R.S. Sarkar

Adverse events associated with apheresis procedures: Incidence and relative frequency

Introduction: Apheresis procedures [Plateletpheresis, Plasmapheresis/ Therapeutic Plasma Exchange (TPE), & Peripheral Blood Stem Cell Collection (PBSC)] are usually well tolerated. Occasionally, Adverse Events (AEs) of variable severity may occur during or after the procedure. AEs that occur in Donors/Patients are divided into local reactions and systemic reactions. Materials and Methods: A total of 3,367 apheresis procedures were performed, out of which 3,120 were plateletpheresis procedures, and out of which 1,401 were on Baxter CS 3000 & 1,719 were on Haemonetics MCS+ cell separators. Rest of 247 TPE & PBSC procedures were done on Haemonetics MCS+ cell separators. Results: 90 AEs were reported in relation to the 3,367 procedures. Out of 90 AEs, 85 AEs (94%) were associated with plateletpheresis (n = 3,120) and 05 AEs (06%) with TPE & PBSC (n = 247). The rate of vascular injury (VI), Citrate reaction (CR), and Presyncopal/Syncopal (PS/S) in plateletpheresis was 1.6% (52/3,120), 0.96% (30/3,120), and 0.096% (03/3,120), respectively. The rate of CR in TPE and PBSC was 1.23% (02/162) and 2.3% (02/85), respectively. The rate of PS/S in PBSC was 1.17% (01/85). AEs for Plateletpheresis, TPE & PBSC were 2.7% (85/3,120), 1.23% (02/162), and 3.5% (03/85), respectively. VI, CR, and PS/S were mostly of mild intensity. Both cell separators were equally safe, when AEs associated with plateletpheresis were compared with each other; 2.8% on CS 3000 & 2.6% on MCS+. Conclusion: Apheresis procedures performed on cell separators are safe, with a low incidence of significant AEs. No significant difference was noted in AEs among the two cell separators studied.

Is seroprevalence of anti-IGM CMV among blood donors relevant in India?

BACKGROUND Infection with cytomegalovirus (CMV) is more common in developing nations and the people belonging to the lower socioeconomic section of the society. The immunosuppressed population for whom CMV-seronegative blood products are requested is increasing due to advances in medical care. AIM To study the prevalence of CMV antibodies among the different sexes and age groups in healthy blood donors. MATERIALS AND METHODS A retrospective study was done on 5600 serum samples stored frozen in a repository for CMV antibodies using the ELISA technique. RESULTS Five thousand three hundred and fifty (95.5%) were male and 250 (4.5%) were female. Four cases (0.071%) out of 5600 samples were positive for anti-IgM CMV with 95% Confidence Interval (95% C.I) of 0.02 - 0.17. CONCLUSION In a developing country like India, screening for IgM antibody on a routine basis may not be feasible, given the likely positive yield to be low and the cost being high. It is recommended that in a tertiary care hospital, blood units to be transfused to neonates, organ transplant recipients, those suffering from malignancies and other immunocompromised patients should be screened for anti-IgM CMV or preventive strategies like universal leucodepletion to be implemented to decrease the transmission of CMV in these groups of patients.

A single-centre study of vasovagal reaction in blood donors: Influence of age, sex, donation status, weight, total blood volume and volume of blood collected

Context: Vasovagal reactions (VVRs) in blood donors. Aim: To find an association of age, sex, donation status, weight, total blood volume and volume of blood collected with occurrence of immediate VVR. Settings and Design: Retrospective single-centre study. Materials and Methods: The study was conducted from March 2000 to November 2010 at a tertiary care blood transfusion centre. All VVRs with or without syncope occurring during or at the end of donation were noted. Statistical Analysis Used: For qualitative association, c 2 -test was used. Unpaired ′t′ test was used for assessing difference between two groups with respect to VVR status. Simultaneous impact of all risk factors was assessed using multivariate logistic regression analysis. The data entry software SPSS (version 17.0) was used for statistical analysis. A P-value <0.05 was considered statistically significant. Results: Overall 1085 VVRs were reported in relation to 88,201 donations, resulting in an overall VVR rate of 1.23%, that is, an incidence of 1 in every 81 donations. Donors with low blood volume, first-time donors, with low weight and female donors had higher absolute donation VVR rates than other donors. Conclusions: Donation-related vasovagal syncopal reactions are a multifactorial process determined largely by weight, age, first-time donor status and total blood volume. Our study reinforces the fact that blood donation is a very safe procedure, which could be made even more event-free by following certain friendly, reassuring practices and by ensuring strict pre-donation screening procedures.

