Transfusion-related Side Effects Research Articles

Is restrictive transfusion sufficient in colorectal cancer surgery? A retrospective study before and during the COVID-19 pandemic in Korea.

Blood transfusion is one of the most common procedures used to treat anemia in colorectal surgery. Despite controversy regarding the adverse effects of blood products, surgeons have maintained standards for administering blood transfusions. However, this trend was restrictive during the COVID-19 pandemic because of a shortage of blood products. In this study, we conducted an analysis to investigate whether the restriction of blood transfusions affected postoperative surgical outcomes. Medical records of 318 patients who underwent surgery for colon and rectal cancer at Ewha Womans University Mokdong Hospital between June 2018 and March 2022 were reviewed retrospectively. The surgical outcomes between the liberal and restrictive transfusion strategies in pre- and post-COVID-19 groups were analyzed. In univariate analysis, postoperative transfusion was associated with infectious complications (odds ratio [OR], 1.705; 95% confidence interval [CI], 1.015-2.865; P=0.044). However, postoperative transfusion was not an independent risk factor for the development of infectious complications in multivariate analysis (OR, 1.305; 95% CI, 0.749-2.274; P=0.348). In subgroup analysis, there was no significant association between infectious complications and the hemoglobin threshold level for the administration of a transfusion (OR, 1.249; 95% CI, 0.928-1.682; P=0.142). During colorectal surgery, the decision to perform a blood transfusion is an important step in ensuring favorable surgical outcomes. According to the results of this study, restrictive transfusion is sufficient for favorable surgical outcomes compared with liberal transfusion. Therefore, modification of guidelines is suggested to minimize unnecessary transfusion-related side effects and prevent the overuse of blood products.

Rotational ThromboElastometry-guided blood component administration versus standard of care in patients with Cirrhosis and coagulopathy undergoing Invasive ProcEdures (RECIPE): study protocol for a randomised controlled trial

BackgroundPatients with cirrhosis often undergo invasive procedures both for management of complications of their advanced liver disease, including treatment for hepatocellular carcinoma, as well as underlying comorbidities. Despite a current understanding that most patients with cirrhosis are in a rebalanced haemostatic state (despite abnormalities in conventional coagulation tests, namely INR and platelet count), patients with cirrhosis are still often given prophylactic blood components based on these conventional parameters, in an effort to reduce procedure-related bleeding. Viscoelastic tests such as Rotational Thromboelastometry (ROTEM) provide a global measurement of haemostasis and have been shown to predict bleeding risk more accurately than conventional coagulation tests, and better guide blood product transfusion in a number of surgical and trauma-related settings. The aim of this study is to assess the utility of a ROTEM-based algorithm to guide prophylactic blood component delivery in patients with cirrhosis undergoing invasive procedures. We hypothesise that ROTEM-based decision-making will lead to a reduction in pre-procedural blood component usage, particularly fresh frozen plasma (FFP), compared with standard of care, whilst maintaining optimal clinical outcomes.MethodsThis is a multi-centre randomised controlled trial comparing ROTEM-guided prophylactic blood component administration to standard of care in patients with cirrhosis and coagulopathy undergoing invasive procedures. The primary efficacy outcome of the trial is the proportion of procedures requiring prophylactic transfusion, with the primary safety outcome being procedure-related bleeding complications. Secondary outcomes include the amount of blood products (FFP, platelets, cryoprecipitate) transfused, transfusion-related side effects, procedure-related complications other than bleeding, hospital length of stay and survival.DiscussionWe anticipate that this project will lead to improved prognostication of patients with cirrhosis, in terms of their peri-procedural bleeding risk. We hope to show that a significant proportion of cirrhotic patients, deemed coagulopathic on the basis of standard coagulation tests such as INR and platelet count, are actually in a haemostatic balance and thus do not require prophylactic blood product, leading to decreased and more efficient blood component use.Trial registrationRECIPE has been prospectively registered with the Australia and New Zealand Clinical Trials Registry on the 30th April 2019 (ACTRN12619000644167).

