[Present state of transfusion errors]

Most serious transfusion error is ABO-incompatible transfusion. The Japanese Society of Blood Transfusion reported the results of the National Survey on the present state of ABO-incompatible blood transfusion in Japan. The targets of the survey were 777 hospitals with more than 300 beds, which have transfused more than 3,000 units of blood products per year. The answer could be obtained from 578(74%) hospitals among them. The questionnaire focused on the presence or absence of ABO-mismatched transfusion between January 1995 and December 1999. 115 hospitals(20%) have experienced ABO-mismatched transfusion in the period of the study. The frequency of ABO-mismatched transfusion increased with increasing the number of beds and the units of transfused blood. The ABO-mismatched transfusions were due to clerical or technical errors. The main causes of errors were misidentification of blood bags(42.8%), incorrect blood typing(15.1%) and failure to identify patient (11.5%). Incorrect blood typing errors were performed in 25 cases, and were caused by doctors in 17 cases, others by laboratory technicians. Majority of incorrect blood typing occurred during holidays or night shifts, and in emergency.

Engraftment of early erythroid progenitors is not delayed after non-myeloablative major ABO-incompatible haematopoietic stem cell transplantation

We hypothesized that patients undergoing major ABO-incompatible non-myeloablative haematopoietic stem cell transplantation (nm-HSCT) might experience prolonged haemolysis after transplant due to the delayed disappearance of host plasma cells producing anti-donor isohaemagglutinins (HAs). To address this question, we analysed data from 107 consecutive patients transplanted with allogeneic peripheral blood stem cells from human leucocyte antigen-matched (related, n = 84; unrelated, n = 23) donors after non-myeloablative conditioning (200 cGy total body irradiation +/- fludarabine). In total, 23 out of the 107 patients received major or major/minor ABO-incompatible transplants. Red blood cell (RBC) transfusion requirements during the first 120 d post transplant were higher in major ABO-mismatched than in ABO-matched recipients (0.12 vs 0.03 median units RBC concentrate/d, P = 0.04). Two patients developed transient pure red cell aplasia, which had resolved spontaneously by 9 months after transplant. Major ABO incompatibility did not influence rates of engraftment. Patients with sustained engraftment experienced gradual declines of anti-donor HAs, and the estimated median time to reaching IgM and IgG titres of < 1:1 was at least 133 d in evaluable patients, approximately twice longer than reported after myeloablative conditioning. There was a strong correlation between degrees of donor chimaerism in erythroid burst-forming units, granulocyte macrophage colony-forming units and granulocytes, indicating that donor erythroid engraftment, defined by early erythroid progenitors, was as prompt as myeloid engraftment. In conclusion, our data suggest that major ABO-incompatibility is not a barrier to successful non-myeloablative HSCT.

Immune complications associated with chronic transfusion

Blood transfusion and component therapy are an integral part of treatment for patients with certain life-threatening illnesses. Any benefit derived from transfusion must be weighed against the potential risk for complications. Patients who are chronically transfused present a unique challenge to practitioners. The presentation will focus on alloimmunization to red blood cell antigens, platelet refractoriness, transfusion-associated graft-versus-host disease, and cytomegalovirus infection. Prevention or management of these complications also will be discussed.

Clinical significance of RBC alloantibodies and autoantibodies in sickle cell patients who received transfusions

BACKGROUND

The clinical significance of alloimmunization to RBC antigens in sickle cell patients was analyzed by a retrospective review of the records of pediatric and adult sickle cell patients who received transfusions and who were followed over a 10-year period.

STUDY DESIGN AND METHODS

Charts of pediatric and adult sickle cell patients followed at Schneider Children's Hospital (SCH) and Long Island Jewish Medical Center between 1989 and 1999 were retrieved. Patients followed at SCH were classified as pediatric, regardless of age. Data on transfusion history, alloimmunization, and transfusion reactions from 1990 were retrieved from computerized blood bank records. Transfusion history, development of alloantibodies and autoantibodies, and transfusion reactions were correlated with clinical evidence of hemolysis or other adverse reactions from the charts. All patients received ABO- and Rh-compatible blood transfusions for which a partial or extended antigen match was not performed.

