The role of blood from HLA-homozygous donors in fatal transfusion-associated graft-versus-host disease after open-heart surgery

Evaluation of living donors for hereditary liver disease (siblings, heterozygotes)

Living donor liver transplantation (LDLT) is recognised as an alternative treatment modality to reduce waiting list mortality and expand the donor pool. Over recent decades, there have been an increasing number of reports on the use of LT and specifically LDLT for familial hereditary liver diseases. There are marginal indications and contraindications that should be considered for a living donor in paediatric parental LDLT. No mortality or morbidity related to recurrence of metabolic diseases has been observed with heterozygous donors, except for certain relevant cases, such as ornithine transcarbamylase deficiency, protein C deficiency, hypercholesterolemia, protoporphyria, and Alagille syndrome, while donor human leukocyte antigen homozygosity also poses a risk. It is not always essential to perform preoperative genetic assays for possible heterozygous carriers; however, genetic and enzymatic assays must hereafter be included in the parental donor selection criteria in the aforementioned circumstances.

Graft-versus-host disease after pediatric liver transplantation: A diagnostic challenge

BACKGROUND

Graft-versus-host disease (GVHD) is a rare but serious complication after pediatric liver transplantation (LTx). Early diagnosis is difficult due to nonspecific presenting symptoms and non-pathognomonic skin histopathological features. The aim of this article was to describe a case of pediatric GVHD after LTx and to review available data on pediatric GVHD highlighting the diagnostic difficulty. We also propose a diagnostic algorithm to improve the diagnostic capability and increase clinical awareness about this potentially fatal condition.

METHODS

We did a comprehensive literatures review on studies on GvHD following pediatric LTx between 1990 and February 2021, chimerism study by short tandem repeat (STR), HLA typing by sequence-specific oligonucleotide (SSO) method, and flowcytometry crossmatch.

RESULTS

Our search yielded 23 case reports. The most common clinical manifestations were fever and rash (91%) followed by diarrhea. Mortality rate was 36.8% mainly due to sepsis and organ failure. Diagnosis was challenging and chimerism study to confirm donor engraftment was performed on only half of the cases. Prevalence of "donor dominant HLA one-way matching" typically occurs in homozygous parents-to-child transplantation was 75% in cases with HLA testing.

CONCLUSION

So far, there are no available standard diagnostic criteria for GVHD following pediatric LTx. Recognition of multiple risk factors through proper laboratory assessment can predict the occurrence, and early chimerism study can confirm suggestive clinical manifestation. The strong likelihood of developing GVHD in "donor one-way HLA match" and the severe problems imposed by this complication may justify avoidance of HLA homozygous parent's donation.

Transfusion Reactions and Adverse Events

Blood transfusions are generally safe but can carry considerable risks. This review summarizes the different types of transfusion reactions and ways to diagnose and manage them. Symptoms are often overlapping and nonspecific. When a reaction is suspected, it is critical to stop the transfusion immediately and report the reaction to the blood bank, as this can affect the patient's outcome. New evidence-based algorithms of transfusion, newer blood screening methods and donor policies and deferrals, new laboratory testing, electronic verification systems, and improved hemovigilance lead to the avoidance of unnecessary transfusions and decrease the incidence of serious transfusion reactions.

Recommendations on Selection and Processing of RBC Components for Pediatric Patients From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative

OBJECTIVES

To present the recommendations and supporting literature for selection and processing of RBC products in critically ill children developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.

DESIGN

Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children METHODS:: The panel of 38 experts developed evidence-based, and when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The RBC processing subgroup included five experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.

RESULTS

Five recommendations reached agreement (> 80%). Irradiated cellular products are recommended for children at risk of transfusion-associated graft versus host disease due to severe congenital or acquired causes of immune deficiency or when the blood donor is a blood relative. Washed cellular blood components and avoidance of other plasma-containing products are recommended for critically ill children with history of severe allergic reactions or anaphylaxis to blood transfusions, although patient factors appear to be important in the pathogenesis of reactions. For children with history of severe allergic transfusion reactions, evaluation for allergic stigmata prior to transfusion is recommended. In children with severe immunoglobulin A deficiency with evidence of antiimmunoglobulin A antibodies and/or a history of a severe transfusion reaction, immunoglobulin A-deficient blood components obtained either from an immunoglobulin A-deficient donor and/or washed cellular components is recommended.

