Deleterious consequences of allogenic blood transfusion on postoperative infection: really a transfusion-related immunomodulation effect?

Packed red blood cell donor age affects overall survival in transfused patients undergoing hepatectomy for non-hepatocellular malignancy

BACKGROUND

Patients undergoing hepatectomy often require packed red blood cell (PRBC) transfusion, which has been associated with worse oncologic outcomes. However, limited data exist regarding the impact of PRBC donor factors. We hypothesized that PRBC donor age impacts survival after hepatectomy for non-hepatocellular malignancies.

METHODS

Patients who underwent hepatectomy for non-hepatocellular malignancy from 2005 to 2014 were retrospectively evaluated. Impact of clinicopathologic and PRBC factors on oncologic outcomes were assessed.

RESULTS

Of 149 identified patients, 76 received a perioperative PRBC transfusion (median 2 units). Transfusion was associated with increased median length of stay (8 vs. 6 days; p < 0.01) and median operative blood loss (700 vs. 350 mL; p < 0.01) versus non-transfused, respectively. In transfused patients, receipt of PRBC from older donors compared to younger resulted in decreased RFS (0.94 vs. 2.63 years, respectively; p = 0.02) and OS (1.94 vs. 3.44 years, respectively; p = 0.6). The PRBC donor age was an independent predictor of decreased recurrence free survival on multivariate analysis (HR 2.5, p = 0.04).

CONCLUSIONS

In patients undergoing hepatectomy for non-hepatocellular malignancies and receiving perioperative transfusion, PRBC donor age may impact survival and warrants further investigation.

Immunomodulatory Effects of Blood Transfusion on Tumor Size, Metastasis, and Survival in Experimental Fibrosarcoma

In spite of efforts, blood transfusion is still accompanied with adverse effects such as transfusion-related immunomodulation (TRIM). The current study aimed to evaluate the effects of allogeneic, syngeneic, fresh and storage blood transfusion on the growth and metastasis of tumors and survival in fibrosarcoma bearing BALB/c mice. Twenty-five BALB/c mice were grouped into five groups of equal size. All groups were injected 1.2 × 10⁶ WEHI-164 cells subcutaneously to induce fibrosarcoma tumor. After expansion of the tumor, in four groups (except for the control group), hemorrhage-induced anemia was developed. Twenty-four hours later, blood deficit was replaced by fresh allogeneic, storage allogeneic, fresh syngeneic and storage syngeneic blood transfusion, respectively. After a blood transfusion, for 13 days, the tumor size and survival of the mice were evaluated. In the day 20, the mice were sacrificed and their spleen tissues were evaluated for TRIM induced metastasis. Tumor size increase in the groups that received allogeneic (fresh and storage) and storage syngeneic blood transfusion was significantly higher than the control group (P value < 0.05). However, no significant difference was present in survival between the experiment groups and the control group. There was no metastasis in none of groups at the end of the study. Allogeneic and storage blood transfusion could have immunomodulatory effects such as increased tumor size. However, it seems that fresh and syngeneic blood transfusion have no effects on tumor growth in fibrosarcoma bearing mice. Further evidence may prove that more attention is warranted in blood transfusion into cancer cases.

TNF-α and TGF-ß level after intraoperative allogeneic red blood cell transfusion in orthopedic operation patients

Background/aim: Blood transfusion is associated with immunosuppression, referred to as transfusion-related immunomodulation (TRIM). In this study, for the first time, changes in the concentration of TGF-ß and TNF-α were measured postoperatively in orthopedic patients with intraoperational allogeneic red blood cell transfusion. Considering the use of packed cell units with different ages, it is possible to suggest the more appropriate product for clinical applications.Materials and methods: Two groups of 35 orthopedic surgery patients (with or without transfusion as case and control groups, respectively) were involved. Serum levels of TNF-α and TGF-ß were measured by ELISA.Results: The data suggested significant differences in age (P = 0.0001), lowered hemoglobin (P = 0.003), and hematocrit (P = 0.003) between the control and case groups. Pre- and postoperation levels of TNF-α and TGF- ßwere not significantly different, but the results showed significant increases in levels of both cytokines after the operation (P = 0.0001) in both groups.Conclusion: Increased levels of TNF-α and TGF-ß are probably related to surgery and packed cell transfusion, respectively. Further studies using more packed cell units or other blood products and assessment of more cytokines are needed to have better understanding about this issue.