RESULTS

Among pediatric patients, 29 percent developed clinically significant alloantibodies, and 8 percent developed autoantibodies. Seven patients developed delayed hemolytic and/or serologic transfusion reactions, two with hyperhemolysis, two with clinical evidence of hemolysis, and three with serologic evidence only. The two patients with hyperhemolysis had received extended antigen-matched RBC transfusions to provide blood compatible with their existing antibodies. Among adult patients, 47.0 percent developed significant alloantibodies, and 9.7 percent developed autoantibodies. Five incidences of delayed hemolytic and/or serologic transfusion reactions occurred, one with hyperhemolysis and four with serologic evidence only.

CONCLUSION

The alloimmunization rate is 29 percent in pediatric and 47 percent in adult sickle cell patients when partial or extended RBC antigen match is not performed. However, the delayed serologic and/or hemolytic transfusion reactions did not result in severe clinical outcome in most instances. The most important adverse event was hyperhemolysis, which may be triggered by a transfusion, but was not prevented by matching for RBC antigens. In most instances, the cause of hyperhemolysis was multifactorial.

Transfusion reactions

Blood components are indicated in a wide variety of disease states. Although most transfusion therapies are administered uneventfully, there are a number of potential adverse transfusion reactions, some of which can assume serious dimensions. These reactions could occur during or even days after a transfusion. A brief description of the adverse effects of transfusion therapy has been outlined in this review. The etiopathogenesis, recognition and treatment of the adverse transfusion reactions have been highlighted. It is imperative that each transfusion of blood components has components be monitored carefully. Prompt recognition of an adverse event and early institution of remedial measures would help in decreasing transfusion related morbidity and mortality.

[Molecular basis and structure-activity relationships of the Duffy blood group antigens: chemokine and Plasmodium vivax receptors]

Duffy blood group antigens are of major interest in clinical medicine as they are not only involved in blood transfusion risks and occasionally in neonatal hemolytic disease, but also in the invasion of red blood cells by the hemoparasitic Plasmodium vivax. The FY locus maps to chromosome 1q22-q23, and is composed of 4 alleles: FY*A and FY*B (coding for the Fya and Fyb antigens, respectively), FY*X and FY*Fy. The Duffy antigens are carried by a 336 amino-acid glycoprotein named the Duffy Antigen/Receptor for Chemokines (DARC) that can bind with high affinity selected members of the CXC and CC classes of chemokines. Today, the genetic bases of the Duffy system have been characterized. The identification of the polymorphisms associated with the 4 alleles FY*A, FY*B, FY*Fy and FY*X has led to the development of a complete genotyping of the Duffy system by PCR, which increases the safety and lessens the risk of blood transfusion, and is useful in determining feto-maternal incompatibilities and in genetic filiation analyses. DARC is not solely expressed in erythroid cells: the same polypeptide isoform is found on the surface of endothelial cells of post-capillary venules throughout the body and also on the surface of Purkinje cells in the cerebellum, although it is encoded by different RNA messengers in each case, i.e., 1.35 and 7.5 kb, respectively. The preliminary analyses of receptor-ligand interaction have shown the existence of a chemokine-binding pocket defined by the close proximity of the first and fourth transmembrane domains of the DARC protein, and also by the importance of the N-terminal extracellular region for the binding of Plasmodium vivax merozoites.

Passenger lymphocyte syndrome with severe hemolytic anemia due to an anti-Jk(a) after allogeneic PBPC transplantation

BACKGROUND

After allogeneic peripheral blood progenitor cell (PBPC) transplantation, a patient developed a severe hemolytic transfusion reaction due to passenger lymphocyte syndrome.

CASE REPORT

A 50-year-old woman with secondary acute myeloid leukemia transforming from a myelodysplastic syndrome received an ABO-compatible PBPC graft from her HLA-identical sister. For prophylaxis of GVHD, the patient was treated with cyclosporine and methotrexate. Eighteen days after the transplant, the patient experienced a severe hemolytic transfusion reaction due to an alloantibody (anti-Jk(a)) produced by donor lymphocytes.