5613475 ADVERSE REACTIONS TO RBC TRANSFUSION: A SINGLE THALASSEMIA AND SICKLE CELL DISEASE DEPARTMENT’S EXPERIENCE

Background: Thalassemia and Sickle Cell Disease patients require regular blood transfusions and iron chelation treatment for the entirety of their lives. Several patients had transfusion-related side effects as a result of frequent and chronic transfusions. Methods: In this study, we analysed the frequency of transfusion reactions and the methods used to address them by reviewing the medical records of 95 patients who received multiple transfusions on a regular basis during a 20-year period. All demographics and charactiristics are in TABLE 1. Table 1: - The Demographics and Characteristics Compared TYPE OF HEMOGLOBINOPATHY β-Thalassemia (51.3%) α-Thalassemia (2.6%) Sickle Cell Disease (12.8%) β-thal/SCD (15.4%) AGE AT THE ONSET OF TRANSFUSIONS < 2 years old (45.7%) > 20 years old (11.4%) > 30 years old (34.3%) occasionally (8.6%) TRANSFUSION FREQUENCY weekly (2.7%) every 15-20 days (54.1%) monthly (34.3%) exchange transfusions (2.7%) Results: Over a 20-year period, 42 percent (42,1%) of the 95 patients who received repeated transfusions reported at least one adverse event during the transfusion (about two per year reported). Our unit’s usual clinical practice is to transfuse patients with Leukoreduced RBC to prevent HLA alloimmunization, CMV transmission, and fever nonhemolytic transfusion reactions.Fever (48.1%), chills (18.5%), anaphylaxis/urticaria (11.2%), swelling (3.7%), hemolysis (11.2%), yersinia enterocolitica (3.7%), and alloimmunization (3.7%) were the most common side effects reported by patients experiencing a transfusion reaction (image 1).In each case, the transfusion was discontinued and the reaction was treated according to local clinical practice. Antibiotic therapy was used to manage infectious complications. Extended blood type matching (ABO, CcDEe, Kell, Duffy, Kidd, MNS,Lewis, Lutheran, etc) has been used in clinical practice as a prophylactic intervention in the case of hemolysis or alloimmunization. Before receiving washed red blood cells in future transfusions, some patients with fever or allergic responses were administered premedication with antihistamines or antipyretics. Nine patients (22.5%) of patients those who had experienced a previously adverse reaction reported a second episode with the following symptoms: allergic reaction/urticaria (44.5%), fever (33.5%), and alloimmunization (22.5%). Patients who developed alloimmunization during the second adverse transfusion event had no history of alloimmunization previously. Conclusions: In the studied population, there was no high prevalence of serious or fatal transfusion adverse effects. Every transfusion requires constant vigilance for the occurrence of transfusion reactions, especially in patients who have received multiple transfusions.

P1741: EXAMINING THE BURDEN OF ILLNESS ASSOCIATED WITH TRANSFUSION-DEPENDENT ΒETA-THALASSEMIA FROM THE PATIENT’S PERSPECTIVE

Background: β-thalassemia is a rare genetic blood disorder affecting approximately 1 in 100,000 people globally. Typically diagnosed in childhood, β-thalassemia is marked by the inability to produce hemoglobin, which results in chronic anemia. Transfusion-dependent β-thalassemia (TDβT) is the most severe form of this disorder, with treatment requiring frequent red blood cell transfusions (RBCTs). Recognized complications of the frequent RBCTs include alloimmunization, iron overload, resultant cardiac and liver disease, and reported poor health-related quality of life (HRQoL). Aims: To examine the burden of illness and HRQoL in patients diagnosed with TDβT. Methods: Potential study participants were recruited with the assistance of the Cooley’s Anemia Foundation. Participants were ≥18 years of age, had a self-reported physician diagnosis of β-thalassemia, and had received ≥1 RBCT in the past 6 months. After providing informed consent, patients completed an institutional review board-approved 30-minute online survey that included both validated patient-reported outcome instruments, and other questions written expressly for the purpose of this study. Data were collected in May 2021. Patients who completed the survey earned an incentive payment of 75 US dollars. Results: A total of 100 patients completed the survey; mean age was 36.0 years (standard deviation [SD] 10.4) and 35% of patients were male. Patients had been diagnosed with TDβT for a mean of 34.4 years (SD 10.3) and experienced a mean of 9.6 (SD 4.3) RBCT events in the past 6 months. As an indication of severity, 66% of patients reported requiring >1 RBCT per month, 31% each month, and 3% every other month. Side effects of RBCT included iron overload (in 81% of patients), rashes/hives (74%), fatigue (61%), and pain/bruising at injection site (52%). Mean time required for an RBCT was 7.4 hours (SD 11.3), including transfusion preparation time. Travel and wait times were an additional 7.1 hours. Among all patients, 70% reported a “moderate” to “extremely high” burden of RBCT. On HRQoL, 71% of patients reported “wondering what life would be like without β-thalassemia,” 86% reported “feeling fatigued” leading up to RBCT, and 42% reported “not being as social with friends/family due to the time needed for RBCT.” On validated psychological instruments, 52% of patients reported mild-to-severe depression (Patient Health Questionnaire [PHQ-9]) and 53% reported mild-to-severe anxiety (Generalized Anxiety Disorder Questionnaire [GAD-7]), over the previous 2 weeks. Summary/Conclusion: The survey results suggest there is a substantial time, side-effect, and HRQoL burden associated with treatment by RBCTs in patients diagnosed with TDβT. This includes considerable time devoted to preparing for and receiving transfusions, transfusion-related side effects, and increases in depression and anxiety. These findings contribute to the understanding of the humanistic and psychological burden of RBCT dependency in patients with β-thalassemia. New treatment options that can improve outcomes in this population are needed.

