Transfusion-related immunomodulation (TRIM): an update

Prognostic value of perioperative red blood cell transfusion and anemia on survival and recurrence in oral squamous cell carcinoma

OBJECTIVE

To evaluate the prognostic effect of allogenic red blood cell transfusion (RBT) and preoperative anemia in patients with oral squamous cell carcinoma (OSCC) undergoing primary tumor resection.

METHODS

We retrospectively analyzed a cohort of 621 patients, diagnosed with OSCC receiving tumor resection in curative intention. Preoperative anemia and perioperative RBT were evaluated according to WHO definition. Overall survival (OAS) as well as recurrence-free survival (RFS) was evaluated in transfused and non-transfused as well as in anemic and non-anemic patients. In addition, outcome parameters were calculated for distinct amounts of perioperatively administered RBTs. Data analysis was performed by uni- and multivariate statistics. Mean follow-up time was 7.3 years.

RESULTS

Preoperative anemia was diagnosed in 29% of OSCC patients. Anemic patients displayed a significantly decreased five-year OAS (44%) in comparison to non-anemic equivalents (69%). 70% of non-transfused OSCC patients were alive after five years, whereas in case of RBT five-year OAS was 41%. These findings were substantiated by subgroup analysis in patients without preoperative anemia. For anemic patients however, no deleterious effect on survival in case of perioperative RBT was seen. Increasing numbers of received RBTs were shown to worsen outcome of OSCC patients in a dose-dependent manner.

CONCLUSION

Preoperative anemia and RBT are significantly associated with impaired long-term outcome of patients suffering from OSCC. Future studies are needed to evaluate differentiated effects of RBTs in anemic and non-anemic OSCC patients and accordingly providing individual transfusion strategies to ameliorate outcome of patients suffering from OSCC.

Impact of autologous blood transfusion after bone marrow harvest on unrelated donor's health and outcome: a CIBMTR analysis

Pre-harvest autologous blood collection from bone marrow (BM) donors is performed to meet potential post-operative transfusion needs. This study examines the impact of autologous blood transfusion on BM donor's health and safety. The study included first-time unrelated BM donors from the United States whose BM harvest was facilitated by the National Marrow Donor Program (NMDP) centers between 2006 and 2017. Examination of 7024 BM donors revealed that 60% received at least one unit of autologous blood. The donors who received autologous blood were older, had lower hemoglobin pre-harvest, underwent longer duration of anesthesia, and higher volume BM harvest. Only donors who underwent high-volume BM harvest, defined as a BM harvest volume >27% of donor's blood volume, benefited from autologous transfusion. After a high-volume BM harvest, autologous blood transfusion was shown to decrease grade 2 to 4 collection-associated toxicities within 48 h of BM donation (p = 0.010) and shorten the time to donor-reported "complete" recovery from donation-associated symptoms (p < 0.001). Therefore, autologous transfusion could be avoided as support of marrow donation in the majority of unrelated BM donors and should be limited to cases where the planned BM harvest volume is expected to exceed 27% of donor's blood volume.

Impact of perioperative blood transfusion on oncologic outcomes in patients with nonmetastatic renal cell carcinoma treated with curative nephrectomy: A retrospective analysis of a large, single-institutional cohort

Purpose

To evaluate the impact of perioperative blood transfusion (PBT) on oncologic outcomes after surgery in patients with nonmetastatic renal cell carcinoma (RCC).

Materials and Methods

This retrospective review included 2,329 patients who underwent partial or radical nephrectomy for localized RCC in a single institution from 2000 to 2014. PBT was defined as transfusion of allogeneic packed red blood cells (pRBCs) during nephrectomy or within the preoperative or postoperative hospitalization period. Oncologic outcomes of interest were recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS).

Results

PBT was performed in 275 patients (11.8%). In the multivariable logistic regression analysis, symptomatic presentation, advanced age at surgery, higher preoperative serum creatinine, and lower preoperative hemoglobin were independent preoperative risk factors for PBT (all p<0.05). Kaplan–Meier plots revealed that transfused patients showed poorer 5-year RFS (65.1% vs. 91.2%, p<0.001), OS (71.4% vs. 92.8%, p<0.001), and CSS (74.0% vs. 95.5%, p<0.001) than nontransfused patients. However, in the multivariable Cox regression analyses, PBT was not significantly associated with RFS, OS, or CSS. In multivariable analyses involving transfused patients only (n=275), an higher number of pRBC units was an independent predictor of worse OS (hazard ratio [HR], 1.043; 95% confidence interval [CI], 1.008–1.078; p=0.016) and CSS (HR, 1.066; 95% CI, 1.033–1.100; p<0.001).

Conclusions

The results of this study are inconclusive in that the influence of PBT on survival outcomes could not be determined in the multivariate analysis. However, increasing pRBC units in transfused patients might be a concern in light of worse OS and CSS. Therefore, efforts to limit PBT overuse seem necessary to improve postoperative survival in patients with RCC.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy With Mitomycin C Used for Colorectal Peritoneal Carcinomatosis

Purpose

This study aimed to assess the evaluation of clinical outcomes and consequences of complications after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for the peritoneal carcinomatosis (PC) from colorectal cancer.

Methods

A total 26 patients underwent CRS and HIPEC for PC from colorectal cancer between March 2009 and April 2018. All the patients underwent CRS with the purpose of complete or near-complete cytoreduction. Intraoperative HIPEC was performed simultaneously after the CRS. Mitomycin C was used as chemotherapeutic agent for HIPEC.

Results

Median disease-free survival was 27.8 months (range, 13.4–42.2 months). Median overall survival was 56.0 months (range, 28.6–83.5 months). The mean peritoneal cancer index (PCI) was 8.73 ± 5.54. The distributions thereof were as follows: PCI <10, 69.23%; PCI 10–19, 23.08%; and PCI ≥20, 7.69%. The completeness of cytoreduction was 96.2% of patients showed CC-0, with 3.8% achieved CC-1. The mean operation time was 8.5 hours, and the mean postoperative hospital stay was 21.6 days. The overall rate of early postoperative complications was 88.5%; the rate of late complications was 34.6%. In the early period, most complications were grades I–II complications (65.4%), compared to grades III–V (23.1%). All late complications, occurring in 7.7% of patients, were grades III–V. There was no treatment-related mortality.

Conclusion

Although the complication rate was approximately 88%, but the rate of severe complication rate was low. In selective patients with peritoneal recurrence, more aggressive strategies for management, such as CRS with HIPEC, were able to be considered under the acceptable general condition and life-expectancy.

Prospective Cohort Study to Assess the Effect of Storage Duration, Leuko-Filtration, and Gamma Irradiation on Cell-Free DNA in Red Cell Components

Introduction

Damage to a cell and the loss of integrity of its cell membrane leads to the release of endogenous immunogenic molecules, which together are classified as "damage-associated molecular patterns" (DAMPs). Cell-free DNA (cf-DNA) released from nucleosomes may serve as a proco-agulant cofactor and may be an important mediator of immunomodulatory and proinflammatory effects associated with blood transfusion.

Objectives

To assess the levels of cf-DNA in supernatants of stored red cell components and the effect of leukoreduction and gamma irradiation on the release of cf-DNA during storage.

