Reducing the wastage of fresh frozen plasma in a hospital blood bank through the use of Six Sigma principles

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Background: MD Anderson Cancer Center is one of the largest users of blood products in the United States, with approximately 3,600 units of blood (PRBCs) transfused per month, and over 500 units of fresh frozen plasma (FFP) transfused per month. The wastage of blood products has both financial and patient care implications, as well as implications to donors. Decreasing blood product wastage is an institutional priority in terms of both resource utilization and cost savings. Methods: Outside metrics for the waste of blood products published by the American Association of Blood Banks (AABB) were compared to current data on the percentage wastage of blood products for fiscal year 2020. A dedicated project team set an aim to reduce the wastage of FFP by 25% from Q4 2020 to Q3 2021. Using Six Sigma principles, a run chart was developed to track units FFP ordered and transfused from October 2020 – March 2021. Minitab software was used to calculate mean FFP ordered, the upper confidence interval, as well as 2 standard deviations above the mean to determine a new maximum FFP thaw level. Results: The historical FFP “thaw level” was 32 units of FFP thawed per day. From October 2020 – March 2021, the average number of FFP units ordered per day was 8. The upper confidence level was 32, and 2 standard deviations was 24 units. After identifying 3 data points that were “out of control” and unrepresentative of actual usage, these values were adjusted to 7.5 units and 19.5 units, respectively. Based on this data, the daily thaw level was adjusted from 32 units per day to 20 units per day on June 21st 2021. As of Q3 2021, this has resulted in a 40.7% decrease in the wastage of FFP. Conclusions: The application of Six Sigma principles was an effective way to identify variation in the ordering of fresh frozen plasma (FFP), and allowed for a sizeable reduction in the daily thaw level of this blood product. Post-intervention, there has been a dramatic decline in the wastage of FFP, resulting in cost savings for our institution and better stewardship of this scare resource.

The Role of Granulocyte Transfusions in Optimizing Candidacy for Chimeric Antigen Receptor T-cell Therapy in Patients With Treatment-refractory Infections

While advancements in cellular therapy have improved outcomes for patients with refractory leukemia, severe infections may hinder access. Granulocyte transfusions, in combination with anti-microbial therapy, may be a safe option to facilitate candidacy for chimeric antigen receptor T-cell therapy in patients with leukemia and prolonged immune-compromised status.

Third-Party BK Virus-Specific Cytotoxic T Lymphocyte Therapy for Hemorrhagic Cystitis Following Allotransplantation

PURPOSE

BK virus-associated hemorrhagic cystitis (BKV-HC) is a common complication of allogenic hematopoietic stem cell transplantation (AHSCT), particularly in recipients of alternative donor transplants, which are being performed in increasing numbers. BKV-HC typically results in painful hematuria, urinary obstruction, and renal dysfunction, without a definitive therapeutic option.

METHODS

We performed a clinical trial (ClinicalTrials.gov identifier: NCT02479698) to assess the feasibility, safety, and efficacy of administering most closely HLA-matched third-party BKV-specific cytotoxic T lymphocytes (CTLs), generated from 26 healthy donors and banked for off-the-shelf use. The cells were infused into 59 patients who developed BKV-HC following AHSCT. Comprehensive clinical assessments and correlative studies were performed.

RESULTS

Response to BKV-CTL infusion was rapid; the day 14 overall response rate was 67.7% (40 of 59 evaluable patients), which increased to 81.6% among evaluable patients at day 45 (40 of 49 evaluable patients). No patient lost a previously achieved response. There were no cases of de novo grade 3 or 4 graft-versus-host disease, graft failure, or infusion-related toxicities. BKV-CTLs were identified in patient blood samples up to 3 months postinfusion and their in vivo expansion predicted for clinical response. A matched-pair analysis revealed that, compared with standard of care, after accounting for prognostic covariate effects, treatment with BKV-CTLs resulted in higher probabilities of response at all follow-up timepoints as well as significantly lower transfusion requirement.

CONCLUSION

Off-the-shelf BKV-CTLs are a safe and effective therapy for the management of patients with BKV-HC after AHSCT.

High Levels of Common Cold Coronavirus Antibodies in Convalescent Plasma Are Associated With Improved Survival in COVID-19 Patients

Background

COVID-19 Convalescent plasma (CCP) is safe and effective, particularly if given at an early stage of the disease. Our study aimed to identify an association between survival and specific antibodies found in CCP.