CONCLUSIONS

The Transfusion and Anemia Expertise Initiative consensus conference developed recommendations for selection and processing of RBC units for critically ill children. Recommendations in this area are largely based on pediatric and adult case report data.

Prevention of Transfusion-Associated Graft-Versus-Host Disease With Blood Product Irradiation: The Past, Present, and Future

Transfusion-associated graft-versus-host disease (TA-GVHD) is a disease with a very high mortality rate. In this report, we discuss TA-GVHD from a historical perspective, highlight the pathogenesis of TA-GVHD, and emphasize the importance of blood product irradiation, which is a very effective means to prevent this disease. We summarize the current recommendations in different patient populations from different countries and review recent developments, such as alternatives for the use of radioactive materials. We also speculate on future directions.

Medical missions for the provision of paediatric cardiac surgery in low- and middle-income countries

This review will outline the role of visiting cardiac surgical teams in low- and middle-income countries drawing on the collective experience of the authors in a wide range of locations. Requests for assistance can emerge from local programmes at a beginner or advanced stage. However, in all circumstances, careful pre-trip planning is necessary in conjunction with clinical and non-clinical local partners. The clinical evaluation, surgical procedures, and postoperative care all serve as a template for collaboration and education between the visiting and local teams in every aspect of care. Education focusses on both common and patient-specific issues. Case selection must appropriately balance the clinical priorities, safety, and educational objectives within the time constraints of trip duration. Considerable communication and practical challenges will present, and clinicians may need to make significant adjustments to their usual practice in order to function effectively in a resource-limited, unfamiliar, and multilingual environment. The effectiveness of visiting trips should be measured and constantly evaluated. Local and visiting teams should use data-driven evaluations of measurable outcomes and critical qualitative evaluation to repeatedly re-assess their interim goals. Progress invariably takes several years to achieve the final goal: an autonomous self-governing, self-financed, cardiac programme capable of providing care for children with complex CHD. This outcome is consistent with redundancy for the visiting trips model at the site, although fraternal, professional, and academic links will invariably remain for many years.

Survey of Irradiation Practice for the Prevention of Transfusion-Associated Graft-versus-Host Disease

Context.—Transfusion-associated graft-versus-host disease is a rare, often fatal complication of cellular blood product transfusion. The requirement that at-risk groups receive irradiated products reduces the incidence of transfusion-associated graft-versus-host disease. A comprehensive survey of irradiation practices has not been performed since 1989; meanwhile, new indications for irradiation have emerged.

Objective.—To assess current irradiation practices at College of American Pathologists member institutions. Changes in irradiation practice indicated by comparing results of a survey of irradiation practices in 1989 with those of a survey performed in 2014 may reveal how the field has developed and what areas (if any) remain to be improved.

Design.—A supplemental College of American Pathologists survey was sent out with questions regarding irradiation practices for specific conditions and circumstances. The questions included conditions for which irradiation is generally considered required for the prevention of transfusion-associated graft-versus-host disease as well as those not considered to be a special risk.

Results.—An average of 2100 organizations responded to each question regarding their irradiation practices. Irradiation for transfusion from blood relatives, human leukocyte antigen–matched products, preterm infants, and Hodgkin disease were the most common indications cited. A few organizations had universal irradiation, whereas others irradiated products by floor/unit or by service.

Conclusions.—For some at-risk populations irradiation of cellular blood products is more common than in 1989, whereas for others this practice has been reduced. Although gains have been made since the last national survey of irradiation practices, work remains to eliminate the possibility of transfusion-associated graft-versus-host disease from known at-risk populations.