Methods

This is a prospective cohort study on 99 stored red cell components, randomly divided into three groups - buffy coat (BC)-depleted, leuko-filtered (LP), and irradiated (IR) packed red blood cells. Red cell supernatants were drawn over a period of 21 days at three different time points (day 0, 7, and 21) from the study units. cf-DNA extraction was done and quantified by a bench top fluorometer. Change in cf-DNA content, rate of change (μg/day), and percent change were estimated and compared across different groups.

Results

cf-DNA content increased (p = 0.000) with storage duration in the BC (median = 238.66 μg, interquartile range [IQR] = 168.42 on day 21 vs. median = 9.44 μg, IQR = 5.23 on day 0) and IR groups (p = 0.000) (median = 245.55 μg, IQR = 253.88 on day 21 vs. median = 7.07 μg, IQR = 13.58 on day 0), while there was a decreasing trend (p = 0.032) in the LP group (median = 4.55 μg, IQR = 10.73 on day 21 vs. median = 8.66 μg, IQR = 6.56 on day 0). The median rate of change in cf-DNA content (11.13 μg/day) and percent change in cf-DNA content (median = 4,106.16%) was highest in the IR group.

Conclusions

Stored red cell components contain significant amount of cf-DNA. Release of cf-DNA is further aggravated by irradiation while leukoreduction leads to a decrease in cf-DNA content.

Impact of Anesthetics, Analgesics, and Perioperative Blood Transfusion in Pediatric Cancer Patients: A Comprehensive Review of the Literature

Cancer is the leading cause of death by disease in developed countries. Children and adolescents with cancer need surgical interventions (ie, biopsy or major surgery) to diagnose, treat, or palliate their malignancies. Surgery is a period of high vulnerability because it stimulates the release of inflammatory mediators, catecholamines, and angiogenesis activators, which coincides with a period of immunosuppression. Thus, during and after surgery, dormant tumors or micrometastasis (ie, minimal residual disease) can grow and become clinically relevant metastasis. Anesthetics (ie, volatile agents, dexmedetomidine, and ketamine) and analgesics (ie, opioids) may also contribute to the growth of minimal residual disease or disease progression. For instance, volatile anesthetics have been implicated in immunosuppression and direct stimulation of cancer cell survival and proliferation. Contrarily, propofol has shown in vitro anticancer effects. In addition, perioperative blood transfusions are not uncommon in children undergoing cancer surgery. In adults, an association between perioperative blood transfusions and cancer progression has been described for some malignancies. Transfusion-related immunomodulation is one of the mechanisms by which blood transfusions can promote cancer progression. Other mechanisms include inflammation and the infusion of growth factors. In the present review, we discuss different aspects of tumorigenesis, metastasis, angiogenesis, the immune system, and the current studies about the impact of anesthetics, analgesics, and perioperative blood transfusions on pediatric cancer progression.

Restrictive allogeneic blood transfusion strategy in patients with extremity bone sarcomas

Allogeneic blood transfusions (ABTs) are common in patients with cancer. The present study investigated the safety of a restrictive ABT strategy in patients with extremity sarcomas.Patients who underwent operations for extremity bone sarcomas between May 2008 and November 2018 were retrospectively reviewed. Clinical outcomes based on hemoglobin concentrations, postoperative infections, and hospital stay were compared between 20 patients who received liberal ABT (control group) and 19 patients who received restrictive ABT (restrictive group). The rates of distant metastasis and death were compared between the groups.The mean number of ABTs was 3.6 ± 3.8 units in the control group and 0.33 ± 0.74 units in the restrictive group (P < .001). Only 3 of 19 patients received transfusions (2 red cell packs each). The hemoglobin levels tended to fall during the first 3 postoperative days but seemed to stabilize within the first postoperative week in both groups. Postoperative surgical site infections only occurred in the patients who received ABTs regardless of the group. The rates of distant metastasis and death were higher in the control group than in the restrictive group (25.0% vs 15.7% and 10.0% vs 0%, respectively), but the differences were not significant.A restrictive ABT strategy may be safely performed in patients with extremity bone sarcomas depending on the intraoperative status and specific characteristics of each patient.

Intraoperative cell salvage: A technology built upon the failures, fads and fashions of blood transfusion

Transfusion, as we know it today, developed into a very sophisticated treatment modality as a result of centuries of experimentation. Intraoperative cell salvage is a transfusion technique where autologous blood lost during surgery is reinfused. The success of this process relies on specialised equipment and techniques to collect, process, anticoagulate filter and reinfuse blood. Through a literature review, we collected information about the early origins of specific techniques relevant to intraoperative cell salvage: the ability to collect lost blood, to prevent collected blood from clotting, to remove debris through processing and other harmful aspects through filtering, the benefits of autologous blood transfusion, reinfusion and traditional concerns and contraindications. A culmination of knowledge specific to each of these techniques over centuries provides the background to the safe intraoperative cell salvage technique used today. In addition, we aimed to identify the reasons why specific equipment and techniques developed, why practice changed and what is still unknown. This article reviews relevant allogeneic transfusion and autotransfusion history, starting in Roman times, and includes landmark events through the centuries.

Perioperative blood transfusion is associated with an increased risk for post-surgical infection following pancreaticoduodenectomy

BACKGROUND/PURPOSE

Perioperative blood transfusion is common after pancreaticoduodenectomy (PD) and may predispose patients to infectious complications. The purpose of this study is to examine the association between perioperative blood transfusion and the development of post-surgical infection after PD.

METHODS

Patients who underwent PD from 2014 to 2015 were identified in the NSQIP pancreas-specific database. Logistic regression analysis was used to compute adjusted odds ratios (aOR) to identify an independent association between perioperative red blood cell transfusion (within 72 h of surgery) and the development of post-operative infection after 72 h.

RESULTS

A total of 6869 patients underwent PD during this time period. Of these, 1372 (20.0%) patients received a perioperative blood transfusion. Patients receiving transfusion had a higher rate of post-operative infection (34.7% vs 26.5%, p < 0.001). After adjusting for significant covariates, perioperative transfusion was independently associated the subsequent development of any post-operative infection (aOR 1.41 [1.23-1.62], p < 0.001), including pneumonia (aOR 2.01 [1.48-2.74], p < 0.001), sepsis (aOR 1.62 [1.29-2.04], p < 0.001), and septic shock (aOR 1.92 [1.38-2.68], p < 0.001).

CONCLUSION

There is a strong independent association between perioperative blood transfusion and the development of subsequent post-operative infection following PD.

Red Blood Cell Transfusions and Anemia on Admission Are Associated with Poor Outcomes in Necrotizing Soft Tissue Infections

BACKGROUND

Necrotizing soft tissue infections (NSTIs) are highly morbid infections often requiring critical care and transfusion support. We explored a large 2-year experience from a regional trauma center with a dedicated soft tissue service (STS) in an attempt to identify factors in current care with potential for improving outcomes for these critically ill patients.

METHODS

New adult (>17 years) STS admissions, 2008-2009, were identified from the Trauma Registry. Patient records were extracted and assessed via descriptive statistics, univariate analysis, and multivariable logistic regression models.