Time and Side-Effect Burden Associated with Red Blood Cell Transfusions in Patients Diagnosed with Transfusion-Dependent β-Thalassemia

▪Introduction: β-thalassemia is a genetic blood disorder marked by the inability to produce hemoglobin. Diagnosed primarily in childhood, transfusion-dependent β-thalassemia (TDT) is the most severe form of this disorder and results in chronic anemia, requiring frequent red blood cell (RBC) transfusions to maintain hemoglobin levels. While previous studies have shown that health-related quality of life (HRQoL) is adversely affected in patients with TDT, the issues associated with the transfusion process itself in these patients (eg, side effects and time requirements) have not always been examined. These issues are the focus of this study.Methods: Following exploratory qualitative interviews with a small sample of patients identified by the Cooley's Anemia Foundation (CAF), a 30-minute web-based survey was developed to assess HRQoL variables in TDT. Subsequently, CAF identified patients in the US who were ≥ 18 years of age, had a self-reported physician diagnosis of β-thalassemia, and had received ≥ 1 RBC transfusion in the past 6 months, and invited them to participate in the study. Following informed consent, patients completed a number of validated and ad hoc questions about their treatment, side effects, psychological burden, time requirements for a transfusion, and caregiver information. Data were collected in May 2021. Descriptive results are presented as frequencies, means, and standard deviations (SD).Results: A total of 100 patients were identified and recruited by CAF and completed the survey. Of these, 35 (35%) were male, with a mean age of 36.0 (SD = 10.4) years. Patients had been diagnosed with TDT for a mean of 34.4 years (SD = 10.3) and had received a mean of 9.6 (SD = 4.3) RBC transfusions in the previous 6 months. In addition to receiving RBC transfusions (100%), other treatments ever received for TDT included iron chelation therapy (94%), surgery (47%), and stem cell/bone marrow transplantation (5%). Regarding RBC transfusions, 66% of patients reported requiring them more than once per month, 31% each month, and 3% every other month. Common patient-reported side effects of RBC transfusions were iron overload (81%), rashes/hives (74%), fatigue (61%), and pain/bruising at the injection site (52%). Additionally, 86% of patients reported feeling fatigued leading up to RBC transfusions, 75% reported that treatments for TDT had become routine, and 64% accepted the routine. Time required for an RBC transfusion was estimated at a mean of 7.4 hours (SD = 11.3) including transfusion preparation time. Travel and wait times were estimated as requiring an additional 7.1 hours. Other time requirements included frequent outpatient visits and frequent laboratory tests, averaging 3.9 visits and 6.1 visits in a 6-month period, respectively. Overall, 13% of patients reported having a caregiver. Caregiver activities included travel to and from appointments (77%), help with household duties (77%), and assistance in treatment decisions (62%).Conclusions: The results of this survey suggest there is a substantial time and side-effect burden associated with transfusion and treatment among patients diagnosed with TDT. This includes considerable time devoted to preparing for and receiving transfusions, transfusion-related side effects, frequent laboratory and outpatient appointments, and help from a caregiver. Medical treatments that would decrease the dependency on transfusions in TDT could decrease this burden and improve overall quality of life. DisclosuresGupta: Kantar Health: Current Employment; Bristol Myers Squibb: Consultancy, Research Funding. Costantino: Kantar Health: Current Employment; Bristol Myers Squibb: Consultancy, Research Funding. Perkowski: Kantar Health: Current Employment; Bristol Myers Squibb: Consultancy, Research Funding. Inyart: Kantar Health: Current Employment; Bristol Myers Squibb: Consultancy, Research Funding. Ashka: Kantar Health: Current Employment; Bristol Myers Squibb: Consultancy, Research Funding. Clapp: Kantar Health: Current Employment; Bristol Myers Squibb: Consultancy, Research Funding. Price: Bristol Myers Squibb: Current Employment, Current equity holder in publicly-traded company. Knoth: Bristol Myers Squibb: Current Employment.

