Merlyn Sayers

Transmission of the hepatitis-C virus by tissue transplantation

The hepatitis-C virus has been the most prevalent cause of chronic hepatitis in both blood and organ recipients. The introduction of a second-generation immunoassay for antibodies to the hepatitis-C virus (HCV 2.0) provided the opportunity to determine if the hepatitis-C virus can be transmitted through tissue transplantation. Banked sera from tissue donors that had previously been found to be non-reactive to the first-generation hepatitis-C virus antibody assay (HCV 1.0) and non-reactive for antibodies to hepatitis-B core antigen were retested with HCV 2.0. The sera from two donors were reactive; the transplant records of recipients of tissues from these donors were reviewed, and the surgeons or hospitals were contacted. The tissue recipients were tested with HCV 2.0, and positive sera were tested for hepatitis-C virus RNA by polymerase chain reaction. Viral nucleic acids isolated from viremic donors and recipients were analyzed for identity by sequencing of the hepatitis-C virus envelope gene (E2) hypervariable region. There were twenty-one grafts, which had been treated with gamma radiation, from one donor; thirteen had been transplanted to twelve recipients. Serum samples from six of the recipients were tested; one was reactive. This patient had other risk factors for infection with the hepatitis-C virus, and sequence analysis demonstrated non-identity between the donor and recipient hepatitis-C virus isolates. Nine of twelve grafts from a second donor had been transplanted in nine recipients. Serum samples from five patients were tested with HCV 2.0; four were reactive. In three of the four patients, the sera were determined to be positive for the hepatitis-C virus by polymerase chain reaction. E2 sequence analyses of hepatitis-C virus RNA isolates from two of these recipients demonstrated sequence identity with the donor isolate. The results of the present report demonstrate that the hepatitis-C virus can be transmitted by bone, ligament, and tendon allografts. They also support the need for testing of all tissue donors for antibodies to the hepatitis-C virus before the tissue is released for transplantation. The results also suggest that seventeen kilo-gray of gamma radiation may inactivate the hepatitis-C virus in tissue.

Guidelines for blood utilization review

Hospitals are required by accrediting agencies to perform blood utilization review. Specific areas that must be addressed are the ordering, distribution, handling, dispensing, and administration of blood components. Monitoring the effects of transfusion on patients is also required. The format of the review process and the criteria for appropriate blood utilization must be developed by each institution. This article provides examples of areas that can be reviewed and procedures that may be used. However, the suggested laboratory values must not be interpreted as defining indications or criteria for transfusion. Each transfusion committee, or its equivalent, is responsible for developing its own institutional blood utilization procedures and audit criteria. Review and approval by the medical staff prior to implementation are essential. The procedures must also be reviewed and revised on a regular basis.

Transfusion-Transmitted Babesiosis in Washington State: First Reported Case Caused by a WA1-Type Parasite

Most cases of babesiosis reported in the United States have been tickborne and caused by Babesia microti, the etiologic agent of all previously described transfusion-transmitted cases. A 76-year-old man with the first recognized case of transfusion-transmitted infection with the recently identified WA1-type Babesia parasite is described. The subject received multiple blood transfusions in 1994. Indirect immunofluorescent antibody testing of serum from 57 blood donors implicated a 34-year-old man (WA1 titer, 1:65,536) whose donation had been used for packed red cells. Isolates of the organisms that infected the recipient and the donor, both of whom were spleen-intact residents of Washington State, were obtained by hamster inoculation. The DNA sequence of a 536-bp region of the nuclear small subunit-rRNA gene of both isolates was identical to that of WA1 (isolated in 1991 from the index WA1 case-patient). Effective measures for preventing transmission of babesiosis by blood transfusion are needed.

Maintaining iron balance in women blood donors of childbearing age: summary of a workshop

T he safety and availability of the national blood supply depends on individuals who can provide repeated blood donations. Frequent donations are generally not possible for women with borderline Hb values caused by iron deficiency. Although women donors have received iron replacement and have become successful repeat donors under well-defined research conditions, the potential value of this practice and the barriers to systemized implementation by organizations that collect volunteer donor blood have not been discussed in a national forum. The medical, economic, and operational feasibility of implementing a program to prevent iron deficiency in women blood donors of childbearing age was therefore explored in a workshop convened in Bethesda, MD, on June 8, 2001, which was cosponsored by the National Heart, Lung, and Blood Institute, the American Association of Blood Banks, America’s Blood Centers, and the American Red Cross. Speakers addressed the potential confounding issues of hemochromatosis and underlying disorders such as occult malignancy that might be masked by iron replacement. Potential protocol designs as well as possible means of implementation in blood centers were also reviewed. The following is a summary of the presentations and discussions of the meeting; the organizers are listed at the end of the report.

Red cell collection by apheresis technology

To determine the feasibility of collecting 2 units (450 mL) of red cells per donation by apheresis technology, apheresis red cell collections were compared to whole‐blood donations. Forty blood donors were equally divided between the two study arms on the basis of gender and iron supplementation (650 mg ferrous gluconate/day vs. no supplementation). During the 1‐year study period, the apheresis participants donated 450 mL of red cells three times, and the whole‐ blood donors gave 225 mL of red cells (1 unit of blood) on six occasions. There were no reported side effects during the 102 whole‐ blood donations, whereas symptoms were noted in 83 percent of the 59 apheresis procedures. The most common symptoms were numbness and tingling, which were relieved by a decrease in the plasma‐return rate or by the administration of oral calcium supplements. Seven donors dropped out or were deferred during the study. Two whole‐blood donors left with medical problems unrelated to the study, one apheresis donor and one whole‐blood donor dropped out of the study because of excessive fatigue, and three non‐iron‐supplemented whole‐blood donors had unacceptably low hematocrit levels. By the end of the study, 70 percent of the apheresis donors considered the procedure acceptable, 15 percent were undecided, and 15 percent thought it was not acceptable. As measures of iron balance, the serum ferritin and the red cell zinc protoporphyrin:heme ratios were significantly more abnormal in the non‐ iron‐supplemented donors than in the iron‐supplemented donors. However, there were no differences in iron balance according to the donation method.