Fatal Graft-Versus-Host Disease Following Adult-To-Adult Living Donor Liver Transplantation From an HLA Nonhomozygous Donor

The use of a human leukocyte antigen (HLA) homozygous donor to a haploidentical recipient is a well-documented cause of transfusion-associated graft-versus-host disease (GVHD). Several authors have reported that use of a graft from an HLA-homozygous donor with 1-way donor-recipient HLA matching led to an extremely high risk of developing GVHD in LDLT. We have experienced a fatal case of acute GVHD following adult-to-adult LDLT from a donor who was heterozygous at a single HLA locus. A 53-year-old female underwent LDLT for chronic hepatitis B and recurrent hepatocellular carcinoma. The donor was her 23-year-old son. The HLA phenotype of the donor was not homozygous (A24, -; B54, -; DR4, 9) and revealed one-way donor-dominant HLA matching at two loci with the recipient (A2, 24; B48, 54; DR4, 12). On the fortieth postoperative day, the patient showed erythematous skin lesions. Skin biopsy revealed typical findings of GVHD. Donor-derived chimerism was demonstrated by performing fluorescent in situ hybridization (FISH) using the recipient's skin tissue. As the clinical course deteriorated, etanercept was started in addition to broad-spectrum antibiotics but there was no improvement. As multi-organ failure progressed, the patient succumbed to death on the 54th postoperative day, which was 2 weeks after onset of GVHD. The prevention of GVHD is more important since the results of treatment have been disappointing. We have experienced a fatal case of acute GVHD following adult-to-adult LDLT from a HLA non-homozygous donor. HLA heterozygosity at a single locus does not preclude the possibility of developing GVHD following adult-to-adult LDLT.

Graft-versus-host disease in paediatric solid organ transplantation: A review of the literature

GvHD is a rare and serious complication of organ transplantation. The literature is sparse following solid organ transplantation. The aim of this report was to review the literature of GvHD in paediatric solid organ transplantation. We searched PubMed for English-language full-text manuscripts between 1990 and 2015 for eligible studies. A total of 28 publications were found pertaining to paediatric GvHD following solid organ transplantation. GvHD had a mean incidence of 11% (range 8.3-13.4%) following SBTx and 1.5% following liver transplantation. Where described, the most common sites for presentation of GvHD were the skin (87%), the native GI tract (43%), the lungs (7%), the eyes (4%), HA (4%), and the kidneys (1%). Diagnosis was confirmed with biopsy (93%) and/or chimerism (41%). Treatments used include steroids (80%), of which 75% showed partial or complete resolution. Mortality was 33.3% (range 0-100%). Novel therapies include ECP and MSC therapy. GvHD is a rare but serious disease with high mortality. Novel therapies may offer hope in the future, but currently there is limited evidence for their efficacy in the context of intestinal or liver transplantation.

Lichenoid Variant of Chronic Cutaneous Graft Versus Host Reaction Post Blood Transfusion: A Rare Event Post Blood Transfusion

Chronic graft versus host disease (GVHD) is a less frequently seen disease that occurs post solid organ or bone marrow transplantation. Chronic GVHD occurring post blood transfusion is an even more uncommon disease. It can present either as a lichenoid disease or as a sclerodermatous disease involving multiple systems. In this article, we report a case of chronic graft versus host reaction occurring in skin secondary to blood transfusion.

Transfusion indications for patients with cancer

BACKGROUND

During the last few years, considerable focus has been given to the management of anemia and coagulopathies. This article provides current concepts of red blood cell (RBC) and plasma coagulation factor replacements.

METHODS

The literature was reviewed for clinical studies relevant to RBC transfusion indications and outcomes as well as for the uses of coagulation factor replacement products for coagulopathies most likely encountered in patients with cancer.

RESULTS

Most patients without complications can be treated with a hemoglobin level of 7 g/dL as an indication for RBC transfusion. However, the effects of disease among patients with cancer may cause fatigue, so transfusions at higher hemoglobin levels may be clinically helpful. Leukoreduced RBCs are recommended as standard therapy for all patients with cancer, most of whom do not develop coagulopathy. Transfusions to correct mild abnormalities are not indicated in this patient population. Data are inconclusive regarding the value of coagulation factor replacement for invasive procedures when the international normalized ratio is below 2.

CONCLUSIONS

Indications for RBC transfusion have become more conservative as data and experience have shown that patients can be safely and effectively maintained at lower hemoglobin levels. Coagulation factor replacement is unnecessary for most modest coagulopathies.