Early high antibody titre convalescent plasma for hospitalised COVID-19 patients: DAWn-plasma.

BackgroundSeveral randomised clinical trials have studied convalescent plasma for coronavirus disease 2019 (COVID-19) using different protocols, with different severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) neutralising antibody titres, at different time-points and severities of illness.MethodsIn the prospective multicentre DAWn-plasma trial, adult patients hospitalised with COVID-19 were randomised to 4 units of open-label convalescent plasma combined with standard of care (intervention group) or standard of care alone (control group). Plasma from donors with neutralising antibody titres (50% neutralisation titre (NT50)) ≥1/320 was the product of choice for the study.ResultsBetween 2 May 2020 and 26 January 2021, 320 patients were randomised to convalescent plasma and 163 patients to the control group according to a 2:1 allocation scheme. A median (interquartile range) volume of 884 (806–906) mL) convalescent plasma was administered and 80.68% of the units came from donors with neutralising antibody titres (NT50) ≥1/320. Median time from onset of symptoms to randomisation was 7 days. The proportion of patients alive and free of mechanical ventilation on day 15 was not different between both groups (convalescent plasma 83.74% (n=267) versus control 84.05% (n=137)) (OR 0.99, 95% CI 0.59–1.66; p=0.9772). The intervention did not change the natural course of antibody titres. The number of serious or severe adverse events was similar in both study arms and transfusion-related side-effects were reported in 19 out of 320 patients in the intervention group (5.94%).ConclusionsTransfusion of 4 units of convalescent plasma with high neutralising antibody titres early in hospitalised COVID-19 patients did not result in a significant improvement of clinical status or reduced mortality.

Evaluation of using fresh frozen plasma for patients with cirrhosis at a tertiary healthcare center in Turkey: Strict transfusion policies are essential

AimManagement of blood transfusions is a critical issue, especially in cirrhotic patients, because of the absence of national policies in many countries. Fresh frozen plasma (FFP) is a common blood component misused excessively in various clinical situations and cirrhosis patients without any scientific rationale. We evaluated the FFP transfusions in patients with cirrhosis at our tertiary care hospital. Material and MethodThe cases with cirrhosis diagnosed between 2014 and 2020 were selected using the hospital database. The appropriateness of FFP transfusion was determined based on the Practice Guidance by the American Association for the Study of Liver Diseases and Italian guidelines. ResultTwo hundred and six liver cirrhosis patients were identified who received FFP transfusion. The median age was 63 (22–94). Of the 206 patients, 79 (38.3 %) were female, and 127 (61.7 %) were men. The most common causes of liver cirrhosis were alcohol (27.7 %). 45.6 % of the patients were in Child-Pugh Class C. We found 62.1 % of FFP replacements were inappropriately used. Most inappropriate use of FFP (22.8 %, n = 47) occurred to correct prolonged INR in the absence of bleeding. ConclusionTo avoid inappropriate usage of FFP, regular utilization reviews and formal education programs can be helpful. Our clinic has planned to arrange educational programs for physicians to use blood products appropriately and minimize transfusion-related side effects.

Effectiveness of Convalescent Plasma Therapy in Severe or Critically Ill COVID-19 Patients: A Retrospective Cohort Study.

