Recipient clinical risk factors predominate in possible transfusion-related acute lung injury

BACKGROUND

Possible transfusion-related acute lung injury (pTRALI) cases by definition have a clear temporal relationship to an alternative recipient risk factor for acute respiratory distress syndrome (ARDS). We questioned whether transfusion factors are important for the development of pTRALI.

STUDY DESIGN AND METHODS

In this nested case-control study, we prospectively identified 145 consecutive patients with pTRALI and randomly selected 163 transfused controls over a 4-year period at the University of California at San Francisco and the Mayo Clinic (Rochester, Minnesota).

RESULTS

For pTRALI, we found evidence against transfusion being important: receipt of plasma from female donors (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.29-2.3; p = 0.70), total number of units transfused (OR, 0.99; 95% CI, 0.89-1.10; p = 0.86), and number of red blood cell and whole blood units transfused (OR, 0.78; 95% CI, 0.59-1.03; p = 0.079). In contrast, we found that risk for pTRALI was associated with additional recipient factors: chronic alcohol abuse (OR, 12.5; 95% CI, 2.8-55; p < 0.001), current smoker (OR, 4.2; 95% CI, 1.67-10.8; p = 0.0024), shock before transfusion (OR, 4.6; 95% CI, 2.0-10.7; p < 0.001), and positive fluid balance before transfusion (OR, 1.32/L; 95% CI, 1.20-1.44; p < 0.001).

CONCLUSION

Recipient risk factors for ARDS rather than transfusion risk factors predominate in pTRALI.

Cancer Incidence and Mortality in a Cohort of US Blood Donors: A 20-Year Study

Blood donors are considered one of the healthiest populations. This study describes the epidemiology of cancer in a cohort of blood donors up to 20 years after blood donation. Records from donors who participated in the Retroviral Epidemiology Donor Study (REDS, 1991-2002) at Blood Centers of the Pacific (BCP), San Francisco, were linked to the California Cancer Registry (CCR, 1991-2010). Standardized incidence ratios (SIR) were estimated using standard US 2000 population, and survival analysis used to compare all-cause mortality among donors and a random sample of nondonors with cancer from CCR. Of 55,158 eligible allogeneic blood donors followed-up for 863,902 person-years, 4,236 (7.7%) primary malignant cancers were diagnosed. SIR in donors was 1.59 (95% CI = 1.54,1.64). Donors had significantly lower mortality (adjusted HR = 0.70, 95% CI = 0.66-0.74) compared with nondonor cancer patients, except for respiratory system cancers (adjusted HR = 0.93, 95% CI = 0.82-1.05). Elevated cancer incidence among blood donors may reflect higher diagnosis rates due to health seeking behavior and cancer screening in donors. A "healthy donor effect" on mortality following cancer diagnosis was demonstrated. This population-based database and sample repository of blood donors with long-term monitoring of cancer incidence provides the opportunity for future analyses of genetic and other biomarkers of cancer.

Genetic research in the blood bank: acceptability to Northern California donors

BACKGROUND

Blood banks have large altruistic donor populations and existing infrastructure that make them attractive sites for genetic epidemiologic research, but donors' willingness to participate and the impact on blood donation are unknown.

STUDY DESIGN AND METHODS

A total of 2162 blood donors in Northern California responded to a cross-sectional questionnaire in August and September 2007. Participants were asked their likelihood of participation and future blood donation under three different scenarios: identity-linked genetic research, identity-unlinked genetic research, and genetic testing as a service.

RESULTS

The majority of blood donors indicated that they would be likely or very likely to participate in identity-linked genetic research (67%) and in identity-unlinked genetic research (54%). While older donors and more frequent donors were more likely to participate in identity-linked research, younger, Caucasian, more educated, and more frequent donors were more likely to participate in identity-unlinked research. Less than 10% of donors indicated they would be less likely to donate blood in the future if genetic research was conducted at blood banks. More than 75% of donors would be interested in genetic testing as an optional service at the blood bank, but more than 20% of donors would be less likely to donate if such a service was offered.

CONCLUSION

Overall, we found that the majority of blood donors would be likely to participate in genetic research and that less than 10% would be less inclined to donate if such research was conducted by blood banks.

Blood donor satisfaction and intention of future donation

BACKGROUND

New regulatory requirements for donor eligibility challenge blood centers to recruit and retain enough donors. This study evaluated correlations between overall satisfaction with the donation process and donor demographics and the effect of both on a donor's intent to return.

