Gordana Ostojic

Stem cells in the arrangement of bone marrow repopulation and regenerative medicine.

Hematopoiesis is a permanent and complex event in which a spectrum of different mature blood cells from a small population of toti/pluri/multipotent stem cells (SCs) are produced through a variety of proliferative and differentiative processes. Hematopoietic SCs are defined as the cells with extensive self–renewal and proliferative potential, together with their ability to differentiate into all blood–cell lineages. Many studies have demonstrated that a multifactorious network of interactive cytokines and other blood–derived mediators regulate the survival, maturation, and proliferation of SCs .

Ibuprofen-induced extensive toxic epidermal necrolysis - a multidisciplinary therapeutic approach in a single case.

Dear Sir, Toxic epidermal necrolysis (TEN) or Lyell’s syndrome is a life-threatening (up to 90% mortality rate), extensive cutaneous, drug-induced adverse event1. Similar skin damage/defects -but usually without a fatal outcome- are observed following drug administration in Stevens-Johnson’s syndrome (SJS; milder form) and TEN/SJS (intermediate type). In these conditions the epidermis can be detached from the underlying structures (dermis) over the whole body surface. Mucous membranes may also be affected. The precise aetiopathogenesis of TEN is still unclear. Some toxic metabolites, inflammatory mediators or modifiers, as well as cytotoxic T lymphocytes, regulatory T cells and dermal dendrocytes could induce apoptosis or necrosis of epithelial cells1–3. The human leucocyte antigen (HLA) system also plays an important role in the pathogenesis of TEN, since some drugs may bind directly to the HLA-complex and create self-reactivity due to the drug-modified HLA-peptide repertoire. This event is mediated by cytotoxic T lymphocytes and/ or natural killer cells after their interaction with cells expressing the HLA-complex3. We report here the case of a 21-year old female with extensive erythema, necrosis, and exfoliating bullous detachment of the epidermis and mucous membranes (conjunctival, oral and genital; affected skin area=80%; Figure 1A and 1B). Initially, she had an influenza-like prodrome after taking ibuprofen to treat a headache and dysmenorrhea. She was admitted to the Clinic for Plastic Surgery of MMA (Belgrade, Serbia) and on presentation she was febrile (39.3 °C) with a characteristic positive Nikolsky’s sign. Laboratory analyses were as follows: haemoglobin, 121 g/L; white blood cell count, 6.77×109/L (neutrophils 80%, lymphocytes 25%, eosinophils 4%, monocytes 1%), platelet count, 466×109/L; elevated levels of C-reactive protein, aspartate aminotransferase and alanine aminotransferase (330 mg/L, 80 IU/L and 145 IU/L, respectively), and low concentrations of total proteins (50 g/L) and albumin (22 g/L). The results of coagulation studies and tests for viral infections were normal. Skin biopsy demonstrated prominent cell death with basal vacuolar changes and lymphocyte infiltrates, obscuring the dermo-epidermal junction (Figure 1C), which confirmed the clinical diagnosis of TEN. Figure 1 A) and B) Female patient with TEN: extensive erythema, necrosis, and critical muco-cutaneous lesions with intense exfoliation. C) Cell destruction with lymphocyte infiltrates and distraction of the dermo-epidermal junction. D) Therapeutic apheresis - ... The first-line treatment was immediate withdrawal of theculprit drug, elimination of the drug and its metabolites, and fluid resuscitation with crystalloid infusions (1 mL/kg of body weight per hour) via a central venous catheter, adjusted on the bases of the arterial blood pressure (>65 mmHg), central venous pressure (≤10 mmHg) and urine output (diuresis rate). The patient was isolated (using aseptic techniques and state) and local dermatological and ocular topical treatment were applied continuously. Nutrition was provided enterally via a nasogastric tube. In the early treatment of this patient, we performed our originally designed multimodal therapeutic apheresis -plasma exchange (PE) combined with leucapheresis- using COBE®-Spectra apheresis-sets (Terumo BCT, Lakewood, CO, USA) and a sterile connected multibag system. Multimodal therapeutic apheresis simultaneously provides rapid improvements in more than one blood abnormality and aids the patient’s recovery from a live-threatening emergency to a clinical condition with a potentially positive outcome4,5. The rationale for initial plasma exchange in this case was to eliminate/decrease the level of residual ibuprofen and its metabolites, critical cytokines (such as tumour necrosis factor-α, interferon-γ), and drug-induced inflammatory mediators (perforin, granzyme B released from cytotoxic T lymphocytes and granulysin secreted by cytotoxic T lymphocytes and natural killer cells) from the circulation (urgent plasma depuration). Plasma exchange was performed on three consecutive days by processing an average of 5900±952 mL of the patient’s whole blood. A total of 5.4-fold the plasma volume was exchanged and replaced by albumin in normal saline (Figure 1D). The basic goal of the leucapheresis-treatment was to reduce the circulating lymphocyte count in the patient’s blood to obtain an immunomodulatory effect. The patient’s subsequent systemic treatment included broad-spectrum antibiotics (chosen on the basis of the skin microbial findings), intravenous immunoglobulins (dose 1.0 g/kg of body weight per day for 3 consecutive days; infused over 6 hours) and corticosteroids (dose 0.5 mg/kg of body weight)1,2. This young female patient recovered completely after 1 month of intensive systemic and topical treatment. In conclusion, this multidisciplinary management -fluid resuscitation, urgent plasma depuration and immunomodulation (multimodal therapeutic apheresis), as well as topical and systemic medications (antibiotics, intravenous immunoglobulins and corticosteroids)- undoubtedly prevented septicaemia and multisystem organ failure, the major cause of death in severe TEN.

