Effect of perioperative blood transfusion on recurrence of Crohn's disease

Systematic Review and Meta-Analysis on the Role of Perioperative Blood Transfusion in Patients Undergoing Radical Cystectomy for Urothelial Carcinoma

BACKGROUND

Radical cystectomy (RC) is the standard of care in patients with muscle-invasive bladder cancer. The impact of perioperative red blood cell (RBC) transfusion on oncological outcomes after RC is not clearly established as the existing publications show conflicting results.

OBJECTIVES

The aim of this systematic review and meta-analysis was to investigate the prognostic role of perioperative RBC transfusion on oncological outcomes after RC.

METHODS

Systematic online search on PubMed was conducted, based on PRISMA criteria for publications reporting on RBC transfusion during RC. Publications with the following criteria were included: (I) reported data on perioperative blood transfusion; (II) Reported Hazard ratio (HR) and 95% -confidence interval (CI) for the impact of transfusion on survival outcomes. Primary outcome was the impact of perioperative RBC transfusion on recurrence-free survival (RFS), cancer-specific survival (CSS) and overall survival (OS). Risk of bias assessment was performed using Newcastle-Ottawa Scale. Statistical analysis was performed using Revman 5.4 software.

RESULTS

From 27 primarily identified publications, 19 eligible articles including 22897 patients were selected. Perioperative RBC transfusion showed no impact on RFS (Z = 1.34; p = 0,18) and significant negative impact on CSS (Z = 2.67; p = 0.008) and OS (Z = 3.22; p = 0.001). Intraoperative RBC transfusion showed no impact on RFS (Z = 0.58; p = 0.56) and CSS (Z = 1.06; p = 0.29) and OS (Z = 1.47; p = 0.14).Postoperative RBC transfusion showed non-significant trend towards improved RFS (Z = 1.89; p = 0.06) and no impact on CSS (Z = 1.56; p = 0.12) and OS (Z = 0.53 p = 0.60).

CONCLUSION

In this meta-analysis, we found perioperative blood transfusion to be a significant predictor only for worse CSS and OS but not for RFS. This effect may be determined by differences in tumor stages and patient comorbidities for which this meta-analysis cannot control due to lack of respective raw data.

Risk factors for postoperative recurrence of Crohn's disease with emphasis on surgical predictors

Intestinal resection for Crohn’s disease is not curative and postoperative recurrence rates remain high. Early detection of indices associated with recurrence and risk stratification are fundamental for the postoperative management of patients. Early endoscopy at 6-12 months is the “gold standard” procedure, whereas other modalities such as fecal calprotectin and imaging techniques can contribute to the diagnosis of recurrence. The purpose of this review is to summarize current data regarding risk factors correlated with postoperative relapse. Smoking is a well-established, modifiable risk factor. There are sufficient data that correlate penetrating disease, perianal involvement, extensive resections, prior surgery, histological features (plexitis and granulomas), and improper management after resection with high rates for recurrence. The literature provides conflicting data for other possible predictors, such as age, sex, family history of inflammatory bowel disease, location of disease, strictureplasties, blood transfusions, and postoperative complications, necessitating further evidence. On the other hand, surgical factors such as anastomotic configuration, open or laparoscopic approach, and microscopic disease at specimen margins when macroscopic disease is resected, seem not to be related with an increased risk of recurrence. Further recognition of histological features as well as gene-related factors are promising fields for research.

Perioperative red blood cell transfusion in orofacial surgery

In the field of orofacial surgery, a red blood cell transfusion (RBCT) is occasionally required during double jaw and oral cancer surgery. However, the question remains whether the effect of RBCT during the perioperative period is beneficial or harmful. The answer to this question remains challenging. In the field of orofacial surgery, transfusion is performed for the purpose of oxygen transfer to hypoxic tissues and plasma volume expansion when there is bleeding. However, there are various risks, such as infectious complications (viral and bacterial), transfusion-related acute lung injury, ABO and non-ABO associated hemolytic transfusion reactions, febrile non-hemolytic transfusion reactions, transfusion associated graft-versus-host disease, transfusion associated circulatory overload, and hypersensitivity transfusion reaction including anaphylaxis and transfusion-related immune-modulation. Many studies and guidelines have suggested RBCT is considered when hemoglobin levels recorded are 7 g/dL for general patients and 8-9 g/dL for patients with cardiovascular disease or hemodynamically unstable patients. However, RBCT is occasionally an essential treatment during surgeries and it is often required in emergency cases. We need to comprehensively consider postoperative bleeding, different clinical situations, the level of intra- and postoperative patient monitoring, and various problems that may arise from a transfusion, in the perspective of patient safety. Since orofacial surgery has an especially high risk of bleeding due to the complex structures involved and the extensive vascular distribution, measures to prevent bleeding should be taken and the conditions for a transfusion should be optimized and appropriate in order to promote patient safety.