RESULTS

Mortality among 253 eligible primary admissions was 8.3% overall and 10.3% for those with an admission diagnosis of NSTI. No significant differences in wound characteristics, use of VAC (vacuum-assisted closure) dressing or hyperbaric oxygen, or wound microbiology emerged between survivors and nonsurvivors. Median time to first debridement was 5 h (interquartile range, 2-21 h). Multivariable modeling indicated association of worse outcome (death or discharge to chronic/rehab care) with age >60 years [odds ratio (OR), 3.82; P < 0.001], anemia (OR, 0.98; P = 0.03), increasing number of transfusions (OR, 1.09; P < 0.001), NSTI diagnosis (OR, 2.47; P = 0.005), preexisting diabetes mellitus (OR, 3.20; P = 0.001), and low admission hemoglobin (OR, 0.80; P = 0.004).

CONCLUSIONS

Mortality was less than previously reported. Number of transfusions and anemia at admission emerged as risk factors for poor outcomes. Future research should focus on the effects of transfusion on NSTI outcomes, on potentially confounding factors, and on whether a restrictive transfusion strategy reduces mortality.

Transfusion of red blood cells does not impact progression-free and overall survival after surgery for ovarian cancer

BACKGROUND

Allogeneic red blood cells (RBCs) have the potential to impact the immunosurveillance of the recipient and may therefore increase the risk of recurrence after cancer surgery. In this article the relationship between perioperative RBC transfusion and the risk of recurrence after ovarian cancer surgery is examined.

STUDY DESIGN AND METHODS

This is a retrospective cohort analysis of a prospective database of patients who underwent surgery due to primary ovarian cancer between 2006 and 2014 and who had no residual disease after surgery. Patients who did and did not receive perioperative RBC transfusion were compared. The primary endpoint was progression-free survival (PFS). Propensity score matching (PSM) and Cox proportional hazards regression (CPH) was used to control for between-group differences of prognostic determinants.

RESULTS

A total of 529 patients with a median follow-up of 51.4 months (95% CI, 46.1-56.5) were eligible for analysis. Of those, 408 patients (77.1%) received allogeneic, leukoreduced RBCs with a median of 4 units (IQR, 2-6) per patient. There was a strong selection bias of prognostic determinants between patients with and without transfusion. In unadjusted analysis, transfusion of RBCs was associated with an increased risk of cancer recurrence (hazard ratio [HR] of PFS 2.71 [95% CI, 1.94-3.77], p < 0.001). After bias reduction, transfusion of RBCs was no longer associated with an increased risk of cancer recurrence, neither in PSM-adjusted (HR 1.03 [95% CI, 0.59-1.80], p = 0.91), nor in multivariable CPH-adjusted analysis (HR 1.26 [95% CI, 0.85-1.86], p = 0.23).

CONCLUSION

Perioperative transfusion of RBCs did not increase the risk of recurrence after ovarian cancer surgery.

Rationale and Design of the CAN Study: an RCT of Survival after Propofol- or Sevoflurane-based Anesthesia for Cancer Surgery

Background:

Based on animal data only, some clinicians have adopted propofol-based anesthesia for cancer surgery with the aim of increased survival.

Objective:

Our objective is to verify or refute the hypothesis that survival increases after cancer surgery with propofol compared with sevoflurane for anesthesia maintenance. This aim deserves a large-scale randomized study. The primary hypothesis is an absolute increase of minimum 5%-units in 1- and 5-year survival with propofol- based anesthesia for breast or colorectal cancer after radical surgery, compared with sevoflurane-based anesthesia.

Method:

Ethics and medical agency approvals were received and pre-study registrations at clinicaltrial.gov and EudraCT were made for our now ongoing prospective, randomized, open-label, multicenter study. A power analysis based on a retrospective study, including a safety margin for drop outs, resulted in a total requirement of 8,000 patients. The initial inclusion period constituted a feasibility phase with an emphasis on the functionality of the infrastructure at the contributing centers and at the monitoring organization, as well as on protocol adherence.

Conclusion:

The infrastructure and organization work smoothly at the different contributing centers. Protocol adherence is good, and the monitors are satisfied. We expect this trial to be able to either verify or refute that propofol is better than sevoflurane for cancer surgery.

The impact of intra-operative cell salvage during open nephrectomy

OBJECTIVE

To assess the impact of intra-operative cell salvage on outcomes in open nephrectomy.

METHODS

A retrospective cohort study was performed of all patients undergoing open nephrectomy for suspected malignancy from 1 October 2013 to 1 October 2017. Patients were grouped and compared based on whether they received intra-operative cell salvage (ICS). Primary outcomes were allogeneic transfusion rates (ATRs), and if histology confirmed cancer, disease recurrence. Secondary outcomes were complications and transfusion-related cost.

RESULTS

Forty patients underwent open nephrectomy for suspected malignancy during the enrolment period. Sixteen patients received ICS while 24 did not (standard group). Compared with the standard group, ICS patients had similar median age (63.5 vs. 61.0 years; p = 0.83) but fewer females (19% vs. 58%; p = 0.013). The groups were similar in pre-operative and discharge haemoglobin, Charlson Comorbidity Index, length of hospital stay and proportion with thoracoabdominal surgical approach. The ICS group had a smaller proportion undergoing partial nephrectomy (19% vs. 54%; p = 0.025) and shorter median follow-up (278 vs. 827 days; p = 0.0005). Histology was malignant for 14 ICS and 15 standard patients. The ICS group had more frequent ≥T2 disease (79% vs. 27%; p = 0.005). There were no positive margins. Both groups had similar ATRs (6% vs. 4%; p = 0.96), complication rates (19% vs. 29%; p = 0.46) and recurrence rates (18% vs. 7%; p = 0.40). Transfusion costs were higher amongst ICS patients (AUD $878.18 vs. $49.65 per patient).

CONCLUSION

ICS appears safe, with low rates of recurrence and complication. Both groups had low ATRs, and therefore cost benefit for ICS was not seen.

Transfusion practice in the non-bleeding critically ill: an international online survey-the TRACE survey

BACKGROUND

Over the last decade, multiple large randomized controlled trials have studied alternative transfusion strategies in critically ill patients, demonstrating the safety of restrictive transfusion strategies. Due to the lack of international guidelines specific for the intensive care unit (ICU), we hypothesized that a large heterogeneity in transfusion practice in this patient population exists. The aims of this study were to describe the current transfusion practices and identify the knowledge gaps.

METHODS

An online, anonymous, worldwide survey among ICU physicians was performed evaluating red blood cell, platelet and plasma transfusion practices. Furthermore, the presence of a hospital- or ICU-specific transfusion guideline was asked. Only completed surveys were analysed.

RESULTS

Nine hundred forty-seven respondents filled in the survey of which 725 could be analysed. Hospital transfusion protocol available in their ICU was reported by 53% of the respondents. Only 29% of respondents used an ICU-specific transfusion guideline. The reported haemoglobin (Hb) threshold for the general ICU population was 7 g/dL (7-7). The highest reported variation in transfusion threshold was in patients on extracorporeal membrane oxygenation or with brain injury (8 g/dL (7.0-9.0)). Platelets were transfused at a median count of 20 × 109 cells/L IQR (10-25) in asymptomatic patients, but at a higher count prior to invasive procedures (p < 0.001). In patients with an international normalized ratio (INR) > 3, 43% and 57% of the respondents would consider plasma transfusion without any upcoming procedures or prior to a planned invasive procedure, respectively. Finally, doctors with base specialty in anaesthesiology transfused critically ill patients more liberally compared to internal medicine physicians.