Patients and Methods

Patients ≥18 years of age who were hospitalized with moderate to severe COVID-19 infection and received CCP at the MD Anderson Cancer Center between 4/30/2020 and 8/20/2020 were included in the study. We quantified the levels of anti-SARS-CoV-2 antibodies, as well as antibodies against antigens of other coronavirus strains, in the CCP units and compared antibody levels with patient outcomes. For each antibody, a Bayesian exponential survival time regression model including prognostic variables was fit, and the posterior probability of a beneficial effect (PBE) of higher antibody level on survival time was computed.

Results

CCP was administered to 44 cancer patients. The median age was 60 years (range 37-84) and 19 (43%) were female. Twelve patients (27%) died of COVID-19-related complications. Higher levels of two non-SARS-CoV-2-specific antibodies, anti-HCoV-OC43 spike IgG and anti-HCoV-HKU1 spike IgG, had PBE = 1.00, and 4 SARS-CoV-2-specific antibodies had PBEs between 0.90 and 0.95. Other factors associated with better survival were shorter time to CCP administration, younger age, and female sex.

Conclusions

Common cold coronavirus spike IgG antibodies anti-HCoV-OC43 and anti-HCoV-HKU1 may target a common domain for SARS-CoV-2 and other coronaviruses. They provide a promising therapeutic target for monoclonal antibody production.

High levels of common cold coronavirus antibodies in convalescent plasma are associated with improved survival in COVID-19 patients

BACKGROUND

COVID-19 Convalescent plasma (CCP) is safe and effective, particularly if given at an early stage of the disease. Our study aimed to identify an association between survival and specific antibodies found in CCP.

PATIENTS AND METHODS

Patients ≥18 years of age who were hospitalized with moderate to severe COVID-19 infection and received CCP at the MD Anderson Cancer Center between 4/30/2020 and 8/20/2020 were included in the study. We quantified the levels of anti-SARS-CoV-2 antibodies, as well as antibodies against antigens of other coronavirus strains, in the CCP units and compared antibody levels with patient outcomes. For each antibody, a Bayesian exponential survival time regression model including prognostic variables was fit, and the posterior probability of a beneficial effect (PBE) of higher antibody level on survival time was computed.

RESULTS

CCP was administered to 44 cancer patients. The median age was 60 years (range 37-84) and 19 (43%) were female. Twelve patients (27%) died of COVID-19-related complications. Higher levels of two non-SARS-CoV-2-specific antibodies, anti-HCoV-OC43 spike IgG and anti-HCoV-HKU1 spike IgG, had PBE = 1.00, and 4 SARS-CoV-2-specific antibodies had PBEs between 0.90 and 0.95. Other factors associated with better survival were shorter time to CCP administration, younger age, and female sex.

CONCLUSIONS

Common cold coronavirus spike IgG antibodies anti-HCoV-OC43 and anti-HCoV-HKU1 may target a common domain for SARS-CoV-2 and other coronaviruses. They provide a promising therapeutic target for monoclonal antibody production.

Practice patterns and clinical outcomes of platelet alloimmunization in a comprehensive cancer center

BACKGROUND

Platelet transfusion refractoriness (PTR) secondary to human leukocyte antigen (HLA) alloimmunization is a challenge in the treatment of hematology-oncologypatients and increases the risk of morbidity and mortality from bleeding events. Guidelines for treating PTR have not been clearly described in literature. We aim to describe the practice patterns for the management of PTR secondary to HLA alloimmunization, and to assess the mortality, thrombosis and bleeding-related clinical outcomes at 30 days from diagnosis.

METHODS

A retrospective review of 51 cases of PTR secondary to HLA alloimmunization were analyzed.

RESULTS

The majority of patients (98 %) had a diagnosis of hematological malignancy of which 88.2 % were undergoing active chemotherapy. Clinically relevant bleeding, by ISTH criteria, was observed in 33.3 %; hemorrhagic shock was diagnosed in 7%. The rate of bleeding-related mortality was estimated at 7.8 %. The use of antifibrinolytics and plasma products (including intravenous immunoglobulin) was more common in cases with major versus non-major bleeding. Grade A or B1U HLA matched products were available in less than half of cases.

CONCLUSIONS

There is heterogeneity in the management of the bleeding risk and bleeding events during PTR, with antifibrinolytics more commonly used in patients who suffered severe bleeding. Grade A and B1U HLA-matched platelets are not always readily available, and HLA-typing and HLA-antibody testing are not always performed prior to PTR. Prospective randomized control trials may help to determine the safety and efficacy of antifibrinolytics and other supportive measures in the management of PTR.