RESULTS

The patient was typed as group A, Jk(a+) before transplantation; the donor was typed as group A, Jk(a-). On Day 18 after transplantation, the immunohematologic screening revealed a positive DAT (C3d 3+) and an alloanti-Jk(a). Hemolysis in the patient at that time was indicated by a drop in the Hb and an increase in the LDH level (maximum, 592 IU/L on Day 23).

CONCLUSION

The course of hemolysis and the time of appearance of an alloantibody in this patient meet the criteria for passenger lymphocyte syndrome. In most cases, this syndrome is triggered by ABO system antibodies. This is the first reported case of passenger lymphocyte syndrome after PBPC transplantation that was due to an alloantibody that did not belong to the ABO system.

[The incidence of irregular antibodies in pregnancy: a prospective study in the region of the 's-Hertogenbosch]

OBJECTIVE

To determine the incidence and clinical relevance of irregular erythrocyte antibodies (IEA), in multiparous women and in primigravidal with a history of blood transfusion.

DESIGN

Prospective longitudinal cohort study.

METHODS

In the 's-Hertogenbosch area, the Netherlands, both primigravidae with a previous blood transfusion and multiparous women were tested for IEA in addition to the regular blood tests during the first trimester of pregnancy. If IEA were discovered, the partners were tested for the presence of the antigen involved. Blood samples of children of positive fathers were tested immediately post partum for signs of haemolytic disease of the newborn (HDN).

RESULTS

During a 2.5-year period (August 1995-January 1998) a total of 2392 pregnant women were screened for IEA: 2204 multiparous women and 188 primigravidae women. In 65 women 81 IEA were discovered. In the group of 30 children positive for the antigen involved, 12 (40%) had clinical symptoms of HDN; intrauterine death was diagnosed once, one child died immediately after delivery. One child had signs of hydrops fetalis and two children needed an exchange transfusion. Phototherapy and/or regular blood transfusion were given to 7 children. Most cases of HDN were caused by anti-D, anti-Kell and anti-c antibodies.

CONCLUSION

Non-RhD-IEA were found in 1.6% of pregnant women screened. First-trimester screening for IEA is recommended as it can be of help in early diagnosis and treatment of HDN.

Postoperative flow cytometry crossmatch in living donor liver transplantation: clinical significance of humoral immunity in acute rejection

BACKGROUND

The role of humoral immunity in acute rejection in solid organ transplantation remains controversial, although it is known that the presence of antidonor antibodies may precipitate graft rejection. We investigated the clinical relevance of antidonor humoral immunity for living donor liver transplantation (LDLT) by means of flow cytometry crossmatch (FCXM).

METHODS

T cell FCXM using fresh donor peripheral lymphocytes was performed before and up to 1 month after LDLT in 58 patients. Ten patients received ABO-incompatible grafts. IgM and IgG antidonor antibodies were analyzed in relation to clinical acute rejection as defined by liver function tests with or without histological evidence.

RESULTS

Pretransplantation FCXM was positive for five patients (8.6%), resulting in two cases of positive posttransplantation FCXM and two rejection episodes. Twelve patients (20.7%) showed positive posttransplantation FCXM. The incidence of acute rejection within 1 month was 100% in FCXM-positive patients and 17.4% in FCXM-negative patients (P<0.001). Thirteen (76.5%) of 17 rejection episodes in ABO-compatible cases were associated with concomitant antidonor IgM antibody. IgG antibody was also identified in six of these episodes. Antidonor antibodies disappeared after rejection treatments in all cases, but with some delay in clinical improvement. On the other hand, no antidonor antibodies were detected in any of the four rejection episodes in ABO-incompatible cases.

CONCLUSIONS

Early acute rejection in LDLT is significantly associated with antidonor T cell antibody formation in ABO-compatible cases. This suggests a definite role for donor-specific humoral immunity in acute rejection. Rejection episodes without antidonor antibodies may suggest graft injury by pure cellular immunity, or possibly the presence of humoral immunity triggered by antigens not present on donor T cells.