CONCLUSION

Red blood cell transfusion practice for the general ICU population is restrictive, while for different subpopulations, higher Hb thresholds are applied. Furthermore, practice in plasma and platelet transfusion is heterogeneous, and local transfusion guidelines are lacking in the majority of the ICUs.

Blood manufacturing methods affect red blood cell product characteristics and immunomodulatory activity

Transfusion of red cell concentrates (RCCs) is associated with increased risk of adverse outcomes that may be affected by different blood manufacturing methods and the presence of extracellular vesicles (EVs). We investigated the effect of different manufacturing methods on hemolysis, residual cells, cell-derived EVs, and immunomodulatory effects on monocyte activity. Thirty-two RCC units produced using whole blood filtration (WBF), red cell filtration (RCF), apheresis-derived (AD), and whole blood-derived (WBD) methods were examined (n = 8 per method). Residual platelet and white blood cells (WBCs) and the concentration, cell of origin, and characterization of EVs in RCC supernatants were assessed in fresh and stored supernatants. Immunomodulatory activity of RCC supernatants was assessed by quantifying monocyte cytokine production capacity in an in vitro transfusion model. RCF units yielded the lowest number of platelet and WBC-derived EVs, whereas the highest number of platelet EVs was in AD (day 5) and in WBD (day 42). The number of small EVs (<200 nm) was greater than large EVs (≥200 nm) in all tested supernatants, and the highest level of small EVs were in AD units. Immunomodulatory activity was mixed, with evidence of both inflammatory and immunosuppressive effects. Monocytes produced more inflammatory interleukin-8 after exposure to fresh WBF or expired WBD supernatants. Exposure to supernatants from AD and WBD RCC suppressed monocyte lipopolysaccharide-induced cytokine production. Manufacturing methods significantly affect RCC unit EV characteristics and are associated with an immunomodulatory effect of RCC supernatants, which may affect the quality and safety of RCCs.

Syngeneic red blood cell-induced extracellular vesicles suppress delayed-type hypersensitivity to self-antigens in mice

BACKGROUND

At present, the role of autologous cells as antigen carriers inducing immune tolerance is appreciated. Accordingly, intravenous administration of haptenated syngeneic mouse red blood cells (sMRBC) leads to hapten-specific suppression of contact hypersensitivity (CHS) in mice, mediated by light chain-coated extracellular vesicles (EVs). Subsequent studies suggested that mice intravenously administered with sMRBC alone may also generate regulatory EVs, revealing the possible self-tolerogenic potential of autologous erythrocytes.

OBJECTIVES

The current study investigated the immune effects induced by mere intravenous administration of a high dose of sMRBC in mice.

METHODS

The self-tolerogenic potential of EVs was determined in a newly developed mouse model of delayed-type hypersensitivity (DTH) to sMRBC. The effects of EV's action on DTH effector cells were evaluated cytometrically. The suppressive activity of EVs, after coating with anti-hapten antibody light chains, was assessed in hapten-induced CHS in wild-type or miRNA-150^-/- mice.

RESULTS

Intravenous administration of sMRBC led to the generation of CD9 + CD81+ EVs that suppressed sMRBC-induced DTH in a miRNA-150-dependent manner. Furthermore, the treatment of DTH effector cells with sMRBC-induced EVs decreased the activation of T cells but enhanced their apoptosis. Finally, EVs coated with antibody light chains inhibited hapten-induced CHS.

CONCLUSIONS AND CLINICAL RELEVANCE

The current study describes a newly discovered mechanism of self-tolerance induced by the intravenous delivery of a high dose of sMRBC that is mediated by EVs in a miRNA-150-dependent manner. This mechanism implies the concept of naturally occurring immune tolerance, presumably activated by overloading of the organism with altered self-antigens.

Perioperative Management of Bleeding and Transfusion for Lung Transplantation

Perioperative allogeneic blood product transfusion is common in lung transplantation and has various implications on the short- and long-term outcomes of lung recipients. This review summarizes the effect of transfusion on outcomes including primary graft dysfunction, chronic lung allograft dysfunction, and all-cause mortality. We outline known risk factors for increased transfusion requirement in lung transplantation and present current evidence regarding the effect of hemostatic agents including antifibrinolytics, recombinant factor VII, and prothrombin complex concentrates. Finally, we highlight the roles of point-of-care coagulation testing and goal-directed transfusion strategies in reducing transfusion requirements in lung transplantation.

Early acute kidney injury after liver transplantation in patients with normal preoperative renal function

AIM

Acute kidney injury (AKI) commonly occurs in patients after liver transplantation (LT). However, few studies have focused on AKI and its correlation with clinical outcomes under the Kidney Disease Improving Global Outcomes (KDIGO) criteria. This study aimed to identity the incidence, risk factors, and impacts of early AKI on outcomes in LT recipients with normal preoperative renal function, according to the KDIGO criteria.

METHODS

Clinical and laboratory data of 227 patients with normal preoperative renal function who underwent LT from January 2011 to January 2015 were retrospectively analyzed.

RESULTS

During the first week after LT, 106 patients (46.7%) developed AKI based on the KDIGO criteria. A multivariate analysis revealed that BMI of > 25, prolonged inferior vena cava clamping, prolonged cold ischemia time, and post-operative RBC requirements > 10 units were independent risk factors for AKI after LT. The area under the receiver operating characteristic curve for the predictive ability of AKI under these risk factors was 0.748. The occurrence of AKI was associated with longer mechanical ventilation time and post-operative ICU stay, increased post-operative 30-day mortality and decreased long-term patient survival.

CONCLUSIONS

Even in patients with normal preoperative renal function, AKI was a frequent complication in LT recipients and had both negative short- or long-term effects on patient outcomes, also the severity of AKI had a dose-response relationship with worse outcomes. Patients with BMI > 25, prolonged inferior vena cava clamping, prolonged cold ischemia time, or post-operative RBC requirement > 10 units should be pay particular attention, which may assist in achieving better clinical outcomes.

Red blood cell transfusion associated with increased morbidity and mortality in patients undergoing elective open abdominal aortic aneurysm repair

BACKGROUND

Red blood cell (RBC) transfusions are associated with increased mortality and morbidity. The aim of this analysis was to examine the association between RBC transfusions and long-term survival for patients undergoing elective open infrarenal abdominal aortic aneurysm (AAA) repair with up to 15 years of follow-up.

METHODS

Prospective cohort study using data from The Danish Vascular Registry from 2000-2015. Primary endpoint was all-cause mortality. Secondary endpoints were in-hospital complications. Transfused patients were divided into subgroups based on received RBC transfusions (1, 2-3, 4-5 or > 5). Using Cox regression multi-adjusted analysis, non-transfused patients were compared to transfused patients (1, 2-3, 4-5, >5 transfusions) for both primary and secondary endpoints.

RESULTS

There were 3 876 patients included with a mean survival of 9.1 years. There were 801 patients who did not receive transfusions. Overall 30-day mortality was 3.1% (121 patients) and 3.6% (112) for all transfused patients. For the five subgroups 30-day mortality was: No transfusions 1.1% (9 patients), 1 RBC 1.2% (4 patients), 2-3 RBC 2.2% (26 patients), 4-5 RBC 1.9% (14 patients) and > 5 RBC 7.9% (68 patients). After receiving RBCs, the hazard ratio for death was 1.54 (95% CI 1.27-1.85) compared to non-transfused patients. There was a significant increase in mortality when receiving 2-3 RBC: HR 1.32 (95% CI 1.07-1.62), 4-5 RBC: 1.64 (1.32-2.03) and >5 RBC: 1.96 (1.27-1.85) in a multi-adjusted model.