The risk of transmitting cytomegalovirus infection by fresh frozen plasma

ABSTRACT: In order to determine if cytomegalovirus seronegative patients are at risk of infection from fresh frozen plasma we reviewed our experience with 21 seronegative marrow transplant recipients who underwent plasma exchange with unscreened plasma. The mean (± SD) number of units of plasma required in the procedure was 47.6 (± 19.5). The majority of patients, 17 of 21, were followed for 100 days. No patients had evidence of cytomegaloviral infection. We conclude that fresh frozen plasma is not infectious for cytomegalovirus.

Recombinant immunoblot and polymerase chain reaction testing in volunteer whole blood donors screened by a multi‐antigen assay for hepatitis C virus antibodies

The purpose of this study was to compare the results of supplementary testing of volunteer whole blood donors who had been screened by the first hepatitis C virus antibody assay licensed in the United States with results from donors screened by a newer, more sensitive, multi‐ antigen assay. In contrast to the earlier assay, the multi‐antigen assay incorporates a recombinant hepatitis C virus antigen, c22‐3, which is encoded by a structural region of the viral genome. Supplementary testing included a second‐generation recombinant immunoblot assay and a highly sensitive polymerase chain reaction assay for evidence of hepatitis C virus genomic RNA. A comparison of supplementary test results reveals a higher percentage of donors screened by the newer assay to be indeterminate on recombinant immunoblot (34.4% vs. 6.4%, p < 0.05). Furthermore, polymerase chain reaction testing of donors with indeterminate blot results shows that 14 percent have evidence of viral RNA. For this reason, counseling of donors with indeterminate patterns on immunoblot must include informing them of the possibility that they are infected.

Changes in blood center red blood cell distributions in the era of patient blood management: the trends for collection (TFC) study.

As patient blood management becomes more widespread, fewer red blood cell (RBC) units have been transfused. This multinational study evaluated changes in blood center RBC distributions.

What if shelf life becomes a consideration in ordering red blood cells

R ed blood cell (RBC) storage solution research has resulted in formulations that have allowed an increasing length of refrigerated shelf life for the product. This development has been a major contributor to efficiency in blood bank operations, especially with regard to managing inventories. Given an adequate inventory in storage, both surges in demand and temporary interruptions in collections can be accommodated. There are also economic benefits in that it is possible to provide hospitals that are far from the processing center with an inventory of units with a longer shelf life, thereby reducing the number of journeys needed to stock the outlying hospitals’ blood banks. Despite these benefits, there has always been concern that longer storage is a benefit occurring at the risk of impaired quality. Elements of this impairment, collectively referred to as the storage lesion, are well characterized both morphologically and metabolically. It has been recognized for a long time that RBCs lose their biconcave disc shape, becoming spherocytic and rigid; that concentrations of adenosine triphosphate and 2,3-diphosphoglycerate (DPG) decrease; and that the sodium-potassium pump is impaired. More recently, however, as highlighted in a minisymposium on RBC storage published in this journal, knowledge of the storage lesion has been expanded with evidence for damage to other RBC systems. More particularly, researchers identified abnormalities in nitric oxide homeostasis and complement activation and proposed a role for release of cell-derived microparticles as contributors to transfusion-related morbidity. Some expressions of the storage lesion are, however, not necessarily permanent. For example, there is evidence that restoration of 2,3-DPG levels begins within a few hours of transfusion and the electrolyte gradients across the RBC membrane are returned to normal within a few days. Nonetheless, it is tempting to link the storage lesion evidence to dysfunction in transfused RBCs, especially since the rheologic properties of less deformable cells do not favor smooth flow through the microcirculation and older stored cells’ increased affinity for oxygen means less release of the gas. Although there is extensive published evidence suggesting that some patients, especially those undergoing cardiac surgery, risk complications when transfused older blood, opinion is divided. Some reviewers point out that many studies linking the transfusion of older blood to increased morbidity and mortality have significant limitations in that they were observational; that they shared significant heterogeneity within classes of patients, despite those patients sharing similar diagnoses; and that transfusion policies were not consistent during the periods under review. If consensus emerges from the differing opinions, then reconciliation is likely to come from a number of randomized clinical trials (RCTs) currently recruiting different classes of patients from cardiac surgery, premature infant, and intensive care unit admissions. The relevance of these trials, which include studies supported by the National Heart, Lung, and Blood Institute and the Transfusion Medicine and Hemostasis Clinical Trials Network, was highlighted by Glynn. She emphasized the importance of understanding if there is a relationship between age of transfused blood and increased morbidity and mortality and characterized a causal relationship, if confirmed, as a “major public impediment” that would drive blood programs to modify recruitment so as not to jeopardize the adequacy of the national blood supply. Against this background we decided to review our experience at a large community blood program centered in the Dallas-Fort Worth Metroplex serving some 200 hospitals in a 57-county region. Our goal was to report on the age of RBCs at shipment from the blood program to the hospitals’ blood banks, paying particular attention to ABBREVIATION: RCT(s) = randomized clinical trial(s).

Trends in US minority red blood cell unit donations

To provide the appropriately diverse blood supply necessary to support alloimmunized and chronically transfused patients, minority donation recruitment programs have been implemented. This study investigated temporal changes in minority red blood cell (RBC) donation patterns in the United States.