Difficulties in identifying antibodies in the Dombrock blood group system in multiply alloimmunized patients

BACKGROUND

Although red cell (RBC) antibodies of the Dombrock blood group system have been reported to cause acute and delayed hemolytic transfusion reactions, the difficulty in identifying these antibodies in patients with multiple RBC alloantibodies has not previously been discussed. The cases of four sickle cell disease patients who developed Dombrock system antibodies after transfusion, three of which were discovered in association with hemolytic transfusion reactions, are reported.

CASE REPORTS

Patient 1 was a 36-year-old woman with multiple RBC alloantibodies. Because of the lack of an increment in hematocrit after transfusion, an investigation was performed; it revealed anti-Do(b) in the serum. Patient 2 was a 30-year-old woman with known anti-C, -E, -K, -S, -Fya, and -Bga. She had received a transfusion 10 days previously. Before further transfusion was begun, antibody identification revealed weak nonspecific reactions, which were thought to be HLA antibodies. She developed acute hemolysis during RBC exchange for acute chest syndrome; anti-Doa was identified in both the serum and eluate. She received 2 units of Do(a-) RBCs without complication. Patient 3 was a 35-year-old woman with known anti-C, -E, -K, -Fya, and -N and a warm autoantibody. Two weeks after transfusion, she had a delayed hemolytic transfusion reaction coincident with the identification of anti-Doa. Patient 4 was a 33-year-old woman with known anti-C, -V, -K, -Fya, -Fy3, Jkb, -S, -N, and -Ytb, who developed anti-Doa 8 weeks after transfusion.

CONCLUSION

An association of Dombrock blood group system antibodies with hemolytic reactions is demonstrated in alloimmunized sickle cell disease patients. In all four cases, identification of Dombrock system antibodies was delayed because high-titer low-avidity antibodies, HLA antibodies, or autoantibodies were thought to explain the serologic findings. The presence of Dombrock system antibodies should be considered when unexplained serologic reactivity occurs during antibody identification in this population.

[Feasibility of following up transfused patients]

The aim of this study was to assess the natural history of patients after transfusion and the acceptability of a standardized biological follow-up. In 1995, during 1 month, in 13 French hospitals, a follow-up at 3 and 6 months after blood transfusion was proposed to all blood recipients who had not received any blood transfusion within the past 6 months (eligible patients): screening for red cell antibodies, alanine aminotransferase (ALT) activity and specific viral markers of hepatitis B (hepatitis B surface antigen and antibody to hepatitis virus core antigen), of hepatitis C (antibodies) and of Human Immunodeficiency Virus (antibodies). At the beginning of the study, 296 patients were followed for 6 months. A complete follow-up was available at 3 months for 183 patients (62%), at 6 months for 168 (57%) and after 6 months, 198 patients (67%) have been once followed. Of eligible patients, 76% were alive at six months. After transfusion, the incidence of red cell alloantibodies and elevated ALT concentration were respectively 4% and 17%. At 6 months, one patient had Hepatitis B surface antigen; the responsibility of blood transfusion was excluded. Within the first 24 hours, 68 patients (23%) required another blood transfusion and 42% of units were transfused to patients with malignant disease. Our study quantifies in real conditions the difficulty of a biological follow-up in a transfused population, mostly composed of patients that could not be followed in the hospital where they were transfused.

[Evaluation of the polyethyleneglycol antiglobulin test in the detection and identification of erythrocyte antibodies]

PURPOSE

The polyethylene glycol antiglobulin test has been found to enhance the reactivity of most alloantibodies.

MATERIAL AND METHODS

To investigate the utility of polyethylene glycol antiglobulin test for detection and identification of red blood cell antibodies, a comparison study of polyethylene glycol (PEG), a low-ionic-strength additive solution (LISS) and bovine serum albumin (BSA) was conducted. The sera of 47 different patients with positive antibody screening test by the LISS method, were tested in parallel with reagent antibody-detection cells using PEG, LISS and BSA.