A systematic review of transfusion-associated graft-versus-host disease

Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare complication of blood transfusion. The clinicolaboratory features of TA-GVHD and the relative contributions of recipient and component factors remain poorly understood. We conducted a systematic review of TA-GVHD reports. The HLA relationship between donor and recipient was classified as D = 0 when no donor antigens were foreign to the recipient vs D ≥ 1 when ≥1 donor antigen disparity occurred. We identified 348 unique cases. Criteria for component irradiation were met in 48.9% of cases (34.5% immune-compromised, 14.4% related-donor), although nonirradiated components were transfused in the vast majority of these (97.6%). Components were typically whole blood and red cells. When reported, component storage duration was ≤10 days in 94%, and 23 (6.6%) were leukoreduced (10 bedside, 2 prestorage, and 11 unknown). Among 84 cases with HLA data available, the category of D = 0 was present in 60 patients (71%) at either HLA class I or II loci and was more common among recipients without traditional indications for component irradiation. These data challenge the historic emphasis on host immune defects in the pathogenesis of TA-GVHD. The dominant mechanism of TA-GVHD in both immunocompetent and compromised hosts is exposure to viable donor lymphocytes not recognized as foreign by, but able to respond against, the recipient.

Prevention of transfusion-associated graft-versus-host disease by irradiation: technical aspect of a new ferrous sulphate dosimetric system

Irradiation of whole blood and blood components before transfusion is currently the only accepted method to prevent Transfusion-Associated Graft-Versus-Host-Disease (TA-GVHD). However, choosing the appropriate technique to determine the dosimetric parameters associated with blood irradiation remains an issue. We propose a dosimetric system based on the standard Fricke Xylenol Gel (FXG) dosimeter and an appropriate phantom. The modified dosimeter was previously calibrated using a ⁶⁰Co teletherapy unit and its validation was accomplished with a ¹³⁷Cs blood irradiator. An ionization chamber, standard FXG, radiochromic film and thermoluminescent dosimeters (TLDs) were used as reference dosimeters to determine the dose response and dose rate of the ⁶⁰Co unit. The dose distributions in a blood irradiator were determined with the modified FXG, the radiochromic film, and measurements by TLD dosimeters. A linear response for absorbed doses up to 54 Gy was obtained with our system. Additionally, the dose rate uncertainties carried out with gel dosimetry were lower than 5% and differences lower than 4% were noted when the absorbed dose responses were compared with ionization chamber, film and TLDs.

Impact of sex, MHC, and age of recipients on the therapeutic effect of transferred leukocytes from cancer-resistant SR/CR mice

Background

Spontaneous Regression/Complete Resistant (SR/CR) mice are resistant to cancer through a mechanism that is mediated entirely by leukocytes of innate immunity. Transfer of leukocytes from SR/CR mice can confer cancer resistance in wild-type (WT) recipients in both preventative and therapeutic settings. In the current studies, we investigated factors that may impact the efficacy and functionality of SR/CR donor leukocytes in recipients.

Results

In sex-mismatched transfers, functionality of female donor leukocytes was not affected in male recipients. In contrast, male donor leukocytes were greatly affected in the female recipients. In MHC-mismatches, recipients of different MHC backgrounds, or mice of different strains, showed a greater negative impact on donor leukocytes than sex-mismatches. The negative effects of sex-mismatch and MHC-mismatch on donor leukocytes were additive. Old donor leukocytes performed worse than young donor leukocytes in all settings including in young recipients. Young recipients were not able to revive the declining function of old donor leukocytes. However, the function of young donor leukocytes declined gradually in old recipients, suggesting that an aged environment may contain factors that are deleterious to cellular functions. The irradiation of donor leukocytes prior to transfers had a profound suppressive effect on donor leukocyte functions, possibly as a result of impaired transcription. The cryopreserving of donor leukocytes in liquid nitrogen had no apparent effect on donor leukocyte functions, except for a small loss of cell number after revival from freezing.

Conclusion

Despite the functional suppression of donor leukocytes in sex- and MHC-mismatched recipients, as well as old recipients, there was a therapeutic time period during the initial few weeks during which donor leukocytes were functional before their eventual rejection or functional decline. The eventual rejection of donor leukocytes will likely prevent donor leukocyte engraftment which would help minimize the risk of transfusion-associated graft-versus-host disease. Therefore, using leukocytes from healthy donors with high anti-cancer activity may be a feasible therapeutic concept for treating malignant diseases.