Perioperative management of liver resection surgery

Advances in liver resection surgery have lead to reductions in both mortality and morbidity. However morbidity remains high so effective multidisciplinary teamwork is essential to optimise the perioperative care of this patient group. In this article we review the current literature on the perioperative management of patients undergoing liver resection surgery.

Fetal rejection: infertility and immunity

Defective reaction toward fetal alloantigens could result in both recurrent spontaneous abortions (RSAs) and recurrent early pregnancy failures (REPFs), the latter existing in couples with unexplained infertility and multiple failures of implantation after in vitro fertilization embryo transfer. Immunological mechanisms leading to RSA and REPF seem to be different, although both syndromes probably have a genetic background that has not been identified so far. Despite the fact that antiphospholipid syndrome is a well-established cause of repeated pregnancy loss, the role of different autoantibodies existing in RSA and REPF patients needs to be elucidated. Immunotherapy is believed to correct the detrimental immune reactions; however, its real effectiveness and safety for the treatment of distinct forms of pregnancy loss need to be reconsidered.

Packed blood cells stored in AS-5 become proinflammatory during storage

BACKGROUND

Studies have shown that packed blood cells (PBCs) stored in AS-1 (Adsol, Baxter) and AS-3 (Nutricel, Medsep Corp.) accumulate proinflammatory substances, which may contribute to increased complications from allogeneic blood transfusion. This study assessed whether supernates from PBCs stored in AS-5 (Optisol, Terumo Corp.) prime neutrophils (PMNs), activate platelets (PLTs), and accumulate proinflammatory cytokines and PMN granule constituents.

STUDY DESIGN AND METHODS

PBC units were prepared in AS-5 from nonleukoreduced (NLR) and leukoreduced (LR) whole-blood units and stored at 4 degrees C. Supernates from samples of PBCs collected at various storage times were analyzed by multiplex enzyme-linked immunosorbent assay for proinflammatory cytokines and myeloperoxidase (MPO) and were incubated with type-matched blood, which was assessed by flow cytometry for expression of CD11b on PMNs, CD62P on PLTs, and formation of PMN-PLT aggregates.

RESULTS

Supernates from NLR PBCs stored for at least 14 days elevated CD11b expression on PMNs and the number of PMN-PLT aggregates compared to supernates from collection day PBCs. The magnitude of these effects correlated with storage age. Supernates from LR PBCs did not elicit these responses. Expression of CD62P on PLTs was not affected by supernates from either NLR or LR PBCs. Levels of interleukin (IL)-1beta, IL-6, IL-8, IL-18, NAP-2, MCP-1, RANTES, and MPO were elevated in supernates from 28- and 42-day NLR units. Tumor necrosis factor alpha and MIP-1alpha did not increase, and cytokine levels in LR PBC units did not increase.

CONCLUSION

Units of NLR PBCs stored in AS-5 become increasingly proinflammatory as a function of storage time. Leukoreduction prevents this change.

Transfusion of blood products and nosocomial infection in surgical patients

PURPOSE OF REVIEW

Liberal transfusion of blood products may be associated with a worse clinical outcome, including in-hospital mortality. This review focuses on the mechanisms by which transfusions may result in an increased risk of bacterial infection.

RECENT FINDINGS

The association between blood transfusion and worse outcome has been attributed to suppression of the recipient's immune function, the so called transfusion-related immunomodulation effect, as well as changes that may occur as blood ages. Despite several attempts to identify the mechanism by which transfusion worsens outcomes, this mechanism, as well as the role of leukoreduction in the mitigation of transfusion-related immunomodulation, have yet to be demonstrated. Bacterial contamination of the blood supply has become a serious problem in the past 20 years, and is currently the second leading cause of transfusion-associated death. Since the implementation of specific platelet transfusion protocols, the incidence of morbidity and mortality caused by infected platelet units appears to be markedly reduced.

SUMMARY

Transfusion of blood and blood products can be life-saving interventions. Consequences of transfusion may ultimately result in worse outcomes. More research will be required in order to identify indications and practices that optimize outcomes of surgical patients who require a blood transfusion.