Perioperative Blood Transfusion and Postoperative Outcome in Patients with Crohn's Disease Undergoing Primary Ileocolonic Resection in the "Biological Era"

BACKGROUND

Perioperative blood transfusion has been shown to be associated with inflammatory response and immunosuppression. Patients receiving blood transfusion may have an increased risk for developing postoperative morbidities. The impact of blood transfusion on the postoperative recurrence of Crohn's disease (CD) has been controversial. The aim of this study was to assess the effect of blood transfusion on postoperative outcomes in CD in the current biological era.

METHODS

This historical cohort study involved data collection and analysis of CD patients who underwent the index ileocolonic resection in our institution between 2000 and 2012. Postoperative complications were compared between the transfused and nontransfused patients. The effects of perioperative blood transfusion on postoperative complications and disease recurrence were analyzed with both univariate and multivariate analyses.

RESULTS

A total of 318 patients were included in the study, and 52 of them (16.5 %) received perioperative blood transfusion. Blood transfusion was found to be associated with an increased risk of postoperative infectious and noninfectious complications both in univariate (P < 0.001 for each) and multivariable analyses (infectious complications: odds ratio [OR] = 8.73, 95 % confidence interval [CI] 2.85-26.78, P < 0.001; noninfectious complications: OR = 3.64, 95 % CI 1.30-10.18; P = 0.014). In addition, the Cox regression model indicated that blood transfusion was associated with both surgical (hazard ratio [HR] = 3.43, 95 % CI 1.92-6.13; P < 0.001) and endoscopic (HR = 2.08, 95 % CI 1.38-3.14; P < 0.001) CD recurrence following the index surgery.

CONCLUSION

Adverse outcomes after perioperative blood transfusion for the primary ileocolonic resection for CD resemble findings in surgery for other diseases. The presumed immunosuppressive effect of blood transfusion did not confer any protective effect on disease recurrence.

Therapeutic Armamentarium for Stricturing Crohn's Disease: Medical Versus Endoscopic Versus Surgical Approaches

One-third of patients with Crohn's disease (CD) present as stricturing phenotype characterized by progressive luminal narrowing and obstructive symptoms. The diagnosis and management of these patients have been intriguing and challenging. Immunomodulators and biologics have been successfully used in treating inflammatory and fistulizing CD. There are issues of efficacy and safety of biological agents in treating strictures in CD. Rapid mucosal healing from potent biological agents may predispose patients to the development of new strictures or worsening of existing strictures. On the other hand, strictures constitute one-fifth of the reasons for surgery in patients with CD. Disease recurrence is common at or proximal to the anastomotic site with the majority of these patients developing new endoscopic lesions within 1 year of surgery. The progressive nature of the disease with repetitive cycle of inflammation and stricture formation results in repeated surgery, with a risk of small bowel syndrome. There is considerable quest for bowel conserving endoscopic and surgical strategies. Endoscopic balloon dilation and stricturoplasty have emerged as valid alternatives to resection. Endoscopic balloon dilation has been shown to be feasible, safe, and effective for the short primary or anastomotic strictures. However, repeated dilations are often needed, and long-term outcomes of endoscopic balloon dilation remain to be investigated. The introduction of stricturoplasty has added another dimension to bowel saving strategy. Although postoperative recurrence rate after stricturoplasty is comparable with surgical resection, there are concerns for increased risk of malignancy in preserved bowel. Laparoscopic surgery has widely been performed with similar outcomes to open approach with fewer complications, quicker recovery, better cosmesis, and lower cost. All of these issues should be considered by physicians involved in the management of patients with stricturing CD.

The prognostic impact of perioperative blood transfusion on survival in patients with bladder urothelial carcinoma treated with radical cystectomy

PURPOSE

The aim of our study was to assess the influence of perioperative blood transfusion (PBT) on survival outcomes following radical cystectomy (RC) and pelvic lymph node dissection (PLND).

MATERIALS AND METHODS

We reviewed and analyzed the clinical data of 432 patients who underwent RC for bladder cancer from 1991 to 2012. PBT was defined as the transfusion of allogeneic red blood cells during RC or postoperative hospitalization.

RESULTS

Of all patients, 315 patients (72.9%) received PBT. On multivariate logistic regression analysis, female gender (p=0.015), a lower preoperative hemoglobin level (p=0.003), estimated blood loss>800 mL (p<0.001), and performance of neoadjuvant chemotherapy (p<0.001) were independent risk factors related to requiring perioperative transfusions. The receipt of PBT was associated with increased overall mortality (hazard ratio, 1.91; 95% confidence interval, 1.25-2.94; p=0.003) on univariate analysis, but its association was not confirmed by multivariate analysis (p=0.058). In transfused patients, a transfusion of >4 packed red blood cell units was an independent predictor of overall survival (p=0.007), but not in cancer specific survival.