Noninfectious serious hazards of transfusion

As infectious complications from blood transfusion have decreased because of improved donor questionnaires and sophisticated infectious disease blood screening, noninfectious serious hazards of transfusion (NISHOTs) have emerged as the most common complications of transfusion. The category of NISHOTs is very broad, including everything from well-described and categorized transfusion reactions (hemolytic, febrile, septic, and allergic/urticarial/anaphylactic) to lesser known complications. These include mistransfusion, transfusion-related acute lung injury, transfusion-associated circulatory overload, posttransfusion purpura, transfusion-associated graft versus host disease, microchimerism, transfusion-related immunomodulation, alloimmunization, metabolic derangements, coagulopathic complications of massive transfusion, complications from red cell storage lesions, complications from over or undertransfusion, and iron overload. In recent years, NISHOTs have attracted more attention than ever before, both in the lay press and in the scientific community. As the list of potential complications from blood transfusion grows, investigators have focused on the morbidity and mortality of liberal versus restrictive red blood cell transfusion, as well as the potential dangers of transfusing "older" versus "younger" blood. In this article, we review NISHOTs, focusing on the most recent concerns and literature.

Donor T-cell-mediated pancytopenia after haploidentical hematopoietic stem cell transplant for severe combined immunodeficiency

Haploidentical hematopoietic stem cell transplant with T-cell depletion may result in donor T-cell engraftment in infants with severe combined immunodeficiency disease. Engraftment of other hematopoietic lines is achieved rarely, and pancytopenia and hemophagocytosis as a result of donor T-cell engraftment have not been reported. We report an infant with severe combined immunodeficiency who developed graft versus host disease with pancytopenia as a result of engraftment of maternal T cells after T-depleted hematopoietic stem cell transplant. His pancytopenia resolved after thymoglobulin and a stem cell boost. Thrombocytopenia resolved with rituximab.

Quality control of blood irradiation with a teletherapy unit: damage to stored red blood cells after cobalt-60 gamma irradiation

BACKGROUND

Previous publications have documented the damage caused to red blood cells (RBCs) irradiated with X-rays produced by a linear accelerator and with gamma rays derived from a 137Cs source. The biologic effects on RBCs of gamma rays from a 60Co source, however, have not been characterized.

STUDY DESIGN AND METHODS

This study investigated the effect of 3000 and 4000 cGy on the in vitro properties of RBCs preserved with preservative solution and irradiated with a cobalt teletherapy unit. A thermal device equipped with a data acquisition system was used to maintain and monitor the blood temperature during irradiation. The device was rotated at 2 r.p.m. in the irradiation beam by means of an automated system. The spatial distribution of the absorbed dose over the irradiated volume was obtained with phantom and thermoluminescent dosimeters (TLDs). Levels of Hb, K+, and Cl(-) were assessed by spectrophotometric techniques over a period of 45 days. The change in the topology of the RBC membrane was investigated by flow cytometry.

RESULTS

Irradiation caused significant changes in the extracellular levels of K+ and Hb and in the organizational structure of the phospholipid bilayer of the RBC membrane. Blood temperature ranged from 2 to 4 degrees C during irradiation. Rotation at 2 r.p.m. distributed the dose homogeneously (92%-104%) and did not damage the RBCs.

CONCLUSIONS

The method used to store the blood bags during irradiation guaranteed that all damage caused to the cells was exclusively due to the action of radiation at the doses applied. It was demonstrated that prolonged storage of 60Co-irradiated RBCs results in loss of membrane phospholipids asymmetry, exposing phosphatidylserine (PS) on the cells' surface with a time and dose dependence, which can reduce the in vivo recovery of these cells. A time- and dose-dependence effect on the extracellular K+ and plasma-free Hb levels was also observed. The magnitude of all these effects, however, seems not to be clinically important and can support the storage of irradiated RBC units for at last 28 days.

Quality control of blood irradiation: determination T cells radiosensitivity to cobalt-60 gamma rays

BACKGROUND

To identify the most appropriate dose for the prevention of transfusion-associated graft-versus-host disease, the radiosensitivity of T cells has been determined in blood bags irradiated with X-rays produced by a linear accelerator and gamma rays derived from the cesium-137 source of a specific irradiator. In this study, the influence of doses ranging from 500 to 2500 cGy was investigated on T cells isolated from red blood cell (RBC) units preserved with ADSOL and irradiated with a cobalt teletherapy unit.

