Richard E. Rosenfield

Outcomes among 562 Recipients of Placental-Blood Transplants from Unrelated Donors

BACKGROUND A program for banking, characterizing, and distributing placental blood, also called umbilical-cord blood, for transplantation provided grafts for 562 patients between August 24, 1992, and January 30, 1998. We evaluated this experience. METHODS Placental blood was stored under liquid nitrogen and selected for specific patients on the basis of HLA type and leukocyte content. Patients were prepared for the transplantation of allogeneic hematopoietic cells in the placental blood and received prophylaxis against graft-versus-host disease (GVHD) according to routine procedures at each center. RESULTS Outcomes at 100 days after transplantation were known for all 562 patients, and outcomes at 1 year for 94 percent of eligible recipients. The cumulative rates of engraftment among the recipients, according to actuarial analysis, were 81 percent by day 42 for neutrophils (median time to engraftment, 28 days) and 85 percent by day 180 for platelets (median, day 90). The speed of myeloid engraftment was associated primarily with the leukocyte content of the graft, whereas transplantation-related events were associated with the patients underlying disease and age, the number of leukocytes in the graft, the degree of HLA disparity, and the transplantation center. After engraftment, age, HLA disparity, and center were the primary predictors of outcome. Severe acute GVHD (grade III or IV) occurred in 23 percent of patients, and chronic GVHD occurred in 25 percent. The rate of relapse among recipients with leukemia was 9 percent within the first 100 days, 17 percent within 6 months, and 26 percent by 1 year. These rates were associated with the severity of GVHD, type of leukemia, and stage of the disease. CONCLUSIONS Placental blood is a useful source of allogeneic hematopoietic stem cells for bone marrow reconstitution.

Instrumented PVP-Augmented Antiglobulin Tests

Abstract. 34 patients found to have positive direct antiglobulin tests were divided into 3 classes: (1) no evidence of active acquired hemolytic anemia (AHA); (2) active warm AHA, and (3) active cold AHA. Of 16 patients in the first category, 4 had multiple myeloma, but 10 others showed IgG alone with both x‐ and Λ‐Iight chains, and 2 others showed both IgG and IgA. None showed C3 or C4. Three patterns of warm AHA were observed: (1) monoclonal IgG without complement; (2) IgA or IgD with C3 but not C4, and (3) multiple immunoglobulins, C3, and C4. In the last group of patients, IgM appeared to be responsible for both PVP‐mediated agglutination and fixation at the red cell surface of complement components. The red cells of paroxysmal cold hemoglobinuria and of IgM cold agglutinin disease carried both C4 and C3, but the cells of cold agglutinin disease also carried IgG and IgA. Two cases of mixed cryoglobulin cold agglutinin disease had corresponding immunoglobulins on their red cells plus C3 and C4, and specificity (anti‐i and anti‐N) was carried by IgG.

Antigenic Determinants of C3 and C4 Complement Components on Washed Erythrocytes from Normal Persons

Well‐washed erythrocytes from normal persons were agglutinated by antisera to C3, C3d, and C4, and this agglutination was specifically inhibited by the corresponding C3 or C4 protein. C3 and C4 antigenic determinants were present on the red blood cells of freshly shed blood promptly anticoagulated with EDTA, heparin, ACD, or CPD, and no significant changes in degree of agglutination were observed on storage of EDTA or CPD blood for two weeks at 4 C. Marked differences in degree of agglutination by anti‐C3, anti‐C3d, and anti‐C4 were observed when erythrocytes of 16 normal persons were assayed, and significant correlations were obtained when the quantitative results with any two anti‐sera were compared. Anti‐C3c did not agglutinate erythrocytes from normal persons, suggesting that the C3 antigens detected on normal cells are carried by the C3d fragment. To avoid significant agglutination of the erythrocytes from some normal persons, very dilute preparations of anti‐C3, ‐C3d, and ‐C4 had to be used for instrumented diagnostic direct antiglobulin tests. Stronger reagents could be used for indirect antiglobulin tests when the result of a suitable control could be subtracted.

Anti-A Autoantibody with Severe Intravascular Hemolysis

Anti-A autoantibody manifested itself clinically in fatal hemolysis and kidney failure in the following case. Case Report A 73-year-old man suddenly experienced severe bilateral lumbar pain associa...

Specific Agglutinability of Erythrocytes from Whole Blood Stored at 4 C

When whole blood is supplemented with adenine, the erythrocytes are suitable for transfusion after at least 35 days of storage at 4C, but information is not available as to whether such cells remain satisfactory for blood typing and pre transfusion tests for evidence of incompatibility. Accordingly, we designed experiments to evaluate by AutoAnalyzer the specific agglutinability of erythrocytes obtained from whole blood stored at 4C. Seven normal volunteer donors of both sexes, aged between 22 and 31 years, were chosen and bled periodically so that, over a three‐day testing period, all blood specimens from each donor could be evaluated. Each donor provided at each bleeding sufficient blood to permit aliquots of 20 ml to be stored as clotted blood and 8 ml to be stored as citrated whole blood. Four kinds of citrate solution were used: ACD Formula A, CPD, ACD supplemented with adenine, and CPD supplemented with adenine. All clotted specimens were tested after 0, 1, 2, 3, 4, and 5 weeks of storage, while all citrated specimens were tested after 0, 1, 2, 3, 4, 5, 6, 8, and 10 weeks of storage. Six blood group systems were used for evaluation with the following reagents: anti‐A or anti‐B, anti‐Rhl (Rho or D), anti‐K2 (k or Cellano), anti‐Jka, anti‐Fya or anti‐Fyb, and anti‐M. Each reagent was used at a dilution to support from 20 to 80 per cent agglutination with freshly drawn blood, and each reagent was tested under two conditions: low ionic and normal ionic.