CONCLUSIONS

Our study was not conclusive to detect a clear association between PBT and survival after RC. However, the efforts should be made to continue limiting the overuse of transfusion especially in patients who are expected to have a high probability of PBT, such as females and those with a low preoperative hemoglobin level and history of neoadjuvant chemotherapy.

The impact of perioperative blood transfusion on cancer recurrence and survival following radical cystectomy

BACKGROUND

While the receipt of a perioperative blood transfusion (PBT) has been associated with an increased risk of mortality for a number of malignancies, the relationship between PBT and survival following radical cystectomy (RC) for bladder cancer (BCa) has not been well established.

OBJECTIVE

To evaluate the association of PBT with disease recurrence and mortality following RC.

DESIGN, SETTING, AND PARTICIPANTS

We identified 2060 patients who underwent RC at the Mayo Clinic between 1980 and 2005. PBT was defined as transfusion of allogenic red blood cells during RC or postoperative hospitalization.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Survival was estimated using the Kaplan-Meier method and was compared with the log-rank test. Cox proportional hazard regression models were used to evaluate the association of PBT with outcome, controlling for clinicopathologic variables.

RESULTS AND LIMITATIONS

A total of 1279 patients (62%) received PBT. The median number of units transfused was 2 (interquartile range [IQR]: 2-4). Patients receiving PBT were significantly older (median: 69 yr vs 66 yr; p<0.0001), had a worse Eastern Cooperative Oncology Group performance status (p<0.0001), and were more likely to have muscle-invasive tumors (56% vs 49%; p = 0.004). Median postoperative follow-up was 10.9 yr (IQR: 7.9-15.7). Receipt of PBT was associated with significantly worse 5-yr recurrence-free survival (58% vs 64%; p = 0.01), cancer-specific survival (59% vs 72%; p<0.001), and overall survival (45% vs 63%; p<0.001). On multivariate analyses, PBT remained associated with significantly increased risks of postoperative tumor recurrence (hazard ratio [HR]: 1.20; p = 0.04), death from BCa (HR: 1.31; p = 0.003), and all-cause mortality (HR: 1.27; p = 0.0002). Among patients who received PBT, an increasing number of units transfused was independently associated with increased cancer-specific mortality (HR: 1.07; p<0.0001) and all-cause mortality (HR: 1.05; p<0.0001). Limitations include selection bias and lack of standardized transfusion criteria.

CONCLUSIONS

We found that PBT is associated with significantly increased risks of cancer recurrence and mortality following RC. While external validation is required, continued efforts to reduce the use of blood products in these patients are warranted.

The relationship between perioperative blood transfusion and overall mortality in patients undergoing radical cystectomy for bladder cancer

OBJECTIVES

The relationship between perioperative blood transfusion (PBT) and oncologic outcomes is controversial. In patients undergoing surgery for colon cancer and several other solid malignancies, PBT has been associated with an increased risk of mortality. Yet, the urologic literature has a paucity of data addressing this topic. We sought to evaluate whether PBT affects overall survival following radical cystectomy (RC) for patients with bladder cancer.

METHODS

The medical records of 777 consecutive patients undergoing RC for urothelial carcinoma of the bladder were reviewed. PBT was defined as transfusion of red blood cells during RC or within the postoperative hospitalization. The primary outcome was overall survival. Clinical and pathologic variables were compared using χ(2) tests, and Cox multivariate survival analyses were performed.

RESULTS

A total of 323 patients (41.6%) underwent PBT. In the univariate analysis, PBT was associated with increased overall mortality (HR 1.40, 95% CI 1.11-1.78). Additionally, an independent association was demonstrated in a non-transformed Cox regression model (HR, 95% CI 1.01-1.36) but not in a model utilizing restricted cubic splines (HR 1.03, 95% CI 0.77-1.38). The c-index was 0.78 for the first model and 0.79 for the second.

CONCLUSIONS

In a traditional multivariate model, mirroring those that have been applied to this question in the general surgery literature, we demonstrated an association between PBT and overall mortality after RC. However, this relationship is not observed in a second statistical model. Given the complex nature of adequately controlling for confounding factors in studies of PBT, a prospective study will be necessary to fully elucidate the independent risks associated with PBT.

Effects of blood transfusion with leucocyte depletion on length of hospital stay, respiratory assistance and survival after curative surgery for colorectal cancer

PURPOSE

To investigate effects of blood transfusion, with/without leucocyte depletion, on duration of hospital stay, need for respiratory support, mortality and long-term survival after curative surgery for colorectal cancer.

METHODS

The trial was a prospective, randomised, multicenter study. Six hundred and forty two patients with colorectal cancer were included. Blood transfusion was given when needed during and/or after operation, randomised to packed red blood cells (RBC) or leucocyte-depleted red blood cells (LDB) using leucocyte filtration. Assisted ventilation in ICU, hospital stay, malignant and nonmalignant specific mortality and overall survival were outcome measures.