STUDY DESIGN AND METHODS

A thermal device consisting of acrylic and foam was constructed to store the blood bags during irradiation. Blood temperature was monitored with an automated data acquisition system. Dose distribution in the blood bags was analyzed based on isodose curves obtained with a polystyrene phantom constructed for this purpose. The influence of cobalt-60 gamma radiation on T cells was determined by limiting-dilution analysis, which measures clonable T cells. T-cell content of the mononuclear cell population plated was assessed by flow cytometry with a monoclonal antibody specific for CD3.

RESULTS

Blood temperature ranged from 2 to 4.5 degrees C during irradiation. Dosimetry performed on the phantom showed a homogenous dose distribution when the phantom was irradiated with a parallel-opposite field. A radiation dose of 1500 cGy led to the inactivation of T cells by 4 log, but T-cell growth was observed in all experiments. At 2500 cGy, no T-cell growth was detected in any of the experiments and a greater than 5 log reduction in functional T cells was noted.

CONCLUSION

The results showed that a dose of 2500 cGy completely inactivates T cells in RBC units irradiated with cobalt-60 source.

Fatal graft-versus-host disease after living donor liver transplantation: differential impact of donor-dominant one-way HLA matching

Graft-versus-host disease (GVHD) is an uncommon but potentially devastating complication following liver transplantation. Recently, it was shown that use of a human leukocyte antigen (HLA)-homozygous donor leading to one-way HLA matching significantly increases the risk of GVHD after living donor liver transplantation (LDLT). However, the precise impact of HLA matching between donor and recipient on the risk of GVHD is not yet clear. We surveyed instances of fatal GVHD following LDLT in Japan and reviewed all 8 cases in detail, especially with respect to HLA matching. Serological typing showed that 7 of those cases had donor-dominant one-way HLA matching in the 3 loci of HLA-A, -B, and -DR, while one had donor-dominant one-way HLA matching in the 2 loci of HLA-A and -DR and identical alleles in the B locus. However, DNA typing revealed that the latter case had 1-way HLA matching in the 3 loci. Further, we analyzed HLA typing of 906 donor-recipient pairs who underwent LDLT. There were 5 cases with donor-dominant one-way matching in 2 loci and 2 with donor-dominant one-way matching in 1 locus. All of those cases except 1, who died from an unrelated cause, are alive without an obvious presentation of GVHD. In conclusion, our results suggest that the total number of loci with donor-dominant one-way HLA matching is important for determining the risk of fatal GVHD following LDLT, and that DNA typing of HLA alleles is indispensable in some cases to identify the true risk of donor-dominant 1-way HLA matching.

Identifying Patients at Risk of Intraoperative and Postoperative Transfusion in Isolated CABG: Toward Selective Conservation Strategies

BACKGROUND

Allogeneic blood product use during cardiac operation is often reported to exceed 40% despite published guidelines and costly blood conservation strategies. We developed a predictive model, based on eight preoperative risk factors, of allogeneic blood product transfusion rates in patients undergoing a cardiac procedure.

METHODS

All 3,046 consecutive, isolated coronary artery bypass graft (CABG) procedures at a university hospital from 1995 to 1998 were included. A logistic regression model was created to identify independent predictors of allogeneic blood product transfusion. This model was validated using a prospective patient sample.

RESULTS

Overall use of allogeneic blood products was 23% with a crude operative mortality of 2.1%. In isolated, elective, first-time CABG cases, 16.9% received allogeneic blood products. Independent predictors of blood product usage in CABG patients were preoperative hemoglobin 12.0 or less, emergent operation, renal failure, female sex, age 70 years or older, left ventricular ejection fraction 0.40 or less, redo procedure, and low body surface area. Prospective validation of this model on 2,117 consecutive isolated CABG patients demonstrated an observed-to-expected allogeneic blood product transfusion rate ratio of 1.06.

CONCLUSIONS

This internally validated logistic regression risk model is a sensitive and specific predictor of allogeneic blood product use in patients undergoing isolated CABG. Utilization of this model allows for preoperative risk stratification and may allow for more rational resource allocation of costly blood conservation strategies and blood bank resources.

