The natural history of transfusion-associated infection with human immunodeficiency virus. Factors influencing the rate of progression to disease

Patients infected by the human immunodeficiency virus (HIV) as a result of blood transfusions are unique in that their dates of infection are well defined and their medical conditions before infection are known. To characterize the natural history of transfusion-associated HIV infection, we studied 694 recipients of blood from 112 donors in whom AIDS later developed and from 31 donors later found to be positive for HIV antibody. Of the recipients tested, 85 were seronegative, 116 were seropositive, and 19 had AIDS. Of 101 HIV-seropositive recipients followed for a median of 55 months after infection, 54 had Centers for Disease Control Class IV disease, including 43 with AIDS. Life-table analysis suggested that AIDS will develop in 49 percent of infected recipients (95 percent confidence limits, 36 to 62 percent) within seven years after infection. As compared with recipients without AIDS, the 43 recipients with AIDS had received more transfusions at the time of infection (median, 21 vs. 7; P = 0.01). HIV-infected blood donors in whom AIDS developed were grouped according to whether AIDS developed within 29 months (the median) after donation (Group 1) or 29 or more months after donation (Group 2). As compared with the 31 recipients of blood from Group 2 blood donors, the 31 recipients of blood from Group 1 donors were more likely to have AIDS four years after infection (49 percent vs. 4 percent; P = 0.005) and illnesses resembling acute retroviral syndrome (14 of 24 vs. 5 of 22; P = 0.03). We conclude that most recipients of HIV-infected blood become seropositive, that AIDS develops in about half these recipients within seven years, and that the risk may be higher when AIDS develops in the blood donor soon after donation.

Establishment of a schedule of optimal preoperative collection of autologous blood

Autologous blood donation prior to elective surgery can protect patients from unnecessary exposure to allogeneic blood. However, the inappropriate use of autologous blood programs, which results in the collection of excessive quantities of blood or of the collection of any blood prior to low-risk surgical procedures, can be wasteful and potentially hazardous. All patients donating autologous blood at a large institution during a period of three months were studied in an effort to develop a schedule of optimal preoperative collection of autologous blood (SOPCAB), which is similar to a maximum surgical blood order schedule. Some 461 consecutive autologous donations from 264 patients were investigated. For certain surgical procedures, primarily the cardiac and orthopedic procedures, undercollection appeared to be the most common problem. For other procedures (laminectomies, nasal surgery), overcollection was more common. A model is presented for the careful scrutiny of autologous blood collection and use to allow for the creation of a SOPCAB for patients undergoing elective surgery.

Cisplatin-induced nonimmunologic adsorption of immunoglobulin by red cells

Antibodies to cisplatin, an extensively used anticancer chemotherapeutic agent, have been implicated previously as a cause of immune hemolytic anemia. Investigation of a suspected case of cisplatin-induced hemolytic anemia in a 40-year-old man demonstrated that IgG could be adsorbed nonimmunologically by reagent red cells in vitro. This phenomenon was found to be a source of possible error in the interpretation of studies identifying specific cisplatin antibodies. Furthermore, cisplatin was found to be capable of producing a positive direct antiglobulin test (DAT), owing to the nonspecific adsorption of immunoglobulin and complement in vivo. Although this finding did not result in acute hemolysis, it may cause confusion in the investigation of DAT-positive hemolytic anemias. We question whether previous reports of cisplatin-induced hemolytic anemia are accurate in their assessment that such hemolysis was mediated immunologically. Future studies of suspected cases of hemolysis induced by this drug should include serologic investigation adequate to demonstrate the presence of specific cisplatin antibodies. A positive DAT in such patients should not be considered proof of drug-induced immune hemolytic anemia.