RESULTS

The RBC group had higher need for assisted ventilation post-operatively (8.1% vs. 3.6%) and significantly higher proportion of patients with prolonged (> 20 days) hospital stay. After median follow-up time of 99.5 months there was no significant difference in mortality or long-term survival between the groups. The median cumulative survival time of 55 months in LDB vs. 36 months in RBC group did not reach significance level. Non-transfused patients had a significantly lower proportion of prolonged hospital stay, and significantly increased survival, compared to transfused patients.

CONCLUSION

Leucocyte depleted transfusions improved the postoperative course following surgery for colorectal cancer, compared with packed red blood cell transfusions.

The impact of perioperative blood transfusion on clinical outcomes in colorectal surgery

Colorectal cancer is the second-leading cause of cancer-related death in the US. The prognosis of advanced colorectal cancer remains poor in spite of the advances obtained in recent years with new therapeutic agents, new approaches in surgical procedures and new diagnostic methods. Currently, colorectal cancer is the second most common cancer in Europe both in terms of incidence and mortality. Approximately 90% of all cancer deaths arise from the metastatic dissemination of primary tumors. It is a matter of vital importance whether perioperative blood transfusion promotes tumor recurrence and morbidity. This paper reviews the relevant medical literature published in English language on the theoretical background, methodological problems, results, as well as the possible clinical impact of blood transfusions in colorectal surgery with well-controlled trials. Searches were last update August 2007.

Factors affecting recurrence after surgery for Crohn’s disease

Although in Crohn’s disease post-operative recurrence is common, the determinants of disease recurrence remain speculative. The aim of this study was to examine factors affecting post-operative recurrence of Crohn’s disease. A Medline-based literature review was carried out. The following factors were investigated: age at onset of disease, sex, family history of Crohn’s disease, smoking, duration of Crohn’s disease before surgery, prophylactic medical treatment (corticosteroids, 5-amino salicylic acid [5-ASA] and immunosuppressants), anatomical site of involvement, indication for surgery (perforating or non-perforating disease), length of resected bowel, anast-omotic technique, presence of granuloma in the specimen, involvement of disease at the resection margin, blood transfusions and post-operative complications. Smoking significantly increases the risk of recurrence (risk is approximately twice as high), especially in women and heavy smokers. Quitting smoking reduces the post-operative recurrence rate. A number of studies have shown a higher risk when the duration of the disease before surgery was short. There were, however, different definitions of ‘short’ among the studies. Prophylactic cortic-osteroids therapy is not effective in reducing the post-operative recurrence. A number of randomized controlled trials offered evidence of the efficacy of 5-ASA (mesalazine) in reducing post-operative recurrence. Recently, the thera-peutic efficacy of immunosuppressive drugs (azathioprine and 6-mercaptopurine) in the prevention of post-operative recurrence has been investigated and several studies have reported that these drugs might help prevent the recurrence. Further clinical trials would be necessary to evaluate the prophylactic efficacy of immunosuppressants. Several studies showed a higher recurrence rate in patients with perforating disease than in those with non-perforating disease. However, evidence for differing recurrence rates in perforating and non-perforating diseases is inconclusive. A number of retrospective studies reported that a stapled functional end-to-end anastomosis was associated with a lower recurrence rate compared with other types of anastomosis. However, prospective randomized studies would be necessary to draw a definite conclusion. Many studies found no difference in the recurrence rates between patients with radical resection and non-radical resection. Therefore, minimal surgery including strictureplasty has been justified in the management of Crohn’s disease. In this review, the following factors do not seem to be predictive of post-operative recurrence: age at onset of disease, sex, family history of Crohn’s disease, anatomical site of disease, length of resected bowel, presence of granuloma in the specimen, blood transfusions and post-operative complications. The most significant factor affecting post-operative recurrence of Crohn’s disease is smoking. Smoking significantly increases the risk of recurrence. A short disease duration before surgery seems, albeit to a very minor degree, to be associated with a higher recurrence rate. 5-ASA has been shown with some degree of confidence to lead to a lower recurrence rate. The prophylactic efficacy of immunosuppressive drugs should be assessed in future. A wider anastomotic technique after resection may reduce the post-operative recurrence rate, though this should be investigated with prospective randomized controlled trials.

[Perioperative transfusion in colorectal surgery]

Several studies have evaluated the role and effect of blood transfusion in colorectal surgery. To date, no recommendation concerning its use in colorectal surgery has been yet published. However, blood transfusion is often required in colorectal surgery, especially in anaemic patients who suffer from malignant disease. The aim of this review is to define the effect of blood transfusion on oncologic and operative results, and to evaluate the clinical potential of alternative to allogeneic blood transfusion in order to promote the development of transfusion policy in colorectal surgery.

Signs and symptoms associated with the transfusion of WBC-reduced RBCs and non-WBC-reduced RBCs in patients with anemia and HIV infection: results from the Viral Activation Transfusion Study

BACKGROUND

RBC transfusion is associated with fever and other reactions in some patients. The Viral Activation Transfusion Study randomly assigned patients to receive either unmodified or WBC-reduced RBCs and thus offered an opportunity to assess the effect of WBC-reduced RBCs on the incidence of transfusion reactions prospectively.

