Neonatal Blood Banking Practices

There is little formal guidance to direct neonatal blood banking practices and, as a result, practices vary widely across institutions. In this vulnerable patient population with a high transfusion burden, considerations for blood product selection include freshness, extended-storage media, pathogen inactivation, and other modifications. The authors discuss the potential unintended adverse impacts in the neonatal recipient. Concerns such as immunodeficiency, donor exposures, cytomegalovirus transmission, volume overload, transfusion-associated hyperkalemia, and passive hemolysis from ABO incompatibility have driven modifications of blood components to improve safety.

Transfusion-Associated Graft-Versus-Host Disease in Adults

Transfusion-associated graft-versus-host disease (TA-GVHD) is a rare but fatal complication of blood transfusion that usually develops two to 30 days following a blood transfusion giving rise to graft versus host disease (GVHD) clinical features that are consisting of fever, skin rash, jaundice, diarrhea, and pancytopenia. The disease is fulminant in most patients with a mortality rate of >90% of cases. The main aim of this review is to enhance awareness among medical practitioners about this fatal disease. Data were extracted manually from the main medical databases (Medline, Scopus, and Google Scholar) after the revision of selected articles and assessed for their contribution to the knowledge of TA-GVHD. TA-GVHD occurs when the viable donor T-cells in the blood or blood products attack the recipient's tissues which his/her immune system is incapable to destroy due to several reasons. The recipient's tissues that are usually involved in TA-GVHD include the liver, intestine, skin, lungs, and bone marrow. Any blood component either whole blood, packed red blood cells (RBCs), platelets, or fresh non-frozen plasma that contains viable T lymphocytes can cause TA-GVHD. Host immunodeficiency, transfusion of fresh blood, and partial human leukocyte antigen (HLA) matching between the donors and the recipients represent the major risk factors of TA-GVHD. Partial HLA matching includes immunocompetent recipients who receive blood from a first-degree relative also, seen in genetically homogenous populations because of high rates of consanguineous marriage. The diagnosis of TA-GVHD is mainly suspected based on clinical manifestations. However, a histopathological study of either skin or rectal biopsy is diagnostic. The treatment of TA-GVHD is generally not effective, unless the patient received emergency stem cell transplantation, while prevention via irradiation of blood or blood products represents the standard of care for this disease. In conclusion, medical practitioners should have a high index of suspicion for this disease. Moreover, future clinical trials targeting and comparing the outcomes of the different therapeutic options for TA-GVHD are required.

Battle of the (Chat)Bots: Comparing Large Language Models to Practice Guidelines for Transfusion-Associated Graft-Versus-Host Disease Prevention

Published guidelines and clinical practices vary when defining indications for irradiation of blood components for the prevention of transfusion-associated graft-versus-host disease (TA-GVHD). This study assessed irradiation indication lists generated by multiple artificial intelligence (AI) programs, or chatbots, and compared them to 2020 British Society for Haematology (BSH) practice guidelines. Four chatbots (ChatGPT-3.5, ChatGPT-4, Bard, and Bing Chat) were prompted to list the indications for irradiation to prevent TA-GVHD. Responses were graded for concordance with BSH guidelines. Chatbot response length, discrepancies, and omissions were noted. Chatbot responses differed, but all were relevant, short in length, generally more concordant than discordant with BSH guidelines, and roughly complete. They lacked several indications listed in BSH guidelines and notably differed in their irradiation eligibility criteria for fetuses and neonates. The chatbots variably listed erroneous indications for TA-GVHD prevention, such as patients receiving blood from a donor who is of a different race or ethnicity. This study demonstrates the potential use of generative AI for transfusion medicine and hematology topics but underscores the risk of chatbot medical misinformation. Further study of risk factors for TA-GVHD, as well as the applications of chatbots in transfusion medicine and hematology, is warranted.