Clinical significance of anti-Yt(b). Report of a case using a 51chromium red cell survival study

Several published reports have documented the variable survival of Yt(a+) red cells (RBC) in patients with anti-Yt(a) as measured by 51Chromium (Cr)-labeled RBC survival studies. Similar studies with anti-Yt(b) have not been reported. A 51Cr-labeled RBC survival study was performed using Yt(b+) RBCs and a monocyte monolayer assay in a young hemodialysis patient who required chronic transfusion therapy and who had developed anti-Yt(b). The survival of the transfused RBCs was 100 and 93 percent at 1 and 24 hours, respectively, with a half life of 21 days at termination of the study (normal, 28 to 32 days). These results showed no evidence of rapid destruction of the Yt(b+) RBCs, indicating that this patient could be transfused safely with blood from Yt(b+) donors. Long-term survival of the 51Cr-labeled Yt(b+) RBCs was shortened moderately, however, a finding that correlated with a slightly abnormal monocyte monolayer assay test.

Predictive value of clinical, laboratory, pathologic, and treatment variables in steroid/immunosuppressive resistant lupus nephritis

Twenty-seven patients with lupus nephritis and nephrotic syndrome had persistent disease activity despite an adequate trial of corticosteroids and immunosuppressive drugs; 30% were Asians, compared with 7% of our overall SLE population. Two years later, seven had a very good outcome and seven a poor outcome. Thirty clinical, pathological, laboratory, and treatment variables were analyzed in a good versus poor responder subset comparison in an effort to determine which factors were associated with favorable outcome. Administration of pulse steroids (P = .069) and a low biopsy chronicity index (P = .048) were associated with the good responder subset. Serum creatinine, biopsy class, blood pressure, complement, and anti-DNA values at entry as well as the choice of immunosuppressive drug were not helpful in predicting outcome. All seven good responders were plasmapheresed (P = .026). Patients with refractory lupus nephritis who have a low biopsy chronicity index may benefit from the use of pulse steroids or plasmapheresis, and controlled studies are suggested.

Plasmapheresis in the treatment of acute relapsing inflammatory demyelinating polyradiculoneuropathy associated with human immunodeficiency virus infection: a case report

Neurologic complications, including both the acute and chronic forms of inflammatory demyelinating polyradiculoneuropathy (IDP) are becoming more prevalent among patients with the acquired immunodeficiency syndrome (AIDS) and AIDS-related-complex (ARC). Although the etiology of the above radiculoneuropathies is not known, an autoimmune process has been postulated. Plasmapheresis has been reported to be of benefit in both the acute and chronic forms of these neuropathies. In this report we describe the use of plasmapheresis in the treatment of a patient with ARC and the acute relapsing form of IDP. The treatment consisted of an intensive course of plasmapheresis following his initial presentation and after an acute relapse which occurred several weeks after his initial presentation. Both the initial presentation and relapse involved respiratory compromise necessitating intubation and mechanical ventilation. In both instances marked clinical improvement was achieved after initiation of plasmapheresis. Thus, plasmapheresis may have a role in the management of acute relapsing IDP associated with human immunodeficiency virus infection.

Treatment of severe platelet dysfunction and hemorrhage after cardiopulmonary bypass: reduction in blood product usage with desmopressin

Impairment of platelet function commonly occurs after cardiopulmonary bypass, and may result in substantial bleeding. Because desmopressin acetate (a synthetic analogue of vasopressin) shortens bleeding time in a variety of platelet disorders, a controlled clinical trial of intravenous desmopressin was performed in 39 patients with excessive mediastinal bleeding (greater than 100 ml/h) and a prolonged template bleeding time (greater than 10 minutes) more than 2 hours after termination of cardiopulmonary bypass. Twenty-three desmopressin recipients and 16 control patients (no desmopressin) were similar in surgical procedure, pump time, platelet count, template bleeding time and amount of bleeding before therapy (p = NS). Compared with the control group, the patients receiving desmopressin (20 micrograms; mean 0.3 micrograms/kg) utilized fewer blood products (29 +/- 19 versus 15 +/- 13 units/patient; p less than 0.05), especially platelets (12 +/- 9 versus 4 +/- 7 units/patient; p = 0.004), while achieving a similarly effective reduction in mediastinal bleeding (4.8- and 4.3-fold, p = 0.001 for both). Severe platelet dysfunction was partially corrected within 1 hour after desmopressin infusion, during which interval no blood products were administered: the template bleeding time shortened (from 17 to 12.5 minutes, p less than 0.05), whereas the platelet count remained unchanged (at 96 +/- 35 and 105 +/- 31 X 10(3)/mm3, p = NS). The plasma levels of two factor VIII components increased: procoagulant activity (VIII:C) from 0.97 +/- 0.43 to 1.52 +/- 0.74 units/ml (p less than 0.05) and von Willebrand factor (VIII:vWF) from 1.28 to 1.78 units/ml (p less than 0.05); these increases correlated with the shortening of the bleeding time (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Use of autologous pregnancy plasma to treat a flare of juvenile rheumatoid arthritis: case report and literature review