CONCLUSION

There is a dose-dependent association between RBC transfusions received during elective AAA repair and an increase in short- and long-term mortality. Approximately 25% of included patients had preoperative anemia. These findings should raise awareness regarding potentially unnecessary and harmful RBC transfusions.

Allogeneic red cell transfusion and its influence on relevant humoral and cellular immunological parameters: A prospective observational trial

BACKGROUND

It is assumed that transfusion of allogeneic red cells is associated with increased peri-operative mortality and morbidity. Also assumed is the theory of transfusion-related immunomodulation.

OBJECTIVE

The aim of this study was to investigate the hypothesis that red cell transfusion specifically leads to an immunological response in surgical patients.

DESIGN

Prospective observational study.

SETTING

Departments of Orthopedic Surgery and Anaesthesia, University Hospital, Thailand.

PATIENTS

Low-risk, noncancer patients, aged 18 to 75 years undergoing elective major spine surgery, with and without red cell transfusion therapy.

INTERVENTIONS

Blood specimens were withdrawn four times (prior to surgery and on days 1, 3 and 5).

MAIN OUTCOME MEASURES

Assessment of immunocompetent cells and cytokines in transfused and nontransfused patients using flow cytometry and multiplex ELISA.

RESULTS

From a total of 78 patients, 61 met the requirements and were analysed in three groups: 19 with no transfusion and 26 and 16 transfused intra-operatively and on day 1 or 2, respectively. No patient experienced peri-operative haemorrhage. Postoperative infection or thrombosis occurred in 5.5% of nontransfused patients and 16.6% of transfused patients; the difference was not significant. There was no significant immunomodulatory effect of red cell transfusion: of 45 immunological parameters, only five little-relevant cytokines were significantly affected, although slightly and nonspecifically.

CONCLUSION

Our data indicate that red cell transfusion alone does not create an immunological response in otherwise healthy surgical patients. Our findings do not generally contradict the transfusion-related immunomodulation phenomenon, which has, however, primarily been observed in patients with an already weakened or procedure-deteriorated immune system, such as from malignant disease, significant comorbidity, extensive abdominal/thoracic surgery and cardiopulmonary bypass.

TRIAL REGISTRATION

The study was registered on 15 May 2014, before enrolment of the first patient, at www.ClinicalTrials.gov, NCT02140216.

Role of transfusions in the development of hospital-acquired urinary tract-related bloodstream infection among United States Veterans

BACKGROUND

Urinary tract-related bloodstream infection (BSI) is associated with substantial morbidity, mortality, and financial costs. We examined the role of red blood cell (RBC) transfusions on developing this condition among US Veterans.

METHODS

We conducted a matched case-control study among adult inpatients admitted to 4 Veterans Affairs hospitals. Cases were patients with a positive urine culture result obtained 48hours or longer after admission and a blood culture obtained within 14days of the urine culture, which grew the same organism. Controls included patients with a positive urine culture result who were at risk for but did not develop BSI (control group 1) and patients without a positive urine culture result who were present in the facility at the time of case diagnosis (control group 2).

RESULTS

Compared with the findings in control group 1, receipt of RBCs was not significantly associated with urinary tract-related BSI (odds ratio, 1.03; 95% confidence interval, 1.00-1.07; P = .07). However, we found increased odds of urinary tract-related BSI compared with the results in patients without infection (control group 2) (odds ratio, 1.11; 95% confidence interval, 1.06-1.17; P < .001).

CONCLUSIONS

Given the heightened risk of urinary tract-related BSI associated with receiving a greater number of RBC transfusions, adhering to recommendations to transfuse the minimum amount of blood products necessary may minimize the risk of this infection among Veterans.

CE: A Review of Current Practice in Transfusion Therapy

: In the United States, roughly 4.5 million patients per year receive transfusions of various blood products. Despite the lifesaving benefits of transfusion therapy, it is an independent risk factor for infection, morbidity, and death in critically ill patients. It's important for nurses to understand the potential complications patients face when blood products are administered and to recognize that patients who have received blood products in the past remain at risk for delayed reactions, including immune compromise and infection. Here, the authors review the blood products that are commonly transfused; discuss potential complications of transfusion, as well as their associated signs and symptoms; and outline current recommendations for transfusion therapy that are widely supported in the medical and nursing literature.

Intraoperative but not postoperative blood transfusion adversely affect cancer recurrence and survival following nephrectomy for renal cell carcinoma

The association between perioperative blood transfusion (PBT) with adverse oncological outcomes have been previously reported in multiple malignancies including RCC. Nevertheless, the importance of transfusion timing is still unclear. The primary purpose of this study is to appraise whether the receipt of intraoperative blood transfusion (BT) differ from postoperative BT in regards to cancer outcomes in renal cell carcinoma (RCC) patients treated with nephrectomy. Data on 1168 patients with RCC, who underwent radical or partial nephrectomy as primary therapy between 1988–2013 were analyzed. PBT was defined as transfusion of allogeneic red blood cells (RBC) during surgery or the postsurgical period. Survival was analyzed and compared using the Kaplan–Meier method with the log-rank test. Of 1168 patients, 198 patients (16.9%) received a PBT. Including 117 intraoperative BT and 81 postoperative BT. Only 21 (10.6%) patients required both intraoperative and postoperative BT. On multivariate analyses, receipt of PBT was associated with significantly worse local disease recurrence (HR: 2.4; P = 0.017), metastatic progression (HR: 2.7; P = 0.005), cancer-specific mortality (HR: 3.5; P = 0.002) and all-cause mortality (HR: 2.1; P = 0.005). Nevertheless, postoperative BT was not independently associated with increased risk of local recurrence (p = 0.1), metastatic progression (P = 0.16) or kidney cancer death (P = 0.63), yet did significantly increase the risk of overall mortality (HR: 2.6; P = 0.004). In the current study, intraoperative transfusion of allogeneic RBC is associated with increased risks of cancer recurrence and mortality following nephrectomy.

Association Between Adverse Clinical Outcomes After Coronary Artery Bypass Grafting and Perioperative Blood Transfusions

Background

Bleeding is a serious complication of coronary artery bypass grafting that often leads to blood transfusion. Approximately 50% of patients who have the surgery receive blood products, and blood transfusions play a role in adverse outcomes after the surgery.

Objective

To examine the association between perioperative blood transfusion and postoperative adverse outcomes in patients undergoing coronary artery bypass grafting.

Methods

A systematic review of the literature, via the matrix method of quality evaluation, was conducted. PubMed, CINAHL, and Science Direct databases for 2000 through 2016 were searched. Inclusion criteria were articles published in English and original research related to clinical outcomes of blood transfusion after coronary artery bypass grafting. Seventeen articles were included in the review.

Results

Mortality, both short- and long-term, was significantly higher in transfusion patients than in nontransfusion patients. Patients with transfusion of red blood cells had higher resource utilization and more complications, including infection, pneumonia, renal failure, graft occlusion, and atrial fibrillation, than did nontransfusion patients.

