Soluble HLA Class I, HLA Class II, and Fas Ligand in Blood Components: A Possible Key to Explain the Immunomodulatory Effects of Allogeneic Blood Transfusions

Efficacy of ferric carboxymaltose in iron deficiency anemia patients scheduled for pancreaticoduodenectomy

Purpose

Perioperative transfusion is reported to be an independent risk factor not only for postoperative complications but also for early recurrence of periampullary carcinoma after pancreaticoduodenectomy (PD). The purpose of this study was to evaluate the safety and efficacy of ferric carboxymaltose (FCM) in reducing the need for perioperative transfusion in iron deficiency anemia patients scheduled for PD.

Methods

Twenty-two male patients (hemoglobin [Hb] 7 to <13 g/dL) and 18 female patients (Hb 7 to <12 g/dL) were enrolled in the study group and administered FCM 1-3 weeks before PD. The perioperative transfusion rate was the primary endpoint; morbidity, length of postoperative hospital stay, change in hematological parameters after FCM injection, and adverse effects of FCM were also investigated.

Results

The perioperative transfusion rate of the study group was 22.5% (9 of 40). Hb level was significantly higher on the day of the operation compared to baseline (P < 0.001). Levels of Hb, transferrin saturation, and ferritin were higher at the follow-up compared to baseline (P = 0.008, P = 0.033, and P < 0.001, respectively).

Conclusions

FCM administration was associated with a reduced need for perioperative transfusion and can safely stabilize hematological parameters.

A scoring system to predict the risk of major complications after laparoscopic liver resection in elderly patients with hepatocellular carcinoma

BACKGROUND

The safety of laparoscopic liver resection (LLR) in elderly patients is a matter of concern because the reduced physiologic reserve increases the risk of postoperative complications. However, there are few score systems for predicting complications after LLR in elderly patients. The aim of this study is to propose a new simplified scoring system based on the Geriatric Nutritional Risk Index (GNRI) to predict major complications after LLR in elderly patients with hepatocellular carcinoma (HCC).

METHODS

We retrospectively reviewed 257 consecutive patients aged ≥ 65 years who underwent LLR for HCC between 2004 and 2019. The GNRI formula was 1.489 × serum albumin (g/L) + 41.7 × present weight/ideal weight (kg). A scoring system to predict the risk of major complications was developed by assigning points to each risk factor equal to its regression coefficient determined in the multivariable analysis. Major complications were defined as complications of Clavien-Dindo grade III or higher.

RESULTS

Of the 257 patients, 219 patients were finally included in this study. Major complications occurred after LLR in 24 patients (10.9%). Multivariable analysis showed that the GNRI (hazard ratio [HR] 3.396, 95% confidence interval [CI] 1.242-9.288, P = 0.017), Child-Turcotte-Pugh score (HR 2.191, 95% CI 1.400-8.999, P = 0.036), major liver resection (HR 2.683, 95% CI 1.082-7.328, P = 0.050), and intraoperative transfusion (HR 1.802, 95% CI 1.428-7.591, P = 0.022) were independent predictors of major postoperative complications. These variables were assigned points based on their HRs, and the resulting 10-point model showed good discrimination (area under the curve 0.756, 95% CI 0.649-0.836, P = 0.001).

CONCLUSION

The scoring system outperformed the GNRI for predicting major complications after LLR in elderly patients with HCC.

The effect of platelet apheresis collection on some immunological factors in donors using two different apheresis devices

INTRODUCTION

The aim of this study was to evaluate and compare two different apheresis and changes in some immunological factors in donors.

MATERIAL AND METHODS

The cross-sectional study was performed from January 2017 to September 2018. Fifty six male blood donors were randomly divided into two groups. CD4, CD8, and CD25 markers by flow cytometry, and TGFBeta by real-time polymerase chain reaction (RT-PCR) method were done before and 7 days after the apheresis procedure. Independent Sample t-test, Mann-Whitney U Test, Wilcoxon signed ranked test, and Fisher exact test were used.

RESULTS

WBC in MCS+ group after donation is significantly higher than before donation (P < 0.05) but no significant difference was seen between MCS+ and Trima groups in these two indicators. But in CD4, CD25, and TGFBeta, there was no significant difference between the two groups.

CONCLUSION

There was no significant difference on CD4, CD25, and TGFBeta gene 7 days after donation.

