsters into an anticoagulant, processed into non-leucoreduced RCC (NL-RCC), and then passed through a prion-reduction filter. Pre- and postfiltration samples were tested for PrP(Sc) by Western blot and infectivity by inoculation of healthy hamsters. Results of the endogenous infectivity study after 200 days post-inoculation are discussed. Exogenous (Spiking) Study: Scrapie-infected hamster brain homogenates containing PrP(Sc) were added to human RCC and then filtered. Levels of PrP(Sc) were determined by Western blot assay. The effect of prior leucodepletion of 'spiked' RCC on PrP(Sc) removal by the prion-removal filter was also assessed. In the endogenous infectivity study, at 200-day observation time, the prefiltered RCC transmitted disease to six of the 187 hamsters, whereas the filtered RCC did not transmit disease to any of 413 animals, P = 0.001. The prion filter also significantly reduced the concentration of leucocytes in the RCC by about 4 logs, P < 0.05. In the exogenous (spiking) study, the level of PrP(res) was significantly reduced in RCC P < 0.05. Prior leucodepletion of the RCC with a leucoreduction filter did not significantly reduce the concentration of exogenously spiked PrP(Sc), P > 0.05. The use of this new prion-reduction filter should reduce the risk of vCJD transmission through transfusion of RCC, the most widely transfused blood component.