Conclusion

An association exists between red blood cell transfusions and adverse clinical outcomes for patients undergoing coronary artery bypass grafting. Transfusion of red blood cells is sometimes unnecessary, may be injurious, and should be used cautiously. Even a single-unit increase in perioperative red blood cell transfusions can have a significant adverse impact on outcomes. Individual benefits and risks should be weighed before transfusion to avoid adverse outcomes. Transfusion guidelines should be reviewed to include the latest evidence to guarantee the most appropriate use of blood products.

Intraoperative cell salvage with autologous transfusion in liver transplantation

Liver transplant (LT) is the primary treatment for patients with end-stage liver disease. About 25000 LTs are performed annually in the world. The potential for intraoperative bleeding is quite variable. However, massive bleeding is common and requires blood transfusion. Allogeneic blood transfusion has an immunosuppressive effect and an impact on recipient survival, in addition to the risk of transmission of viral infections and transfusion errors, among others. Techniques to prevent excessive bleeding or to use autologous blood have been proposed to minimize the negative effects of allogeneic blood transfusion. Intraoperative reinfusion of autologous blood is possible through previous self-donation or blood collected during the operation. However, LT does not normally allow autologous transfusion by prior self-donation. Hence, using autologous blood collected intraoperatively is the most feasible option. The use of intraoperative blood salvage autotransfusion (IBSA) minimizes the perioperative use of allogeneic blood, preventing negative transfusion effects without negatively impacting other clinical outcomes. The use of IBSA in patients with cancer is still a matter of debate due to the theoretical risk of reinfusion of tumor cells. However, studies have demonstrated the safety of IBSA in several surgical procedures, including LT for hepatocellular carcinoma. Considering the literature available to date, we can state that IBSA should be routinely used in LT, both in patients with cancer and in patients with benign diseases.

Gastric cancer surgery: clinical outcomes and prognosis are influenced by perioperative blood transfusions

Gastric cancer in patients is often associated with bleeding; when it occurs, especially in the presence of an anemia, a transfusion is necessary to avoid further deterioration of the patient's clinical state. The aim of this study was to evaluate the relationship between the administration of peri-operative transfusions due to the anemia or the clinical status and the post-operative clinical outcomes. 188 patients diagnosed with of gastric cancer were recruited at Surgery 2 of the Department of General and Specialist Surgery of the Tertiary Care Hospital "A. Cardarelli" of Naples. All patients had a total or a subtotal gastrectomy accompanied by D2 lymphectomy for gastric cancer. The clinical data most frequently associated with blood transfusion is the appearance of a post-operative infection (OR 2.26, 95% CI 0.87-5.79, P = 0.061). If the administration time of transfusion is considered, the clinical outcomes are different: preoperative transfusions showed a higher incidence of infections (OR 2.26, 95% CI 0.87-5.79, P = 0.061) and acute renal failure (OR 2.82, 95% CI 0.70-10.78, P = 0.078); patients who received intra or post-operative transfusions showed a prolonged hospitalization (OR 8.66, 95% CI 1.73-83.00, P = 0.002). The administration of blood products in the perioperative period is correlated in a statistically significant manner to the incidence of infections, acute renal failure and prolonged hospitalization; therefore, transfusions should be avoided unless clinically necessary and in particular intraoperative transfusions should be avoided because the immunomodulation effect linked to surgical stress may be enhanced hence worsening the prognosis.

Red blood cell transfusion in liver resection

BACKGROUND

Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes.

PURPOSE

Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion.

RESULTS

Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods.

CONCLUSION

Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.

The impact of preoperative anaemia and anaemic subtype on patient outcome in colorectal cancer

AIM

Preoperative anaemia is associated with adverse outcomes in colorectal cancer (CRC). To clarify the reason for this we aimed to comprehensively assess the association of preoperative anaemia with tumour characteristics, host systemic inflammation and nutrition status, and perioperative blood transfusion.

METHOD

We used an integrated database of 592 CRC patients. The association of preoperative anaemic subtype, calculated from haemoglobin and erythrocyte mean corpuscular volume levels, with patient outcome, preoperative serum data relating to systemic inflammation and nutrition and perioperative blood transfusion was analysed.

RESULTS

Preoperative anaemia was significantly associated with poorer overall survival and relapse-free survival (RFS); in particular microcytic anaemia had a trend to poorer RFS than other forms of anaemia (P = 0.0648). In addition, preoperative anaemia was significantly correlated with right-sided tumours, greater depth of tumour invasion, use of neoadjuvant chemotherapy, poorer prognostic nutritional index and higher modified Glasgow Prognostic Score (mGPS). Microcytic anaemia in particular had a strong association with a greater depth of tumour invasion (P = 0.0072) and higher mGPS (P = 0.0058) than other causes of anaemia. Perioperative blood transfusion for CRC patients with anaemia was associated with adverse outcomes.

CONCLUSIONS

Preoperative anaemia, especially microcytic anaemia, was associated with poor patient outcomes, possibly due to poor systemic inflammatory and nutritional status, and it was not improved by perioperative blood transfusion. Our data suggest that preoperative anaemia and the anaemic subtype may serve as an easily available predictor of outcome in CRC.

Anaemia requiring red blood cell transfusion is associated with unfavourable 90-day survival in surgical patients with sepsis

Objective

The mortality associated with sepsis remains unacceptably high, despite modern high-quality intensive care. Based on the results from previous studies, anaemia and its management in patients with sepsis appear to impact outcomes; however, the transfusion policy is still being debated, and the ideal approach may be extremely specific to the individual. This study aimed to investigate the long-term impact of anaemia requiring red blood cell (RBC) transfusion on mortality and disease severity in patients with sepsis. We studied a general surgical intensive care unit (ICU) population, excluding cardiac surgery patients. 435 patients were enrolled in this observational study between 2012 and 2016.

Results

Patients who received RBC transfusion between 28 days before and 28 days after the development of sepsis (n = 302) exhibited a significantly higher 90-day mortality rate (34.1% vs 19.6%; P = 0.004, Kaplan–Meier analysis). This association remained significant after adjusting for confounders in the multivariate Cox regression analysis (hazard ratio 1.68; 95% confidence interval 1.03–2.73; P = 0.035). Patients who received transfusions also showed significantly higher morbidity scores, such as SOFA scores, and ICU lengths of stay compared to patients without transfusions (n = 133). Our results indicate that anaemia and RBC transfusion are associated with unfavourable outcomes in patients with sepsis.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3988-z) contains supplementary material, which is available to authorized users.

Red blood cell transfusion and its alternatives in oncologic surgery-A critical evaluation

Although blood transfusions have been used for more than 100 years and their potential to save lives is indisputable, there is still limited data on medium- and long-term outcomes after hemotherapy. Until recently, red blood cell transfusions represented the most commonly employed treatment for cancer anemia. As transfusions have been related to worse patient outcome in oncologic surgery, preventive strategies and alternative treatment approaches in the perioperative setting are warranted. This review aims to evaluate the evidence concerning the impact of transfusion on the course of malignant diseases with a focus on oncologic surgery and to provide a bundle of measures to improve patient care. The perioperative period is pivotal in determining long-term cancer outcome. An increasingly recognized area for improvement during this highly sensitive period is the treatment of anemia for three main reasons: Firstly, anemia has been recognized as an independent predictor of poor prognosis in cancer patients. Secondly, anemia is largely undertreated. Thirdly and probably most importantly, anemia therapy relied and often still relies heavily on red blood cell (RBC) transfusions, which may be an often suboptimal stopgap treatment. Perioperative RBC transfusions should be kept to a minimum due to growing concerns regarding the associated risks, which this review tries to clarify by providing an update of recent literature. This review furthermore discusses treatments for anemia and provides best-practice approaches to improve perioperative management of oncology patients undergoing surgery.