RESULTS

In the sera of 47 patients, 57 antibodies were detected. We identified 39 antibodies by the three methods. Twelve antibodies reacted by the BSA method and the LISS method but did not react with the PEG method (8 anti-I, 1 anti-P1, 1 anti-Lea(a), and two antibodies missed by the PEG method because they did not react with anti-IgG: 1 anti-M and 1 anti-K). Three antibodies reacted only with the LISS method (3 anti-I). Four clinically significant antibodies were detected only by the PEG method (2 anti-Jka, 1 anti-Jkb, 1 anti-c). The serum from a patient with delayed hemolytic transfusion reaction and no antibody detectable by the LISS and the BSA methods was tested by the PEG method. We were able to detect an anti-Jka by PEG in the pretransfusion sample. In 24 (60%) of 40 samples with clinically significant antibodies, PEG antiglobulin reactions were stronger (total score 221) than LISS antiglobulin reactions (total score 170) and BSA antiglobulin reaction (total score 184); in 14 (35%) of 40 samples, they were identical, and in 2 (5%) agglutination in the PEG method was weaker.

CONCLUSION

In our experience, the polyethylene glycol antiglobulin test is more sensitive than LISS and BSA in detecting clinically significant antibodies and is an acceptable technique for routine compatibility test.

A comparison of different filters for white cell reduction

Removal of white blood cells (WBCs) from blood components before transfusion by filters with at least 3 log10 depletion may prevent or delay leukocyte-associated transfusion reactions such as HLA alloimmunization, non-hemolytic febrile reactions, transmitted infections (e.g., CMV, HTLV-1), and immunomodulation. The aim of this study was to compare the leukocyte removal efficiency (LRE) of six commercial bedside filters that are said to achieve 3 log10 (Bio R-01), Leucostop 4LT-1, Pall RC 50) and 4 log10 (Bio R-01 Plus, Pall RC 400, Pall RC XL-1) WBC depletion. A total of 430 units of whole blood ranging from 32 to 92 for each filter type were analyzed by an automated counter before and after filtration. Postfiltration blood samples were also evaluated for WBCs by Nageotte chamber. All the filters demonstrated leukocyte removal about 1 log10 less than the manufacturer's claim. The fourth generation filters showed a better performance than the third generation filters. Of them, Pall RC XL-1 showed the best efficacy with 99.93 percent leukocyte removal and a median residual WBCs of 1.6 x 10(6) per unit. These results indicate that the fourth generation filters, which are designed for the filtration of packed red cells, in particular Pall RC XL-1, are also able to reduce WBCs from whole blood below the critical antigenic leukocyte load (5 x 10(6)), and can be efficiently used for polytransfused patients to prevent alloimmunization.

[Analysis of transfusion incident reports filed at 15 blood transfusion centers and health facilities during 17 months. Groupe Receveurs de laSFTS]

The principal result of the development of hemovigilance since 1994 has been the declaration of undesirable effects likely to be due to transfusions of labile blood products. Using the 1,694 cases of undesirable effects registered, it seemed worthwhile to us to analyze the distribution of the signs noticed, their frequency and the types of blood products responsible. This analysis allowed us to observe that the majority of reactions were shivery-feverish (47%) or allergic (24%). Most of them are linked to platelet concentrate transfusions especially simple donor platelets (with a frequency of ten reactions for thousand apheresis platelet concentrates transfused). In this study the frequency of undesirable effects reported is 2 per 1,000 apheresis platelet concentrate transfusions. Further investigations are necessary to determine the physiological mechanisms of these reactions and to estimate the degree to which transfusions are responsible for their occurrence.

Induction of a secondary human anti-HLA alloimmune response in severe combined immunodeficient mice engrafted with human lymphocytes

BACKGROUND

Experimental manipulation of transfusion-induced alloimmunization is limited in humans by ethical considerations. Conversely, studies of alloimmunization in animal models may not reflect the human immune system closely enough to be of optimal benefit. The development of an in vivo model of human alloimmunization that is amenable to experimental manipulation is thus desirable.

STUDY DESIGN AND METHODS

An in vivo model of human alloimmunization was evaluated by using mice with severe combined immunodeficiency (SCID). SCID mice underwent gamma-radiation (200 cGy) and received an intraperitoneal injection of human peripheral blood lymphocytes (PBLs) from donors immunized to HLA antigens by prior pregnancy (reconstitution). These Hu [human]-PBL-SCID mice were then challenged with HLA-mismatched PBLs. Alloantibodies were evaluated by flow cytometry and a standard two-stage microlymphocytotoxicity assay.

