Blood transfusion and renal transplantation

Pregnancy zone protein is a carrier and modulator of placental protein-14 in T-cell growth and cytokine production

A successful pregnancy can only occur when the maternal immune system fails to attack the allogeneic fetus. Two plasma proteins with described immunoregulatory activities, pregnancy zone protein (PZP) and placental protein-14 (PP14; also known as glycodelin-A), increase dramatically during pregnancy, prompting us to examine their potential role in mediating fetal protection. First, we demonstrated that both native PZP and its receptor-recognized monoamine-activated form (MA-PZP) bound non-covalently and specifically to PP14, exhibiting K(d) values greater than 3 microM, as determined by surface plasmon resonance. Our evidence further suggests that PZP is potentially a more effective carrier of PP14 than its relative alpha2-macroglobulin. Second, we found that T-cell activation, as measured by increased proliferation and IL-2 production, was inhibited by either PZP or PP14 in a dose-dependent manner. However, when PZP and PP14 were combined, they acted synergistically to inhibit T cell proliferation and IL-2 production. Interestingly, the combination of PZP and PP14 had little effect on the production of T(H)2 cytokine, IL-4. Based upon these findings, we hypothesize that PZP and PP14 form a stable complex in the plasma of pregnant women and together act synergistically to selectively modulate T-cell activation. Mechanistically, this activity appears to be independent of the PZP receptor (CD91) or PZP's anti-proteinase activity.

The influence of homologous blood transfusion on immunity and clinical outcome in aortic surgery

OBJECTIVES

To evaluate the influence of homologous blood transfusion on immune responses and post-operative morbidity in aortic surgery.

DESIGN

Analysis of the effects of homologous blood transfusion in 128 patients in a prospective randomised trial evaluating homologous and autologous blood transfusion in aortic surgery.

MATERIALS AND METHODS

Blood sampled before and at five times after surgery was assayed for C-reactive protein (CRP), neutrophil elastase, TNF-alpha and IL-6. Transfusions, morbidity and mortality were recorded; factors associated with poor outcome were identified by logistic regression.

RESULTS

homologous transfusion during surgery was required in 32 patients and precipitated an increase in neutrophil elastase (p=0.008) and TNF-alpha (p=0.015) but not IL-6 and CRP. Elastase peaked early in transfused patients at 41.27 (13.92-52.11) Deltang/ml by 2 h compared to a peak of 21.51 (10.64-31.13) Deltang/ml by 24 h in those who were not transfused. TNF-alpha peaked at 1.2 (0-4.33) Deltapg/ml by wound closure in transfused patients and at -0.1 (-2.05-2.52) Deltapg/ml by 2 h without transfusion. Intra-operative homologous transfusion was associated with increased mortality (p=0.01) and prolonged intensive care stay (p=0.03). Mortality increased with age (p=0.003) and was inversely related to the CRP peak (p=0.007). Prolonged surgery predicted post-operative complications (p=0.025).

CONCLUSION

Homologous transfusion increased the inflammatory response to aortic surgery and was associated with mortality.

The role of immunization treatment in preventing recurrent abortion

Published reports of controlled studies of immunization treatment in recurrent abortion have not shown any ability of either third-party cells or the husband's cells to prevent further abortions, whereas preliminary results of ongoing studies speak in favor of a beneficial effect of third-party cells. However, the lack of significant differences so far does not prove that immunotherapy in habitual abortion is ineffective, because all of these studies include too few patients in each group to give any conclusive results. Only a mega-trial could evaluate the efficacy and side effects of leukocyte immunotherapy. Such controlled studies are needed to clarify the true benefits, risks, and limitations of immunization treatment in recurrent abortion. Factors such as appropriate inclusion criteria, the time relationship between immunization and the next pregnancy, the number of immunizations required, the cell source and cell doses need to be established. Until this additional information is available this treatment should not be considered routinely indicated. This approach should be restricted to a few centers in order to provide maximal possibilities for collection and evaluation of the data.

Transfusion-induced immunosuppression and red cell clearance

While blood transfusion is increasingly implicated in the aetiology of tumour recurrence, the mechanism of this effect is unclear. Cancer-bearing patients are known to have factors in their sera which depress the function of normal lymphocytes. It is possible that blood transfusion accentuates this natural suppression. An animal model was therefore developed to study the effect of blood transfusion on humoral immunosuppressive activity and its possible relationship to red cell clearance. WAG rats given a transfusion of chromium-labelled allogeneic but blood-group compatible DA rat blood, developed significantly increased (P < 0.001) levels of lymphocyte suppressive factors in plasma (maximum at 7 days) which coincided with accelerated red cell clearance (t1/2 = 7 days). A transfusion of syngeneic WAG blood caused only a small transient increase in plasma suppression and red cells were cleared at a normal rate (t1/2 = 13 days) consistent with previous studies. However, when syngeneic WAG red cells were lysed and the red cell membranes infused there was a rapid increase in plasma suppression (P < 0.001), similar to but less prolonged than that achieved with allogeneic blood. The immunosuppressive effect of blood transfusion may result from accelerated clearance of allogeneic or damaged syngeneic red blood cells.