Open MHC Class I Conformers: A Look through the Looking Glass

Studies carried out during the last few decades have consistently shown that cell surface MHC class I (MHC-I) molecules are endowed with functions unrelated with antigen presentation. These include cis–trans-interactions with inhibitory and activating KIR and LILR, and cis-interactions with receptors for hormones, growth factors, cytokines, and neurotransmitters. The mounting body of evidence indicates that these non-immunological MHC-I functions impact clinical and biomedical settings, including autoimmune responses, tumor escape, transplantation, and neuronal development. Notably, most of these functions appear to rely on the presence in hematopoietic and non-hematopoietic cells of heavy chains not associated with β2m and the peptide at the plasma membrane; these are known as open MHC-I conformers. Nowadays, open conformers are viewed as functional cis-trans structures capable of establishing physical associations with themselves, with other surface receptors, and being shed into the extracellular milieu. We review past and recent developments, strengthening the view that open conformers are multifunctional structures capable of fine-tuning cell signaling, growth, differentiation, and cell communication.

Intra-Operative Abdominal Drain Placement for Gallbladder Cancer Surgery and Risk of Infectious Complications

Background: Routine intra-operative abdominal drain placement (IADP) is not beneficial for uncomplicated cholecystectomies though outcomes in gallbladder cancer surgery is unclear. This retrospective study hypothesized that patients with IADP (+IADP) for gallbladder cancer surgery have a higher risk of post-operative infectious complications (PIC) compared with patients without IADP (-IADP). Patients and Methods: The 2014-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for +IADP and -IADP patients who had gallbladder cancer surgery. Post-operative infectious complications were defined as septic shock, organ/space infection (OSI), or percutaneous drainage. Multivariable analyses were performed to analyze the associated risk of PIC. Results: Of 385 patients, 237 (61.6%) were +IADP. The +IADP patients had higher rates of post-operative bile leak, OSI, re-admission, and increased length of stay (p < 0.05). The +IADP patients were not associated with increased risk of PIC (p > 0.05). Bile leak (odds ratio [OR], 10.61; p < 0.001), peri-operative blood transfusion (OR, 3.77; p = 0.003), biliary reconstruction (OR, 2.88; p = 0.018), and pre-operative biliary stent placement (OR, 3.02; p = 0.018) were the strongest associated risk factors of PIC. Patients with drains in place at or longer than 30 days post-operatively had an increased associated risk compared with patients who did not (OR, 6.88; 95% confidence interval [CI], 2.16-21.86; p < 0.001). Conclusions: More than 60% of gallbladder cancer surgeries included IADP and was not associated with an increased risk of PIC. Intra-operative abdominal drain placement was not associated with an increased risk of PIC, unless drains were left in place for 30 days or longer. Increased risk of PIC was associated with bile leak, peri-operative blood transfusion, pre-operative biliary stent placement, and biliary reconstruction.

Postoperative morbidity adversely impacts long-term oncologic prognosis following hepatectomy for hepatocellular carcinoma: A multicenter observational study

BACKGROUND & AIMS

Postoperative morbidity following hepatectomy for hepatocellular carcinoma (HCC) is common and its impact on long-term oncological outcome remains unclear. This study aimed to investigate if postoperative morbidity impacts long-term survival and recurrence following hepatectomy for HCC.

METHODS

The data from a multicenter Chinese database of curative-intent hepatectomy for HCC were analyzed, and independent risks of postoperative 30-day morbidity were identified. After excluding patients with postoperative early deaths (≤90 days), early (≤2 years) and late (>2 years) recurrence rates, overall survival (OS), and time-to-recurrence (TTR) were compared between patients with and without postoperative morbidity.

RESULTS

Among 2,161 patients eligible for the study, 758 (35.1%) had postoperative 30-day morbidity. Multivariable logistic regression analysis showed that diabetes mellitus, obesity, Child-Pugh grade B, cirrhosis, and intraoperative blood transfusion were independent risks of postoperative morbidity. The rates of early and late recurrence among patients with postoperative morbidity were higher than those without (50.7% vs. 38.8%, P < 0.001; and 41.7% vs. 34.1%, P = 0.017). Postoperative morbidity was associated with decreased OS (median: 48.1 vs. 91.6 months, P < 0.001) and TTR (median: 19.8 vs. 46.1 months; P < 0.001). After adjustment of confounding factors, multivariable Cox-regression analyses revealed that postoperative morbidity was associated with a 27.8% and 18.7% greater likelihood of mortality (hazard ratio 1.278; 95% confidence interval: 1.126-1.451; P < 0.001) and recurrence (1.187; 1.058-1.331; P = 0.004).

