Kamille A. West

Low frequency of anti-D alloimmunization following D+ platelet transfusion: the Anti-D Alloimmunization after D-incompatible Platelet Transfusions (ADAPT) study.

The reported frequency of D alloimmunization in D− recipients after transfusion of D+ platelets varies. This study was designed to determine the frequency of D alloimmunization, previously reported to be an average of 5 ± 2%. A primary anti‐D immune response was defined as the detection of anti‐D ≥ 28 d following the first D+ platelet transfusion. Data were collected on 485 D− recipients of D+ platelets in 11 centres between 2010 and 2012. Their median age was 60 (range 2–100) years. Diagnoses included: haematological (203/485, 42%), oncological (64/485, 13%) and other diseases (218/485, 45%). Only 7/485 (1·44%; 95% CI 0·58–2·97%) recipients had a primary anti‐D response after a median serological follow‐up of 77 d (range: 28–2111). There were no statistically significant differences between the primary anti‐D formers and the other patients, in terms of gender, age, receipt of immunosuppressive therapy, proportion of patients with haematological/oncological diseases, transfusion of whole blood‐derived or apheresis platelets or both, and total number of transfused platelet products. This is the largest study with the longest follow‐up of D alloimmunization following D+ platelet transfusion. The low frequency of D alloimmunization should be considered when deciding whether to administer Rh Immune Globulin to D− males and D− females without childbearing potential after transfusion of D+ platelets.

Autologous lymphapheresis for the production of chimeric antigen receptor T cells

The first step in manufacturing chimeric antigen receptor (CAR) T cells is to collect autologous CD3+ lymphocytes by apheresis. Patients, however, often have leukopenia or have other disease‐related complications. We evaluated the feasibility of collecting adequate numbers of CD3+ cells, risk factors for inadequate collections, and the rate of adverse events.

Granulocyte transfusions in the management of invasive fungal infections

Granulocyte transfusions have a long history of being used in patients with neutropenia or neutrophil dysfunction to prevent and treat invasive fungal infections. However, there are limited and conflicting data concerning its clinical effectiveness, considerable variations in current granulocyte transfusion practices, and uncertainties about its benefit as an adjunct to modern antifungal therapy. In this review, we provide an overview on granulocyte transfusions and summarize the evidence on their role in the prevention and treatment of invasive fungal infections.

Hot and Cold

A 5-year-old boy presents to the emergency department (ED) with 2 days of fever (temperature 100.7 °F), fatigue, jaundice, and dark urine. The parents note that the child had symptoms of a viral upper respiratory illness 2 weeks before presentation and that he was previously healthy with no history of blood transfusion. In the ED, the child weighs 21.3 kg, and laboratory workup reveals severe anemia with hemoglobin (Hgb) 5.4 g/dL, elevated total bilirubin 5.1 mg/dL, aspartate aminotransferase (AST) 357 U/L (normal range, 8–60 U/L), and lactate dehydrogenase (LDH) 8126 U/L. Serum haptoglobin is undetectable. Urinalysis results are as follows: color, dark; red blood cells (RBCs), 0–3 per high-power field; and urine Hgb, 3+ positive. Notably, the onset of symptoms (fever, fatigue, jaundice, dark urine) was associated with eating a bowl of ice cream. An ethylenediaminetetraacetic acid (EDTA) anticoagulant type and screen sample is submitted to the blood bank along with a request for RBC transfusion.

Accepting hereditary hemochromatosis blood donors: ask not why, ask why not: EDITORIAL

