Alfredo Mendrone Júnior

Profile of blood donors with serologic tests reactive for the presence of syphilis in São Paulo, Brazil

BACKGROUND: Syphilis screening of blood donors is a common practice worldwide, but very little is known about the meaning of a positive serologic test for syphilis in blood donors and the risk profile of these donors. The aim of this study was to determine the demographic characteristics and risk behaviors of blood donors with recent and past syphilis and their implications for blood bank testing and deferral strategies.

Human immunodeficiency virus transfusion transmission despite nucleic acid testing

The residual risk of human immunodeficiency virus (HIV) transmission by blood transfusion in our blood center, Fundação Pró-Sangue (FPS), São Paulo, Brazil, was estimated to be approximately 1 per 100,000 donations by applying fourth-generation HIV antigen-antibody testing (Genscreen Ultra HIV Ag-Ab, Bio-Rad, Marnes La Coquette, France) and projected to be further reduced to 0.68 per 100,000 donations after adoption of nucleic acid testing (NAT, Bio-Manguinhos, Fiocruz, Brazil) on minipools of six donations in May 2011. In November 2012, a leukemia patient was submitted to serologic and nucleic acid testing (NAT). Anti-HIV reactivity (CMIA HIV Ag/Ab Combo Architect System, Abbott, Wiesbaden, Germany) was observed with a concomitant nonreactive Western blot (WB HIV Blot 2.2 Western blot assay, MP Diagnostics, Singapore) and HIV RNA was detected by NAT. This patient was previously tested for anti-HIV in July 2012 with nonreactive results. Between August and November 2012, he had received 47 transfusions of red blood cells (RBCs) and platelets (PLTs), all derived from FPS donors. Repository plasma samples from the corresponding donations, which are required by Brazilian guidelines to be retained for 6 months after donation, were retested individually by NAT (BioManguinhos) with nonreactive results. All implicated donors were invited to return to our blood center and provide a follow-up sample. Among the 37 donors that accepted this invitation, one seroconversion to anti-HIV was verified in a sample drawn on December 17, 2012, with a concomitant viral load of 39,658 copies/mL (HIV real-time viral load assay, Abbott). This donor has a history of two previous donations at our service before the implicated (index) donation that occurred on September 28, 2012. The repository sample from this donation also showed undetectable viremia by the same viral load test (95% limit of detection [LOD], 40 copies/mL). The HIV-infected recipient received the RBCs from this donation after 11 days of storage at 4°C, while the PLT component was transfused into another patient who died 2 days later, precluding further investigation. The plasma component from this donation was not transfused and subsequently retrieved, allowing for further study, as detailed below. The HIV pol gene (protease and RT) for the donor and recipient follow-up samples were polymerase chain reaction amplified, sequenced, and submitted to phylogenetic analysis together with pol sequences from several contemporary HIV isolates from São Paulo city blood donors and from distinct HIV Group M subtypes. After nucleotide substitution model estimation, a maximum likelihood tree was reconstructed with support values estimated from 1000 bootstrap replicates. The donor and recipient pol sequences showed 100% sequence identity, and according to the phylogenetic tree, belong to B subtype clade, the commonest among Brazilian patients (Fig. 1). The plasma bag from the index donation was thawed and used to prepare three coded panels consisting of 20 replicates of the undiluted index plasma, five replicates of this plasma diluted 6¥ with negative plasma, mimicking minipools of 6, and one sample from the diluent plasma. These panels were submitted to testing using three different NAT platforms: cobas TaqScreen MPX (95% LOD, 49 IU/mL; Roche, Branchburg, NJ), Procleix Ultrio (95% LOD, 20.72 copies/mL; Gen-Probe, San Diego), and NAT hepatitis C virus and HIV (95% LOD, 30 IU/mL or 13-39.9 copies/mL; Bio-Manguinhos); all three HIV RNA 95% LOD values were obtained from the respective package inserts. Reactivity was verified in a fraction of the undiluted aliquots by the Roche (3/20) and Novartis (13/20) assays. Interpolation of the detection rates verified into the probit analysis from the package inserts allows the estimation of the viral load to be in between 7.5 and 3.7 IU/mL, respectively, for Ultrio and TaqScreen (conversion factor, 0.6 copies/IU) confirming very low viremia in the index donation, well below the 40 copies/mL detection limit of viral load and minipool NAT assays (Table 1). This result suggests that the donor was in the eclipse or very early ramp-up phase at the time of the implicated donation, probably a few days after the infection. The implicated donor denied all risk factors in the interview performed at the time of the index donation and continued to deny high-risk behavior in three subsequent visits to the blood bank, after his HIV status was disclosed to him. He also missed the opportunity of self-deferral given by the confidential unit exclusion process preceding the implicated donation. It has been estimated that approximately 7% of our blood donors are test seekers and that the prevalence of test seekers is actually higher among first-time (FT) community donors than FT replacement donors. However, this individual, a 22-yearold male, was a repeat community donor, with a history of three previous donations at our center. Three relatives of the HIV-infected patient, who were the best candidates for marrow donation based on HLA compatibility typing, were tested for the CCR5D32 deletion in consideration of possible transplant to cure both his leukemia and his HIV infection, but unfortunately all were wild-type homozygous, not bearing the mutation associated with resistance to HIV infection. Highly active antiretroviral therapy was introduced and, after 60 days, the viral load was reduced to 69 copies/mL, when marrow transplantation was carried out. Up to March 28, 2013, the patient was alive and did not show any clinical sign of progression to AIDS. This report illustrates the limitation of laboratory testing for prevention of transmission of infectious agents,