Granulocyte transfusions in patients with skin and soft tissues infections and leukemia: Are they useful?

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Background: Granulocyte transfusions (GTX) have been proposed to improve clinical outcome of neutropenic patients (pts) with serious infections. We evaluated the impact of unirradiated GTX in pts with skin and soft tissue infections (SSTI) and leukemia. Methods: We did a retrospective analysis of pts with leukemia and SSTI that received GTX from 2014 to 2018. We analyzed infection outcome and changes in ANC after GTX. Donors were mobilized using G-CSF plus oral dexamethasone 12 hours prior to apheresis. Results: Twenty-seven pts received 141 GTX for 33 SSTI. Transfusions were unirradiated, except for 10 (7%) radiated units administered due to availability. Twenty pts were male (74%); median age was 59 yrs (20–83 yrs). Hematologic diagnoses included AML (23, 70%), MDS (3, 9%), ALL (3, 9%), CLL (2, 6%), CML (1, 3%), and MF (1, 3%). In 24 (73%) SSTI, pts had a baseline ANC<0.5 x109/L, 3 (9%) had ANC between 0.51x109L to 0.99 x 109L, and 6 (18%) with ANC >1 x109/L. After GTX, ANC increased in 99 (70%) cases by a median of 0.7 x 109/L (0.02 to 10.03) with a median peak time of 9 hrs (4 to114 hrs), with a median time from GTX to first drop of 34 hrs (10 to 136 hrs). ANC decreased in 27 (19%) (by a median -0.5 x 109/L,-0.02 to -2.41). There was no change of ANC in 15 (11%). Improvement was determined by reduction in fever and inflammation, or resolution of SSTI 7 days after first GTX. Twenty-seven (82%) episodes improved. In those improved, ANC remained <1.5x109/L in 15 (56%) episodes after last GTX and after improvement. Main adverse reactions were fever in 21% (29), and respiratory complications in 6% (9) (pulmonary effusion, respiratory distress and acute hypoxemia). One pt (3%) required intubation. There was no transfusion-related GVHD. Cumulative survival from first GTX on each SSTI by Kaplan-Meier Survival was 82% (8) at 30 days, 49% (17) at 90 days, 41% (17) at 180 days, and 24% (12) at 360 days. Eight of this pts died of infections, 4 of which were SSTI described on this paper. Conclusions: GTX have a beneficial effect on clinical improvement in patients with SSTI and underlying hematological malignancies and severe neutropenia. It can be safely administered without GVHD. Further prospective studies are warranted.

A small amount of cyclooxygenase 2 (COX2) is constitutively expressed in platelets

Cyclooxygenase (COX) is the rate-limiting enzyme in conversion of arachidonic acid to prostanoids, and has two isoforms, COX1 and COX2, which share ~65% amino acid homology. COX1 is universally expressed in many cell types including platelets; however, expression of COX2 is known to be more limited. We examined expression of COX2 mRNA and protein in platelets and platelet-derived microparticles (MPs); using quantitative RT-PCR, immunostaining, and Western blotting. We have detected a significant amount of COX2 in platelets, both at mRNA and protein levels. We found that COX1/COX2 mRNA and protein ratios in platelets were 370:1 and 17:1, respectively. Expression level of COX2 in platelets was less than COX1, but comparable to the expression of COX2 in malignant epithelial cells. Considering the important role of COX2 in tumorigenesis and thrombosis, and the large number of circulating platelets, we propose that platelet COX2 may play an important role in physiologic and pathologic conditions.

Lipid profile of platelets and platelet-derived microparticles in ovarian cancer

Background

Ovarian cancer patients have a high risk of developing venous thrombosis. The membrane lipid bilayer of platelets and platelet-derived microparticles (PMP) provides a platform for assembly of coagulation proteins and generation of blood clots.

Methods

We compared the lipid composition of platelets and PMPs in patients with ovarian cancer to those in healthy subjects. We used shotgun lipidomics to quantify 12 classes and 177 species of lipids.

Results

We found a significant change in 2 classes of lipids in platelets and PMPs isolated from ovarian cancer patients: higher phosphatidylinositol and lower lyso-phosphatidylcholine. The level of 28 species of lipids was also significantly altered in the direction of an increase in the pro-coagulant and a reduction in the anticoagulant lipids. We found that cancer platelets expressed less lipid phosphate phosphatase 1 (LPP1), a key enzyme in phospholipid biosynthesis pathways, than normal platelets. The reduction in LPP1 might contribute to the changes in the lipid profile of cancer platelets.