KEY ISSUES IN ADVANCED BLEEDING CARE IN TRAUMA

The incidence of hemostatic abnormalities in the early hours after traumatic incident is high and represents an independent predictor of mortality. Key factors in the development of traumatic coagulopathy include the severity of injury, hypothermia, acidosis, hemorrhagic shock, hemodilution, clotting factor consumption, and fibrinolysis. Assessment of bleeding includes evaluation of the mechanism of injury, vital signs, biochemistry, detection of external and internal bleeding sources, injuries found upon secondary investigation, and response to treatment. Priority in treating the bleeding trauma patient should be given to prevention of further bleeding, hypothermia, acidosis, coagulopathy, and maintenance of tissue oxygenation, achieved by careful physical handling, damage control surgery, analgesia, maintenance of normothermia, correction of coagulopathy, control of blood pH, and serum calcium. Priority during initial treatment is to restore tissue perfusion and achieve hemostasis in vital functions; other nonvital procedures may generally be delayed. This state-of-the-art review aims to address key issues in acute control of bleeding in the trauma patient.

Vascular occlusion to decrease blood loss during hepatic resection

BACKGROUND

Historically, the primary hazard with liver surgery has been intraoperative blood loss. This led to the refinement of inflow and outflow occlusive techniques. The utility of the different methods of inflow and outflow techniques for hepatic surgery were reviewed.

METHODS

A search of the English literature (Medline, Embase, Cochrane library, Cochrane clinical trials registry, hand searches, and bibliographic reviews) using the terms "liver," "hepatic," "Pringle," "total vascular exclusion," "ischemia," "reperfusion," "inflow," and "outflow occlusion" was performed.

RESULTS

A multitude of techniques to minimize blood loss during hepatic resection have been studied. The evidence suggests that inflow occlusion techniques are generally well tolerated. These should be used with caution in patients with cirrhosis, fibrosis, steatosis, cholestasis, and recent chemotherapy, and for prolonged time intervals.

CONCLUSIONS

Harmful effects of intraoperative blood loss and transfusion occur during hepatic resection. Portal triad clamping (PTC) is associated with less blood loss compared with no clamping. In procedures with ischemic times <1 hour in length, PTC-C (continuous) is likely equal to PTC-I (intermittent). In patients with chronic liver disease or undergoing lengthy operations, PTC-I is likely superior to PTC-C. PTC is superior to total vascular exclusion except in patients with tumors that are large and deep seated, hypervascular, and/or abutting the hepatic veins or vena cava and in patients with increased right-sided heart pressures.

Coagulopathy and blood component transfusion in trauma

Trauma is a serious global health problem, accounting for approximately one in 10 deaths worldwide. Uncontrollable bleeding accounts for 39% of trauma-related deaths and is the leading cause of potentially preventable death in patients with major trauma. While bleeding from vascular injury can usually be repaired surgically, coagulopathy-related bleeding is often more difficult to manage and may also mask the site of vascular injury. The causes of coagulopathy in patients with severe trauma are multifactorial, including consumption and dilution of platelets and coagulation factors, as well as dysfunction of platelets and the coagulation system. The interplay between hypothermia, acidosis and progressive coagulopathy, referred to as the 'lethal triad', often results in exsanguination. Current management of coagulopathy-related bleeding is based on blood component replacement therapy. However, there is a limit on the level of haemostasis that can be restored by replacement therapy. In addition, there is evidence that transfusion of red blood cells immediately after injury increases the incidence of post-injury infection and multiple organ failure. Strategies to prevent significant coagulopathy and to control critical bleeding effectively in the presence of coagulopathy may decrease the requirement for blood transfusion, thereby improving clinical outcome of patients with major trauma.

Management of Jehovah’s Witness patients with haematological problems

The management of practising Jehovah's Witnesses who have haematological problems presents many different challenges both at the level of treatment strategy and ethics. This article focuses on the beliefs of Jehovah's Witnesses and addresses treatment modalities available for and acceptable to these individuals. Recent advances in the development of novel therapeutic agents have aided the management of Jehovah's Witnesses. Finally, the background to the ethical dilemmas raised by these issues is discussed.

Supernatant from stored red blood cell primes inflammatory cells: influence of prestorage white cell reduction

BACKGROUND

The contribution of RBC transfusion to adverse patient outcomes is controversial. There is conflicting clinical data and limited biologic data that provide an underpinning biologic rationale for any adverse impacts from RBC transfusion. This study used in-vitro measures of PMN stimulation to determine the ability of supernatant from RBCs to stimulate allogeneic WBCs and to determine the influence of residual donor WBCs and storage time on the proinflammatory potential of RBCs.

STUDY DESIGN AND METHODS

Three types of RBCs were assessed: standard non-WBC-reduced RBCs (S-RBCs), buffy coat-poor RBCs (BCP-RBCs), and prestorage WBC-filtered RBC (LF-RBCs). Supernatant was collected weekly up to Day 42 of storage. PMN priming by supernatant from RBCs was determined by three methods: induction of CD11b expression on PMNs, induction of IL-8 release from PMNs, and the chemotactic effect of supernatant on PMNs.