PurposeCoronavirus disease-2019 (COVID-19) is a novel respiratory infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); there are few specific treatments. Convalescent plasma (CP), donated by people who have recovered from COVID-19, is an investigational therapy for severe or critically ill patients with COVID-19.Materials and MethodsThis retrospective cohort study evaluated the effectiveness of CP therapy in patients with severe or life-threatening cases of COVID-19 at two hospitals in Seoul, Korea, between May and September 2020. Clinical outcomes were evaluated in 20 patients with CP therapy in a descriptive manner. Additionally, the changes in cycle threshold (Ct) values of 10 patients with CP therapy were compared to those of 10 controls who had the same (±0.8) initial Ct values but did not receive CP.ResultsOf the 20 patients (mean age 66.6 years), 18 received high-dose oxygen therapy using mechanical ventilators or high-flow nasal cannulas. Systemic steroids were administered to 19 patients who received CP. The neutralizing antibody titers of the administered CP were between 1:80 and 1:10240. There were two ABO-mismatched transfusions. The World Health Organization ordinal scale score and National Institutes of Health severity score improved in half of the patients within 14 days. Those who received CP showed a higher increase in Ct values at 24 h and 72 h after CP therapy compared to controls with similar initial Ct values (p=0.002). No transfusion-related side effects were observed.ConclusionCP therapy may be a potential therapeutic option in severe or critically ill patients with COVID-19.

English

There is increasing evidence of the clinical importance of microparticles (MPs) and their role in blood transfusion-related side effects and the transmission of pathogens. The study aims to examine the red blood cell-derived MPs in blood bags during storage under standardized blood bank conditions. The samples were tested at various times to demonstrate the presence of RBC-derived MPs by flow cytometry. The quantitative assay was carried out in stored erythrocyte concentrate on days 0, 25 and 35 and their number from day 0 to 25 and 35 and the number of day 25 to day 35 were compared. The MPs were counted after being concentrated in a supernatant (labeled with the respective antibodies CD47, CD235a and Annexin V) obtained by a specific centrifugation procedure. The analysis showed that the number of Annexin V positive MPs increased between day 0 and day 35 (~ 0.001) and CD47 expression on MPs at day 25 and day 35 decreased compared to day 0 (~ 0.001). In addition, CD235a expression had shown minimal insignificant changes with an upward trend (> 0.05) during the storage period. It is concluded that monitoring the release of MPs from RBC units during storage is a sensitive approach to identifying MPs for transfusion drugs and, more broadly, for cell-based therapies. Key words: Red blood cells, phosphatidylserine, cell-derived microparticle.

Convalescent Plasma Therapy for Coronavirus Disease 2019.

Convalescent plasma has been used for decades to prevent and treat a wide range of infectious diseases for which no specific treatment is available. The use of convalescent plasma involves transfusing plasma collected from patients who have recovered from a viral illness, in an attempt to transfer virus-neutralizing antibodies and confer passive immunity. In addition to the antiviral mechanisms of neutralizing antibodies, the immunomodulatory effects of plasma components could have benefits. Several small and large-scale studies have shown the effects of convalescent plasma for the treatment of severe coronavirus disease 2019 (COVID-19). In addition to transfusion-related side effects, unexpected side effects such as antibody-dependent enhancement (ADE) may occur during convalescent plasma therapy, but early safety studies have not found any cases of ADE among more than 5,000 participants. With historical precedents and recent clinical studies, convalescent plasma therapy should be considered as a candidate therapy for COVID-19 given the limited effectiveness of antiviral drugs and lack of a vaccine. A system to secure safe collection and use of convalescent plasma should be developed as a response to the pandemic. Further clinical trials should be conducted to determine the safety and efficacy of convalescent plasma therapy concurrently with its clinical use.

Point-of-care monitoring for the management of trauma-induced bleeding.

Knowledge of trauma-induced coagulopathy has been grown in the past and point-of-care suitable devices for coagulation testing have been introduced. Methodology and clinical application of different systems for point-of-care coagulation monitoring are shown with a focus on thrombelastography as measured by TEG, rotational thromboelastometry as measured by ROTEM and impedance aggregometry as measured by the multiplate analyser and ROTEM platelet. Two different methods for point-of-care coagulation assessment are available: viscoelastic tests (ROTEM, TEG) and impedance aggregometry. In different settings these methods have been evaluated in various publications pointing out the possibility of reducing transfusion requirements, transfusion-related side effects, and resulting costs. Point-of-care assessment of coagulation in trauma patients appears to be at least promising. However, because published data mostly are of retrospective or observational nature only, there is a need for prospective, randomized and controlled studies.