Demographics and appropriateness of cellular blood component irradiation practices: Ambispective analysis from a tertiary care center

BACKGROUND

Transfusion-associated graft versus host disease (TA-GVHD) is often underreported. There may also be lapses in TA-GVHD prevention practices due to lack of revision of some of the existing clinical guidelines as well as limited audits on practices of blood component irradiation. This study was undertaken to highlight these shortcomings, and generate data for development of institutional guidelines.

METHODS/MATERIALS

Study cohort was selected from patients requiring transfusion support during June 2019 to May 2020. Transfusion history of these patients were followed, both retrospectively and prospectively till July 2021. Transfusion requisitions were categorized as IR (with request for irradiation) or NIR (with no request for irradiation) and justified or unjustified according to published international guidelines.

RESULTS

Total 6963 requisitions for cellular blood components were received from 255 patients included in the study cohort. Of these, 3690 (54.9 %) were IR requisitions, while remaining 3029 (45.1 %) requisitions were NIR. Overall, 4242 (63.1 %) requisition were justified for their irradiation status as per published guidelines and 1595 (23.8 %) were found to be Unjustified while justification could not be assessed for remaining 882 (13.1 %) of the requisitions. The highest proportion of Unjustified demands in NIR requisitions was observed in patients with Severe Aplastic anemia (59.4 %).

CONCLUSION

Many units were unnecessarily irradiated (7.7 %) while irradiation was missed in 16 % of the requisitions included in analysis which may be attributed to lack of institutional guidelines. We recommend that every centre should adopt a published well-researched guideline including amendments based on review of practices at their center.

Adverse transfusion reactions and what we can do

INTRODUCTION

Transfusions of blood and blood components have inherent risks and the ensuing adverse reactions. It is very important to understand the adverse reactions of blood transfusion comprehensively for ensuring the safety of any future transfusions.

AREAS COVERED

According to the time of onset, adverse reactions of blood transfusion are divided into immediate and delayed transfusion reactions. In acute transfusion reactions, timely identification and immediate cessation of transfusion is critical. Vigilance is required to distinguish delayed responses or reactions that present non-specific signs and symptoms. In this review, we present the progress of mechanism, clinical characteristics and management of commonly encountered transfusion reactions.

EXPERT OPINION

The incidence of many transfusion-related adverse events is decreasing, but threats to transfusion safety are always emerging. It is particularly important for clinicians and blood transfusion staff to recognize the causes, symptoms and treatment methods of adverse blood transfusion reactions to improve the safety. In the future, at-risk patients will be better identified and can benefit from more closely matched blood components.

Effects of Freshly Irradiated vs Irradiated and Stored Red Blood Cell Transfusion on Cerebral Oxygenation in Preterm Infants: A Randomized Clinical Trial

IMPORTANCE

Gamma irradiation of leukoreduced red blood cells (RBCs) prevents transfusion-associated graft-vs-host disease but also exacerbates storage lesion formation in RBCs. It is unknown whether freshly irradiated RBCs are more efficacious than irradiated and stored RBCs in preterm infants with high transfusion requirements.

OBJECTIVE

To examine whether transfusion of freshly irradiated vs irradiated and stored RBC components improves cerebral oxygen delivery in preterm infants with anemia.

DESIGN, SETTING, AND PARTICIPANTS

This single-center, double-blinded, proof-of-concept randomized clinical trial was conducted at the neonatal intensive care unit of Wellington Regional Hospital in Wellington, New Zealand, between December 1, 2017, and November 30, 2018. Participants were preterm infants (<34 weeks' gestation at birth) who were at least 14 days of age and had anemia. Participants underwent nonurgent transfusions, and these episodes were randomized to the intervention group (in which the infants received a transfusion of RBCs that were freshly irradiated on the day of transfusion) or control group (in which the infants received a transfusion of RBCs that were irradiated and stored for up to 14 days). Data were analyzed using the evaluable population approach.

INTERVENTION

Transfusion of freshly irradiated RBCs.