Conclusion

Our results support a procoagulant lipid profile of platelets in ovarian cancer patients that can play a role in the increased risk of venous thrombosis in these patients.

General significance

As far as we are aware, our study is the first study on platelet lipidomics in ovarian cancer. The importance of our findings for the future studies are: 1) a similar change in lipid profile of platelets and PMP may be responsible for hypercoagulability in other cancers, and 2) plasma level of high-risk lipids for venous thrombosis may be useful biomarkers.

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Lipid composition of platelet and PMP is altered in ovarian cancer.

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The change in lipid composition of platelet and PMP is in a procoagulant direction.

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LPP1 enzyme is reduced in cancer platelets.

Pure Red Cell Aplasia in Major ABO-Mismatched Allogeneic Hematopoietic Stem Cell Transplantation Is Associated with Severe Pancytopenia

In major ABO-mismatched allogeneic hematopoietic stem cell transplantation (HSCT) persistence of antidonor isohemagglutinins leads to pure red cell aplasia (PRCA). To investigate severe pancytopenia noted in a previous study of PRCA, we analyzed all major ABO-mismatched HSCT between January 2003 and December 2012. Of 83 PRCA patients, 13 (16%) had severe pancytopenia. Severe pancytopenia was defined as an absolute neutrophil count (ANC) < 1.5 K/μL or requiring granulocyte colony-stimulating factor, platelets < 50 K/μL or transfusion dependent, and PRCA with RBC transfusion dependence at post-transplant day 90. In 6 patients (46%) severe pancytopenia resolved after PRCA resolution. Two patients (15%) received a second transplant because of persistent pancytopenia/secondary graft failure, 1 (8%) died from secondary graft failure despite a stem cell boost, 1 (8%) did not recover his platelet counts despite RBC/ANC recovery, and 3 patients (23%) died from disease relapse. We found that severe pancytopenia is frequently associated with PRCA in 16% of major ABO-incompatible HSCT with a higher incidence in males and pancytopenia resolved with resolution of PRCA in 46% of patients.

Granulocyte concentrates from a single high-yield apheresis can be split to support multiple patients

Allogeneic granulocyte transfusion has evolved into a viable therapeutic option for immunocompromised severely neutropenic leukemic patients and those with hematopoietic stem cell transplant with life-threatening bacterial and fungal infections. The collection of larger cell doses of granulocyte concentrates (GCs) has been facilitated by the stimulation of donors with granulocyte colony stimulating factor (G-CSF) and dexamethasone. The synergistic effect of G-CSF and dexamethasone has allowed the collection of larger cell doses of GCs and its use has increased steadily. This has allowed us to split the high-yield GC products and facilitated distribution of the split GC products to a second or third patient who needs GCs but lacks donors. The main objective of this article was to present our rationale for splitting GC products and how the split GC units were transfused to multiple patients. We believe that split GCs are as equally effective as unsplit GCs and that multiple patients benefit from splitting GCs.

Analysis of the leprosy agents Mycobacterium leprae and Mycobacterium lepromatosis in four countries

OBJECTIVES

To differentiate the leprosy agents Mycobacterium leprae and Mycobacterium lepromatosis and correlate them with geographic distribution and clinicopathologic features.

METHODS

Species-specific polymerase chain reactions were used to detect each bacillus in archived skin biopsy specimens from patients with leprosy from Brazil (n = 52), Malaysia (n = 31), Myanmar (n = 9), and Uganda (n = 4). Findings were correlated with clinical and pathologic data.

RESULTS

Etiologic species was detected in 46 of the 52 Brazilian patients, including 36 patients with M leprae, seven with M lepromatosis, and three with both bacilli. The seven patients with sole M lepromatosis all had tuberculoid leprosy, whereas only nine of the 36 patients infected with M leprae exhibited this type, and the rest were lepromatous (P < .001). All patients with dual infections had lepromatous leprosy. Of the nine patients from Myanmar, six were test positive: four with M leprae and two with M lepromatosis. Of the Malaysian and Ugandan patients, only M leprae was detected in 27 of the 31 Malaysians and two of the four Ugandans.

CONCLUSIONS

The leprosy agents vary in geographic distribution. Finding M lepromatosis in Brazil and Myanmar suggests wide existence of this newly discovered species. The leprosy manifestations likely vary with the etiologic agents.