Males without apparent alloimmunization could have HLA antibodies that recognize target HLA specificities expressed on cells.

Human leukocyte antigen (HLA) antibodies, which are involved in the development of transfusion-related side effects such as transfusion-related lung injury, are sometimes found in males without a history of alloimmunization (eg, transplantation and transfusion). Whether HLA antibodies in male donors can interact with their target HLA specificities expressed on cells have not been completely investigated. The HLA antibodies detected in 7 male donors were characterized. Flow cytometry and immunocomplex capture fluorescence analysis were performed to evaluate the ability of these antibodies to bind with target HLA specificities expressed on cells. The association of these antibodies with complement was examined using anti-C1q antibody. Sustainability of HLA antibodies over time was compared in 26 male vs 57 female donors. The antibodies from all 7 donors recognized intact HLA molecules coated onto microbeads. The antibodies in 2 of 7 donors also recognized their target HLA specificities expressed on cells. Furthermore, the antibodies in one of these 2 donors showed HLA specificities that involved complement binding. Twenty-one of 26 initially positive male donors had turned negative for HLA antibody at least 1 year after their initial positive screening, whereas HLA antibody positivity was maintained for a long time in most female donors. Males without apparent alloimmunization could have HLA antibodies that recognize their target HLA specificities on cells and that could potentially modify molecular events in affected cells.

Viscoelastic testing for hepatic surgery: a systematic review with meta-analysis-a protocol.

BackgroundViscoelastic tests, including thromboelastography (TEG) and rotational thromboelastometry (ROTEM), provide a global assessment of haemostatic function at the point of care. The use of a TEG or ROTEM system to guide blood product administration has been shown in some surgical settings to reduce transfusion requirements. The aim of this review is to evaluate all published evidence regarding viscoelastic testing in the setting of hepatic surgery.MethodsWe will search MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials databases to identify randomised controlled trials examining the use of viscoelastic testing for hepatic surgery. Two reviewers will independently screen titles and abstracts of studies identified and will independently extract data. Any disagreements will be resolved by discussion with a third reviewer. A meta-analysis will be conducted if feasible.DiscussionViscoelastic devices such as TEG and ROTEM are increasingly available to clinicians as a bedside test. Patients undergoing hepatic surgery have a significant risk of blood loss and coagulopathy requiring transfusion. Theoretical benefits of use of a TEG or ROTEM system in the hepatic surgical setting include a rationalisation of blood products, a reduction in transfusion-related side effects, an improvement in patient outcomes including mortality, and a reduction in cost. This systematic review will summarise the current evidence regarding the use of viscoelastic testing for hepatic surgery.Systematic review registrationPROSPERO CRD42016036732Electronic supplementary materialThe online version of this article (doi:10.1186/s13643-016-0326-1) contains supplementary material, which is available to authorized users.

Perioperative bleeding management in pediatric patients.

Managing the bleeding pediatric patient perioperatively can be extremely challenging. The primary goals include avoiding hypotension, maintaining adequate tissue perfusion and oxygenation, and maintaining hemostasis. Traditional bleeding management has consisted of transfusion of autologous blood products, however, there is strong evidence that transfusion-related side-effects are associated with increased morbidity and mortality in children. Especially concerning is the increased reported incidence of noninfectious adverse events such as transfusion-related acute lung injury, transfusion-related circulatory overload and transfusion-related immunomodulation. The current approach in perioperative bleeding management of the pediatric patient should focus on the diagnosis and treatment of anemia and coagulopathy with the transfusion of blood products only when clinically indicated and guided by goal-directed strategies. Current guidelines recommend that a comprehensive multimodal patient blood management strategy is critical in optimizing patient care, avoiding unnecessary transfusion of blood and blood product and limiting transfusion-related side-effects. This article will highlight current guidelines in perioperative bleeding management for our most vulnerable pediatric patients with emphasis on individualized targeted intervention using point-of-care testing and specific coagulation products.