STUDY DESIGN AND METHODS

An anonymous, self-administered questionnaire was given to donors at multiple sites of one blood center over a 3-week period. First-time and repeat donors were asked questions on demographic characteristics, satisfaction with the current donation process, motivation for current and future donations, and intent to return.

RESULTS

More than 75 percent of donors rated the overall donation process at 9 or 10 on a scale of 10 (mean, 9.19; standard deviation, 1.09), with female, high school-educated, and first-time donors giving higher satisfaction ratings than male, college-educated, and repeat donors, respectively (all p < 0.001). Donor satisfaction was correlated with intent to return for another donation (p = 0.002). For the current donation, donors rated altruistic motivations most highly. Medical testing was the most highly rated incentive for future donations, followed by frequent donor programs and convenient donation times and locations; preferences varied by demographic subgroup.

CONCLUSIONS

Blood donor satisfaction varies among demographic and donation history subgroups and is positively correlated with the intent to return for future donation. Although the primary motivation among all donors was altruism, incentives to future donation may need to be tailored according to demographic subgroups.

The consequences of temporary deferral on future whole blood donation

BACKGROUND

The consequences of temporary deferral are not well understood. This study sought to investigate blood donor return after deferral expiration.

STUDY DESIGN AND METHODS

A retrospective cohort analysis of allogeneic whole-blood donation was conducted. All deferred donors and a random sample of eligible donors were identified from the year 2000, with subsequent blood center visits through December 2005 captured. Stratified results are reported as the percentage returning, rates of return, and time to return. Measures of statistical association and Cox regression modeling are reported.

RESULTS

For first-time (FT) donors, 25 percent of temporarily deferred donors returned during the 5-year follow-up period compared to 47 percent of eligible donors (p < 0.0001); for repeat donors, 81 and 86 percent of deferred and eligible donors returned, respectively (p < 0.0001). Depending on the deferral category, 14 to 31 percent of FT and 58 to 90 percent of repeat donors returned. Rates (per year) of successful donation during the follow-up period were 0.09 for index-deferred FT donors, 0.28 for eligible FT donors, 1.0 for deferred repeat donors, and 1.45 for eligible repeat donors. Multivariate modeling indicated that in addition to deferral, age, sex, race, and education were associated with return in both FT and repeat donors.

CONCLUSION

The effects of deferral were more pronounced than expected, affecting both FT and repeat donors. For FT donors, the type and duration of deferral, while important, were not as relevant as hypothesized because so few returned, suggesting the need to develop appropriate interventions to recapture those donors likely to be eligible.

Quantifying losses to the donated blood supply due to donor deferral and miscollection

BACKGROUND

Donors are deferred for multiple reasons. Losses related to disease marker rates are well established. Donor and donation losses for other reasons, however, have not been extensively quantified.

STUDY DESIGN AND METHODS

To quantify these losses, three data sets from the Blood Centers of the Pacific were combined, permitting detailed analysis of year 2000 allogeneic whole-blood donations.

RESULTS

During 2000, 13.6 percent of 116,165 persons who presented for donation were deferred at presentation. Short-term deferral accounted for 68.5 percent (hematocrit was most common at 60%); long-term deferral accounted for 21 percent (travel to a malarial area and tattoo or other nonintravenous drug use needle exposure were most common at 59 and 29%, respectively); and multiple-year or permanent deferral accounted for 10.5 percent (UK travel [variant Creutzfeldt-Jakob disease] risk and emigration from a malarial area were most common at 38 and 11%, respectively). Disease-marker-reactive donations represented 0.9 percent of donor outcomes. The prevalence of deferral and also miscollection (under- and overweight units) varied by age, sex, and first-time versus repeat donor status. Overall, miscollection led to a loss of 3.8 percent of 100,141 collections, ranging from 1.9 percent in repeat male donors 40 to 54 years of age to 10.7 percent in first-time female donors 16 to 24 years of age.

CONCLUSION

Loss of units from both first-time and repeat donors due to temporary deferral and loss of units from miscollection are more common events than losses due to disease marker testing. Some of these losses may be avoidable and could increase the blood supply without having to recruit new donors.

Do blood donors read and understand screening educational materials?

BACKGROUND

Blood donors with high-risk behaviors may not self-defer because they failed to read or understand the screening educational materials.

STUDY DESIGN AND METHODS

In 1993, a total of 34,726 allogeneic donors responded to an anonymous mail survey of 50,162 donors that inquired about demographics, donor status, amount of the donor educational materials read, new HIV knowledge gained, and donors' opinions on the length and difficulty of materials.