Seroprevalence of human parvovirus B19 in healthy blood donors

BACKGROUND Human parvovirus B19 is an emerging transfusion transmitted infection. Although parvovirus B19 infection is connected with severe complications in some recipients, donor screening is not yet mandatory. To reduce the risk of contamination, plasma-pool screening and exclusion of highly viraemic donations are recommended. In this study the prevalence of parvovirus B19 in healthy blood donors was detected by ELISA. METHODS A total of 1633 samples were screened for IgM and IgG antibodies against parvovirus B19 by ELISA. The initial 540 samples were screened for both IgM and IgG class antibodies and remaining 1093 samples were screened for only IgM class antibodies by ELISA. RESULTS Net prevalence of IgM antibodies to human parvovirus B19 in our study was 7.53% and prevalence of IgG antibodies was 27.96%. Dual positivity (IgG and IgM) was 2.40%. CONCLUSION The seroprevalence of human parvovirus B19 among blood donor population in our study is high, and poses an adverse transfusion risk especially in high-risk group of patients who have no detectable antibodies to B19. Studies with large sample size are needed to validate these results.

The effect of repeated freezing and thawing on levels of vitamin K-dependent coagulation factors and fibrinogen in fresh frozen plasma

Background: Fresh frozen plasma (FFP) is considered adequate for transfusion immediately after thawing or for up to 24 hours if kept at 1–6°C, and is currently used very often to replace deficient clotting factors. If factor levels in refrozen FFP are within normal limits, then this component can possibly be transfused, thus avoiding wastage of FFP. Aim: To study the fate of vitamin K-dependent coagulation factors (F II, F VII, F IX, F X) and fibrinogen activity levels in repeatedly (twice) frozen and thawed FFP. Materials and Methods: Two hundred FFP units comprising 50 units of each major blood group (A, B, AB, and O) were thawed at 37°C and 10–20 mL of FFP transferred to transfer bags with the help of a sterile connecting device (SCD). The FFP samples were taken into tubes (first sampling), and then the transfer bags were kept for 24 hours at 4°C. After 24 hours, repeat samples were taken in tubes from the transfer bag (second sampling), and then the bags were re-stored at < -18°C. One week later, the above procedure was repeated. Activity of coagulation factors and fibrinogen levels were measured by the automated coagulation analyzer. Results: The levels of F II, F VII, F IX, F X, and fibrinogen of all the 200 FFP units, at all four time points, were above the lower normal value, but well within the normal range. Conclusion: The levels of F II, F VII, F IX, F X, and fibrinogen remain stable and adequate for transfusion in twice-thawed-and-refrozen FFP. This component can be safely used for transfusion as a source of vitamin K-dependent clotting factors and fibrinogen.

Factor IX deficiency (Christmas disease)

Hemophilia B is the second most common type of hemophilia.1,2 It is also known as factor IX deficiency, or Christmas disease. It was originally named “Christmas disease” after the first person diagnosed with the disorder back in 1952. Hemophilia A is 7 times more common than hemophilia B, occurring in about 1 in 25,000 male births in US and 1 in 30,000–60,000 in India.3,4 All races and economic groups are affected equally. Hemophilia B is inherited as an X-linked recessive disorder, where males are affected, with females being carriers. Here we present a case that manifested with adult onset spontaneous gastrointestinal and gingival bleeding at 32 years of age.