CONCLUSION

This large multicenter study provides strong evidence that postoperative morbidity adversely impacts long-term oncologic prognosis after hepatectomy for HCC. The prevention and management of postoperative morbidity may be oncologically important.

Bilateral Nephrectomy in Patients with Autosomal Dominant Polycystic Kidney Disease and End-Stage Chronic Renal Failure

BACKGROUND

In patients with autosomal dominant polycystic kidney disease (ADPKD) and end-stage kidney disease, bilateral nephrectomy (BN) is currently performed predominantly via the laparoscopic approach. We analysed the results of BN depending on the approach and preoperative and perioperative factors.

PATIENTS AND METHODS

This was a single-centre retrospective study carried out from April 2010 to March 2020, including a total of 142 patients presenting with ADPKD who were treated by BN. Of these, 108 patients meeting the inclusion criteria were selected to analyse the results. We compared therapeutic outcomes depending on the surgical approach (laparotomy or laparoscopy) and the type of the operation (emergent or elective).

RESULTS

Of the 108 eligible patients, 36 (group I) underwent laparoscopic BN and the remaining 72 patients (group II) were subjected to midline laparotomy. Sixty-nine patients underwent elective surgery and 39 endured emergent operations. The most frequent indications (87 patients, 80.6%) for surgical treatment were urinary tract infection and infected cysts. The median length of hospital stay for group I and group II patients amounted to 8 days (IQR: 7.5-9) and 12.5 days (IQR: 9-16.5), respectively (p < 0.001). However, comparing the patients operated on electively, the actual difference in the length of hospital stay was inconsiderable: median 8 days (IQR: 7-9) in group I and 9 days (IQR: 9-11.5) in group II. The median duration of the operation was significantly (p < 0.001) longer in group I amounting to 217.5 min (IQR: 197.5-305) than in group II equalling 115 min (IQR: 107.5-145). The frequency of postoperative complications, lethal outcomes, and blood loss volume did not statistically significantly differ depending on the surgical approach. Only patients operated on emergency underwent releparotomy due to intraoperative large bowel injury. Lethal outcomes (n = 18, 16.7%) after surgery were observed only in emergent patients. Sepsis prior to surgery, systemic inflammation response syndrome (SIRS) with the CRP level above 173 mg/mL, prolonged preoperative antibacterial therapy, and undiagnosed large bowel injury were associated with a lethal outcome after BN.

CONCLUSION

The results of open and laparoscopic BN in elective surgery were comparable. Emergency operations for infected renal cysts and SIRS were associated with increased incidence of large bowel injury and lethal outcomes.

The Immune Nature of Platelets Revisited

Platelets are the primary cellular mediators of hemostasis and this function firmly acquaints them with a variety of inflammatory processes. For example, platelets can act as circulating sentinels by expressing Toll-like receptors (TLR) that bind pathogens and this allows platelets to effectively kill them or present them to cells of the immune system. Furthermore, activated platelets secrete and express many pro- and anti-inflammatory molecules that attract and capture circulating leukocytes and direct them to inflamed tissues. In addition, platelets can directly influence adaptive immune responses via secretion of, for example, CD40 and CD40L molecules. Platelets are also the source of most of the microvesicles in the circulation and these miniscule elements further enhance the platelet’s ability to communicate with the immune system. More recently, it has been demonstrated that platelets and their parent cells, the megakaryocytes (MK), can also uptake, process and present both foreign and self-antigens to CD8+ T-cells conferring on them the ability to directly alter adaptive immune responses. This review will highlight several of the non-hemostatic attributes of platelets that clearly and rightfully place them as integral players in immune reactions.

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Platelets can act as circulating sentinels by expressing pathogen-associated molecular pattern receptors that bind pathogens and induce their killing and elimination.

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Activated platelets secrete and express a multitude of pro- and anti-inflammatory molecules that attract and capture circulating leukocytes and direct them to inflamed tissues.

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Platelets express and secrete many critical immunoregulatory molecules that significantly affect both innate and adaptive immune responses.

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Platelets are the primary source of microparticles in the circulation and these augment the platelet’s ability to communicate with the immune system.