Clinical efficacy of riboflavin and ultraviolet light inactivated fresh frozen plasma evaluated with INR-quantification

Treatment of blood products by riboflavin and ultraviolet (UV) light prevents of white blood cell (WBC) replication and inactivates of pathogens. The aim of this study was to determine the effects of the inactivation by riboflavin and UV light upon plasma clinical performance, based on effect on the pretransfusion international normalized ratio (INR). A prospective, controlled randomized study included 60 patients who received transfusion of plasma on the Clinic for hematology of Clinical Centre in Nis. Experimental group (EG; 30 patients) was treated with Mirasol-inactivated fresh frozen plasma (FFP) and control group (CG; 30 patients) was transfused with noninactivated FFP. Besides pretransfusion vs. posttransfusion INR, the improvement in INR patients plasma level per one FFP unit transfused was evaluated. Total of 68 units of FFP were transfused to patients of CG (2.24±0.83 units per patient). Patients of EG received 84 units of Mirasol-inactivated plasma (i.e. 2.80±1.19 units per patient). There was significant increase in number of FFP transfusions that normalized coagulation parameters in EG compared to CG (p=0.039). Also, there was a significant improvement of INR after every FFP unit application (p=0.046). We found a linear relationship between pretransfusion INR and improvement of INR (r=0.97; p<0.001). Plasma treated with riboflavin and UV light retains hemostatic competence and can be used efficiently in the therapy of congenital or acquired coagulopathies, but in larger quantity as compared to noninactivated FFP volume.

Our first experiences in applying an original method for removal of ABO-isoagglutinins in ABO-incompatible kidney recipients

BACKGROUND/AIM Due to improved methods for removal of ABO isoagglutinins and novel immunosuppressive protocols, short and long-term outcome in blood group incompatible is similar to blood group compatible kidney transplantation. The aim of this study was to determine the efficacy of our original method for removal of ABO isoagglutinins from the blood in ABO-incompatible kidney allograft recipients. METHOD Between 2006 and 2008 twelve patients were transplanted from ABO incompatible living donors. Titers of ABO isoagglutinins were 4-128 (IgG). Immunosuppressive therapy started 14 days before kidney transplantation with rituximab, followed by a triple therapy (prednisone + tacrolimus + mycophenolate mofetil) and the first plasma exchange (PE) procedure, in which one plasma volume was substituted with albumin and saline on day 7 before transplantation. For selective extracorporeal immunoadsorption, the removed plasma was mixed with donor blood type filtered red blood cells, centrifuged and the supernatant separated and preserved. In the next PE procedure, the removed plasma was replaced with immunoadsorbed plasma, and so on. Titers of ABO agglutinins, renal allograft function and survival were followed-up. RESULTS The pre-transplant treatment consisting of 1-5 PE procedures and immunosuppressive therapy resulted in target ABO agglutinins titers below 4. During a 10-24 month follow-up three patients had an early acute rejection, one patient acute rejection and hemolytic anemia, two patients surgical complications and one of them lost his graft. In the post-transplant period, the titers of ABO antibodies remained below 4. All the patients had stable kidney allograft function with mean serum creatinine +/- SD of 129 +/- 45 micromol/l at the end of the study. CONCLUSION Our method for removal of ABO antibodies was effective in a limited series of patients and short-term follow-up.