H ereditary hemochromatosis (HH) is an inherited disorder of iron metabolism, treated by regular therapeutic phlebotomy to prevent iron accumulation and organ damage. Recognized as a potential source of blood for allogeneic transfusion for years, therapeutic donations from persons with HH are accepted in many countries but still resisted in others because of lingering concerns about safety, operational compliance, or cost. Safety concerns historically stem from the possibility of creating an incentive to donate blood for free rather than to pay for therapeutic phlebotomy, possibly encouraging HH donors to deny risk factors for infectious diseases. In the Final Rule that became effective in May 2016, the US Food and Drug Administration codified the requirements for HH donors in the Code of Federal Regulations (CFR), thus eliminating the need for a variance to collect whole blood more frequently than every 8 weeks (or double red blood cells more frequently than every 16 weeks) and distribute units without special labeling from HH donors who meet all eligibility requirements. Notably, the CFR retains the requirement for obtaining a prescription for therapeutic phlebotomy from a licensed health care provider and performing therapeutic phlebotomy free of charge [21 CFR 630.15(a)(2)]. Therefore, the question of the safety of HH blood in this context is a timely one for blood collectors and transfusion services. In this issue of TRANSFUSION, Hoad and coworkers address the issue of infectious risk in blood donated from HH donors in a retrospective cohort study of all whole blood donations at the Australian Red Cross Blood Service in a 3-year period comparing therapeutic HH donors and voluntary whole blood donors. The authors examined postdonation notification of infectious illnesses, bacterial contamination screening results, and positive tests for blood-borne viruses in therapeutic and voluntary nontherapeutic whole blood donors. The strengths of the study are its impressive scale, including more than 100,000 donations from almost 12,000 HH donors and more than 2.5 million donations from more than 460,000 voluntary donors. Importantly, this institution provided free phlebotomy to HH donors who were not eligible to donate for transfusion, as a safety measure to remove any perceived incentive to deny risk factors about transfusion-transmissible infection (TTI). Furthermore, the study included donors in the induction phase (ironlowering phase) as well as those in the maintenance phase of therapeutic phlebotomy, which is not a universal practice. The authors report a lower risk of TTI in therapeutic HH donations intended for transfusion compared to voluntary donations and no significant difference in TTI rates when donations destined for product discard due to self-declared risk factors are included in the analysis. In addition, bacterial contamination of pooled platelet collections and self-reported postdonation illness are not different among HH donors compared to voluntary whole blood donors. Most HH donations are from repeat donors, and the authors did not adjust their analysis for first-time donation status, which they identified as a limitation, but is appropriate for a pragmatic comparison of the safety of HH donors compared to the general voluntary pool. The study supports the conclusion that therapeutic HH donors undergoing depletion and maintenance therapeutic phlebotomy are a safe and acceptable source of donated whole blood with a low infectious disease risk profile. These safety data directly assuage the niggling concern about collecting blood from HH donors that has been a source of debate for some time. Since the molecular basis of the disease was elucidated in 1996, it has been posited that the condition itself poses no harm to the recipient. The question concerns the motives of the HH donor to give blood and the possibility of incentive to withhold information from blood establishments about infectious risk factors. Recalling that it was the discontinuation of remuneration for blood donation that first significantly reduced transmissiontransmitted hepatitis, some blood establishments still might be reluctant to accept blood from “motivated” donors. However, the incentive in the case of HH donors is for phlebotomy, not necessarily for allogeneic blood donation. As long as the availability of therapeutic phlebotomy is kept independent from the disposition of the blood, by providing phlebotomy free of charge to eligible and ineligible HH donors alike, the point becomes moot. The National Institutes of Health (NIH) experience, like the experience of the Australian Red Cross and doi:10.1111/trf.13919 Published 2016. This article is a U.S. Government work and is in the public domain in the USA. TRANSFUSION 2016;56;2907–2909

Are You Kidding

A 72-year-old male with myelodysplastic syndrome, multiply transfused with a known history of anti-E and anti-c antibodies, presents to the outpatient transfusion service. He was transfused with 2 units of red blood cells (RBCs) 5 weeks ago. The patient’s hematocrit (Hct) is now 22 % and 1 unit of RBCs is requested for the patient. A type and crossmatch sample (ethylenediaminetetraacetic acid, EDTA anticoagulant) is submitted to the blood bank.

Initial serum ferritin predicts number of therapeutic phlebotomies to iron depletion in secondary iron overload.

Therapeutic phlebotomy is increasingly used in patients with transfusional siderosis to mitigate organ injury associated with iron overload (IO). Laboratory response variables and therapy duration are not well characterized in such patients.

The “Unfraction” Reaction

An 8-year-old boy with congenital heart disease is admitted to the hospital for a planned mitral valve repair and revision. The patient has had multiple admissions to the hospital for surgery and complications relating to the congenital heart condition, most recently 1 month ago, and has required support with multiple transfusions of blood products over the years. His prior blood bank tests show that he is group A-positive with a negative antibody screen. A type and screen sample (ethylenediaminetetraacetic acid [EDTA] anticoagulant) is submitted to the blood bank along with a request for crossmatch of two units of red blood cells (RBCs).

I “Pitty” Thee

A 74-year-old man is admitted to hospital for workup of gastrointestinal (GI) bleeding; he is scheduled for colonoscopy the following day. An ethylenediaminetetraacetic acid (EDTA) anticoagulant sample is submitted to the blood bank for type and screen.

How “Dara” You!

A 73-year-old man with immunoglobulin (Ig)G kappa multiple myeloma is referred for outpatient transfusion due to severe anemia with hemoglobin (Hgb) of 6.6 g/dL. The patient has a history of red blood cell (RBC) transfusion at your hospital 2 years ago at which time the antibody screen was negative. An ethylenediaminetetraacetic acid (EDTA) anticoagulant sample is submitted to the blood bank for type and screen along with a request for two units of irradiated RBCs.