Donor-Derived Ex-Vivo Activated NK Cells in Management of Relapse after Allogeneic Hematopoietic Stem Cell Transplantation in High-Risk Acute Leukemia

Introduction: Relapse remains the main cause of failure of hematopoietic stem cell transplantation (HSCT) in acute leukemia. NK cells have the property of killing leukemia cells without GVHD aggravation theoretically. Moreover, in some cases, leukemia cells may lost HLA-I and/HLA-II antigens which would result in poor response to the immunotherapy except NK-based adoptive effectors.Objective: In present study, the safety and efficacy of donor-derived ex-vivo activated NK cells in management of relapse after allogeneic HSCT in high-risk acute leukemia were examined.Patients and methods: Between July 2012 and July 2014, 29 patients with acute leukemia who received NK cell infusion after HSCT were analyzed retrospectively. Some cases failed to chemotherapy combined with donor lymphocyte infusion (DLI) before NK cell therapy. The diagnosis were ALL (10 cases), AML (18 cases) and mixed acute leukemia (1 case). All patients were high-risk leukemia. The disease status before transplant was CR1 in 8 cases, CR2 in 7, CR3 in 1 and non-remission in 13. The types of donor included identical sibling (5 cases), haploientical family member (21 cases) and unrelated donor (3 cases). The conditioning and GVHD prophylactic regimens were reported previously (Lu DP et al., Blood 2006; 107:3065). Minimal residual disease (MRD) was detected by either quantitative RT-PCR for fusion genes or flow cytometry or both. The expression of HLA-I and HLA-II antigens in leukemia cells was evaluated by flow cytometry. Donor-derived either peripheral blood stem cells or lymphocytes were cultured for 6 days using original culture system (AIM-V medium with IL-2, IL-12, IL-15 and IL-21) or modified culture system (SCGM medium with IL-2, IL-12, IL-15, IL-18 and IL-21). Escalated dosage of NK cells were infused starting with 1×105 cells/kg (recipient’s body weight) with or without IL-2 injection. Nine patients were in prevention group and 20 cases were in treatment group. The patients with hematologic relapse received NK cells 3 days later after chemotherapy.Results: Compared with our original culture system, the modified culture system enhanced approximately 10% to 20% of the purity and 4 to 8 fold in number of NK cells by day 6. Furthermore, our modified culture system elevated the expression of function phenotype including TRAIL, NKG2D and CD62L on NK cells in approximately 8 to 10 folds at day 6 and simultaneously stimulated higher level of IFN-γ. One to 4 NK cell infusions were given in each case with two week interval. Two of 29 cases developed mild skin GVHD. No transfusion-related side effects were noted. In prevention group, four of 9 cases remain complete remission, and the other 5 patients became MRD positive or relapse. In treatment group, seven of 20 cases have response to NK cell therapy, and two out of 7 cases who response to NK cells had failed to chemotherapy plus DLI before. Among 11 patients who had response to NK cells, eight of them are AML, and the remaining 3 patients are ALL. Higher response rate (10/23 cases) was seen with NK cell therapy by our modified culture system compared with the one (1/6 cases) by our original culture system.Conclusions: Our preliminary results have demonstrated that donor-derived ex-vivo activated NK cells are safe and effective modality in the management of relapse after allogeneic HSCT in high-risk acute leukemia even failed to chemotherapy combined with DLI. Optimal culture system has improved not only NK cell’s purity, number and function phenotype but also clinical efficacy. DisclosuresNo relevant conflicts of interest to declare.

Detection of microparticles from human red blood cells by multiparametric flow cytometry.

During storage, red blood cells (RBC) undergo chemical and biochemical changes referred to as "storage lesions". These events determine the loss of RBC integrity, resulting in lysis and release of microparticles. There is growing evidence of the clinical importance of microparticles and their role in blood transfusion-related side effects and pathogen transmission. Flow cytometry is currently one of the most common techniques used to quantify and characterise microparticles. Here we propose multiparametric staining to monitor and quantify the dynamic release of microparticles by stored human RBC. RBC units (n=10) were stored under blood bank conditions for up to 42 days. Samples were tested at different time points to detect microparticles and determine the haemolysis rate (HR%). Microparticles were identified by flow cytometry combining carboxyfluorescein diacetate succinimidyl ester (CFSE) dye, annexin V and anti-glycophorin A antibody. We demonstrated that CFSE can be successfully used to label closed vesicles with an intact membrane. The combination of CFSE and glycophorin A antibody was effective for monitoring and quantifying the dynamic release of microparticles from RBC during storage. Double staining with CFSE/glycophorin A was a more precise approach, increasing vesicle detection up to 4.7-fold vs the use of glycophorin A/annexin V alone. Moreover, at all the time points tested, we found a robust correlation (R=0.625; p=0.0001) between HR% and number of microparticles detected. Multiparametric staining, based on a combination of CFSE, glycophorin A antibody and annexin V, was able to detect, characterise and monitor the release of microparticles from RBC units during storage, providing a sensitive approach to labelling and identifying microparticles for transfusion medicine and, more broadly, for cell-based therapies.