Risk factors for deferral due to low hematocrit and iron depletion among prospective blood donors in a Brazilian center

Objective Deferral of blood donors due to low hematocrit and iron depletion is commonly reported in blood banks worldwide. This study evaluated the risk factors for low hematocrit and iron depletion among prospective blood donors in a large Brazilian blood center. Method A case–control study of 400 deferred donors due to low hematocrit and 456 eligible whole blood donors was conducted between 2009 and 2011. Participants were interviewed about selected risk factors for anemia, and additional laboratory tests, including serum ferritin, were performed. Bivariate and multivariate analyses were performed to assess the association between predictors and deferral due to low hematocrit in the studied population and iron depletion in women. Results Donors taking aspirins or iron supplementation, those who reported stomachache, black tarry stools or hematochezia, and women having more than one menstrual period/month were more likely to be deferred. Risk factors for iron depletion were repeat donation and being deferred at the hematocrit screening. Smoking and lack of menstruation were protective against iron depletion. Conclusion This study found some unusual risk factors related to gastrointestinal losses that were associated with deferral of donors due to low hematocrit. Knowledge of the risk factors can help blood banks design algorithms to improve donor notification and referral.

Study of possible clinical and laboratory predictors of alloimmunization against red blood cell antigens in cancer patients.

Background The inflammatory background of patients influences the process of alloimmunization against red blood cell antigens. Proof of this statement to clinical practice is still lacking. Objective The aim of this study was to verify whether factors related to disease severity and inflammatory status of cancer patients can predict alloimmunization. Methods This was a case-control study in which alloimmunized oncologic patients treated between 2009 and 2012 were compared with a non-alloimmunized control group regarding the severity of the disease (metastasis/performance status/body mass index) and C-reactive protein levels. Results The groups did not differ significantly in terms of C-reactive protein, Eastern Cooperative Oncology Group (ECOG)/Karnofsky performance status, presence of metastasis and body mass index. Conclusion It is not possible to predict alloimmunization in cancer patients based on severity of illness and inflammatory markers. Strategies of screening patients by phenotyping blood based on these criteria are not justified.

Sangue periférico como fonte de células para terapia celular

Peripheral blood has been routinely used as a source of hematopoietic progenitor cells for allogeneic and autologous bone marrow transplantation. Recent studies have demonstrated that a low number of mesenchymal stem cells are also present in the peripheral blood. They share the same surface markers as bone marrow-derived mesenchymal stem cells and are capable of differentiating into mesenchymal lineage cells including osteocytes, adipocytes and chondrocytes. Although their origin and destination are unclear, their presence in the peripheral blood of adults seems to represent an important and powerful tool for regenerative medicine and cell therapy.

Prevalência da infecção pelo citomegalovírus: a importância de estudos locais

O citomegalovirus (CMV) ou herpesvirus-5 (HHV-5) e um virus envelopado e que apresenta o maior genoma entre os virus que infectam especies animais. Embora na maioria dos individuos imunocompetentes seja responsavel por infeccoes assintomaticas, a infeccao em pacientes imunocomprometidos representa uma importante causa de morbidade e mortalidade. Nesses pacientes, os sintomas sao muito variados, compreendendo desde manifestacoes diretas da multiplicacao viral, como febre, leucopenia, trombocitopenia, hepatite, enterite e pneumonia, ate sequelas indiretas incluindo elevado indice de rejeicao ao enxerto renal e comprometimento da resposta imune celular.1,2 O predominio da infeccao ocorre em regioes pobres e carentes de recursos e educacao e, principalmente, onde as condicoes de higiene sao precarias. De um modo geral, a taxa de prevalencia em adultos varia de 40% a 60% em paises do hemisferio Norte. Na Africa e na America Latina, a prevalencia na populacao adulta e mais alta, variando de 80% a 100%.3 No Brasil, estudos de soroprevalencia na populacao entre 15 e 45 anos de idade revelaram 81% de positividade na cidade do Rio de Janeiro4 e aproximadamente 90% na cidade de Sao Paulo5 e em Santa Catarina.6 Nesta edicao da RBHH, encontramos um estudo conduzido por Matos e colaboradores, no qual 636 doadores de sangue da cidade de Salvador (BA) foram testados para avaliacao da presenca de anticorpos contra o CMV. Neste estudo, os autores encontraram uma prevalencia de 87,9% de IgG-CMV.7 A contaminacao pelo virus geralmente e inter-humana, atraves de contatos intimos, nos quais as secrecoes biologicas possam atuar como vetores. O CMV e encontrado na saliva, urina, leite materno, semen, secrecoes vaginais e respiratorias, fezes, sangue e lagrima. A infeccao primaria pode ocorrer no periodo pre-natal, perinatal, ou pos-natal, tanto por via natural como por via iatrogenica atraves de transfusoes de hemocomponentes ou transplantes de orgaos. Estudos mostram que existem dois periodos de maior ocorrencia da infeccao primaria. O primeiro na infância, com aquisicao precoce em decorrencia da infeccao perinatal, e o segundo na adolescencia, atraves da transmissao sexual ou pelo beijo. Apos uma infeccao aguda, o virus nao e eliminado do organismo e permanece sob uma forma latente, podendo ser reativado em diferentes circunstâncias, principalmente nos casos de alteracoes da imunidade. As celulas mononucleadas do sangue periferico parecem ser os principais sitios de Prevalencia da infeccao pelo citomegalovirus: a importância de estudos locais Prevalence of cytomeglovirus infection: the importance of local studies