STUDY DESIGN AND METHODS

This prospective, randomized, double-blind, multicenter study compared prestorage WBC-reduced RBCs to unmodified RBCs in HIV-infected, CMV-seropositive, and transfusion-naive persons who required transfusions for anemia. Primary endpoints were survival and change in the plasma HIV RNA level at 7 days after transfusion. The incidence of transfusion reactions was prospectively evaluated.

RESULTS

The two groups had similar baseline characteristics and study endpoints; 3864 RBC units (median storage age, 9 days) were administered to 531 patients during 1745 transfusions. The most frequent signs reported were elevated temperature and hypotension. Subjects who reported fever within the week prior to transfusion were more likely to have an elevation in temperature associated with transfusion. The administration of RBCs that were less than 10 days old was associated with a marginal increase in the incidence of transfusion-associated temperature elevation among recipients of unmodified RBCs, but not among recipients of WBC-reduced RBCs. Caregivers reported fewer instances of both elevated temperature and hypotension than were identified by review of transfusion records.

CONCLUSIONS

The incidence of elevated temperature and hypotension associated with transfusion in this population was unexpectedly high. Use of WBC-reduced RBCs had no effect on the overall rates of elevated temperature or hypotension associated with transfusion of RBCs. The occurrence of a pre-existing fever was associated with a higher frequency of transfusion-associated elevated temperature.

Blood transfusions downregulate hematopoiesis and subsequently downregulate the immune response

BACKGROUND

Blood transfusions are associated with numerous clinical phenomena attributable to reduced posttransfusion immunocompetency. The exact mechanism by which blood transfusions induce a state of reduced immune responsiveness remains unclear.

STUDY DESIGN AND METHODS

The effect of a large-volume blood transfusion on the frequency and responsiveness of immune cells in lymphoid compartments was examined in normovolemic rats. The effects of syngeneic and allogeneic blood transfusions were compared.

RESULTS

The results in normovolemic rats were compared to those in nontransfused and saline-infused animals. In the normovolemic rats, there was a significant decrease in cells of erythroid lineage in bone marrow, with a slight increase in the percentage of cells in the bone marrow myeloid and lymphoid lineages; a significant increase in the percentage of the OX7+ Thy1+ cell population in bone marrow cells (stem cells are contained in this population) and blood cells; a decrease in the bone marrow OX6+ cell population (HLA class II-positive cells); a decrease in the responsiveness of blood, spleen, lymph node, and bone marrow cell populations to mitogens; and a downregulating effect of both syngeneic and allogeneic blood transfusions on hematopoiesis and cell responsiveness.

CONCLUSION

Massive whole blood transfusion, either syngeneic or allogeneic, constitutes a strong downregulating signal for hematopoiesis, affecting the erythroid, myeloid, and lymphoid cell lineages. It leads also to an attenuation of the responsiveness of hematopoietic tissues to mitogenic stimuli.

Blood transfusion and total joint replacement surgery: T helper 2 (TH2) cytokine secretion and clinical outcome

Surgery and blood transfusions have both been reported to cause decreases in various measures of cell-mediated immunity. A study of in vitro T helper lymphocyte type 2 (Th2) cytokine secretion after major joint replacement surgery was performed because these cytokines (IL4 and IL10) generally down-regulate cellular immune function. Th1 cytokines such as IL2 tend to up-regulate cellular immunity. Forty-three patients undergoing elective joint replacement surgery had pre- and multiple post-operative levels of IL2, IL4 and IL10 secretion measured and analysed with regard to demographic and clinical outcome data. Total joint replacement alone without allogeneic transfusions led to substantial increases in peak mean IL4 (2.1 times the pre-operative level) and IL10 secretion in vitro (4.3-fold) compared with much more modest increases in IL2 (1.36-fold) (P < 0.0001 for changes from baseline for each cytokine). In 14 patients who received allogeneic transfusions, these changes were greater than those in recipients of only autologous blood for IL4 (5.0-fold; P = 0.0036 vs. no allogeneic transfusion) and IL10 (15.7-fold; P = 0.079) but not for IL2 (1.38-fold; P = 0.38). The dramatic increase in Th2 cytokine secretion and minimal change in Th1 cytokine secretion after total joint replacement, with or without allogeneic transfusions, was seen regardless of type of anaesthetic, duration of surgery or whether knee or hip replacement occurred. These changes in cytokine patterns may contribute to the decreases in cellular immune function seen after surgery. Allogeneic transfusions but not autologous transfusions appear to exacerbate this immune deviation toward a T helper 2 (Th2) type response, and thus probably contribute to down-regulation of cellular immunity in the setting of joint replacement surgery.