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Platelets and megakaryocytes can act as antigen presenting cells and present both foreign- and self-peptides to T-cells.

Implications of perioperative allogeneic red blood cell transfusion on the immune-inflammatory response

Background

The allogeneic transfusion-related immunomodulation (TRIM) may be responsible for an increase in survival of renal transplants but in contrast it could increase the rate of bacterial infections or the recurrence rate of tumors post-operatively.

Objective

This review focuses in the implications of perioperative allogeneic transfusions on the immune-inflammatory response of surgical transfused patients.

Results

ABTs modify immune functions in recipients including decrease of the number of lymphocytes; decrease the CD4 cells; decrease the CD4/CD8 T-cell ratio; decrease NK cells; and decrease the lymphocyte response to mitogens. TRIM effects may be mediated by allogeneic white cells present in blood products; soluble peptides present in transfused plasma; and/or biologic mediators released into the supernatant of blood units. A recent systematic review and meta-analysis including 36 clinical observational studies (n = 174,036) concluded that perioperative ABTs not only decreased overall survival and reduced colorectal cancer-specific survival. Furthermore ABTs increased the rate of infectious, cardiac, pulmonary and anastomotic complications in colorectal cancer patients undergoing surgery.

Conclusions

It has been demonstrated by laboratory tests that TRIM is associated with transfusion recipient immune alterations but its influence in colorectal cancer recurrence after resection remains controversial though may exist. Surgical techniques reducing intraoperative blood loss have limited the number of ABTs perioperatively, however increase in mortality continues to be reported in literature after ABT in colorectal cancer surgery. Poor survival associated to TRIM in colorectal cancer might be due to higher number of allogeneic transfused units and/or prolonged length of blood storage.

Allogeneic blood transfusion in 163 children with acute lymphocytic leukemia (a STROBE-compliant article)

Little research has been done about the effects of allogeneic blood transfusion (ABT) on the recurrence and prognosis in the cases with childhood acute lymphocytic leukemia (cALL). In order to provide a basis for clinical safe blood transfusion, the data of 163 cases with cALL were retrospectively analyzed to explore the issue.The data of 163 cases with cALL between 2006 and 2011 were retrospectively analyzed. According to the frequency of blood transfusion, the 163 cases were divided into 4 groups including non-transfusion group, 1 to 10-time transfusion group, 11 to 25-time transfusion group, and >25-time transfusion group. Survival rates were compared with Log-Rank test. Cox regression analysis was used in the effects of risk factors on recurrence and death.ABT was performed in 152 cases with cALL (93.25%). In low-risk and intermediate-and-high risk cALL, the survival rate significantly decreased in all transfusion groups compared with that in non-transfusion group (all P < .01). Cox regression analysis showed that >25-time transfusion was an independent prognosis index of recurrence (odds ratio [OR] = 3.015, 95% confidence interval [CI]: 1.368-6.646) and death (OR = 3.979, 95% CI: 1.930-8.207) in cALL.Frequency of ABT appears to affect the recurrence and death in cALL. We should be careful with blood transfusion and avoid unnecessary blood transfusion as far as possible in the cases with cALL.

Anemia and Transfusion in Critical Care

Objective:

The objective of this report is to review the physiology and management of anemia in critical care. Selected publications on physiology and transfusion related to anemia and critical care, including the modern randomized trials of conservative versus liberal transfusion policy, were used. Anemia is compensated and tolerated in most critically ill patients as long as oxygen delivery is at least twice oxygen consumption. There are risks to blood transfusion which can be minimized by blood banking practice. The availability of cultured red cells may allow correction of anemia without significant risk. The benefit of transfusion in anemia must be weighted against the risk in any specific patient.

Conclusion and Recommendation:

In a criticially ill patient, anemia should be managed to avoid oxygen supply dependency (oxygen delivery less than twice comsumption) and to maintain moderate oxygen delivery reserve (DO2/VO2 > 3).