[Effect of the transfusion of blood and hemoderivatives on the prognosis of colorectal cancer]

In recent years in the literature several investigators described a negative effect of perioperative transfusion of blood and hemoderivatives on the prognosis of malignant tumors. Concerning the patients with colorectal carcinoma operated between 1979 and 1983 at Erlangen University Hospital these results could be proven. We observed a significantly worse 5-year survival rate for patients who received perioperative blood transfusion. However, multivariant analysis in Cox-regression model revealed other factors like tumor stage and localisation responsible for the poorer prognosis. Therefore blood transfusion seems not to have any influence on the prognosis itself. Furthermore we observed a significantly poorer prognosis concerning patients who perioperatively received fresh frozen plasma (FFP). Surprisingly multivariant analysis showed that FFP substitution in contrast to blood transfusion has an own prognostic influence. This difference in prognosis cannot be explained by selection criteria. The mechanism of the negative influence of FFP on the prognosis of colorectal carcinoma remains unclear and is investigated currently in prospective studies.

Perioperative blood transfusion and solid tumour recurrence

Evidence regarding the association of blood transfusions with recurrence of solid tumours is largely conflicting. This is perhaps unsurprising given the retrospective nature of the studies performed to date, the complexity of the disease and its treatment, and variations in local transfusion practices. Nonetheless, new data demonstrating that transfusions of whole blood, as opposed to red cell concentrates, are associated with earlier cancer recurrence are most readily explained by a cause and effect relationship. There is a growing literature documenting previously unforeseen immunologic consequences of homologous blood transfusion. These possible clinical consequences include earlier cancer recurrence and increased susceptibility to infection with bacteria and viruses. The questions raised in this review can be answered conclusively only by controlled prospective studies. For the present the prudent clinician will select red blood cells rather than whole blood for transfusion, employ autologous transfusions whenever feasible, and recognize that blood transfusion is a therapy with considerable benefits, but also considerable risks.

Perioperative blood transfusion and solid tumor recurrence--a review

Evidence regarding the association of blood transfusions with recurrence of solid tumors is largely conflicting. This is perhaps not surprising given the retrospective nature of the studies, the complexity of the disease and its treatment, and variations in local transfusion practices. Nonetheless, data demonstrating that transfusions of whole blood are associated with earlier cancer recurrence are most readily explained by a cause and effect relationship. There is a growing literature documenting previously unforeseen immunologic consequences of homologous blood transfusion. These possible clinical consequences may include earlier cancer recurrence, and increased susceptibility to infection with bacteria and viruses. The questions raised in this review will likely be answered by further studies. For the present, the prudent clinician will select red blood cells rather than whole blood for transfusion, and recognize that blood transfusion is a therapy with considerable benefits, but also considerable risks.

Effect of perioperative blood transfusion on recurrence of colorectal cancer

The aim of the present study was to examine the outcome of 517 patients undergoing curative surgery for colonic and rectal cancer, and to compare the recurrence and mortality rates in transfused and non-transfused groups of patients. The two groups were evenly matched for age, sex, Dukes' stage and histological differentiation. There were significantly more rectal tumours in the transfused group (P less than 0.01), but the distribution of colonic lesions did not differ. Life table analysis revealed that the transfused patients had a 20 per cent greater probability of recurrence at 5 years (P less than 0.005) and there were 16 per cent more cancer related deaths (P less than 0.01). Even when all rectal cancers were excluded, a similar trend was seen for the colonic lesions: a 24 per cent greater probability of recurrence at 5 years (P less than 0.025) and 15 per cent more cancer related deaths (P less than 0.02). We conclude that blood transfusion may be associated with increased mortality and recurrence in patients undergoing curative surgery for colorectal cancer.