Case report: Lifesaving therapeutic plasma exchange by cell saver in an obstetric emergency

Introduction. Abnormally high levels of triglycerides (hyperlipidemia) are often the result of a number of disorders in the body, which over time can lead to conditions such as hypothyroidism, nephrotic syndrome, diabetes, obstruction of the biliary ducts, hepatic impairment et al. The topic of how to treat the extreme hyperlipidemia has been an important discussion point in medical circles. Case report. This paper presents the case of a 33-yearold pregnant women in the 34th week of the first proper pregnancy with laboratory-verified extreme hyperlipidemia, who was brought in critical condition to the Clinical Center of Kragujevac. After the emergency cesarean section was performed, due to the general poor condition of the patient and extremely high levels of triglycerides and cholesterol, lipopheresis was indicated, which in our institution was not technically possible to treat and therefore it was necessary to find an alternative solution. Conclusion. It was shown that the application of intraoperative blood salvage can be used successfully not only in heavy bleeding during surgery, but also for cleaning the blood itself, which was clearly shown in the laboratory analysis. key words: hyperlipidemia, operative blood salvage, blood transfusion, autologous. SaŽetak Uvod. Povećane vrednosti triglicerida (hiperlipidemija) obično su posledica niza poremećaja u organizmu koji vremenom mogu dovesti do stanja poput hipotireoze, nefrotskog sindroma, dijabetesa, opstrukcije žučnih puteva, oštećenja funkcije jetre i dr. Kako lečiti ekstremnu hiperlipidemiju značajna je tema za diskusiju u medicinskim krugovima. Prikaz slučaja. U ovom radu prikazan je slučaj 33godišnje trudnice u 34. nedelji prve uredne trudnoće sa laboratorijski verifikovanom ekstremnom hiperlipidemijom, koja je u kritičnom stanju dovezena u Klinički centar Kragujevac. Nakon hitno izvršenog porođaja carskim rezom zbog opšteg lošeg stanja pacijentkinje i ekstremno visokih vrednosti triglicerida i holesterola, indikovana je lipofereza, za čiji tretman u našoj ustanovi ne postoje tehničke mogućnosti, te je bilo neophodno pronaći alternativno rešenje. Zaključak. Pokazano je da aparat za intraoperativno spasavanje krvi može biti uspešno upotrebljen ne samo kod obilnog krvarenja u toku hirurške intervencije nego i za čišćenje same krvi, što jasno pokazuju laboratorijske analize. ključne reči: hiperlipidemija, operativno spašavanje krvi, transfuzija krvi, autologna. CASE REPORT: LifESAving ThERAPEuTiC PLASmA ExChAngE by CELL SAvER in An ObSTETRiC EmERgEnCy Marija Vranes1, Zvezdana Lojpur1, Milena Todorovic2, Gordana Ostojic3, Elizabeta Ristanovic3, Bela Balint3,4 1Department for Transfusion Medicine, Clinical Center of Kragujevac, Kragujevac, Serbia 2Clinic for Hematology, Clinical Center of Serbia, Belgrade, Serbia 3Military Medical Academy, Belgrade, Serbia 4Serbian Academy of Sciences and Arts, Belgrade, Serbia PRikAz SLučAjA: TERAPijSkA zAmEnA PLAzmE PuTEm AuTOLOgnE TRAnSfuzijE u AkušERSkOm uRgEnTnOm STAnju Marija Vraneš1, Zvezdana Lojpur1, Milena Todorović2, Gordana Ostojić3, Elizabeta Ristanović3, Bela Balint3,4 1Služba za transfuziju, Klinički centar Kragujevac, Kragujevac 2Klinika za hematologiju, Klinički centar Srbije, Beograd 3Vojnomedicinska akademija, Beograd 4Srpska akademija nauka i umetnosti, Beograd