CD8(low)CD28(-) T Cells: A Human CD8 T-Suppressor Subpopulation With Alloantigen Specificity Induced by Soluble HLA-A2 Dimer In Vitro

CD8(+) suppressor T cells have been demonstrated to provide protection of allografts from rejection. We previously reported that soluble peptide/HLA-A2 dimer shows peptide-specific inhibitory effects on alloresponse in a coculture of peptide-pulsed T2 cells with HLA-A2 negative lymphocytes in vitro. Here we found a subset of CD8(low)CD28(-) T cells that was induced in the dimer-treated coculture. Importantly, this population showed hyporesponsiveness to the alloantigen restimulation as well as alloantigen-specific suppression on alloreactive T cells in a cell-cell contact-dependent fashion. The suppressive mechanisms of CD8(low)CD28(-) T cells involved an elevated expression of membrane-bound TGF-β1, but not Foxp3, CTLA-4, or IL-10. Furthermore, an overrepresention of CD8(low)CD28(-) T cells was observed in the patients after allogeneic platelet transfusion and positively correlated with the elevated concentrations of plasma HLA class I antigens. Our findings demonstrated that soluble HLA-A2 dimer could efficiently induce the tolerant CD8(low)CD28(-) T cells with alloantigen-specific suppression on alloreactive T cells. This study might provide a new strategy for preparation of donor-specific suppressor T cells and represent an attractive alternative for induction of allograft tolerance.

Allogeneic platelet transfusions prevent murine T-cell–mediated immune thrombocytopenia

Allogeneic platelet MHC class I transfusions can both prevent and/or alleviate anti-CD61 (GPIIIa) T-cell–mediated ITP. The transfusions reverse abnormal bone marrow megakaryocyte histology and inhibit CD61-induced cytotoxicity.

The effect of pre-storage whole-blood leukocyte reduction on cytokines/chemokines levels in autologous CPDA-1 whole blood

BACKGROUND

In this study, we aimed to investigate the effectiveness of pre-storage leukocyte filtration of autologous blood (AB), especially focusing on the cytokines/chemokines accumulation on blood products.

MATERIALS AND METHODS

After approval of the ethics committee of the University of Tokyo, a total of 26 orthopedic patients, who donated AB prior to surgery after informed consent, were enrolled. The effects of filtration on blood cell counts were analyzed, and the accumulation of cytokines and chemokines were measured on pre- and post-leukoreduced (LR) samples, using the Luminex system. The time-dependent changes of the cytokines/chemokines and the effect of the filtration on their concentration were analyzed, and compared with the normal plasma levels reported in the literature.

RESULTS

LR effectively reduced the number of leukocytes and platelets, without affecting that of red cells. The concentration of most of the cytokines/chemokines analyzed, except the EGF, sCD40-L and sFas-L, decreased time-dependently of storage or did not change in pre-LR samples. However, EGF, sCD40L and sFas-L were significantly reduced by LR. Some, such as IL-8 and RANTES, were also importantly decreased by LR, and others, such as IL-1β and TNF-α, were not significantly affected by LR.

CONCLUSIONS

Leukocyte filtration effectively removes platelets and leukocytes from AB, thus preventing the accumulation of cytokines/chemokines. Since adverse effects due to AB transfusion, although rare, are observed, there is need to consider the implementation of pre-storage leukocyte reduction (PSLR) for AB.

Impact of complications on long-term survival after resection of colorectal liver metastases

Background

Postoperative complications may have an adverse effect not only on short-term but also long-term outcome among patients having surgery for cancer. A retrospective series of patients who had surgery for colorectal liver metastases (CLM) was used to assess this association.

Methods

Patients who had surgery with curative intent for CLM from 2000 to 2009 were included. The impact of postoperative complications, patient characteristics, disease stage and treatment on long-term survival was analysed using multivariable Cox regression models.

Results

A total of 251 patients were included. The median age was 58 (interquartile range 51–68) years and there were 87 women (34·7 per cent). A minor or major postoperative complication developed in 41 and 14 patients respectively, and five patients (2·0 per cent) died after surgery. The 5-year recurrence-free (RFS) and overall survival rates were 19·5 and 41·9 per cent respectively. Multivariable analysis revealed that postoperative complications independently predicted shorter RFS (hazard ratio (HR) 2·36, 95 per cent confidence interval 1·56 to 3·58) and overall survival (HR 2·34, 1·46 to 3·74). Other independent predictors of shorter RFS and overall survival included lymph node metastasis, concomitant extrahepatic disease, a serum carcinoembryonic antigen level of at least 100 ng/dl, and the use of radiofrequency ablation (RFS only). The severity of complications also correlated with RFS (P = 0·006) and overall survival (P = 0·001).