Bleeding management for pediatric craniotomies and craniofacial surgery.

Pediatric patients when undergoing craniotomies and craniofacial surgery may potentially have significant blood loss. The amount and extent will be dictated by the nature of the surgical procedure, the proximity to major blood vessels, and the age, and weight of the patient. The goals should be to maintain hemodynamic stability and oxygen carrying capacity and to prevent and treat hyperfibrinolysis and dilutional coagulopathy. Over transfusion and transfusion-related side effects should be minimized. This article will highlight the pertinent considerations for managing massive blood loss in pediatric patients undergoing craniotomies and craniofacial surgery. North American and European guidelines for intraoperative administration of fluid and blood products will be discussed.

Desmopressin Acetate in Intracranial Haemorrhage

Introduction. The secondary increase in the size of intracranial haematomas as a result of spontaneous haemorrhage or trauma is of particular relevance in the event of prior intake of platelet aggregation inhibitors. We describe the effect of desmopressin acetate as a means of temporarily stabilising the platelet function. Patients and Methods. The platelet function was analysed in 10 patients who had received single (N = 4) or multiple (N = 6) doses of acetylsalicylic acid and 3 patients (control group) who had not taken acetylsalicylic acid. All subjects had suffered intracranial haemorrhage. Analysis was performed before, half an hour and three hours after administration of desmopressin acetate. Statistical analysis was performed by applying a level of significance of P ≤ 0.05. Results. (1) Platelet function returned to normal 30 minutes after administration of desmopressin acetate. (2) The platelet function worsened again after three hours. (3) There were no complications related to electrolytes or fluid balance. Conclusion. Desmopressin acetate can stabilise the platelet function in neurosurgical patients who have received acetylsalicylic acid prior to surgery without causing transfusion-related side effects or a loss of time. The effect is, however, limited and influenced by the frequency of drug intake. Further controls are needed in neurosurgical patients.

Microparticle formation in apheresis platelets is not affected by three leukoreduction filters

Microparticles in blood components might contribute to transfusion-related immunomodulation or other side effects. To elucidate the role of leukofiltration, we compared three commercially available filters for their effect on platelet (PLT)-derived (PDMP), leukocyte-derived (LDMP), and red blood cell-derived (RDMP) microparticle formation in apheresis PLTs. Apheresis PLTs from pairs of ABO-identical male donors were pooled and divided into four volumes. One volume was stored without filtration, whereas the other three were filtered with different devices. PDMPs, LDMPs, and RDMPs were measured by flow cytometry during 2 weeks of controlled-temperature (22°C) agitated storage. On average, PDMPs doubled over 5 days of storage, followed by a much steeper increase by which PDMPs on Day 14 were nearly 20 times higher than on Day 0. LDMP and RDMP counts were relatively stable over 14 days. Significant differences among filtered and nonfiltered products did not emerge. Although the conditions of this study showed no favorable or unfavorable effects of three different filters on microparticle formation, surveillance and investigation of unanticipated outcomes in other experimental and clinical circumstances should continue.

ABO血液型不適合生体腎移植術中に用いた新鮮凍結血漿製剤で輸血副作用を呈した1症例

原疾患の慢性糸球体腎炎による慢性腎不全のため2003年より血液透析を導入された62歳，男性．生体腎移植目的にて入院，手術となった．術中に用いた新鮮凍結血漿製剤（fresh frozen plasma: FFP）により輸血副作用のなかでも問題となっている輸血関連急性肺障害（transfusion-related acute lung injury：TRALI）が疑われたので報告する．本症例はABO血液型不適合移植のため術中に血液製剤使用を行ったが，これに起因する呼吸状態悪化を認めた．原因精査と加療を行いながら移植腎機能を保全するという状況下での麻酔管理を余儀なくされた症例であった．今後も増加するであろうABO血液型不適合生体腎移植とそれに伴う輸血療法についての若干の考察を加え症例報告することとする．