Allogeneic versus autologous blood during abdominal aortic aneurysm surgery

OBJECTIVES

To determine if cell-salvaged autologous blood can serve as an alternative to homologous blood, and to examine the incidence of infected complications and length of postoperative stay.

DESIGN

A prospective randomised study comprising autologous and homologous blood transfusions in patients undergoing elective infrarenal abdominal aortic surgery.

METHODS

Fifty patients undergoing AAA surgery were prospectively randomised to homologous blood (n = 27), or autologous blood transfusion (n = 23), using a cell salvage autotransfusion device.

RESULTS

The haemoglobin at the time of hospital discharge was similar for both groups (11.0 vs. 10.8 g/dl) with no difference in perioperative mortality. The length of stay was reduced in those patients who received autologous blood (9 days vs. 12 days, p < 0.05 Mann-Whitney U test). There were four infected cases in the autologous group and 12 in the homologous group (p = n.s., Fisher's exact probability test). However, patients who received 3-4 units of homologous blood had an increased risk of infection compared to those who received a similar amount of autologous blood (50% vs. 0%).

CONCLUSIONS

Cell salvage autologous blood can safely replace, or at least decrease, exposure to homologous blood transfusion, with a reduction in the mean hospital stay.

Blood transfusion and bone allografts. Effect on infection and outcome

Intraoperative and postoperative blood replacement have been implicated in increased rates of wound infection, decreased rates of renal allograft transplant rejection, and increased rates of local recurrence and metastasis of certain kinds of tumors, all presumably on the basis of some alteration in the immune system. Because patients who have bone allograft surgery for tumors often require transfusion and because the procedure is associated with a high rate of failure (20%), infection (9%-10%), and local recurrence (10% for high grade tumors), the effect of transfusion (range, 0-4750 ml) was studied for 264 patients who had proximal humeral, proximal or distal femoral resections, and massive cadaveric allografts but who did not have adjuvant chemotherapy or radiation. An attempt was made to statistically correlate the tumor and allograft outcome and rate of infection with patient age and gender, anatomic site, diagnosis, stage, type of graft, number of subsequent procedures, surgical margins, perioperative transfusions, blood loss, duration of operative procedures, and number of pregnancies. Of the variables studied, only blood loss, transfusion, and duration of surgery had an effect on outcome and, more specifically, on infection rate and time to union. No effect was observed on metastasis, recurrence, or the ultimate outcome of the procedure.

Detrimental effects of perioperative blood transfusion

Evidence suggests that perioperative allogeneic blood transfusion increases the risk of infectious complications after major surgery and of cancer recurrence after curative operation. This has been attributed to immunosuppression. Several authors have suggested that filtered whole blood and/or red cell concentrate, or leucocyte- and buffy coat-reduced red cells in artificial medium or their own plasma, may reduce postoperative immunosuppression. It was also anticipated that the use of autologous blood might minimize the risk of perioperative transfusion, but studies have unexpectedly shown similar postoperative infectious complications and cancer recurrence and/or survival rates in patients receiving autologous blood donated before operation and those receiving allogeneic blood. Future studies should identify common risk factors associated with blood storage.

Changes in peripheral blood CD5 (Bla) B-cell populations and autoantibodies following blood transfusion

BACKGROUND

CD5 B cells and the natural autoantibodies they produce play a role in antigen presentation, tolerance induction, and maintenance of an idiotypic immune network. The effects of transfusion on autoantibodies and peripheral blood CD5 B cells were studied.

STUDY DESIGN AND METHODS

Eight previously transfused patients with sickle cell anemia and five patients who underwent orthopedic surgical procedures with transfusion were enrolled in the study. Patients in both groups received 1 to 2 units of allogeneic packed red cells. Ten untransfused healthy adults and five patients who underwent orthopedic surgery without transfusion were enrolled as controls. Peripheral blood CD5 B cells, serum levels of IgM, antinuclear antibodies, rheumatoid factor, and anticardiolipin IgM were quantitated either at the beginning of the study (baseline sample), before transfusion, or before surgery and either at 1-, 2-, 4-, 6-, and 8-week intervals after transfusion, after surgery, or after the baseline sample was obtained.

RESULTS

IgM levels and the absolute number of B cells that coexpressed CD5 rose to twice pretransfusion levels in six of eight transfused sickle cell anemia patients and in four of five transfused orthopedic surgery patients. No comparable increases in CD5 B cells were noted in untransfused controls. Preexisting rheumatoid factor and antinuclear antibody levels increased in four of five transfused orthopedic surgery patients. One sickle cell anemia patient developed anti-Fya despite receiving Fya-negative blood. Increasing titers of anti-Fya paralleled the increases in IgM and CD5 B cells after transfusion. One patient who developed a positive direct antiglobulin test after transfusion had large increases in serum anticardiolipin IgM. Anticardiolipin IgM was subsequently eluted from direct antiglobulin test-positive red cells obtained after transfusion. Antibodies with anti-Fya-like activity and anticardiolipin IgM were produced in vitro by CD5 B cells and not by conventional CD5-negative B cells.