MAIN OUTCOMES AND MEASURES

The prespecified primary outcome was the change in cerebral regional oxygen saturation (crSO2) from baseline (immediately before) to immediately after the transfusion. The prespecified secondary outcomes were the change in cerebral fractional tissue oxygen extraction (cFTOE) at different time points (immediately after, 24 hours after, and 120 hours or 5 days after transfusion). Outcomes were measured by blinded clinicians using near-infrared spectroscopy. A covariate-adjusted linear mixed model was used to quantify mean treatment effects and account for multiple transfusions in some infants.

RESULTS

A total of 42 infants (mean [SD] gestational age, 26 [10] weeks and 3 days; 29 [69%] boys) were enrolled in the trial and underwent 64 transfusion episodes, which were randomized to the intervention (n = 31) or control (n = 33) group. Compared with infants in the control group, those in the intervention group showed a covariate-adjusted mean increase in crSO2 (2.0 percentage points; 95% CI, 1.2-2.8 percentage points) and a mean decrease in cFTOE (0.02; 95% CI, 0.01-0.04) immediately after transfusion. These differences were sustained up to 120 hours or 5 days after transfusion. There were negligible mean changes in crSO2 or cFTOE in infants in the control group at any of the follow-up time points.

CONCLUSIONS AND RELEVANCE

Results of this trial showed that transfusion of freshly irradiated RBCs conferred a small advantage in cerebral oxygenation for at least 5 days after transfusion compared with transfusion of irradiated and stored RBC components. On-demand irradiation of RBC components may be considered to optimize oxygen delivery in the recipient, but this physiological finding requires further research.

TRIAL REGISTRATION

ANZCTR Identifier: ACTRN12617001581358.

Diacetylene-Based Colorimetric Radiation Sensors for the Detection and Measurement of γ Radiation during Blood Irradiation

Blood and its cellular components are irradiated by ionizing radiation before transfusion to prevent the proliferation of viable T lymphocytes which cause transfusion associated-graft versus host disease. The immunodeficient patients undergoing chemotherapy for various malignancies are at risk of this disease. The international guidelines for blood transfusion recommend a minimum radiation exposure of 25 Gray (Gy) to the midplane of the blood bag, while a minimum dose of 15 Gy and a maximum dose of 50 Gy should be given to each portion of the blood bag. Therefore, precise dosimetry of the blood irradiator is essential to ensure the adequate irradiation of the blood components. The paper presents the fabrication of diacetylene-based colorimetric film dosimeters for the verification of irradiated doses. The diacetylene analogues are synthesized by tailoring them with different amide-based headgroups followed by their coating to develop colorimetric film dosimeters. Among all the synthesized diacetylene analogues, aminofluorene-substituted diacetylene exhibits the most significant color transition from white to blue color at a minimum γ radiation dose of 5 Gy. The quantitative study of color change is performed by the digitization of the scanned images of film dosimeters. The digital image processing of the developed film dosimeters facilitates rapid dose measurement which enables their facile implementation and promising application in routine blood irradiator dosimetry.

Quantifying the influences of radiation therapy on deformability of human red blood cells by dual-beam optical tweezers

Radiation therapy is widely used as a treatment tool for malignancies. However, radiation-related complications are still unavoidable risks for off-target cells. Little is known about radiation therapy's possible effects on mechanical features of the off-target cells such as human red blood cells (RBCs). RBCs are nucleus-free circulating cells that can deform without losing functionality in healthy conditions. Thus, to evaluate in vitro effects of radiation therapy on the healthy plasma membrane of cells, RBCs were selected as a primary test model. RBCs were exposed to clinically prescribed radiotherapy doses of 2 Gy, 12 Gy and, 25 Gy, and each radiotherapy dose group was compared to a non-irradiated group. Cells were characterized by stretching using dual-beam optical tweezers and compared using the resulting deformability index. The group receiving the highest radiation dose was found statistically distinguishable from the control group (DI_0Gy = 0.33 ± 0.08), and revealed the highest deformability index (DI_25Gy = 0.38 ± 0.11, p = 0.0068), while no significant differences were found for 2 Gy (DI_2Gy = 0.33 ± 0.08, p = 0.9) and 12 Gy (DI_12Gy = 0.31 ± 0.09, p = 0.2) dose groups. Based on these findings, we conclude that radiotherapy exposure may alter the deformability of red blood cells depending on the dose amount, and measurement of deformability index by dual-beam optical tweezers can serve as a sensitive biomarker to probe responses of cells to the radiotherapy.