RESULTS

Although 78 percent reported reading all materials, only 32 percent indicated reading carefully; 34 percent learned new information about HIV and 95 percent perceived the materials as easy to understand. First-time donors were more likely to read carefully (OR, 7.9) and gain more HIV knowledge from the materials (OR, 1.9) than repeat donors. Minority, less educated, screening test-reactive, and HIV test-seeking donors reported reading the materials more carefully and learning more about HIV than their respective counterparts. Donors with less education, those with reactive screening tests, those seeking HIV test results, and those not reporting a risk behavior were more likely to find the materials difficult to understand.

CONCLUSION

Most donors reported skimming and not having difficulty understanding the educational materials. Some donors may be aware that they should not donate or are failing to assimilate the information in the materials. Methods to present information more clearly and concisely are clearly needed. However, some high-risk donors may still continue donating no matter how improved the educational materials are.

Detecting failed WBC-reduction processes: a quality assurance program introduced in a blood center

BACKGROUND

Pragmatic yet statistically valid quality assurance (QA) programs are necessary so that blood centers can select, validate, and monitor their WBC-reduction processes. A QA system for WBC-reduction processes based on the practical application of statistical theory within a large blood center was developed. The system identifies parameters for procedure and component evaluation and provides sample size and formatting suggestions.

STUDY DESIGN AND METHODS

Analyses of both procedure and component performance were undertaken during the purchase, validation, and control of filtration and apheresis WBC-reduction processes at Blood Centers of the Pacific from 1997 through 1999. QA analysis was categorized on the basis of whether the process was new to the organization or was a modification of a previously validated system. The numbers of samples necessary to consistently detect failure in platelet yield, unit volume, pH, and WBC count was statistically determined by parametric and nonparametric techniques.

RESULTS

Parametric analysis (power analysis) of the mean +/- SD of smaller numbers of samples was highly sensitive to shifted distributions, but only if the shift was normally distributed. Nonparametric analysis, necessary when the nature of the underlying distribution is unknown, suggested a minimal sample of 40 was required to achieve high confidence that significant bimodal failure (a secondary population with WBCs 5% above the cutoff) would be detected.

CONCLUSION

A QA system, developed for the evaluation of new or revised WBC-reduction processes, was based on statistical analysis of normally and non-normally distributed process failure. The number of samples was determined that allowed the achievement of confidence and tolerance levels considered appropriate within the blood center. Suggestions for outlier evaluation and a format for performance documentation have also been developed. To better define blood center quality goals, further research is necessary on donor and component biologic variability and the most significant modes of WBC-reduction process failure.

An evaluation of the need for shared blood donor deferral registries

OBJECTIVE

This study examined the frequency with which allogeneic, volunteer blood donors who had been deferred from donation at one blood collection facility donated, or attempted to donate, at a second blood collection facility.

METHODS

The blood donor computer files of two local blood collection facilities were-combined and matched donors on the donor deferral registry of each blood collection facility were identified.

RESULTS

Of 26,300 donors in the hospital-based blood bank file, 6732 (25.6%) were matched to the community blood center donor file (active donor base approximately 275,000). Matched donors on the donor deferral registry at each blood collection facility numbered 427 (6.3% of total matched donors). A total of 103 evaluable donors (1.5% of total, or 24.1% of deferred, matched donors) had been deferred at one blood collection facility and then later donated, or attempted donation, at the other blood collection facility. Of these 103, 51 were allogeneic donors who had been notified of their deferral status and should not have subsequently attempted blood donation. Thirty-two donors on the donor deferral registry of one blood collection facility made donations at the second blood collection facility which entered the general blood inventory.

CONCLUSION

Shared donor deferral registries may be valuable at the local or regional level to prevent deferred blood donors from donating at other blood collection facilities. Whether or not a national donor deferral registry would be efficacious remains to be proven and deserves further study.

An unusual case of autoimmune hemolytic anemia with reticulocytopenia, erythroid dysplasia, and an IgG2 autoanti-U

BACKGROUND

Autoantibodies with anti-U specificity, usually in combination with autoantibodies of other specificities, have occasionally been identified in association with autoimmune hemolytic anemia. A case of life-threatening autoimmune hemolytic anemia, characterized by several atypical features, including apparent intravascular hemolysis associated with an IgG2 anti-U, reticulocytopenia, and bone marrow dyserythropoiesis is described.