Perioperative blood transfusion associated with infectious complications after colorectal cancer operations

We prospectively studied 168 consecutive patients with colorectal cancer to identify perioperative determinants of infectious complications. All patients received preoperative bowel preparation with laxatives, enemas, oral neomycin and erythromycin base, and intravenous cefazolin. Age, sex, admission hematocrit value, operative procedure, specimen length, duration of operation, blood loss, transfusions, tumor size, tumor differentiation, nodal status, and Dukes' stage were evaluated in relation to infectious complications using multivariate analysis. Infectious complications developed in 24 of the 168 patients in the study (14 percent) and these accounted for the four deaths. Blood transfusion (p = 0.0100) and admission hematocrit value (p = 0.0191) were significantly related to postoperative infectious complications. Low admission hematocrit values appeared to protect patients from infectious complications. Patients who had postoperative infectious complications received 2.14 +/- 2.75 units of blood compared with 0.82 +/- 1.37 units in patients without infectious complications (p = 0.0005). Although blood transfusion was associated with high operative blood loss, prolonged procedures, and large specimens (p less than 0.005), none of these factors was significantly associated with infectious complications (p greater than 0.10). Blood transfusion is immunosuppressive in other clinical situations and may be a more significant factor affecting postoperative immune function and susceptibility to infectious complications than previously recognized.

Immunologic effects of blood transfusion upon renal transplantation, tumor operations, and bacterial infections

Blood transfusions appear to exert a suppressive effect on many aspects of the immune system. In transplantation, this has been used to advantage; in other areas, the consequences can be deleterious. It is likely that various components of the immune system are affected by different mechanisms and possibly by different components of transfused blood. Before rational strategies can be evolved for minimizing the deleterious effects of blood transfusions, it is essential that these mechanisms be clearly defined. Studies must take into account any influence the underlying disease state might have on the immune system. In the absence of any satisfactory substitute, blood transfusion remains an essential therapeutic modality in the management of surgical patients. With current evidence, however, it seems reasonable to avoid the administration of small-volume transfusions whenever possible and encourage the use of autodonated blood for elective surgery.

Blood transfusion, skin test reactivity, and lymphocytes in inflammatory bowel disease

Peripheral lymphocytes, T and B cell counts, and skin test reactivity to five recall antigens were determined before operation and 6 to 18 months after operation with or without blood transfusion in 59 patients with inflammatory bowel disease. Significantly reduced preoperative peripheral lymphocyte and T cell counts reached normal levels 6 to 18 months after operation in patients who had not received perioperative blood transfusions. However, lymphocytes and T cells of transfused patients remained decreased, unchanged from preoperative levels, and significantly lower than those of control subjects (p less than 0.005) and levels of patients who had not been transfused (p less than 0.05). Before operation, transfused and untransfused patients were identical in age, Crohn's disease activity index, and peripheral lymphocyte and T and B cell counts. Equal numbers of patients were taking steroids and were anergic to skin tests with five recall antigens. Transfused patients weighed less preoperatively than untransfused patients, and these patients then gained a significant amount of weight. These results suggest that some of the immunologic abnormalities that accompany inflammatory bowel disease may be influenced by blood transfusions.

CAPD and renal transplantation

Continuous ambulatory peritoneal dialysis (CAPD) is believed to improve the immune competence of end-stage renal failure patients and to increase the risk of graft rejection following subsequent renal transplantation. At this centre, 220 consecutive renal transplants have been studied in patients treated by either CAPD or haemodialysis (HD). Patient and graft survival was not significantly different for the two treatment groups over a five year follow-up. When only first cadaver recipients were considered (152 grafts) one-year graft survival (non-immunological failures excluded) was 77 per cent for CAPD and 79 per cent for HD patients (P greater than 0.05). Time on dialysis and number of pre-operative transfusions were significantly greater for the HD patients (P less than 0.05). A group of HD and CAPD patients were identified as being matched for age, sex, HLA, A, B, DR antigen matches, pre-operative transfusions and time-on dialysis. One-year graft survival of the CAPD patients was 82 per cent and for the HD patients 61 per cent. Studies of patient lymphocyte function and plasma suppressive activity in vitro revealed no differences between CAPD and HD treated patients. CAPD is not an immunological risk factor in renal transplantation and its continued use in the preparation of patients for transplantation is recommended.