CONCLUSION

An association was found between transfusion-induced increases in CD5 B cells and increased autoantibody production. These data may have implications for immunologic intervention to prevent the induction of red cell antibodies and other changes in the immune system caused by exposure to foreign antigens via blood transfusion.

Immunologic effects of blood transfusion

Blood transfusion is associated with numerous clinical phenomena attributable to immune suppression. Homologous blood transfusion is associated with declines in lymphocyte numbers and inhibition of lymphocyte function. In dialysis patients this immune suppression is accompanied by prolongation of survival of subsequently transplanted allografts. For patients undergoing surgical procedures, the receipt of homologous blood increases the risk of postoperative infectious complications. Patients with malignancies have significantly increased recurrence and mortality rates when removal of their tumor is accompanied by the administration of blood. The clinical course of Crohn's disease may be beneficially influenced by transfusion at the time of resection of diseased bowel. Women suffering recurrent abortion may carry to term following transfusion of spouse leukocytes. Experimental studies, in addition to replicating the clinical studies, have documented that transfusion inhibits wound healing. Blood transfusion, the oldest form of transplantation, causes profound and prolonged alterations in immune function which result in clinical phenomena which can be either beneficial or detrimental to the recipient.

The effect of previous blood transfusion on lymphocyte subsets and natural killer cell function in patients with colorectal cancer

To elucidate the possible influence of previous blood transfusion on immune functions, the transfusion history of 153 patients admitted to hospital for elective colorectal surgery was correlated with lymphocyte subsets and natural killer (NK) cell function. The subsets determined were CD2, CD3, CD4, CD8, CD16, CD20, CD56, CD57 and HLA-DR-positive. The NK cell function was determined by measuring the killing capacity against cFDA-labelled K562 target cells monitored via a flow-cytometer. We found that 42 patients (27%) had been transfused before surgery, of these 13 had been transfused less than 30 days before surgery and 29 (19%) transfused more than 30 days before (median 10 years, range 0.1-37 years). In transfused patients, we found a significantly reduced number of B lymphocytes (CD20; p = 0.01), a reduction in HLA-DR-positive cells (p = 0.02) and a just significant reduction of NK cell function in transfused compared to nontransfused patients. The reduction in NK cell function is marginal and the NK cell function is within normal range, and probably without clinical significance. Reduction in NK cell function has been described before, whereas the reduction in B cells has not been reported earlier. The results may suggest an impaired humoral immunity and a minor reduction in cellular immunity in patients following blood transfusion.

Improved survival from potentially lethal graft-vs.-host disease by donor pretreatment with a recipient-specific blood transfusion. I. Requirements for induction and specificity of the effect

Pretreatment of prospective donors of hemopoietic cells with a single recipient-specific blood transfusion can significantly decrease the morbidity and mortality of graft-vs.-host disease (GVHD) in lethally irradiated, allogeneically reconstituted mice. This beneficial effect of donor pretreatment could be demonstrated in donor-recipient strain combinations that were H-2 + non-H-2, H-2, or only class II-disparate, but not in the class I-disparate C57BL-B6.C-H-2bm1 strain combination. The effect was proportional to the amount of recipient-strain blood used for transfusion. Donor transfusion with a single dose of 1 ml recipient-specific whole blood resulted in minimum GVHD, lower doses being less or not effective. The interval between donor pretreatment and the use of their hemopoietic cells for reconstitution appeared to be important. The best survival was found at an interval of 4 days. Multiple transfusion was not more effective than a single one. We compared the effectiveness of whole blood and irradiated spleen cells for donor pretreatment. Both protocols have been shown previously to suppress anti-recipient delayed-type hypersensitivity. It appeared that the blood transfusion protocol was superior to the spleen cell protocol. The beneficial effect appeared to be recipient specific, since a third-party blood transfusion did not improve GVHD. We found that the beneficial effect of donor blood transfusion was due to suppression of the anti-host immune response. The donor blood transfusion was able to induce bystander suppression to alloantigens that were not used for the induction of suppression, provided they were co-expressed with the specific alloantigens by the recipients. This also indicates that, although the induction of suppression is specific, the ultimate suppressive effect is non-specific.

Effects of anaesthesia and surgery on the immune response

Alterations have been found to occur in every component of immune response during anaesthesia and surgery. These alterations represent the body's general physiological responses and are mainly dependent on the extent of surgery, as well as other factors such as the patient's age and health status, medication and blood transfusion. Anaesthetic and operative complications have profound effects on these responses. Basically, the immune response to anaesthesia and surgery is a beneficial reaction, needed in local host defences and wound healing and in preventing the body from making autoantibodies against its own tissues. The responses may, however, contribute to the development of postoperative infections and spread of malignant disease. During uncomplicated conventional surgery, the immune response usually passes clinically unnoticed without any harmful effects. Absent responses and excessively high responses, on the other hand, harm the patient. Our understanding of immunological phenomena and our possibilities of controlling mediator activation are now lagging behind the technical advances made in operative treatment. If we want to decrease operative morbidity and mortality to below their present levels, more attention should be directed to immune responses to major surgery, injuries and operative complications with massive mediator release which place the surgical patient at risk. Experimental evidence suggests that results of treatment in injured and operated patients can in the future be improved by controlling immune responses and their mediator systems. Our current level of knowledge of immune responses is already helping us to avoid many immune-mediated complications. However, routine interference with these responses is not indicated.