Incidence and natural history of pure red cell aplasia in major ABO-mismatched haematopoietic cell transplantation

Major ABO mismatching is not considered a contraindication to allogeneic haematopoietic stem cell transplantation (HSCT). Modern reduced-intensity conditioning and reduced-toxicity regimens cause much less myeloablation than conventional myeloablative regimens, such as cyclophosphamide with busulfan or total body irradiation, which may affect the incidence of pure red cell aplasia (PRCA). We estimated the incidence and described the natural history of PRCA in patients with major ABO-mismatched donor stem cells. Between 2007 and 2008, 161 (27% of all patients undergoing HSCT) underwent allogeneic HSCT with major ABO-mismatched stem cells and 12 (7·5%) of these patients developed PRCA. Thirty and ninety day T-cell and myeloid cell chimerism and neutrophil and platelet engraftment did not differ between patients who developed PRCA and those who did not. The only risk factor associated with PRCA was the use of a fludarabine/busulfan conditioning regimen. All patients with PRCA needed red cell transfusion for several months after HSCT resulting in significant iron overload. Pure red cell aplasia resolved spontaneously in the majority (seven patients) but only resolved after stopping tacrolimus in three patients. Hence, after major ABO-mismatched HSCT, the incidence of PRCA was 7·5% and it resolved spontaneously or after withdrawal of immunosuppression in the majority of patients.

Use of granulocytes concentrates from a single high yield apheresis to support more than one patient

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Background: Allogeneic granulocyte transfusion therapy is sometimes the only therapeutic option in immunocompromised neutropenic leukemic/HSCT patients with life threatening bacterial and fungal infections. Collection of larger cell doses of granulocyte concentrates (GC) by automated apheresis following G-CSF/steroids administration has renewed interest and its use has grown steadily. Methods: Donors were recruited from family/friends of the patients and informed consent was obtained. GCs were collected via donor stimulation with a single subcutaneous dose of G-CSF (600 mcg). First time donors received an oral dose of dexamethasone (8 mg). GCs were harvested by Hetastarch-assisted leukapheresis 12 hours later via peripheral venous access with the continuous flow cell separator Spectra (COBE Caridian BCT, Lakewood, CO). Results: GCs were collected from 93 donors (67M: 26F; age median 40 (19-73 years) and 1 ½ x blood volume processed median 7048 (3212-8085 mL). The pre/post wbc were median 8.1 (4.1-22.8)/ 42.7 (22.4-77.5). The volume collected was based on the post G-CSF wbc count (> 35 K/UL - 800 mL; <35 K/UL between 600-700 mL). The original yield (10 x10e) was median 9.7 (5.1-17.2 units), volume median 718 (538-860 mL) and WBC median 132.7 (84.2 -241.6 K/UL per bag). The Split GCs were median 4.48 (2.70-7.72 units), with neutrophils median 87% (54-97% per bag). GCs were transfused to 51 patients (31M: 20F; age median 58 [19-83 years]) who received median 3.5 (1-18 split units), containing wbcs median 10734.69 [5778-42 -162698.09 (x10^3/uL)/unit) and achieved a WBC increment median 0.2 (0.0-8.3K/UL). Conclusions: The GCs were split due to the primary care team's reluctance to transfuse the entire volume of the product due to volume restrictions or for some other medical reason. The same rationale to split platelets from high yield single apheresis was used to split our GC products. We found that GCs from each donor was utilized maximally and also brought partial relief to other patients who lacked donors. We would like to make the case that when adequate numbers of GCs are collected it may be feasible to split the unit. This may offer a glimmer of hope to other patients in need of GCs who lack a donor network support.

Results of HLA antibody testing using ELISA vs the fluorescent bead method and retrospective review of data for recipients of packed RBCs and platelets from male HLA-immunized donors

We reviewed HLA antibody testing results using an enzyme-linked immunosorbent assay (ELISA) for all male blood donors at our institution during a 3.5-month period to look for HLA immunization. Confirmatory testing of 33 blood samples positive for HLA class I and/or II antibodies was performed using the fluorescent bead method. A retrospective review of recipients of packed RBCs and platelets processed from these 33 HLA-immunized male donors were conducted to identify transfusion-related acute lung injury and cognate antigens. The agreement rates between the methods for HLA class I and II antibodies were 21% (7/33) and 6% (2/33), respectively. We noted HLA antibodies in the male donors corresponding to cognate antigens in 2 recipients of packed RBCs and in 3 recipients of platelets. Of 8 donors positive for HLA antibodies, 5 did not have a history of blood transfusion. We conclude that ELISA was too sensitive and had a high false-positive rate for the detection of HLA class II antibodies.