CASE REPORT

A 36-year-old man with a severe case of acute-onset autoimmune hemolytic anemia was admitted to another hospital; he had a hematocrit of 15 percent, elevated bilirubin and lactate dehydrogenase, and positive direct and indirect antiglobulin tests. He received 7 units of incompatible red cells without improvement in hematocrit, and he was transferred to University Hospitals of Cleveland (OH). He was jaundiced and became syncopal in the sitting position. His serum was reddish pink; he had a hematocrit of 11.8 percent and a reticulocyte count of 2.5 percent. No spherocytes were observed in the peripheral blood smear. Shortly after admission, the hematocrit fell to 6.9 percent. He was given 3 units of "least-incompatible" red cells and was started on prednisone, with little improvement. An IgG2 autoanti-U was detected in his serum. Seven units of U- red cells were transfused over the next 4 days. The hematocrit improved to 23 percent and continued to rise without further transfusion. A bone marrow examination, initially revealing erythroid hyperplasia accompanied by dyserythropoiesis, became morphologically normal. Drug studies failed to show evidence of drug-related hemolysis. He remains well 2 years after discharge without evidence of recurrent hemolysis.

CONCLUSION

Severe life-threatening autoimmune hemolytic anemia, in this instance induced by an autoanti-U, may be associated with IgG2 autoantibody and characterized by apparent intravascular hemolysis and bone marrow dyserythropoiesis. Early treatment with U- blood, in addition to steroids, may be beneficial.

Bacterial contamination of platelets at a university hospital: increased identification due to intensified surveillance

BACKGROUND

A cluster of bacterial contamination of platelets occurred at a university hospital in a one-month period. This unusual clustering allowed us to examine the likely mechanism of contamination and clinical sequelae.

METHODS

We reviewed medical records of patients receiving random donor platelet transfusions to determine numbers of platelets transfused, reactions reported, and episodes of bacterial contamination. We also reviewed procedures at the collecting blood agencies and the hospital blood bank.

RESULTS

Four patients received bacterially contaminated platelets during June and July 1991. The rates of reported platelet transfusion reactions increased significantly (P < 0.001) from September 1989 through July 1991 (study period); in addition, the rate of contamination of platelets during June and July 1991 was 23-fold higher than during the previous 21 months (P < 0.001). Surveillance methodology changed dramatically during the study period, contributing to the recognition of the current cluster. Pathogens isolated from the contaminated platelet pools were Bacillus cereus, Staphylococcus epidermidis, or Pseudomonas aeruginosa in titers ranging from 10(6) to 10(8) colony forming units/mL. Four constituent individual platelet units identified as the probable cause of the outbreak (including one postepidemic episode) were significantly older (mean age, 4.8 days) than 106 randomly selected individual platelet units (mean age, 3.7 days; P = 0.04). Platelet pools were transfused an average of 2.5 hours after pooling. Review of blood collection and platelet preparation practices did not identify breaks in procedure or technique that could have caused contamination.

CONCLUSIONS

Increased awareness of platelet transfusion reactions by clinical staff and routine culturing of all platelets associated with transfusion reactions will identify contaminated platelets. Identification of contaminated platelets is necessary to treat affected patients appropriately and to determine the prevalence of and risk factors for contaminated platelets (Infect Control Hosp Epidemiol 1994;15:82-87).

A prospective microbiologic surveillance program to detect and prevent the transfusion of bacterially contaminated platelets

After two patients received bacterially contaminated platelet transfusions, a prospective surveillance program was instituted to perform Gram staining and microbiologic culturing of platelets at the time of transfusion. In 12 months, 3141 random-donor platelet pools (prepared from 14,481 units) and 2476 single-donor apheresis units were cultured. All single-donor apheresis units were sterile, but 6 (0.19%) of the random-donor pools were found to be bacterially contaminated, with 1 unit of 5 in the pool being the source in each case. Contaminants were Staphylococcus epidermidis (4 cases), Bacillus cereus (1), and Staphylococcus aureus (1) at counts of 0.5 x 10(2) to 10(11) colony-forming units per mL in platelet pools and 10(3) to 10(13) colony-forming units per mL in source units. The contamination rate for units transfused at < or = 4 days (1.8/10,000) was significantly lower than that at 5 days (11.9/10,000; p < 0.05), as was the magnitude of contamination (p < 0.05). Use of the pretransfusion Gram stain on 4- and 5-day-old platelet pools was 100 percent sensitive (4/4 true positives) and 99.93 percent specific (1 false positive) in detecting contaminated pools. These data define the extent and magnitude of platelet bacterial contamination and demonstrate the efficacy of the pretransfusion Gram stain on platelet units stored for 4 and 5 days in preventing the transfusion of heavily contaminated units. It is concluded that the risk of platelet contamination is related to the duration of component storage.(ABSTRACT TRUNCATED AT 250 WORDS)