Impact of Foley Catheter Placement by Medical Students on Rates of Postoperative Urinary Tract Infection

BACKGROUND

The aim of this study was to evaluate the impact of medical student placement of Foley catheters on rates of postoperative catheter-associated urinary tract infection (CAUTI).

STUDY DESIGN

We included adult surgical patients in our institutional National Surgical Quality Improvement Program (NSQIP) database, and defined CAUTI according to NSQIP criteria. A multivariable model risk-adjusting for patient and operative variables associated with CAUTI in univariate analysis (exploratory p < 0.20) evaluated the independent effect of medical student placement of Foley catheters on the odds of CAUTI.

RESULTS

There were 891 patients who had a Foley catheter placed by a surgical resident (61%; n = 547), operating room nurse (25%; n = 227), or medical student (13%; n = 117). After risk-adjustment, patients with Foleys placed by medical students were at a more than 4-fold increased risk of CAUTI (odds ratio [OR] 4.09, p = 0.02) compared with patients with catheters placed by nurses. Patients with catheters placed by residents did not have an increased risk-adjusted odds of CAUTI (OR 2.16, p = 0.15). Other significant predictors of postoperative CAUTI included female sex (OR 2.61, p = 0.01), partial/total functional dependence (OR 4.81, p = 0.008), blood transfusion (OR 34.7, p = 0.02), and increased length of Foley stay (OR 1.06, p < 0.001).

CONCLUSIONS

Surgical patients with Foley catheters placed by medical students are at increased risk-adjusted odds of postoperative CAUTI. More intense supervision of medical students during urinary catheter insertion in the operating room and improved education regarding sterile technique may be important factors in reducing rates of postoperative CAUTI in academic institutions.

Assessment of the knowledge and perceptions of Brazilian medical residents on transfusion medicine

Background

Medical education has a major social impact because it ultimately influences the quality and safety of the health service offered to the population. Several studies have acknowledged the relationship between medical knowledge on transfusion medicine and the proper use of this therapy. The rational use of blood has become a worldwide concern. In this context, the aim of the present study was to evaluate medical residents' knowledge on transfusion medicine in hospitals located in Rio de Janeiro, Brazil, and their training during their medical education.

Methods

One hundred and six residents from eight medical specialties of four hospitals participated. A questionnaire developed by the Biomedical Excellence for Safer Transfusion (BEST) group was applied to evaluate the participants' medical knowledge. Another questionnaire was also applied to evaluate participant profiles regarding frequency of transfusion prescriptions, self-perceived knowledge and relevance of the subject.

Results

The mean number of correct answers to the questionnaire on knowledge about transfusion practices was 43.5% (range: 15-80%). A relationship between training during medical residency and the obtained result was observed (p-value = 0.0007). Most residents (73%) did not receive training in transfusion medicine during their graduation or residency and 93% would like to receive additional training.

Conclusion

A clear deficit in the knowledge of transfusion medicine was verified, indicating the need for change in the teaching of this specialty. This result is similar to some developed countries.

Relationship between perioperative blood transfusion and surgical site infections in pediatric general and thoracic surgical patients

BACKGROUND

Recently, perioperative transfusions were demonstrated to be associated with higher rate of surgical site infections (SSIs) in neonates. We sought to examine whether a similar relationship exists between perioperative blood transfusions and SSI among non-neonatal pediatric general surgical patients.

METHODS

We conducted an IRB-approved retrospective study reviewing non-neonatal patients (age greater than 28days and less than 18years) who underwent a general or thoracic surgical procedure in 2012, 2013, 2014, in the American College of Surgeons National Safety and Quality Improvement Project-Pediatric (ACS-NSQIP-P) Participant User Files. We used Chi-square analyses to perform a bivariate analysis comparing proportions of SSI's between patients who received blood transfusion to those who did not. Multiple logistic regression analyses compared the odds of SSIs in transfused versus nontransfused patients controlling for organ failure, steroid use, nutritional status, current infection, American Society of Anesthesiologists (ASA) Physical Status classification, and wound classification.

RESULTS

There were 55,133 patients with 1779 patients who received blood transfusion (≥25ml/kg body weight) during or within 72h of surgery. Bivariate analysis showed at least twice the rate of infection in transfused patients compared to nontransfused patients (p<0.01): superficial SSI 3.5% vs 1.5%; deep SSI 0.8% vs 0.2%, organ space SSI 3.8% vs 1.6%; deep dehiscence 2% vs 0.3%. Total wound infections and dehiscence for transfused patients were 10.5% vs 3.8% in nontransfused patients (p<0.01). Multiple regression analysis showed that nutritional issue, current infection, and wounds not classified as "clean" have statistically significant correlation with SSI. Although there was significant interaction between ASA and transfusion (p<0.0001), we found statistically significant associations between transfusions and SSI for ASA class 1-2 (OR=5.51, 95% CI 3.47-7.52), ASA class 3 (OR=2.06, 95% CI 1.63-2.61), and ASA class 4-5 (OR=1.67, 95% CI 1.15-2.42).

CONCLUSION

In non-newborn pediatric general and thoracic surgery patients, transfusions were associated with higher risk of SSI or wound dehiscence. Although there was a significant interaction between ASA and transfusion, OR for SSI was stronger for lower ASA classes.

TYPE OF STUDY

Retrospective Review.

LEVEL OF EVIDENCE

II.

Effect of storage period of red blood cell suspensions on helper T-cell subpopulations

BACKGROUND

The aim of this study was to investigate the immunological alterations that occur during the storage of erythrocyte suspensions which may lead to transfusion-related immunomodulation following allogeneic blood transfusion.

MATERIALS AND METHODS

One part of the erythrocyte suspensions obtained from donors was leucoreduced while the other part was not. The leucoreduced (LR) and non-leucoreduced (NL) erythrocyte suspensions were then further divided into three equal amounts which were stored for 0, 21 or 42 days prior to measurements, by enzyme-linked immunosorbent assays, of cytokine levels in their supernatants. T-helper (Th) lymphocyte subgroups and gene expression were analysed in the NL erythrocyte suspensions by flow cytometry and real-time polymerase chain reaction, respectively. Results were compared to those of storage day 0.

RESULTS

By day 21, the number of Th2 cells had increased significantly and the numbers of Th1, Th22 and Treg cells had decreased significantly in the NL erythrocyte suspensions. On day 42 the numbers of Th2 and Treg cells in the NL suspensions were significantly increased while the number of Th1 cells was significantly decreased. The levels of transcription factors (TBX21, GATA3, and SPI.1) were significantly decreased on days 21 and 42, and AHR, FOXP3 and RORC2 levels were significantly increased on day 42 in NL erythrocyte suspensions. The decrease in interleukin-22 and increase in transforming growth factor-β levels found in NL erythrocyte suspensions on day 21 were statistically significant. Elevated levels of interleukin-17A were found in both LR and NL erythrocyte suspensions on day 42.