Blood transfusion and recurrent Crohn's disease

The effect of blood transfusion on the postoperative recurrence of Crohn's disease has been investigated. Clinical and pathological data from 197 patients treated by right hemicolectomy between 1947 and 1988 have been analysed. Symptomatic recurrences confirmed radiologically or histologically have been recorded and cumulative recurrence rates calculated for transfused and non-transfused patients. Perioperative blood transfusion does not influence the development of recurrent disease (log rank test, chi 2 = 0.112).

Recurrence of Crohn's disease after resection

Recurrent Crohn's disease develops in most patients after surgical resection if the patient is followed for sufficient time. This review examines various aspects of recurrent Crohn's disease. It is concluded that Crohn's disease is a diffuse condition of the gastrointestinal tract and that radical resection of Crohn's disease does not prevent recurrence. Assorted factors thought to be associated with recurrence are examined and the relevance of these factors to the surgeon treating Crohn's disease is discussed.

The effect of perioperative blood transfusion on recurrence after primary operation for Crohn's disease

The effect of perioperative blood transfusion on recurrence after primary operation was retrospectively studied in a group of 104 patients with Crohn's disease. Patients who had minor procedures like strictureplasty, segmental small-bowel resection, and operation for perianal fistula were excluded. Patients who had more extensive surgery were selected, to have an approximately equal distribution of blood transfusion in the different subgroups. Sixty-six female and 45 male patients were included; 65 patients had perioperative blood transfusion and 39 did not. Irrespective of blood transfusion it was confirmed that patients with small-bowel localization have a better prognosis than patients with combined or colonic localization. Patients who had resection of a specimen of less than 30 cm or more than 70 cm had a worse prognosis than the others. The reason for this observation is unclear. Except for patients with colonic localization only, blood transfusion was about equally distributed among patients with ileocaecal localization (19 of 36) and patients with ileal disease (17 of 34). Perioperative blood transfusion had no effect on disease recurrence, either for the whole group of transfused patients or for any of the subgroups, apart from those with colonic localization only. They had a significantly lower recurrence, as diagnosed before 60 months of follow-up. This is ascribed to the fact that these patients had large colonic resection with a lower chance of having active recurrent disease. In conclusion, we could not confirm the protective effects of blood transfusion on recurrence of Crohn's disease, as observed by others.

Transfusion-induced immunomodulation and its clinical consequences

The bulk of experimental and clinical data support the theory that homologous transfusion causes significant down-regulation of immunologic functions in a number of settings. These changes in immune function may account for the beneficial associations of transfusion with increased renal allograft survival, and decreased recurrence in Crohn's disease. Conversely, these transfusion-induced effects may be responsible in part for the deleterious association of homologous transfusion with increased cancer recurrence, and increased posttransfusion bacterial and viral infection rates. Host defenses against malignancy and infection may in some instances be severely compromised by transfusions of homologous blood, but the circumstances under which this occurs need to be better defined. Likewise, the hypothesis that modification of blood components to contain fewer leukocytes or less plasma might ameliorate these effects is attractive, but little or no data exist to support or refute it. Future clinical studies will no doubt address these issues.

Association of transfusion with postoperative bacterial infection

Homologous blood transfusion has been implicated as a modulator of the host immune system in a number of clinical settings. Improved renal allograft survival is observed in patients receiving pretransplant transfusions. Decreased recurrence of active inflammatory bowel disease has been recently reported in transfused patients with Crohn's disease. Conversely, deleterious immunomodulatory effects of transfusion may explain the association between transfusion and increased susceptibility to cancer recurrence and bacterial and viral infection. Clinical studies regarding cancer recurrence and transfusion are retrospective and conflicting. There is epidemiologic evidence for more rapid progression of HIV-1 infection in heavily transfused patients. Studies on transfused surgical patients have shown transfusion to be associated with an increased frequency of postoperative bacterial infections. Some studies have come to different conclusions. These investigators have suggested that transfusion may represent a surrogate marker for other risk factors for infection. Animal models designed to control for confounding factors have supported an association between transfusion and bacterial infection severity in most, but not all, reports. Attempts to define the immunologic alterations associated with transfusion have revealed a generalized impairment of cellular immunity in both humans and animals. Although the preponderance of data supports an association between perioperative transfusion and increased susceptibility to postoperative bacterial infection, it is not certain to what extent this relationship constitutes cause and effect.