Autologous blood donation in nonorthopaedic surgical procedures as a blood conservation strategy

Autologous blood donation in many nonorthopaedic procedures is controversial. Our study of 408 consecutive such procedures could be divided into two groups. In group I, the anticipated probability for homologous blood transfusion was very low (less than 5%): vaginal hysterectomy and miscellaneous gynecologic procedures, obstetrical delivery, mammoplasty and cholecystectomy. In group II, the anticipated probability for homologous blood transfusion was high (greater than 5%): open heart and vascular surgery, neurosurgery, mastectomy, abdominal and radical hysterectomy, and extensive urologic procedures. We conclude that for procedures in which the blood transfusion probability is very low, autologous blood donation should not be encouraged; this practice should be promoted in procedures in which the blood transfusion probability is 'high' (i.e. greater than 5%), with emphasis on maximizing autologous blood collection in order to minimize homologous blood transfusion.

Antibodies to hepatitis C virus in autologous blood donors

Hepatitis C virus (HCV) is the major cause of posttransfusion hepatitis. Two anti-HCV enzyme immunoassay (EIA) kits and one recombinant immunoblot assay (RIBA) were used to test serum samples of 1476 donations from 692 autologous blood donors to assess the prevalence of anti-HCV and its relationship to transfusion history. Of all autologous blood donations, 23 (1.6%) reacted when tested with one EIA kit and 29 (2.0%) reacted when tested by the other EIA kit. Of the autologous donors, 12 (1.78%) reacted by the first EIA kit and 14 (2.02%) by the second. Discrepancies in the EIA results from different donations by the same donor were seen in seven donors. The RIBA was positive or indeterminate in 33 percent of the EIA-reactive donations and in 41 percent of EIA-reactive donors. All RIBA-positive and -indeterminate samples reacted with both EIA kits. There was no significant difference in the EIA-reactive rates of autologous and first-time homologous blood donors. Previously transfused autologous blood donors had a higher anti-HCV EIA-reactive rate than nontransfused autologous donors, but the difference was not significant. In regard to hepatitis C, the use of autologous blood for homologous transfusion appears to be as safe as the use of blood from first-time homologous donors. Universal testing of previously transfused patients for hepatitis C appears premature at this time. Discrepant anti-HCV EIA results from different donations from the same individual have implications regarding donor deferral.

Hb Cleveland or alpha 2 beta 2(93)(F9)Cys----Arg;121(GH4)Glu----Gln

Hb Cleveland is characterized by two amino acid substitutions, namely beta 121(GH4)Glu----Gln as in Hb D-Los Angeles and beta 93(F9)Cys----Arg as in Hb Okazaki, and shares with Hb Okazaki a decreased stability, an increase in oxygen affinity, and decreases in Bohr effect and heme-heme interaction. It is the 13th beta chain variant with two substitutions that has been described thus far.

Mutant cells defective in poly(ADP-ribose) synthesis due to stable alterations in enzyme activity or substrate availability

We used two different approaches to develop cell lines deficient in poly(ADP-ribose) synthesis to help determine the role of this reaction in cellular functions. One approach to this problem was to develop cell lines deficient in enzyme activity; the other approach was to develop cell lines capable of growing with such low nicotinamide adenine dinucleotide (NAD) levels so as to effectively limit substrate availability for poly(ADP-ribose) synthesis. The selection strategy for obtaining cells deficient in activity of poly(ADP-ribose) polymerase was based on the ability of this enzyme to deplete cellular NAD in response to high levels of DNA damage. Using this approach, we first obtained cell lines having 37-82% enzyme activity compared to their parental cells. We now report the development and characterization of two cell lines which were obtained from cells having 37% enzyme activity by two additional rounds of further mutagenization and selection procedures. These new cell lines contain 5-11% enzyme activity compared to the parental V79 cells. In pursuit of the second strategy, to obtain cells which limit poly(ADP-ribose) synthesis by substrate restriction, we have now isolated spontaneous mutants from V79 cells which can grow stably in the absence of free nicotinamide or any of its analogs. These cell lines maintain NAD levels in the range of 1.5-3% of that found in their parental V79 cells grown in complete medium. The pathway of NAD biosynthesis in these NAD-deficient cells is not yet known. Further characterization of these lines showed that under conditions that restricted poly(ADP-ribose) synthesis, they all had prolonged doubling times and increased frequencies of sister chromatid exchanges.