Graft-versus-host disease following living donor liver transplantation

Graft-versus-host disease (GVHD) is the most common and well-known cause of morbidity and mortality following allogeneic bone marrow transplantation. Sporadic cases have been reported after cadaveric donor liver transplantation with usually fatal outcomes, however, the actual incidence and the characteristics of GVHD after living donor liver transplantation (LDLT) remain unknown. We herein report a person who developed fatal GVHD following LDLT and discuss the applicability of an HLA-homozygous donor to an HLA-haploidentical recipient. A 48-year-old male underwent LDLT for unresectable hepatocellular carcinoma with alcoholic liver cirrhosis. The donor was his 20-year-old son whose pretransplant HLA typing was homozygous at all loci. GVHD occurred 35 days after LDLT and was characterized by fever, diarrhea, maculopapular rash, and leukopenia, which led to the development of fatal pneumonia. We identified 4 cases of GVHD after LDLT in Japan and 1 in the United States, all associated with the use of an HLA-homozygous donor. The use of an HLA homozygous donor which results in a complete 1-way donor-recipient HLA match carries an extremely high risk of developing GVHD after LDLT. Therefore, it is possible that LDLT should be ruled out for such donors. A pretransplant work-up of the HLA type in both the donors and recipients is therefore imperative before determining the indications for LDLT.

Quality control system for blood irradiation using a teletherapy unit

BACKGROUND AND OBJECTIVES

Irradiation of whole blood and blood components before transfusion is currently the only accepted methodology to prevent transfusion-associated graft-vs.-host disease. In the present work, we developed an automated system for blood bag storage during irradiation, using a teletherapy unit.

MATERIALS AND METHODS

A device with two thermal compartments was constructed in acrylic and foam, for the storage of blood bags during irradiation. An automatic acquisition system, coupled with an amplifier and a thermal-sensitive probe, were developed to check blood temperature during irradiation. A polystyrene phantom was constructed to simulate the volume of blood routinely irradiated. The dose distribution was measured in the phantom using thermoluminescent dosimeters and represented in terms of isodose curves.

RESULTS

The thermal device kept the blood temperature below 6 degrees C for more than 2 h. Our system allowed the simultaneous irradiation of two different blood components while maintaining a constant temperature. The temperature monitoring system remained invariant (0.2 degrees C) over the whole irradiation interval. Phantom dosimetric results showed a homogeneous dose distribution when the phantom was irradiated, using rotational fields with a 2 r.p.m. frequency.

CONCLUSIONS

The methodology developed in the present work provides appropriate storage conditions during irradiation of both red blood cells and platelet blood components using a teletherapy unit.

Unusual onset of chronic graft-versus-host disease after adult living-related liver transplantation from a homozygous donor

Graft-versus-host disease (GVHD) is a rare complication that occurs after living-related liver transplantation (LRLT). This condition usually occurs early after transplantation and is fatal. Although one-way matching between a human leukocyte antigen (HLA)-homozygous donor and a haploidentical recipient has been shown to be a significant risk factor for the development of acute GVHD, chronic GVHD has not been clarified. A 50-year-old woman underwent LRLT for primary biliary cirrhosis with her 32-year-old HLA-homozygous son as the donor. The patient developed chronic GVHD 114 days posttransplant, presenting with a skin rash only. Her atypical onset included neither fever nor gastrointestinal symptoms. The patient responded to corticosteroid therapy and is now doing well at home. Careful donor selection and HLA matching before LRLT should be performed to prevent GVHD. However, the risks associated with grafts from homozygous donors may be unavoidable at present because of the shortage of cadaveric donors in Japan.

21. Immunohematologic disorders

Immunohematologic disorders are a broad group of entities in which hematologic diseases, usually cytopenias, are caused by immune reactions. These reactions lead to the development of hemolytic anemia, thrombocytopenia, or neutropenia, either separately or in combination. Common underlying mechanisms include immunodeficiency, systemic autoimmunity, and drug-induced reactions. Transplacental transfer of maternal alloantibodies can lead to fetal and neonatal cytopenias. Other immune reactions include antibodies to clotting factors, which result in both thrombosis and hemorrhage, and hemolytic and nonhemolytic reactions during transfusion of blood products.

