Kjell Titlestad

Management of an acute outbreak of diarrhoea-associated haemolytic uraemic syndrome with early plasma exchange in adults from southern Denmark: an observational study

BACKGROUND Diarrhoea-associated haemolytic uraemic syndrome in adults is a life-threatening, but rare multisystem disorder that is characterised by acute haemolytic anaemia, thrombocytopenia, and renal insufficiency. We aimed to assess the success of management of this disorder with plasma exchange therapy. METHODS Patients diagnosed with diarrhoea-associated haemolytic uraemic syndrome in southern Denmark were treated with daily plasma exchange by centrifugation and substitution with fresh frozen plasma. Stool culture and serological testing was done to identify the cause of disease, and the success of management with plasma exchange therapy was assessed from change in platelet count, glomerular filtration rate, and lactate dehydrogenase. FINDINGS During May 25-28, 2011, five patients with a median age of 62 years (range 44-70) presented with diarrhoea-associated haemolytic uraemic syndrome, which was caused by an unusual Shiga-toxin-producing Escherichia coli serotype O104:H4. Strains of E coli showed a high resistance to third-generation cephalosporins because the strains had extended-spectrum β lactamases. After plasma exchange, median platelet count and glomerular filtration rate increased, median lactate dehydrogenase concentration decreased, and neurological status improved. The time interval from onset of bloody diarrhoea to start of plasma exchange had an inverse correlation with reduction of lactate dehydrogenase concentrations by plasma exchange (p=0.02). All patients were discharged with normal neurological status at 7 days (range 5-8) after starting plasma exchange. INTERPRETATION Early plasma exchange might ameliorate the course of diarrhoea-associated haemolytic uraemic syndrome in adults. However, this finding should be verified in randomised controlled trials FUNDING None.

Survival after blood transfusion

BACKGROUND: Long‐term survival of transfusion recipients has rarely been studied. This study examines short‐ and long‐term mortality among transfusion recipients and reports these as absolute rates and rates relative to the general population.

Risk of cancer after blood transfusion from donors with subclinical cancer: a retrospective cohort study

BACKGROUND Although mechanisms for detection of short-term complications after blood transfusions are well developed, complications with delayed onset, notably transmission of chronic diseases such as cancer, have been difficult to assess. Our aim was to investigate the possible risk of cancer transmission from blood donors to recipients through blood transfusion. METHODS We did a register-based retrospective cohort study of cancer incidence among patients who received blood from donors deemed to have a subclinical cancer at the time of donation. These precancerous donors were diagnosed with a cancer within 5 years of the donation. Data from all computerised blood bank registers in Sweden and Denmark gathered between 1968 and 2002 were merged into a common database. Demographic and medical data, including mortality and cancer incidence, were ascertained through linkages with nationwide, and essentially complete, population and health-care registers. The risk of cancer in exposed recipients relative to that in recipients who received blood from non-cancerous donors was estimated with multivariate Poisson regression, adjusting for potential confounding factors. FINDINGS Of the 354 094 transfusion recipients eligible for this analysis, 12,012 (3%) were exposed to blood products from precancerous donors. There was no excess risk of cancer overall (adjusted relative risk 1.00, 95% CI 0.94-1.07) or in crude anatomical subsites among recipients of blood from precancerous donors compared with recipients of blood from non-cancerous donors. INTERPRETATION Our data provide no evidence that blood transfusions from precancerous blood donors are associated with increased risk of cancer among recipients compared with transfusions from non-cancerous donors.

The new Scandinavian Donations and Transfusions database (SCANDAT2): a blood safety resource with added versatility

Risks of transfusion‐transmitted disease are currently at a record low in the developed world. Still, available methods for blood surveillance might not be sufficient to detect transmission of diseases with unknown etiologies or with very long incubation periods.

Blood transfusion exposure in Denmark and Sweden

BACKGROUND: Although essential for the evaluation of blood transfusion safety, the prevalence of blood transfusion in the general population is not presently known. This study estimated the exposure to blood transfusion in the general Scandinavian population.