Conclusion

Postoperative complications were independently associated with decreased long-term survival after surgery for CLM with curative intent. The prevention and management of postoperative adverse events may be important oncologically.

Alloimmunization and erythrocyte autoimmunization in transfusion-dependent Egyptian thalassemic patients

BACKGROUND

Alloimmunization to red blood cells' (RBCs) antigens and formation of autoantibodies against RBCs is a frequent complication among immunocompetent transfusion-dependent patients. Autoantibodies can result in clinical hemolysis and difficulty in cross-matching blood. The objective of this study was to evaluate the presence of alloantibodies and autoantibodies in regularly transfused β-thalassemic patients and the factors influencing the development of alloantibodies.

MATERIALS AND METHODS

The clinical and transfusion records of 95 Egyptian β-thalassemic patients, with a mean age of 17.07 years, presenting to the National Blood Transfusion Centre for regular blood transfusion were evaluated for alloimmunization and antibody formation.

RESULTS

Alloantibodies were encountered in 27 patients (28.4%). The most frequent alloantibodies encountered were anti-Kell (23.6%) and anti-E (23.6%). Patients with blood group O were the highest in developing antibodies (37.9%). Patients with blood phenotypes R2r Kell negative developed more alloantibodies. Autoantibodies were encountered in only 1 patient.

CONCLUSIONS

Alloimmunization to RBCs' antigens is a frequent finding among Egyptian transfusion-dependent thalassemic patients, with the majority of patients being transfused with blood matched for ABO and D antigens only. Absence of phenotypically matched donors, except for a limited number of patients, may have contributed to this problem.

Bleeding, mortality, and antiplatelet therapy: results from the Clopidogrel for High Atherothrombotic Risk and Ischemic Stabilization, Management, and Avoidance (CHARISMA) trial

BACKGROUND

The association between bleeding severity and cause of mortality in the non-acute setting is unclear. We sought to investigate the association between bleeding and mortality subtype, and assess whether this association differs in patients on dual antiplatelet therapy (DAPT) versus aspirin alone.

METHODS

Using multivariable Cox proportional hazards survival regression, we examined the association between moderate or severe bleeding and all-cause, cardiovascular, and cancer mortality in 15,603 patients with cardiovascular disease or multiple risk factors enrolled in the CHARISMA trial.

RESULTS

Patients with moderate or severe bleeding had a higher incidence of all-cause, cardiovascular, and cancer mortality (P < .001 for each). After multivariable adjustment, moderate/severe bleeding remained independently associated with not only all-cause mortality (adjusted hazard ratio [HR] 1.66; 95% confidence interval [CI] 1.24-2.21) and cardiovascular mortality (HR 2.05, 95% CI 1.38-3.04) but also cancer mortality (HR 4.76, 95% CI 2.60-8.69). However, there was a significant interaction between bleeding and potency of antiplatelet therapy for all-cause (P = .002), cardiovascular (P = .02), and cancer mortality (P = .03); in subjects on aspirin alone, moderate/severe bleeding was associated with all-cause (HR 5.27, 95% CI 3.56-7.80), cardiovascular (HR 4.33, 95% CI 2.55-7.37), and cancer mortality (HR 9.01, 95% CI 4.41-18.43), but not in subjects on DAPT (all-cause: HR 1.48, 95% CI 0.93-2.34; cardiovascular: HR 1.04, 95% CI 0.58-1.86; and cancer mortality: HR 1.79, 95% CI 0.56-5.74).

CONCLUSIONS

In stable patients, moderate or severe bleeding is associated with a significantly increased risk of all-cause, cardiovascular, and cancer mortality. However, this risk appeared different in subjects on single antiplatelet therapy versus DAPT.

Correlation between postoperative infective complications and long-term outcomes after hepatic resection for colorectal liver metastasis

BACKGROUND

The impact of postoperative morbidity, and in particular infective complications on long-term outcomes, following hepatic resection for colorectal liver metastasis (CRLM) is not widely published.

OBJECTIVE

To evaluate the effect of postoperative complications on disease recurrence and overall survival in patients undergoing hepatic resection for CRLM.

METHODS

All patients undergoing hepatic resection for CRLM from January 1993 and March 2007 were identified, and postoperative complications analyzed. Patients who died of postoperative complications within 30 days of surgery were excluded form the study. Postoperative complications were graded using a validated system of classification. Complications were further classified into infective and noninfective complication groups and the primary end points of the study were disease free survival (DFS) and overall survival (OS) at 5 years.