From the simple detection of microchimerism in patients with autoimmune diseases to its implication in pathogenesis

Long-term persistence of fetal cells in parous women (fetal microchimerism, FM) as well as maternal cells in their offspring (maternal microchimerism, MM) have been reported. Systemic sclerosis (SSc), primary biliary cirrhosis (PBC), and Sjögren's syndrome (SS) share similar epidemiology with a predilection for females following childbearing years, with clinical similarities to chronic graft-versus-host disease, a known condition of chimerism. This led to the hypothesis that FM could be involved in the pathogenesis of autoimmune diseases. Initial investigations were conducted in SSc, where the hypothesis was supported by the more frequent occurrence and, quantitatively, a greater degree of FM in women with SSc compared to matched healthy women. Long-term persistence, however, of fetal cells in healthy women indicates that FM per se is not sufficient for causing SSc, but may be important in the context of other risk factors, such as genetic susceptibility and HLA relationship among host and nonhost cells. Contradictory results have recently been published for both PBC and SS and cause difficulty in drawing any conclusions about the role of FM in their pathogenesis. On the other hand, MM has been investigated as a risk factor in patients with systemic lupus (SLE) and juvenile dermatomyositis (JDM). A potential role of MM has been suggested in the pathogenesis of SLE. Recent publications also support the hypothesis that MM might lead to increased risks for JDM. In conclusion, contradictory results have been observed. This reflects a need for standardization of protocols and the selection of control populations. Detection of microchimerism has to be quantitatively studied in the context of genetic factors in order to study its relationship to the pathogenesis of autoimmune diseases.

Directed blood donation in pediatric general surgery: Is it worth it?

PURPOSE

To date, there are no data to support the safety, efficacy, and cost-benefit ratio of donor-directed blood donation (DD). The objectives were to determine whether a DD program in pediatric general surgery practice is justified.

METHODS

A retrospective analysis was conducted of the transfusion practice and all DD requests received by transfusion services in a full calendar year (1997) at a tertiary care pediatric hospital. The authors examined the donations, utilization, and possible benefits for the recipients.

RESULTS

A total of 22,527 units of blood were transfused in 1997. General surgery used 471 (2%) of the total and 471 of 4,825 (10%) of all surgical transfusions. Total DD requests were 219 with only 11 of 219 (5%) originating from the general surgery department. After all the exclusions, 133 of 219 (61%) requests had DD blood available. DD blood had a higher true-positive rate for transmissible disease (1.1% v 0.10%), high-risk activity (2.5% v 1.2%), and malaria risk (3.1% v 0.31%). Total utilization of DD blood was 132 of 236 units (55.9%) and general surgery utilized 4 of 11 (36.4%) of their directed donations. Thirty-seven patients (27.8%) benefited from decreased donor exposure. No general surgery patient received more than 1 blood component to benefit from decreased donor exposure.

CONCLUSIONS

DD deferral rates are higher than for volunteer donors for infectious disease markers, malaria, and high-risk activities. There is no evidence that DD is safer than volunteer donation. DD blood wastage of 63.6% is much higher than in volunteer donation (7%). Thirty-seven patients (28%) received multiple units from one donor suggesting a benefit from decreased donor exposure. Given the low frequency of transfusion and the poor utilization of DD in general surgical practice, a DD program is not justified.

Full hematopoietic engraftment after allogeneic bone marrow transplantation without cytoreduction in a child with severe combined immunodeficiency

Bone marrow transplantation (BMT) for severe combined immunodeficiency (SCID) with human leukocyte antigen (HLA)-identical sibling donors but no pretransplantation cytoreduction results in T-lymphocyte engraftment and correction of immune dysfunction but not in full hematopoietic engraftment. A case of a 17-month-old girl with adenosine deaminase (ADA) deficiency SCID in whom full hematopoietic engraftment developed after BMT from her HLA-identical sister is reported. No myeloablative or immunosuppressive therapy or graft-versus-host disease (GVHD) prophylaxis was given. Mild acute and chronic GVHD developed, her B- and T-cell functions became reconstituted, and she is well almost 11 years after BMT. After BMT, repeated studies demonstrated: (1) Loss of a recipient-specific chromosomal marker in peripheral blood leukocytes (PBLs) and bone marrow, (2) conversion of recipient red blood cell antigens to donor type, (3) conversion of recipient T-cell, B-cell, and granulocyte lineages to donor origin by DNA analysis, and (4) increased ADA activity and metabolic correction in red blood cells and PBLs.