Shanna Morgan

Platelet and Red Blood Cell Utilization and Transfusion Independence in Umbilical Cord Blood and Allogeneic Peripheral Blood Hematopoietic Cell Transplants

Allogeneic hematopoietic cell transplantation (HCT) recipients have substantial transfusion requirements. Factors associated with increased transfusions and the extent of blood product use in umbilical cord blood (UCB) recipients are uncertain. We reviewed blood product use in 229 consecutive adult recipients of allogeneic HCT at the University of Minnesota: 147 with leukemia, 82 lymphoma or myeloma; 58% received unrelated UCB and 43% sibling donor peripheral blood stem cell (PBSC) grafts. Although neutrophil recovery was prompt (UCB median 17, range: 2-45 days, and PBSC 14, range: 3-34 days), only 135 of 229 (59% cumulative incidence) achieved red blood cell (RBC) independence and 157 (69%) achieved platelet independence by 6 months. Time to platelet independence was prolonged in UCB recipients (median UCB 41 versus PBSC 14 days) and in patients who had received a prior transplant (median 48 versus 32 days). Patients who received UCB grafts required more RBC through day 60 post-HCT (mean UCB 7.8 (95% confidence interval [CI] 6.7-8.9) versus PBSC 5.2 (3.7-6.7) transfusions, P = .04), and more platelet transfusions (mean 25.2 (95% CI 22.1-28.2) versus 12.9 (9.4-16.4), P < .01) compared to PBSC recipients. Patients receiving myeloablative (MA) conditioning required more RBC and platelet transfusions during the first 2 months post-HCT compared to reduced-intensity conditioning (RIC) (7.4 versus 6.2, P = .30 for RBC; 23.2 versus 17.5, P = .07 for platelets). Despite prompt neutrophil engraftment, UCB recipients had delayed platelet recovery as well as more prolonged and costly blood product requirements. Enhanced approaches to accelerate multilineage engraftment could limit the transfusion-associated morbidity and costs accompanying UCB allotransplantation.

Haemolysis after treatment with intravenous immunoglobulin due to anti-A

Background: Intravenous immunoglobulin (IVIG) is used to treat an increasing number of conditions. IVIG contains immunoglobulin G (IgG) directed against many targets, including red blood cell (RBC) antigens.

National Institutes of Health State of the Science Symposium in Therapeutic Apheresis: Scientific Opportunities in Extracorporeal Photopheresis

The clinical use of extracorporeal photopheresis (ECP) for accepted indications such as graft-versus-host disease, transplant rejection, and cutaneous T-cell lymphoma continues to increase. Expanded applications for ECP, such as the treatment of select autoimmune diseases, are being explored. Extracorporeal photopheresiss capacity to both immunotolerize in the autoreactive setting, while immunizing against a lymphoma is unusual and suggestive of a unique mechanism. It is likely that ECPs induction of dendritic cells is key to its efficacy in both of these settings, but exactly how ECP impacts other immune components and their interactions is not fully understood. Further basic science research is necessary to elucidate how these dissimilar cellular activities are functionally integrated. On the clinical side, collaborative multicenter trials designed to recognize the principal variables controlling therapeutic responses and improve prognostic indicators may enable tailoring devices, treatment schedules, and doses to the needs of the individual patients or diseases. This review describes our current understanding of how ECP influences the immune system, reviews the existing clinical applications of ECP, and explores areas for future basic science and clinical research as presented at the National Institutes of Health State of the Science Symposium in Therapeutic Apheresis in November 2012.

Extracorporeal photopheresis practice patterns: An international survey by the ASFA ECP subcommittee

Although many apheresis centers offer extracorporeal photopheresis (ECP), little is known about current treatment practices.

Report of the ASFA apheresis registry study on Wilson's disease

Wilsons disease is a rare autosomal recessive genetic disorder that results in accumulation of copper in the liver, brain, cornea and kidney. Therapeutic plasma exchange (TPE) has been used to remove copper and provide a bridge to liver transplantation. We report here the collective experiences through the ASFA apheresis registry on Wilsons disease.

Therapeutic plasma exchange in neuromyelitis optica: a case series.

Neuromyelitis optica (NMO) is a relapsing inflammatory disease of the central nervous system that predominantly affects the spinal cord and optic nerves. The clinical hallmark of the disease is a step‐wise deterioration of visual and spinal cord function. This study reviews patients with steroid resistant relapsing NMO presenting for therapeutic plasma exchange (TPE) at our institution from December 2005 to December 2012. A total of five patients were treated with single volume TPE. Both subjective and objective clinical response to TPE was estimated by three different sources (the patient, a Transfusion Medicine physician, and the treating Neurologist) with the patient and Transfusion Medicine physicians final assessment of response made at the time of the last TPE in the series and the treating neurologists assessment of response made at the time of the next neurological exam after the last TPE. A total of 17 TPE series were performed with the average course of therapy being three series (ranged 1–5) with five TPE (ranged 3–7) per series. All patients demonstrated improvement with each series of TPE and all procedures were well tolerated with only transient and well‐described reactions all of which were successfully resolved with minor or no sequelae. J. Clin. Apheresis 29:171–177, 2014.

Simulation-based education for transfusion medicine.