RESULT

A total of 705 patients underwent hepatic resection in the study period. Median follow-up was 38 months. Operative morbidity and mortality were 28% and 3.6%, respectively. The total number of patients was 197 (28%) with complications, and 508 (72%) without complications. The 5 year DFS and OS for those with and without complications were: 13% versus 26% (P < 0.001) and 24% versus 37% (P < 0.001), respectively. Multivariate analysis showed inflammatory response to tumor score, blood transfusion, tumor number >8, and postoperative sepsis to be independent factors associated with DFS, and inflammatory response to tumor, tumor number >8, and postoperative sepsis to be independent predictors for OS. Intra-abdominal and respiratory infection but not wound infections were associated with poorer long-term outcomes.

CONCLUSIONS

Postoperative complications influence long-term outcomes in hepatic resection for CRLM. Specifically, postoperative sepsis is an independent predictor of disease free and overall survival. Thorough preoperative optimization, meticulous surgical technique and careful management in the postoperative period may reduce the incidence of these complications and influence long-term outcomes.

Noninfectious complications of blood transfusion

CONTEXT

Serious noninfectious complications are far more likely to occur than viral disease transmission from blood component transfusion.

OBJECTIVE

To compile a comprehensive list of the noninfectious risks of transfusion, examples of published risk estimates, and summaries of recent information regarding cause, prevention, or management of noninfectious transfusion risks.

DATA SOURCES

Information was obtained from peer-reviewed English-language medical journal publications since 1990.

CONCLUSIONS

Early complications, although potentially more serious, usually occur less frequently (<1 in 1000 transfusions) than late complications, which often affect more than 1% of recipients. Areas of active investigation and discussion include acute hemolytic reactions, transfusion-related acute lung injury, red cell alloimmunization, platelet transfusion refractoriness, and transfusion immunosuppression. Continued effort toward research and education to promote recognition and prevention of noninfectious complications associated with blood components is warranted.

A divalent human leukocyte antigen-B7 fusion-protein up-regulates CD25 and CD69 in alloreactive CD8+ T cells bypassing CD28 costimulation

BACKGROUND

T cells recognize major histocompatibility complex (MHC) molecules and their cryptic antigenic peptides on antigen-presenting cells and are generally triggered to proliferate, and when sufficient, co-stimulation is available. In soluble form, monomeric MHC molecules can induce apoptosis, anergy, or decreases of the T-cell receptor (TCR).

METHODS

A dimeric fusion protein of the human leukocyte antigens (HLA)-B7 was molecularly engineered and expressed in a B-cell line to allow secretion. Alloreactive T cells were generated according to the standard protocol.

RESULTS

A dimer of approximately 160 kD was obtained, affinity purified, and used to study T-cell interaction. In immobilized form, this protein efficiently stimulated alloreactive T cells to proliferate and produce interleukin (IL)-2 and interferon (IFN)-gamma in a concentration-dependent manner, up-regulating CD25 and CD69 expression. In contrast, the soluble fusion protein induced T-cell apoptosis.

CONCLUSIONS

The dichotomy in T-cell regulation by a divalent MHC fusion protein warrants the use of MHC multimers as custom-designed immune-regulatory molecules both in transplantation and autoimmune disease.

rhG-CSF effect on mixed lymphocyte cultures and circulating soluble HLA antigen levels in volunteer stem cell donors

OBJECTIVE

Recombinant human granulocyte colony-stimulating factor (rhG-CSF) is a cytokine widely used in the procurement of peripheral blood stem cells (PBSC) from donors for allogeneic hematopoietic cell transplantation. Therefore, we were interested in its immediate and long-term effects on cellular and soluble factors known to be involved in the immune response.

METHODS

We studied 35 PBSC donors by mixed lymphocyte culture (MLC) and lymphocyte transformation test (LTT), and 41 for soluble plasma factors (soluble human leukocyte antigen [sHLA]-G, -class I, -DR, and interleukin [IL]-10) pre and 5 days post initial rhG-CSF administration, respectively. In addition, 10 donors were reexamined at an average of 2 months (3-16 weeks) post-rhG-CSF.