RESULTS

Hu-PBL-SCID mice (n = 22) that were challenged with PBLs expressing the HLA antigens to which the donors had previously been immunized, made significantly more IgM and IgG alloantibodies than did the unchallenged mice. Responses were measurable by 1 week after reconstitution and challenge. Prior treatment of SCID mice with anti-asialo GM1, which depletes murine natural killer cells and macrophages, further increased the alloantibody response of challenged mice. The human alloantibodies generated were specific to the challenge HLA antigens as assessed by microlymphocytotoxicity assay.

CONCLUSION

Hu-PBL-SCID mice are a useful model system in which to study and manipulate the induction of secondary human alloimmune responses against cellular HLA class I antigens. This model will be valuable for testing the in vivo effect of novel immunotherapies on the inhibition of the human alloantibody response.

[Abnormal agglutination by reducing surface charge of red cell membrane as source of error in ABO typing and actual cases of incompatible ABO blood transfusion due to various factors]

T activation of red cells results from the effects of microbial sialidase catalysing the cleavage of sialic acid from red cell membrane. Abnormal agglutination may be induced when human-derived antiA,B antibodies containing antiT are used. By the using of mouse-derived antiA,B monoclonal antibodies this type of polyagglutination as source of error could be overcome. Most common cause of ABO mismatch is due to more simple technical or clerical error resulting in transfusion of the wrong blood to the recipient. Three such cases with non-fatal hemolytic transfusion reaction are described.

[Errors in detection of subgroups in the ABO blood group system]

In the ABO blood group system, several subgroups have been described based on: 1) the difference of reactivities of the red cells with anti-A, anti-B, anti-A1, and anti-H, 2) the presence or absence of anti-A, anti-B, anti-A1, anti-H, and anti-HI in serum, and 3) the presence of A, B, H substances in the saliva of ABH secretors. Subgroups of A are more frequent in Caucasians than in Japanese, while those of B are more frequent in Japanese. Both the red cell typing (testing red cells for A and B antigens) and serum typing (testing the antibodies in the serum against red cells of known ABO groups) are important to identify and not to overlook these ABO subgroups. When transfusion is required in individuals with these subgroups, compatible blood products must be selected according to the presence or absence of antibodies active at 37 degrees C.

Maternal immunization to Gov system alloantigens on human platelets

BACKGROUND

Immunization to platelet alloantigens can occur during pregnancy or after the transfusion of blood components. Platelet alloantibodies can cause neonatal alloimmune thrombocytopenia and posttransfusion purpura. Transfusion-induced alloimmunization to a novel platelet alloantigen system, Gov, expressed on the 175-kDa glycosyl phosphatidylinositol-anchored platelet glycoprotein, CD109, was previously described. This report describes three unrelated patients who were alloimmunized to Gov(a) or Gov(b) during pregnancy.

STUDY DESIGN AND METHODS

Platelets were typed by using radioimmunoprecipitation for HPA-1a, -3a, -5a, -5b, Gov(a), and Gov(b) and by polymerase chain reaction-restriction fragment length polymorphism for HPA-1a, -1b, -3a, and -3b. Maternal sera were screened for platelet antibodies by using radioimmunoprecipitation and the antigen capture assay.

RESULTS

Patients 1 and 2 were investigated after the diagnosis of neonatal alloimmune thrombocytopenia in their children, and alloantibodies specific for Gov(b) and Gov(a), respectively, were detected in maternal serum. Serum from patient 3, who had mild idiopathic thrombocytopenia purpura with no detectable autoantibody, was found to contain alloantibodies to Gov(b) and to HPA-5b, presumably as a result of immunization during pregnancy. Platelet typings confirmed that the patients were at risk for alloimmunization to the respective antigen.

CONCLUSION

This report of three cases of maternal alloimmunization to antigens in the Gov system indicates that immunization can occur via placental transfer of antigen and that Gov system alloantibodies may be associated with neonatal alloimmune thrombocytopenia.