RESULTS

Supernatant from S-RBCs induced the expression of CD11b on PMNs, primed PMNs to release IL-8, and was chemotactic for PMNs. The magnitude of this PMN-priming progressively amplified with storage time. In contrast, supernatant from BCP-RBCs or LF-RBCs did not significantly prime PMNs. The PMN-priming effect of supernatant from RBCs correlated more closely with the level of MNCs in the RBCs than PMN content.

CONCLUSION

Supernatant from stored S-RBCs prime unstimulated allogeneic PMNs in vitro. Prestorage buffy-coat WBC reduction was as effective as WBC depletion in abrogating this proinflammatory response elicited by supernatants from RBCs. The clinical consequences, if any, of these findings for transfusion recipients are unknown.

Meta-analysis of randomized controlled trials comparing the risk of postoperative infection between recipients of allogeneic and autologous blood transfusion

BACKGROUND AND OBJECTIVES

A previous meta-analysis of randomized controlled trials (RCTs), comparing the risk of postoperative infection between recipients of allogeneic blood or autologous blood obtained by preoperative autologous blood donation (PABD), did not detect an immunomodulatory (TRIM) effect of allogeneic blood transfusion (ABT). If such a TRIM effect was mediated by white blood cell (WBC)-derived soluble mediators accumulating during storage, however, stored autologous blood obtained by PABD would not prevent the TRIM effect, whereas unstored autologous blood obtained by acute normovolemic haemodilution (ANH), intraoperative blood recovery (IBR), or postoperative blood recovery (PBR), would abrogate the TRIM effect.

MATERIALS AND METHODS

RCTs reported through January 2002 were retrieved, and five studies met the criteria for meta-analysis. Summary odds ratios (ORs) of postoperative infection in recipients of allogeneic vs. autologous blood were calculated across studies.

RESULTS

No difference in the risk of infection between the comparison arms was detected across all five RCTs [summary OR = 1.22, 95% confidence interval (95% CI): 0.75-1.98], or when the results of studies using PABD or ANH/IBR/PBR were integrated separately (summary OR = 1.35; 95% CI: 0.45-4.08; and summary OR = 1.49; 95% CI: 0.69-3.22, respectively).

CONCLUSIONS

The finding of no TRIM effect of ABT across RCTs using ANH/IBR/PBR to obtain autologous blood does not support the hypothesis that a TRIM effect of ABT is mediated by WBC-derived soluble mediators accumulating during storage. The null finding of the overall meta-analysis also does not support a TRIM effect of ABT mediated by other blood constituents.

Allogeneic blood transfusion and postoperative duration of mechanical ventilation: effects of red cell supernatant, platelet supernatant, plasma components and total transfused fluid

BACKGROUND AND OBJECTIVES

In patients undergoing open-heart surgery, allogeneic blood transfusion (ABT) may be related to an enhanced inflammatory response and impaired pulmonary function, resulting in a need for prolonged mechanical ventilation. Transfused red blood cell (RBC) supernatant, platelet supernatant or plasma components, may exercise varying effects on pulmonary function, because these fluids differ in their content of soluble biological-response modifiers.

MATERIALS AND METHODS

The records of 416 patients undergoing coronary artery bypass graft operations at the Massachusetts General Hospital were reviewed. Possible predictors and the number of days of postoperative ventilation, as well as the number of all transfused blood components, were recorded. The association between mechanical ventilation past the day of operation and the volume of transfused RBC supernatant, platelet supernatant, or plasma components, was calculated by logistic regression analyses.

RESULTS

The volume of each transfused fluid differed (P < 0.0001) among patients ventilated for 0, 1, 2, 3, or > or = 4 days after the day of the operation. After adjusting for the effects of confounding factors, the volume of administered RBC supernatant was associated (P = 0.0312) with the likelihood of postoperative ventilation past the day of operation, but the volume of platelet supernatant, plasma components, or total transfused fluid was not (P = 0.1528, P = 0.1847, and P = 0.0504, respectively).

CONCLUSIONS

These results are congruent with the hypotheses that ABT may impair postoperative pulmonary function and that any such adverse effect of ABT is probably mediated by the supernatant fluid of stored RBCs. Both hypotheses should be examined further, in future studies of the outcomes of ABT.