RESULTS

At 5 days post-rhG-CSF the donors presented a significant (p < 0.05) decrease of MLC, LTT mitogen, and recall antigen reactions. Plasma levels of sHLA-G, -class I, -DR, and IL-10 (p < 0.005 each) were significantly increased. The changes in IL-10 but not in sHLA were significantly (p < 0.05) correlated with LTT responses. In the 2-month follow-up there was no significant difference in alloreactivity and LTT reactions as compared to the pre-rhG-CSF results. The results generated after 3 to 16 weeks did not depend on the time point of investigation. Consistently, soluble factors decreased to pre-rhG-CSF levels.

CONCLUSIONS

rhG-CSF administration suppresses cellular immune functions within 5 days and increases sHLA and IL-10 plasma levels. These immunomodulatory effects appear to be short-term only and vanished at an average of 2 months after rhG-CSF application.

Randomized clinical trial of intraoperative autotransfusion in surgery for abdominal aortic aneurysm

Background

Perioperative homologous blood transfusion (HBT) is associated with adverse reactions and risks transmission of infection. It has also been implicated as an immunosuppressive agent. Intraoperative autotransfusion (IAT) is a potential method of autologous transfusion.

Methods

This was a single-centre randomized clinical trial of IAT in surgery for abdominal aortic aneurysm. Forty patients were randomized to IAT and 41 underwent surgery with HBT only. Patients in both groups received HBT to maintain haemoglobin levels above 8 g/dl. Transfusion requirements, and incidence of systemic inflammatory response syndrome (SIRS) and infection, were compared.

Results

Significantly fewer patients in the IAT group required HBT (21 versus 31; P = 0·038) and the median blood requirement per patient was 2 units lower (P = 0·012). There was a higher incidence of chest infection (12 versus four patients; P = 0·049) and SIRS (20 versus nine patients; P = 0·020) in the HBT group. Risk of SIRS was related to aortic cross-clamp time in the IAT group only.

Conclusion

Use of autotransfusion effectively reduced the need for HBT and was associated with a reduced incidence of postoperative SIRS and infective complications.

Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases

OBJECTIVE

To determine if transfusion affected perioperative and long-term outcome in patients undergoing liver resection for metastatic colorectal cancer.

SUMMARY BACKGROUND DATA

Blood transfusion produces host immunosuppression and has been postulated to result in adverse outcome for patients undergoing surgical resection of malignancies.

METHODS

Blood transfusion records and clinical outcomes for 1,351 patients undergoing liver resection at a tertiary cancer referral center were analyzed.

RESULTS

Blood transfusion was associated with adverse outcome after liver resection. The greatest effect was in the perioperative course, where transfusion was an independent predictor of operative mortality, complications, major complications, and length of hospital stay. This effect was dose-related. Patients receiving one or two units or more than two units had an operative mortality of 2.5% and 11.1%, respectively, compared to 1.2% for patients not requiring transfusions. Transfusion was also associated with adverse long-term survival by univariate analysis, but this factor was not significant on multivariate analysis. Even patients receiving only one or two units had a more adverse outcome.

CONCLUSIONS

Perioperative blood transfusion is a risk factor for poor outcome after liver resection. Blood conservation methods should be used to avoid transfusion, especially in patents currently requiring limited amounts of transfused blood products.

Umbilical cord blood dendritic cells are a rich source of soluble HLA-DR: synergistic effect of exosomes and dendritic cells on autologous or allogeneic T-Cell proliferation

In this study, we compared soluble HLA-DR (sHLA-DR) production in the culture supernatants of various cell sources [T and B cells, monocytes and dendritic cells (DCs) either from adult peripheral blood (PB) or umbilical cord blood (UCB)]. DCs produced the highest amount of sHLA-DR molecules as compared to other cell sources, with UCB DCs producing the highest amount. Different kinetics of sHLA-DR production were found between immature and mature UCB DCs (mDC, iDC) (derived either from CD34(+) or CD14(+) cells). Maximum production of sHLA-DR was observed in 72-hour culture supernatants of both CD34- and CD14-derived mDCs, whereas it peaked in the 24-hour culture supernatants from iDC. sHLA-DR molecules were pelleted after sequential centrifugation from UCB CD34(+) DCs and were found to contain both 36 kD alpha-chain and 29 kD beta-chain of HLA-DR, CD86, and Fas molecules. These sHLA-DR containing vesicles/exosomes alone evoked weak proliferative responses from autologous and allogeneic T cells, but the immune response was significantly increased when vesicles/exosomes were presented with DCs.