The administration of blood products is frequently determined by physicians without subspecialty training in transfusion medicine (TM). Education in TM is necessary for appropriate utilization of resources and maintaining patient safety. Our institution developed an efficient simulation‐based TM course with the goal of identifying key topics that could be individualized to learners of all levels in various environments while also allowing for practice in an environment where the patient is not placed at risk.

Anti‐A and anti‐B titers in group O platelet units are reduced in PAS C versus conventional plasma units

We have read with great interest the recent results of progressive impairments in nitric oxide (NO)–mediated vasodilation through stored red blood cells (RBCs). Because of their in vitro studies, Alexander and colleagues concluded that RBC-mediated vasoinhibitory mechanism did not work by NO scavenging. Although they recognize that their results do not specifically argue against vasoconstriction caused by cell-free hemoglobin (Hb), they arrive at the conclusion that the RBC-derived inhibitory activity appears much more potent than the vasoconstrictive activity of cell-free Hb. In view of these findings, the results of an in vivo study recently finished by our group may add valuable additional insight on the vasoinhibitory activity of stored RBCs. After transfusion of stored RBCs (older than 14 days) we found indications for enhanced scavenging of vasodilating nitric oxide by cell-free Hb. We conducted detailed hemodynamic and biochemical studies in 16 patients requiring transfusion of RBCs. The arterial function was studied noninvasively. In particular, we determined the pulse wave velocity as well as the aortic augmentation index as indicators of arterial stiffness. Patients (n = 8) who received stored RBCs showed a significantly increased aortic augmentation index (27.67% vs. 20.67%, p = 0.04) as well as an enhanced pulse wave velocity (13.46 m/sec vs. 11.45 m/sec, p = 0.004). Additionally, stored RBCs increased the nitrosylhemoglobin concentration (0.061 μmol/L vs. 0.018 μmol/L, p = 0.048) in transfusion recipients, possibly due to increased reaction between cell-free Hb (released because of agedepended RBC hemolysis) and nitric oxide. The described hemodynamic and biochemical alterations were absent in patients (n = 8) who received fresh RBCs (younger than 14 days). These data document that transfusion of aged RBCs has profound effects on arterial function in patients and show that the vasoconstrictive activity of free Hb may exceed what Alexander and colleagues assume in their studies. In addition to large clinical meta-analyses our results provide further evidence of the mechanism of deleterious transfusion outcomes in patients with stored RBCs. CONFLICT OF INTEREST

Effect of therapeutic plasma exchange on coagulation parameters in patients on warfarin.

Therapeutic plasma exchange (TPE) without plasma replacement results in coagulation factor removal. Warfarin decreases the activity of vitamin K dependent coagulation factors. The combined effect of TPE and warfarin on the coagulation system has not been studied. A prospective, observational study was conducted in patients undergoing TPE while on warfarin. One plasma volume TPEs were performed on the COBE Spectra Apheresis System (Terumo BCT, Lakewood, CO) with 5% albumin. International normalized ratio (INR), fibrinogen, and factor II activity were obtained pre and post procedure. Eight patients underwent 121 TPEs that met study criteria with pre and post data. The average pre values were INR 2.09 ± 0.58, fibrinogen 263 ± 76 mg/dl, and factor II 29 ± 16% and the average post values were INR 4.12 ± 1.44, fibrinogen 105 ± 31 mg/dl, and factor II 13 ± 7%. The pre‐INR was ≥2.00 for 55% of TPEs. The pre value (Y0) predicts the post value (Y) by the following equations Y = −0.54 + 2.21Y0, Y =12.10 + 0.35Y0, and Y =1.83 + 0.39Y0 for INR, fibrinogen, and factor II respectively. In conclusion, pre procedure laboratory values can predict the post laboratory values for patients on warfarin receiving single plasma volume TPE with albumin replacement. The post‐INR is approximately twice the pre‐INR. At normal and mildly elevated pre‐INR, the effect of TPE on the INR is less marked. A single plasma volume TPE decreases the plasma level by ∼65% for fibrinogen and 60% for factor II. J. Clin. Apheresis 29:75–82, 2014.

Therapeutic plasma exchange in neuromyelitis optica

Neuromyelitis optica (NMO) is a relapsing inflammatory disease of the central nervous system that predominantly affects the spinal cord and optic nerves. The clinical hallmark of the disease is a step‐wise deterioration of visual and spinal cord function. This study reviews patients with steroid resistant relapsing NMO presenting for therapeutic plasma exchange (TPE) at our institution from December 2005 to December 2012. A total of five patients were treated with single volume TPE. Both subjective and objective clinical response to TPE was estimated by three different sources (the patient, a Transfusion Medicine physician, and the treating Neurologist) with the patient and Transfusion Medicine physicians final assessment of response made at the time of the last TPE in the series and the treating neurologists assessment of response made at the time of the next neurological exam after the last TPE. A total of 17 TPE series were performed with the average course of therapy being three series (ranged 1–5) with five TPE (ranged 3–7) per series. All patients demonstrated improvement with each series of TPE and all procedures were well tolerated with only transient and well‐described reactions all of which were successfully resolved with minor or no sequelae. J. Clin. Apheresis 29:171–177, 2014.