Universal Leukocyte Reduction

Comparing Outcomes with Bone Marrow or Peripheral Blood Stem Cells as Graft Source for Matched Sibling Transplants in Severe Aplastic Anemia across Different Economic Regions

Bone marrow (BM) is the preferred graft source for hematopoietic stem cell transplantation (HSCT) in severe aplastic anemia (SAA) compared with mobilized peripheral blood stem cells (PBSCs). We hypothesized that this recommendation may not apply to those regions where patients present later in their disease course, with heavier transfusion load and with higher graft failure rates. Patients with SAA who received HSCT from an HLA-matched sibling donor from 1995 to 2009 and reported to the Center for International Blood and Marrow Transplant Research or the Japan Society for Hematopoietic Cell Transplantation were analyzed. The study population was categorized by gross national income per capita and region/countries into 4 groups. Groups analyzed were high-income countries (HIC), which were further divided into United States-Canada (n = 486) and other HIC (n = 1264); upper middle income (UMIC) (n = 482); and combined lower-middle, low-income countries (LM-LIC) (n = 142). In multivariate analysis, overall survival (OS) was highest with BM as graft source in HIC compared with PBSCs in all countries or BM in UMIC or LM-LIC (P < .001). There was no significant difference in OS between BM and PBSCs in UMIC (P = .32) or LM-LIC (P = .23). In LM-LIC the 28-day neutrophil engraftment was higher with PBSCs compared with BM (97% versus 77%, P = .002). Chronic graft-versus-host disease was significantly higher with PBSCs in all groups. Whereas BM should definitely be the preferred graft source for HLA-matched sibling HSCT in SAA, PBSCs may be an acceptable alternative in countries with limited resources when treating patients at high risk of graft failure and infective complications.

Why implement universal leukoreduction?

The improvement of transfusion medicine technology is an ongoing process primarily directed at increasing the safety of allogeneic blood component transfusions for recipients. Over the years, relatively little attention had been paid to the leukocytes present in the various blood components. The availability of leukocyte removal (leukoreduction) techniques for blood components is associated with a considerable improvement in various clinical outcomes. These include a reduction in the frequency and severity of febrile transfusion reactions, reduced cytomegalovirus transfusion-transmission risk, the reduced incidence of alloimmune platelet refractoriness, a possible reduction in the risk of transfusion-associated variant Creutzfeldt-Jakob disease transmission, as well as reducing the overall risk of both recipient mortality and organ dysfunction, particularly in cardiac surgery patients and possibly in other categories of patients. Internationally, 19 countries have implemented universal leukocyte reduction (ULR) as part of their blood safety policy. The main reason for not implementing ULR in those countries that have not appears to be primarily concerns over costs. Nonetheless, the available international experience supports the concept that ULR is a process that results in improved safety of allogeneic blood components.

Universal Leukocyte Reduction of Transfused Red Cells Does Not Provide Benefit to Patients Undergoing Cardiac Surgery

OBJECTIVE

A policy of universal leukocyte reduction of the blood supply in Finland was implemented at the beginning of 2003. The aim of the present evaluation was to determine the potential role of leukocyte-reduced red blood cells in decreasing postoperative infections.

DESIGN

A retrospective cohort study.

SETTING

A major university clinic.

PARTICIPANTS

Consecutive patients undergoing cardiac surgery during the years 2002 and 2003.

INTERVENTIONS

Transfused patients received either buffy-coat-depleted red blood cells before leukocyte reduction (n = 782) or leukocyte-reduced red blood cells after leukocyte reduction (n = 632).

MEASUREMENTS AND MAIN RESULTS

The evaluated outcome parameters were culture-proven postoperative infections, 90-day mortality, and length of stay in the intensive care unit. The percentage of patients transfused with red blood cells (56% v 53%, p = 0.16) and amounts of transfused red blood cells (4.3 +/- 6.7 [3.0] units v 4.3 +/- 6.6 [2.0] units, means +/- standard deviation [median], p = 0.48) were comparable between the study groups (buffy-coat-depleted group and leukocyte-reduced group, respectively). The 90-day mortality (6.6% v 6.3%, p = 0.28), the length of intensive care stay (3.6 +/- 4.7 [2.0] days v 4.3 +/- 7.1 [2.0] days, p = 0.34), and the number of patients with culture-proven infections (8.8% v 10.9%, p = 0.19) were unchanged after universal leukocyte reduction. In multivariate comparisons, the leukocyte reduction was not associated with culture-proven postoperative infections and 90-day mortality.

CONCLUSION

No beneficial effect of the universal leukocyte reduction in cardiac surgery was found for culture-positive infection rates, 90-day mortality, or length of intensive care stay.

Allogeneic blood transfusions explain increased mortality in women after coronary artery bypass graft surgery

BACKGROUND

Postoperative mortality is greater in women than men after coronary artery bypass graft surgery. Because allogeneic blood transfusions are more common in women and have been associated with immunomodulation, the impact of transfusion on sex differences in infection and mortality was examined.

METHODS

A cohort study was conducted using Michigan Medicare beneficiaries who had undergone coronary artery bypass graft surgery. Information was used regarding allogeneic blood transfusion, infection, and mortality within the 100-day period after surgery.

RESULTS

Blood transfusions were more common in women than in men (88.2%, 95% CI 87.1%-89.2% vs 66.7%, 95% CI 65.5%-67.9%). Patients who received transfused blood were more likely to have an infection than patients who did not (14.6%, 95% CI 13.8%-15.5% vs 4.9%, 95% CI 4.1%-5.9%). There was a dose-response relationship between the number of units of whole blood or packed red cells received and the prevalence of infection (P = .035). The unadjusted risk of mortality attributable to female sex was 13.9% (95% CI 8.1%-19.6%), but was no longer statistically significant when adjusted for blood transfusion (population attributable risk 0.6%, 95% CI -6.0% to 6.6%). Patients who received a transfusion were 5.6 times as likely to die within 100 days after surgery as those who did not receive a transfusion (95% CI 3.7-8.6).

CONCLUSION

The increased risk of mortality in women after bypass surgery may be explained by transfusion-related immunosuppression.