BLOOD ELEMENTS AT FOREIGN SURFACES: IN VITRO EVALUATION OF BIOMATERIALS IN A SPINNING DISC APPARATUS*

A large number of possibilities for assessing the magnitude and manner of interaction of plasma proteins with foreign surfaces was considered in our paper presented earlier in this conference.1 Because many different candidate thromboresistant materials are available, it is essential to emerge from a world of abstract possibilities and generate a compact set of data by which these materials may actually be compared with each other with respect to their performance as blood boundaries. Initially, such a data set must be a compromise between the knowledge in depth that is necessary to understand the complex process of plasma protein adsorption, with subsequent participation in thrombus formation, and the need for simplicity, conciseness, and applicability of the data analysis to a wide range of materials. Thus, to date a simple, two-step hypothesis was proposed and tested on some seventeen candidate biomaterials furnished by contractors of the Biomaterials Program of the National Heart, Lung, and Blood Institute, NIH. The hypothesis stipulates that thrombogenesis is consequent to platelet adhesion and that platelet adhesion is related to antecedent adsorption of plasma proteins. In this paper are described the methods used for studying protein adsorption and platelet adhesion, including an explanation of critical choices made in the design of the test procedures. Steady state and time-varying data for the adsorption of human albumin, gamma globulin, and fibrinogen are presented and discussed. Corresponding data for the adhesion of canine platelets are presented and compared with protein adsorption results, from which a partial justification of the hypothesis is obtained. Then, the extent of nonuniformity of protein adsorption and platelet adhesion is tested and shown to be considerable. Finally, refined procedures and hypotheses for future testing are suggested.

Quantitative Blood Typing Profiles of Human Erythrocytes

Automated, sequential, quantitative blood typing has been achieved by modification of two previously described single channel AutoAnalyzers. In each of these channels, agglutination has been potentiated, either with bromelin and polyvinylpyrrolidone (PVP K‐90) or mannitol and protamine sulfate. Phased pulse‐sampling of both erythrocytes and prediluted antisera through micro‐probes and micro T‐fittings allow sampling rates of 80 tests/hour.

A “New” Infrequent Red Cell Antigen, Rd (Radin)

Five examples of a “new” blood group antibody, anti‐Rd (Radin), are reported. The corresponding antigen, Rd, is infrequent and does not correspond to any other known “low‐incidence” antigen. Family studies indicate that Rd is an autosomal dominant character which does not belong to the ABO, MNSs, Rh, Lutheran, Kell or Kidd blood group systems. Furthermore, the gene determining Rd is not closely linked to either the haptoglobin or red cell acid phosphatase loci. Anti‐Rd caused mild to moderate hemolytic disease of the newborn in all five families and has appeared with the first pregnancy.

Augmentation of Hemagglutination by Low Ionic Conditions

Short incubation at 37 C, 80 per cent reduction in ionic concentration and removal of liquid phases after each reaction step, provided the basis for the construction of four new serologic tests for alloantibodies to human erythrocytes. In the first, the incubation fluid was replaced with protamine sulfate to aggregate intensely the evaluated red blood cells. After dispersal by phosphate buffer, residual antibody mediated agglutination could be discerned. As a second method, this low ionic polycation (LIP) test was followed by a normal ionic IgG antiglobulin test (LIP‐AGT). A third method employed low ionic washing of erythrocytes and low ionic antiglobulin serum (LIAGT). Finally, a modified LIP test was conducted entirely under low ionic conditions and followed by a low ionic antiglobulin test (modified LIP‐AGT). LIP, LIP‐AGT and LIAGT were successfully employed for all routine blood bank serology tests. Their sensitivity and impact on blood bank performance are described.

Intrauterine fetal transfusions for the management of erythroblastosis

Initial experience with the technique of intrauterine fetal transfusion is reported. Eight fetuses received 11 intraperitoneal transfusions for severe Rh erythroblastosis. Four infants survived, 3 died from persistent hydrops, and 1 died from intercurrent sepsis. Elavated concentrations of amniotic fluid protein relative to the stage of gestation were found to correlate with fetal hydrops. Following intrauterine therapy, decreasing amniotic fluid protein content correlated with an improving fetus; both amniotic fluid Δ O.D. 450 mμ units and the bilirubin/protein ratio values reflected the extent of residual fetal hemolytic disease. In 2 cases suppression of fetal erythropoiesis followed multiple intrauterine transfusions and eliminated the need for subsequent exchange transfusions. Positive antiglobulin tests of Rh-negative cord blood after intrauterine transfusions were encountered and found to be associated with a condition of maternal antibodies against penicillin and the prophylactic administration of intraperitoneal penicillin to the fetus.