Little is known about radiation therapy's possible effects on mechanical features of off-target cells such as human red blood cells. Here, irradiated human red blood cells were stretched using dual-beam optical tweezers and compared using the resulting deformability index.

Inventory Management and Product Selection in Pediatric Blood Banking

Blood banks need to understand patterns of use and ordering practices to provide the blood donor centers with the best information with which to develop daily scheduled deliveries of blood products. Blood use is a large component of this process through maximizing physician education about appropriate ordering practices and use of appropriate tools. Simple measures can help provide guidance on the number of available components and the need to order more from the blood donor center. Special product requests in pediatrics, such as fresh blood, leukoreduction, irradiation, and antigen-negative units can also drive inventory practices and use patterns.

Missed irradiation of cellular blood components for vulnerable patients: Insights from 10 years of SHOT data

Background

Irradiation of cellular blood components is recommended for patients at risk of transfusion‐associated graft‐vs‐host disease (TA‐GvHD). Prestorage leucodepletion (LD) of blood components is standard in the UK since 1999.

Study Design and Methods

Analysis of 10 years' reports from UK national hemovigilance scheme, Serious Hazards of Transfusion (2010‐2019), where patients failed to receive irradiated components when indicated according to British Society for Haematology guidelines (2011).

Results

There were 956 incidents of failure to receive irradiated components all due to errors. One hundred and seventy two incidents were excluded from analysis, 125 of 172 (72.7%) because of missing essential information. No cases of TA‐GvHD were reported in this cohort. The 784 patients received 2809 components (number unknown for 67 incidents). Most failures occurred in patients treated with purine analogues (365) or alemtuzumab (69), or with a history of Hodgkin lymphoma (HL) (192). Together these make up 626 of 784 (79.9%). Poor communication is an important cause of errors.

Conclusion

Leucodepletion appears to reduce the risk for TA‐GvHD. None of 12 cases of TA‐GvHD reported to SHOT prior to introduction of LD occurred in patients with conditions recommended for irradiated components by current guidelines. Irradiation indefinitely for all stages of HL is not based on good evidence and is a difficult guideline to follow. Further research on long‐term immune function in HL is required. Variation between different national guidelines reflects the very limited evidence.

Immunotherapy Using Chimeric Antigen Receptor-Engineered T Cells: A Novel Cellular Therapy with Important Implications for the Clinical Laboratory

BACKGROUND

We have entered a new era of cancer therapy, with a number of immune-based therapies already used clinically as a standard of care. Adoptive cellular immunotherapy using T cells genetically modified with chimeric antigen receptors (CAR-T cells) represents a novel therapeutic approach. CAR-T cells have produced clinical responses in B-cell malignancies that are otherwise refractory to conventional therapies. Two CAR-T cell therapies obtained regulatory approval in 2017, with many more of these therapies under clinical development.

CONTENT

This review focuses on the current state of adoptive cellular immunotherapy, specifically CAR-T cells, in the clinic and how this therapy differs from traditional small molecule and biologic therapies. Areas in which the clinical laboratory is affected by these novel therapies are discussed. Opportunities for the clinical laboratory to help guide these therapies are also highlighted.