Determination of Fetal RHD Genotype Including the RHD Pseudogene in Maternal Plasma

To examine the accuracy of fetal RHD genotype and RHD pseudogene determination in a multiethnical population.

Autologous hematopoietic stem cell transplantation in classical Hodgkin's lymphoma

Background Hodgkins lymphoma has high rates of cure, but in 15% to 20% of general patients and between 35% and 40% of those in advanced stages, the disease will progress or will relapse after initial treatment. For this group, hematopoietic stem cell transplantation is considered one option of salvage therapy. Objectives To evaluate a group of 106 patients with Hodgkins lymphoma, who suffered relapse or who were refractory to treatment, submitted to autologous hematopoietic stem cell transplantation in a single transplant center. Methods A retrospective study was performed with data collected from patient charts. The analysis involved 106 classical Hodgkins lymphoma patients who were consecutively submitted to high-dose chemotherapy followed by autologous transplants in a single institution from April 1993 to December 2006. Results The overall survival rates of this population at five and ten years were 86% and 70%, respectively. The disease-free survival was approximately 60% at five years. Four patients died of procedure-related causes but relapse of classical Hodgkins lymphoma after transplant was the most frequent cause of death. Univariate analysis shows that sensitivity to pre-transplant treatment and hemoglobin < 10 g/dL at diagnosis had an impact on patient survival. Unlike other studies, B-type symptoms did not seem to affect overall survival. Lactic dehydrogenase and serum albumin concentrations analyzed at diagnosis did not influence patient survival either. Conclusion Autologous hematopoietic stem cell transplantation is an effective treatment strategy for early and late relapse in classical Hodgkins lymphoma for cases that were responsive to pre-transplant chemotherapy. Refractory to treatment is a sign of worse prognosis. Additionally, a hemoglobin concentration below 10 g/dL at diagnosis of Hodgkins lymphoma has a negative impact on the survival of patients after transplant. As far as we know this relationship has not been previously reported.

Guidelines on transfusion of red blood cells: Prognosis of patients who decline blood transfusions

Faculdade de Ciências Médicas da Santa Casa de São Paulo (FCMSCSP), São Paulo, SP, Brazil Hemocentro de Ribeirão Preto, Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo HCFMRP-USP), Ribeirão Preto, SP, Brazil Hemocentro da Universidade Estadual de Campinas (Unicamp), Campinas, SP, Brazil Fundação Pró-Sangue, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brazil Associação Médica Brasileira (AMB), São Paulo, SP, Brazil

Virus SEN: epidemiologia e sua relação com doenças hepáticas

SENV, a new, recently-identified human virus, has been considered a possible causative agent of non-A to E hepatitis. It is a single stranded, non-enveloped DNA virus classified within the Circoviridae family. Prevalence in different populations shows great variability with differences between countries and ethnic groups. Although parenteral route is an efficient way for virus transmission, other routes of transmission cannot be excluded. The effect of SENV on acute and chronic liver diseases has been studied. In spite of the fact that the prevalence of SENV is higher among patients with hepatic disorders, there is no evidence that SENV infection is able to cause acute hepatitis or to change the clinical course of hepatitis A, B or C. There is also no evidence that alanine aminotransferase (ALT) is higher or that the histological parameters are worse in patients with hepatic disorders co-infected with SENV as compared to patients without co-infections. Unlike chronic hepatitis B Virus or Hepatitis C Virus infection, SENV infection has not been considered a risk factor for developing hepatocellular carcinoma. Finally, although it is clear that the prevalence of SENV is higher in blood transfusion recipients, there is no clear evidence that this virus is the causative agent of post-transfusion hepatitis. Further studies are needed to define the clinical importance of SENV infection.