A patient with juvenile rheumatoid arthritis whose disease was in remission during pregnancy underwent third-trimester plasmaphereses. The stored plasma was returned to her 1 year postpartum, when the disease flared, without beneficial results. The literature on the use of blood products in rheumatoid arthritis and pregnancy is reviewed.

Transfusion-associated noncardiogenic pulmonary edema. Report of a case and a warning regarding treatment

Although noncardiogenic pulmonary edema (NCPE) is a recognized complication of blood transfusion, the precise etiology is not well understood. NCPE may be secondary to complement-mediated pulmonary capillary injury initiated by either donor or recipient anti-leukocyte antibodies. It is not caused by simple volume overload. Recent blood banking texts and published case reports continue to suggest diuretics as part of the initial therapy for this complication. We report a case of transfusion-associated NCPE in which empirical diuretic therapy clearly was detrimental and suggest that the use of diuretics for treatment of this condition is not warranted. Reversal of progressive hypoxemia is the mainstay of therapy. Hemodynamic monitoring is important in differentiating NCPE from pulmonary edema secondary to cardiac failure or volume overload and should be used as a guide for further therapy.

Positive direct antiglobulin tests and immune hemolytic anemia in patients receiving procainamide

To characterize the autoimmune phenomena in patients receiving procainamide, we studied the prevalence of positive direct antiglobulin (Coombs') tests and immune hemolytic anemia in 100 such patients and compared them with 100 age-matched and sex-matched controls. There was a significant increase in the frequency of positive direct antiglobulin tests in patients receiving procainamide (21 vs. 10 per cent, P = 0.05). The mechanism of red-cell sensitization in patients receiving procainamide was the production of red-cell autoantibody, which was serologically indistinguishable from that seen in warm autoimmune hemolytic anemia. In contrast, positive direct antiglobulin tests in control patients were due to the presence of complement components. Red-cell autoantibody production secondary to procainamide was not correlated with a higher-than-expected frequency of antinuclear antibodies or the clinical syndrome of drug-induced lupus erythematosus. In the series of 100 patients receiving procainamide, we identified three cases of immune hemolytic anemia. In two of the three cases, the anemia resolved after the medication was discontinued and did not require steroid therapy. We conclude that procainamide often results in the production of red-cell autoimmune phenomena.

Lymphadenopathy associated virus infection of a blood donor--recipient pair with acquired immunodeficiency syndrome

A retrovirus isolated from three patients with the acquired immunodeficiency syndrome (AIDS) in the United States was morphologically and antigenically identical to lymphadenopathy associated virus isolated in France. Two of these isolates were from a blood donor-recipient pair, each of whom developed AIDS. Lymphadenopathy associated virus was isolated from the blood donor's lymphocytes 12 months after his onset of AIDS symptoms and from the blood recipient's lymphocytes 1 month after her onset of AIDS symptoms. Two isolates from the blood donor-recipient pair and an isolate from an epidemiologically unrelated homosexual man were examined by competitive radioimmunoassay to determine their antigenic relatedness to each other and to other human retroviruses. The major core proteins (p25) of the isolates were antigenically identical and all three isolates were identical to prototype lymphadenopathy associated virus isolated in France.

Plasmapheresis versus lymphoplasmapheresis in rheumatoid arthritis: immunologic comparisons and literature review

Eight patients with Functional Class III, seropositive, erosive rheumatoid arthritis unresponsive to remittive drugs each underwent nine aphereses over 3 weeks. Four had a 40-ml/kg plasma exchange and four others had a 40-ml/kg plasma exchange plus a mean 5.67 X 10(9) lymphocyte depletion. Both groups appeared to improve clinically. T and B cell counts and OK T4 and OK T8 ratios decreased in the lymphoplasmapheresis group. Phytohemagglutinin stimulation decreased in lymphoplasmapheresis and increased in plasmapheresis patients with significant comparisons (p = 0.02). These findings confirm and extend previous work. Plasmapheresis and lymphoplasmapheresis appear to have fundamentally different actions on lymphocyte function.