Transfusion medicine and solid organ transplant – Update and review of some current issues

Transfusion medicine holds a place of prime importance in organ transplant surgeries. There is a huge demand of organs worldwide with long waiting periods before the organ is available for transplant. Currently the dependency on ABO and HLA matching has decreased considerably with the use of modern immunosuppressant drugs and transplant techniques. The greatest advance in clinical implementation of ABO-incompatible transplants came about through desensitization and isoagglutinin elimination techniques with immunoadsorption and anti-CD20 antibodies becoming the norm, and spleenectomy fading out. The implications and practices of transfusion medicine in organ transplant are also undergoing drastic changes. The practice of infusion of one unit of donors blood preoperatively for immunomodulation is no longer practiced. Use of leuco-reduced products has shown decreasing trends of alloimmunization and graft rejection in cases of multiple surgeries related to organ transplants. Worldwide donor and recipient registry programmes are being setup and existing ones are being upgraded. Such a registry system has been opened in India for kidney transplant cases very recently. Due to such registry programmes the dependency on siblings and directed donations have decreased considerably. This review deals with some of the current issues contributing to the successful outcome of mismatched transplants and the changing concepts of transfusion medicine related to it.

Drug-induced immune hemolytic anemia (Direct Antiglobulin Test positive).

Drug-induced immune hemolytic anemia occurs rarely (1 in 1 million population).1 It is an uncommon finding characterized by a sudden decrease in hemoglobin after treatment with the putative drug. To date, about 100 drugs have been implicated in causing a positive Direct Antiglobulin Test (DAT) and/or hemolytic anemia. The most common drugs associated with this, are penicillin and its derivatives, cephalosporins (cefotetan, ceftriaxone etc.), methyldopa, β-lactamase inhibitors and quinidine. Drug antibodies fall into two types: drug-independent (autoantibodies) and drug-dependent (“penicillin type” or “immune complex type”). Some drugs cause non-immunologic protein adsorption onto drug-treated red blood cells (RBCs).1–3 All these mechanism are associated with positive DAT which may lead to hemolytic anemia.

Evolution of the role of army transfusion services in the management of trauma patients and battle casualties with massive hemorrhage

Providing blood at the times of national emergencies and war-like scenarios is a challenge to the blood transfusion services. The dictum should be adequate bleeding, minimum storage time, quick transportation and maximum utilization of blood as soon as possible. For the successful implementation of its role, forward transfusion services should be fully mobile with integral transportation and communication systems. Supplementation of blood supplies has to be prompt, & for this adequate air transport facilities will have to be established. A rational approach to using blood products in patients with bleeding, requires an understanding of the principles of managing hemorrhagic shock. The main priorities are controlling hemorrhage and restoring adequate oxygen delivery to the tissues. Surgical control and treatment of coagulopathy are required to stop hemorrhage in these patients. Resuscitation with fluids and red cells are necessary to improve perfusion and oxygen delivery to tissues. Once patients are resuscitated and further bleeding is stopped, use of conservative transfusion triggers is recommended to avoid excessive transfusion and adverse outcomes. A host of new technologies are being developed that have the potential of reducing blood loss. These will help in reducing the transfusion requirements in trauma patients with massive hemorrhage.

Is high pressure liquid chromatography an effective screening tool for characterization of molecular defects in hemoglobinopathies

INTRODUCTION Hemoglobinopathies constitute entities that are generated by either abnormal hemoglobin or thalassemias. high pressure liquid chromatography (HPLC) is one of the best methods for screening and detection of various hemoglobinopathies but it has intrinsic interpretive problems. The study was designed to evaluate the different mutations seen in cases of hemoglobinopathies and compare the same with screening tests. MATERIALS AND METHODS 68 patients of hemoglobinopathies were screened by HPLC. Mutation studies in the beta globin gene was performed using the polymerase chain reaction (PCR)-based allele-specific Amplification Refractory Mutation System (ARMS). Molecular analysis for the sickle cell mutation was done by standard methods. RESULTS The IVS 1/5 mutation was the commonest mutation seen and it was seen in 26 (38.23%) of the cases. This was followed by the IVS 1/1, codon 41/42, codon 8/9, del 22 mutation, codon 15 mutation and the -619 bp deletion. No mutation was seen in eight cases. There was a 100% concordance between the sickle cell trait as diagnosed by HPLC and genetic testing. DISCUSSION AND CONCLUSION Our study underlies the importance of molecular testing in all cases of hemoglobinopathies. Although HPLC is a useful screening tool, molecular testing is very useful in accurately diagnosing the mutations. Molecular testing is especially applicable in cases with an abnormal hemoglobin (HbD, HbE and HbS) because there may be a concomitant inheritance of a beta thalassemia mutation. Molecular testing is the gold standard when it comes to the diagnosis of hemoglobinopathies.