Daniel R. Ambruso

Hypotension and acute pulmonary insufficiency following transfusion of autologous red blood cells during surgery: a case report and review of the literature

summary. Transfusion of autologous blood is associated with fewer complications, although all untoward events of transfusion may not be negated with this strategy. We report a case of acute pulmonary insufficiency and hypotension following transfusion of autologous packed red blood cells (PRBCs) in a patient, who was undergoing major surgery. Anti‐HLA class‐I and class‐II and anti‐granulocyte antibodies were measured in the unit and in the recipient. Neutrophil (PMN)‐priming activity was measured as the augmentation of the formyl‐Met‐Leu‐Phe‐activated respiratory burst. No immunoglobulins were identified; however, significant lipid‐priming activity was present in the implicated, autologous PRBC unit that primed PMNs from both healthy people and the recipient. In addition, lipids, identical to those that accumulate during PRBC storage, caused significant hypotension when infused into rats at similar concentrations found in stored PRBCs. We conclude that the observed transfusion‐related acute lung injury reaction with significant hypotension may be the result of two independent events: the first is related to inherent host factors, in this case major surgery, and the second is the infusion of lipids that accumulate during the routine storage of PRBCs.

Functional characteristics of neutrophils collected and stored after administration of G–CSF

BACKGROUND: Granulocyte transfusion may be used in neutropenic patients with severe bacterial or fungal infections that are unresponsive to antibiotic therapy. However, the inability to store granulocyte concentrates limits their clinical usefulness.

Spectra Optia granulocyte apheresis collections result in higher collection efficiency of viable, functional neutrophils in a randomized, crossover, multicenter trial

Granulocyte transfusion from healthy donors is used in the treatment of patients with granulocyte function defects, or transient neutropenia and severe bacterial or fungal infections resistant to maximal antimicrobial treatment.

Long term G-CSF-induced remission of ulcerative colitis-like inflammatory bowel disease in a patient with glycogen storage disease Ib and evaluation of associated neutrophil function.

We present a 23‐year‐old female with Glycogen storage disease Ib (GSD Ib) who was diagnosed with ulcerative colitis‐like inflammatory bowel disease (IBD) at 7 years of age. G‐CSF therapy reversed the IBD, was required to maintain IBD remission and was well tolerated. Neutrophil functions at time of diagnosis showed impaired chemotaxis but normal superoxide anion production and bactericidal activity. Ulcerative colitis‐like IBD may also be seen in GSD Ib and is responsive to G‐CSF therapy. Neutrophil dysfunction is variable among patients with GSD Ib. Pediatr Blood Cancer. 2010;55:1410–1413.

Bioactive lipids from stored cellular blood components: in vitro method is crucial for proper interpretation

We read with interest the recent publication of Vlaar and colleagues,1 which detailed the accumulation of bio-active lipids during the storage of blood products and their findings that these lipids are not cell but plasma and temperature dependent. In this article the authors demonstrated that lyso-PCs did not accumulate during the routine storage of prestorage leukoreduced (buffy coat removal) red blood cells (LR-RBCs) in SAGM, 42 days at 2 to 4°C, and did not evidence priming activity using a 30-minute neutrophil (PMN) priming assay in which the respiratory burst was measured in the presence of the plasma or plasma fraction of the stored component. However, if plasma was added to the LR-RBCs then there was a significant increase in lyso-PCs on Day 1 that did not increase over the storage interval. In addition, platelet (PLT) concentrates, stored in plasma, did evidence lyso-PC accumulation during routine storage, 7 days at 20 to 24°C, and the plasma fraction primed the PMN oxidase after 30 minutes. The accumulation of lyso-PCs was inhibited; however, the priming activity was not abrogated when SSP was substituted as the storage solution (65%–95%)Final. The authors concluded that the observed accumulation of lyso-PCs was time and temperature dependent and had little to do with the cellular constituents of the stored product.

Transfusion‐related acute lung injury and granulocytes from stored packed RBCs

Transfusion-related acute lung injury and granulocytes from stored packed RBCs We read with interest the article by Zupanska et al.1 regarding transfusion-related acute lung injury (TRALI) that was published in the September 1999 issue of TRANSFUSION. TRALI is a serious complication of hemotherapy, and, while the incidence is likely higher than reported (1/5000 transfusions),2 we question this diagnosis in the patient described by Zupanska et al. The clinical findings of TRALI consist of the rapid onset of symptoms, which include fever (> 1°C), tachypnea, cyanosis, and dyspnea.2,3 These symptoms often occur within 1 to 2 hours of transfusion,2,3 but may present up to 6 hours after the administration of blood components. The patient described by Zupanska et al. did have fever and other symptoms likely related to the transfusion, but pulmonary symptoms did not occur until approximately 48 hours after the transfusion of RBCs, and therefore the described case does not fit the criteria for the diagnosis of TRALI. Furthermore, the authors suggest that granulocyteagglutinating antibodies in the recipient reacted with transfused granulocytes from the donor. While their laboratory analysis might support this, the fact that the transfused units of non-WBC-reduced RBCs were 14 and 16 days old makes this very unlikely, given that granulocytes are not viable in storage for this long. Although it is possible that the recipient’s antibodies reacted with other WBCs (e.g., monocytes) that survive storage better than granulocytes, TRALI, like acute respiratory distress syndrome is a syndrome, of excessive neutrophil function, and the role of activated, transfused MNCs in acute lung injury has not been defined. As Zupanska et al. mentioned, it has been proposed that the development of TRALI requires two insults, one deriving from the clinical condition of the patient and the other from the stored blood component.4,5 Their patient did have paroxysmal nocturnal hemoglobinuria, which may have provided the initial insult, and, while he likely did have a tranfusion reaction that may ultimately have contributed to his respiratory symptoms, the diagnosis of TRALI does not appear to be the correct one. Having said this, we appreciate the authors’ thoughtfulness in considering this diagnosis and believe that further attention should be paid to this potentially lifethreatening complication of blood component transfusion. Julie Zimbelman, MD Department of Pediatrics Christopher C. Silliman, MD, PhD Department of Surgery University of Colorado School of Medicine Denver, CO Daniel R. Ambruso, MD Bonfils Blood Center Denver, CO REFERENCES

In Vivo Treatment With Granulocyte Colony-Stimulating Factor Does Not Delay Apoptosis in Human Neutrophils by Increasing the Expression of the Vacuolar Proton ATPase

Background Neutrophils die by apoptosis, and in vivo administration of granulocyte colony-stimulating factor (G-CSF) delays this apoptotic cell death. G-CSF administered in vitro correlates delayed apoptosis with upregulation of the vacuolar proton ATPase (v-ATPase). Because this enzyme requires assembly of membrane and cytosolic domains to function, we hypothesized that in vivo G-CSF would increase synthesis and assembly of v-ATPase components to delay apoptosis. Methods Volunteers received G-CSF for 5 days, and each had a paired control. Neutrophils were isolated from subjects before the first and after the fifth injection. Proteins from cytosol or plasma membrane or from whole cell lysates were resolved by SDS-polyacrylamide gel electrophoresis and immunoblotted with antibody to the 33kDa v-ATPase E subunit. Densitometry quantified immunoreactivity. Results No significant increase on the E subunit occurred between treated and control groups. Conclusion In vivo G-CSF does not increase the amount of v-ATPase in neutrophils. Although G-CSF in vivo delays apoptosis, the mechanism(s) by which this occurs is not known.