Use of erythrocytapheresis in the treatment of patients with sickle cell anemia

We performed exchange transfusions, utilizing the technique of automated erythrocytapheresis, for the treatment of patients with sickle cell anemia. In an attempt to determine guidelines for the use of erythrocytapheresis, we studied the use of this procedure in three distinct clinical situations in nine patients with sickle cell disease. Patients with dangerous complications of sickle cell disease such as acute respiratory distress and priapism responded well to erythrocytapheresis, showing marked improvement within 24-48 hours. Patients with prolonged painful vasoocclusive crises showed only variable improvement after erythrocytapheresis therapy, insufficient to justify exposing the patient to the risks of the procedure. Patients treated to decrease the frequency of painful crises demonstrated no prolongation in symptom-free intervals between crises. Therefore, erythrocytapheresis has its main value in the management of acute, dangerous complications of sickle cell disease.

Immunologic dynamics in cryapheresis for rheumatoid arthritis

Five patients with erosive rheumatoid arthritis (RA) who had previously experienced a favorable response to lymphoplasmapheresis were treated with cryapheresis. Cryapheresis was performed 9 times in 3 weeks using a membrane filtration device that selectively removes plasma proteins with molecular weights greater than 100,000 daltons. Four of the 5 patients so treated improved clinically. The membranes selectively removed more immunoglobulins and complement components that were part of circulating immune complexes than those that were not. Plasma or albumin replacement was not necessary in these patients. Cryapheresis might be a safe and effective technology in treating patients with refractory RA.

Preparation and in vitro function of granulocyte concentrates for transfusion to neonates using the IBM 2991 blood processor

Clinical studies have suggested that granulocyte transfusions may be of value in the treatment of septic neonatal patients who present with severe granulocytopenia. We have developed a protocol for the preparation of granulocyte concentrates from freshly collected units of whole blood, using an automated blood cell processor. The red cells were washed with saline. Then, the buffy coats were collected from the washed red cells and studied for their suitability as granulocyte concentrates for neonatal transfusion. The mean number of granulocytes per concentrate was 1.6 X 10(9) in a mean volume of 25 ml. Studies of granulocyte function, including viability, random mobility, chemotaxis, phagocytosis and nitro-blue tetrazolium reduction, demonstrated that the granulocytes were functionally unimpaired following preparation of the concentrates. These studies suggest that concentrates of functional granulocytes, suitable for transfusion to neonatal patients, can be prepared from fresh units of whole blood, using a cell processor. This procedure is more cost-effective than leukapheresis and allows for delivery of granulocytes for transfusion in a more timely fashion.

Therapeutic trial of cryofiltration in patients with rheumatoid arthritis

Cryofiltration, a new technique for on-line plasma separation and its treatment by cold filtration, enables the selective removal of immune complexes and eliminates the need for replacement proteins. Fifteen patients with rheumatoid arthritis were treated for nine to 10 consecutive sessions over a three- to five-week period. Circulating immune complexes decreased by an average of 78 percent and rheumatoid factor by 32 percent. This was accompanied by significant clinical improvement in morning stiffness, articular index, 50-foot walking time, grip strength, and target joint circumference. Cryofiltration might thus be beneficial for a subgroup of rheumatoid arthritis patients in whom conventional therapy has failed.

Safety of autologous blood donation prior to elective surgery for a variety of potentially "high-risk" patients

We studied 342 potentially "high-risk" patients, including patients with severe heart disease, elderly patients, children, and pregnant women, to determine the incidence of complications related to phlebotomy. Our patients had an adverse reaction rate associated with blood donation of 4 percent, which is no greater than would be expected among normal volunteer blood donors. No patient experienced a dangerous complication associated with phlebotomy. We conclude that many patients currently denied the opportunity to donate blood preoperatively are actually suitable candidates for autologous blood transfusion programs.