DISCUSSION

Our results suggest that allogeneic leucocytes and cytokines may play significant roles in the development of transfusion-related immunomodulation.

Platelet Storage Lesions: What More Do We Know Now?

Platelet concentrate (PC) transfusions are a lifesaving adjunct to control and prevent bleeding in cancer, hematologic, surgical, and trauma patients. Platelet concentrate availability and safety are limited by the development of platelet storage lesions (PSLs) and risk of bacterial contamination. Platelet storage lesions are a series of biochemical, structural, and functional changes that occur from blood collection to transfusion. Understanding of PSLs is key for devising interventions that prolong PC shelf life to improve PC access and wastage. This article will review advancements in clinical and mechanistic PSL research. In brief, exposure to artificial surfaces and high centrifugation forces during PC preparation initiate PSLs by causing platelet activation, fragmentation, and biochemical release. During room temperature storage, enhanced glycolysis and reduced mitochondrial function lead to glucose depletion, lactate accumulation, and product acidification. Impaired adenosine triphosphate generation reduces platelet capacity to perform energetically demanding processes such as hypotonic stress responses and activation/aggregation. Storage-induced alterations in platelet surface proteins such as thrombin receptors and glycoproteins decrease platelet aggregation. During storage, there is an accumulation of immunoactive proteins such as leukocyte-derive cytokines (tumor necrosis factor α, interleukin (IL) 1α, IL-6, IL-8) and soluble CD40 ligand which can participate in transfusion-related acute lung injury and nonhemolytic transfusion reactions. Storage-induced microparticles have been linked to enhanced platelet aggregation and immune system modulation. Clinically, stored PCs have been correlated with reduced corrected count increment, posttransfusion platelet recovery, and survival across multiple meta-analyses. Fresh PC transfusions have been associated with superior platelet function in vivo; however, these differences were abrogated after a period of circulation. There is currently insufficient evidence to discern the effect of PSLs on transfusion safety. Various bag and storage media changes have been proposed to reduce glycolysis and platelet activation during room temperature storage. Moreover, cryopreservation and cold storage have been proposed as potential methods to prolong PC shelf life by reducing platelet metabolism and bacterial proliferation. However, further work is required to elucidate and manage the PSLs specific to these storage protocols before its implementation in blood banks.

Age-Dependent Association Between Pre-transplant Blood Transfusion and Outcomes of Pediatric Heart Transplantation

Avoidance of red blood cell (RBC) transfusions in patients awaiting heart transplantation (HTx) has been suggested to minimize the risk of allosensitization. Although recent studies have suggested that an immature immune system in younger HTx recipients may reduce risks associated with RBC transfusion, the role of age in moderating the influence of transfusion on HTx outcomes remains unclear. We used available data from a national transplant registry to explore whether the association between pre-transplant transfusions and outcomes of pediatric HTx varies by patient age. De-identified data were obtained from the United Network for Organ Sharing registry, including first-time recipients of isolated HTx performed at age 0-17 years in 1995-2015. The primary exposure was receiving blood transfusions within 2 weeks prior to HTx. Patient survival after HTx was evaluated using multivariable Cox proportional hazards, where age at transplant was interacted with exposure to pre-transplant transfusion. Age-specific hazard ratios (HRs) of pre-transplant transfusion were plotted across ages at transplant. There were 4883 patients meeting inclusion criteria, of whom 1258 died during follow-up (mean follow-up duration 6 ± 5 years). Patients receiving pre-transplant transfusions were distinguished by younger age, higher prevalence of prior cardiac surgery, greater likelihood of being in the intensive care unit, and greater use of left ventricular assist device bridge to transplant. In multivariable analysis, pre-transplant transfusions were associated with increased mortality hazard among infants < 1 year of age (HR = 1.46; 95% CI 1.23, 1.74; p < 0.001). For each additional year of age, the excess hazard associated with pre-transplant transfusions decreased by 3% (interaction HR = 0.97; 95% CI 0.98, 0.99; p = 0.003). By age 8, the association between pre-transplant transfusions and post-transplant mortality was no longer statistically significant (HR = 1.15; 95% CI 0.99, 1.32; p = 0.060). Pre-transplant transfusions were associated with increased mortality hazard only among younger children (age < 8 years) undergoing HTx. These data support the current practices of transfusion avoidance prior to HTx, particularly in younger patients.

Effects of propofol-based total intravenous anesthesia on gastric cancer: a retrospective study

Background

Several kinds of cancer surgeries with propofol-based total intravenous anesthesia (TIVA) have been shown to have better outcomes than those with sevoflurane-based inhalational anesthesia (INHA). However, the effects of this anesthetic technique have not been investigated in patients with gastric cancer. In this study, the authors retrospectively examined the link between the choice of anesthetic technique and overall survival in patients undergoing gastric cancer resection.

Methods

We conducted a retrospective analysis of the database of all patients undergoing gastric cancer resection for gastric cancer between 2007 and 2012. Patients who received TIVA or INHA were administered patient-controlled intravenous analgesia for 72-120 hours postoperatively. Survival was estimated using the Kaplan-Meier log-rank test, and associations between anesthetic technique and outcomes were analyzed using Cox proportional hazards regressions after propensity matching.

Results

A total of 2,856 anesthetics using INHA or TIVA were delivered in the study period. After propensity matching, 897 patients remained in each group. According to Kaplan-Meier analysis, the use of TIVA was associated with improved survival (P<0.001). TIVA was associated with a hazard ratio (HR) of 0.67 (95% confidence interval [CI]: 0.58-0.77) for death in univariate analysis and 0.65 (95% CI: 0.56-0.75) after a multivariate analysis of known confounders in the matched group. Cancer stage (HR =0.74, 95% CI: 0.64-0.86, P<0.001) and degree of differentiation (HR =1.28, 95% CI: 1.11-1.47, P<0.001) were also associated with survival in the univariate analysis in the matched group. In the multivariable Cox model, cancer stage (HR =0.72, 95% CI: 0.62-0.84, P<0.001) and degree of differentiation (HR =1.23, 95% CI: 1.07-1.42, P<0.001) were associated with survival in the matched group.

Conclusion

These results indicate that TIVA may be associated with improved survival in gastric cancer patients who undergo resection.

Transfusion-related immunomodulation: a reappraisal

PURPOSE OF REVIEW

This review summarizes current and prior observations regarding transfusion-related immunomodulation (TRIM) and puts these ideas into a modern immunological context, incorporating concepts from innate, adaptive, and nutritional immunity. We propose that TRIM research focus on determining whether there are specific, well-defined immunosuppressive effects from transfusing 'pure' red blood cells (RBCs) themselves, along with the by-products produced by the stored RBCs as a result of the 'storage lesion.' Macrophages are a key cell type involved in physiological and pathological RBC clearance and iron recycling. The plasticity and diversity of macrophages makes these cells potential mediators of immune suppression that could constitute TRIM.

RECENT FINDINGS

Recent reports identified the capacity of macrophages and monocytes to exhibit 'memory.' Exposure to various stimuli, such as engulfment of apoptotic cells and interactions with ß-glucan and lipopolysaccharide, were found to induce epigenetic, metabolic, and functional changes in certain myeloid cells, particularly macrophages and monocytes.

SUMMARY

Macrophages may mediate the immunosuppressive aspects of TRIM that arise as a result of transfused RBCs and their storage lesion induced by-products.