SUMMARY

The clinical laboratory will play an integral role in the care of patients undergoing adoptive cellular therapy with engineered T cells. There are many ways that this new therapeutic approach affects the clinical laboratory, and the clinical laboratory will likely play a critical role in managing patients that are treated with CAR-T cell therapy.

Transfusion-associated graft-versus-host disease: A concise review

Transfusion-associated graft-versushost disease (TA-GVHD) represents a rare fatal event observed in immunocompromised patients and immunocompetent individuals. The main clinical features of this transfusion reaction are pancitopenia and multiorgan failure (skin, liver, gut). The possible pathogenesis includes donor T lymphocyte proliferation in blood, their engraftment and host tissue attack. The purpose of this narrative review was analyzing the international guidelines for irradiation of cellular blood components to prevent TA-GVHD. A literature search was conducted using PubMed articles published between January 2000 to July 2018. American, Australian, British and Japanese transfusion guidelines have been compared regarding clinical indications. The contribution of manuscripts has been focused on recipients of Haematopoietic Stem Cell Transplantation, severe cellular immunodeficient patients, fetuses and neonates, immunocompentent individuals. Furthermore, 348 cases of TA-GVHD in the last five decades have been documented according to a recent systematic review. The standard of care to prevent this complication is gamma or x irradiation of cellular blood products. New treatments with pathogen inactivation appear safe and effective against proliferating white blood cells and T cells. Further clinical and biological studies are necessary to better characterize immunocompetence of T cells and select alternative preventive strategies.

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.

Platelet Transfusion for Patients With Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update

Purpose

To provide evidence-based guidance on the use of platelet transfusion in people with cancer. This guideline updates and replaces the previous ASCO platelet transfusion guideline published initially in 2001.

Methods

ASCO convened an Expert Panel and conducted a systematic review of the medical literature published from September 1, 2014, through October 26, 2016. This review builds on two 2015 systematic reviews that were conducted by the AABB and the International Collaboration for Transfusion Medicine Guidelines. For clinical questions that were not addressed by the AABB and the International Collaboration for Transfusion Medicine Guidelines (the use of leukoreduction and platelet transfusion in solid tumors or chronic, stable severe thrombocytopenia) or that were addressed partially (invasive procedures), the ASCO search extended back to January 2000.

Results

The updated ASCO review included 24 more recent publications: three clinical practice guidelines, eight systematic reviews, and 13 observational studies.

Recommendations

The most substantial change to a previous recommendation involved platelet transfusion in the setting of hematopoietic stem-cell transplantation. Based on data from randomized controlled trials, adult patients who undergo autologous stem-cell transplantation at experienced centers may receive a platelet transfusion at the first sign of bleeding, rather than prophylactically. Prophylactic platelet transfusion at defined platelet count thresholds is still recommended for pediatric patients undergoing autologous stem-cell transplantation and for adult and pediatric patients undergoing allogeneic stem-cell transplantation. Other recommendations address platelet transfusion in patients with hematologic malignancies or solid tumors or in those who undergo invasive procedures. Guidance is also provided regarding the production of platelet products, prevention of Rh alloimmunization, and management of refractoriness to platelet transfusion ( www.asco.org/supportive-care-guidelines and www.asco.org/guidelineswiki ).

Adverse Reactions to Transfusion of Blood Products and Best Practices for Prevention

Transfusion, a common practice in critical care, is not without complication. Acute adverse reactions to transfusion occur within 24 hours and include acute hemolytic transfusion reaction, febrile nonhemolytic transfusion reaction, allergic and anaphylactic reactions, and transfusion-related acute lung injury, transfusion-related infection or sepsis, and transfusion-associated circulatory overload. Delayed transfusion adverse reactions develop 48 hours or more after transfusion and include erythrocyte and platelet alloimmunization, delayed hemolytic transfusion reactions, posttransfusion purpura, transfusion-related immunomodulation, transfusion-associated graft versus host disease, and, with long-term transfusion, iron overload. Clinical strategies may reduce the likelihood of reactions and improve patient outcomes.