Positive predictive value of serological diagnostic measures in celiac disease

Abstract Background: Celiac disease (CD) antibodies, immunoglobulin A (IgA) anti-tissue transglutaminase (anti-tTG), IgA endomysium antibody (EMA), IgA and IgG anti-gliadin antibodies (IgA and IgG AGA) are first-line diagnostic tools used in selecting patients for duodenal biopsy. The goal of this study was to evaluate the diagnostic quality of serological testing for CD. Methods: CD serological tests (IgA and IgG AGA, anti-tTG and EMA) from 11,915 individuals were measured. Data were combined with clinical data and results of duodenal biopsy using a unique Danish personal identification number. Results: The positive predictive value (PPV) varied according to different combinations of positive CD antibodies, being highest when all antibodies were positive (97.6%). The anti-tTG concentration correlated strongly with EMA positivity, number of additional positive antibodies, and higher PPV. A logistic regression model predicted the probability of later biopsy-proven CD in relation to concentrations of IgA AGA and anti-tTG at initial serological screening. Conclusions: The anti-tTG concentration at initial serological CD screening was highly informative in relation to EMA positivity, number of additional CD specific antibodies and PPV. Furthermore, in the high-risk group of patients investigated, the concentrations of anti-tTG and IgA AGA at initial serological screening could accurately predict the probability of future biopsy-proven CD. Clin Chem Lab Med 2010;48:685–91.

Epidemiology of Massive Transfusion: A Binational Study From Sweden and Denmark*

Objective:There is an increasing focus on massive transfusion, but there is a paucity of comprehensive descriptions of the massively transfused patients and their outcomes. The objective of this study is to describe the incidence rate of massive transfusion, patient characteristics, and the mortality of massively transfused patients. Design:Descriptive cohort study. Setting:Nationwide study with data from Sweden and Denmark. Patients:The study was based on the Scandinavian Donations and Transfusions database, including all patients receiving 10 or more red cell concentrate transfusions in Sweden from 1987 and in Denmark from 1996. A total of 92,057 patients were included. Patients were followed until the end of 2012. Measurements and Main Results:Descriptive statistics were used to characterize the patients and indications. Post transfusion mortality was expressed as crude 30-day mortality and as long-term mortality using the Kaplan-Meier method and using standardized mortality ratios. The incidence of massive transfusion was higher in Denmark (4.5 per 10,000) than in Sweden (2.5 per 10,000). The most common indication for massive transfusion was major surgery (61.2%) followed by trauma (15.4%). Massive transfusion due to obstetrical bleeding constituted only 1.8%. The overall 5-year mortality was very high (54.6%), however with large differences between indication groups, ranging from 91.1% among those transfused for a malignant disease without surgery to 1.7% among patients transfused for obstetrical bleeding. The early standardized mortality ratios were high and decreased thereafter, but remained elevated throughout the time period. Conclusions:This large-scale study based on nationwide data from Sweden and Denmark describes the complete range of massive transfusion. We report a nonnegligible incidence and both a high absolute mortality and high standardized mortality ratio. The general pattern was similar for Sweden and Denmark, and we believe that similar patterns may be found in other high-resource countries. The study provides a relevant background for clinicians and researchers for designing future studies in this field.

Cesarean section: Is pretransfusion testing for red cell alloantibodies necessary?

Background.  Routine pretransfusion testing for red cell alloantibodies (RBCab) in cesarean patients is standard practice in many obstetric centers. The objective of the present study was to evaluate the usefulness of this test.

Lack of association between blood donor age and survival of transfused patients

To the editor: The possible rejuvenating effects of transfusions from young donors to older patients have generated considerable interest recently, following publication of a study showing improvements in muscle regeneration when older mice were transfused with blood from younger mice.[1][1]

Detection of Irregular Red Cell Antibodies: More than 3 Years of Experience with a Gel Technique and Pooled Screening Cells

Background and objectives: The purpose of this study was to evaluate more than 3 years of experience with a gel technique in combination with pooled screening cells for the detection of irregular red cell antibodies. Materials and methods: Conventional serologic methods were used for blood typing, antibody screening and cross‐matching until the end of 1992. We introduced the gel technique as a routine assay for antibody detection and identification in 1993. Results: After the tube technique had been abandoned, the number of false‐positive antibody screening tests was reduced by 71%, positive antibody screening tests by 33%, enzyme agglutination by 100% and rouleaux reactions and cold‐reacting antibodies by more than 50%. There was a 40% increase in first‐time detection of clinically relevant antibodies. We saw no increase in delayed haemolytic transfusion reactions. Conclusions: For the detection of irregular red cell antibodies, pooled screening cells in combination with a gel technique are at least as efficient and safe as a conventional tube technique with unpooled test cells.