The influence of surgical operations on components of the human immune system

Surgical operations have been shown to cause a variety of immunological disturbances in man both in vivo and in vitro. With few exceptions the overall picture is one of a generalized state of immunodepression in the postoperative period. The implications of these observations are that host defences may be compromised by surgical procedures, thus providing a 'fertile soil' for bacterial invasion and tumour cell metastasis at the very time when risks from invading pathogens and viable tumour cells are maximal. We have studied the effects of surgical operations on the immune system in 35 patients with benign disease. Surgical procedures were classified as either minor (n = 15) or major (n = 20). A panel of monoclonal antibodies was used to identify peripheral blood lymphocyte subpopulations and analysis was performed using flow cytometry. Simultaneous estimations of plasma alpha-1 proteinase inhibitor (alpha-1-PI), alpha-2-macroglobulin (alpha-2-M), alpha-2-pregnancy-associated glycoprotein (alpha-2-PAG) and plasma suppressive activity (PSA) on stimulated allogeneic lymphocytes were performed before operation and on postoperative days 1, 3, 7, 17 and 21. Circulating numbers of all lymphocyte subpopulations fell significantly following surgery, except for B lymphocytes which did not change. The magnitude, and duration of the reduction in cell numbers and the subpopulation affected was significantly related to the degree of surgical trauma, and returned to pre-operative values by postoperative day 7. Changes in alpha-1-PI, alpha-2-M, alpha-2-PAG and PSA were also significantly related to the degree of surgical trauma, and these plasma changes persisted longer than the cellular disturbances. Surgical operations induce a reversible depression of cellular immunity which precedes plasma suppressive activity in its return to pre-operative levels. Immunostimulating agents such as interferon and the interleukins deserve evaluation as prophylactic agents pre-operatively.

Allosensitization in tumor therapy and prophylaxis, and in female contraception--a prospect for clinical use

A hypothesis is presented on the possible role of allosensitization in therapy and prophylaxis of human tumors, and in human female contraception. The essence of the proposed treatment of human malignancies is allosensitization with allogeneic white blood cells by means of application of two blood transfusions from normal healthy donors within a certain time interval to patients with invasive or metastasizing cancer. The therapy should be accompanied by immunoglobulins, bacterial toxins and a single dose of cytostatics. In the case of a successful tumor regression a prophylaxis of recurrence should be made with two doses of intradermally injected allogeneic lympho-leucocytic concentrates mixed with bacterial toxins; such treatment might also be effective in tumor prophylaxis, or in long-lasting contraception in women. The hypothesis is supported by recent literature as well as by our recent results in the area of cell-mediated control of tissue proliferation, fetal allograft survival or tumor development. It is concluded that tumor rejection can be mediated not only by the direct effect of anti-tumor drugs but more effectively by the organisms mechanisms responsible for removal of undesirable tissue.

Blood transfusion and disease-free survival in carcinoma of the breast

A retrospective study was undertaken to determine the effect of perioperative blood transfusion on disease-free survival rates in patients with carcinoma of the breast. The charts of 81 patients participating in a NSABP breast cancer protocol at The Mt. Sinai Medical Center, Cleveland, Ohio, were reviewed. There was no statistically significant difference in disease-free survival between those patients receiving blood transfusions and those that did not when considering the entire group of patients or subgroups based upon age, nodal status, estrogen receptor status, or progesterone receptor status. However, the subgroup of patients receiving tamoxifen chemotherapy, especially those with positive estrogen receptors, had significantly reduced disease-free survival (P less than .05) when given blood transfusions. These results suggest an adverse effect of blood transfusion on disease-free survival in breast cancer patients treated with tamoxifen chemotherapy.

The role of protease in immunoregulation

Whilst immunodepression is widely recognized in patients subject to trauma or chronic disease, the mechanism of this process is poorly understood. We found that most of the lymphocyte suppressive activity of plasma from severely ill patients was attributable to the protein alpha 2-macroglobulin (alpha 2 M) and low molecular weight peptide (less than 10000). The only major variation in alpha 2 M concentration was found in patients subject to trauma, when it was depressed at times of high plasma suppressive activity. In order to explain qualitative immunosuppressive differences in alpha 2 M we studied its functional role as the main route for binding and degrading proteolytic enzyme (protease). In normal plasma minor degrees of protease complex formation to alpha 2 M caused greatly increased suppressive activity due principally to alpha 2 M and the abnormal appearance of low molecular weight peptide (less than 10000). Study of protease inhibitor function in patients suffering from acute or chronic illness suggested that in these patients their plasma becomes immunosuppressive due to inadequate handling of protease, resulting in alpha 2 M-protease complexes or inhibitory peptides persisting in the circulation. Opportunities for background immunoregulation by altering protease metabolism are considered.

Plasma suppressive activity and kidney graft survival

Over the past few years many centres have shown that blood transfusions given to potential renal transplant patients are beneficial to subsequent graft survival. Results from this centre have shown that an elevated ability of plasma to suppress lymphocyte reaction to antigen is associated with blood transfusions in chronic renal failure patients. In a prospective study, plasma suppressive activity was measured at the time of transplantation in 49 patients who were followed for between 3 and 15 months. Results showed that patients with a low level of plasma suppressive activity were at risk from early graft loss due to acute rejection. Furthermore, most of the suppressive activity was related to the naturally occurring plasma protein. alpha 2-macroglobulin. This prospective study reports a significant association between low plasma suppressive activity and early kidney graft loss through rejection, and suggests an explanation for the beneficial effects of blood transfusion on graft survival.