Thomas J. Gniadek

A rare, potentially life‐threatening presentation of passenger lymphocyte syndrome

Passenger lymphocyte syndrome occurs when donor lymphocytes are transplanted with a solid organ and produce alloantibodies that react with antigens on the recipients red blood cells (RBCs). Typically, passenger lymphocyte syndrome presents as immunoglobulin G antibody‐mediated, extravascular hemolytic anemia with reticulocytosis. Often, the donor was alloimmunized before transplantation.

Drug-induced immune hemolytic anemia associated with anti-vancomycin complicated by a paraben antibody

Drug‐induced immune hemolytic anemia (DIIHA) is rare, but potentially life‐threatening. A high index of clinical suspicion is required for diagnosis, since the number of medications known to induce DIIHA continues to expand. Additionally, in vitro antibody reactivity against reagent additives has been reported, which may complicate test interpretation.

Measuring Autophagosome Flux

ABSTRACT Macroautophagy/autophagy is a proteolytic pathway that is involved in both bulk degradation of cytoplasmic proteins as well as in selective degradation of cytoplasmic organelles. Autophagic flux is often defined as a measure of autophagic degradation activity, and many techniques exist to assess autophagic flux. Although these techniques have generated invaluable information about the autophagic system, the quest continues for developing methods that not only enhance sensitivity and provide a means of quantification, but also accurately reflect the dynamic character of the pathway. Based on the theoretical framework of metabolic control analysis, where the autophagosome flux is the quantitative description of the rate a flow along a pathway, here we treat the autophagy system as a multi-step pathway. We describe a single-cell fluorescence live-cell imaging-based approach that allows the autophagosome flux to be accurately measured. This method characterizes autophagy in terms of its complete autophagosome and autolysosome pool size, the autophagosome flux, J, and the transition time, τ, for autophagosomes and autolysosomes at steady state. This approach provides a sensitive quantitative method to measure autophagosome flux, pool sizes and transition time in cells and tissues of clinical relevance. Abbreviations: ATG5/APG5, autophagy-related 5; GFP, green fluorescent protein; LAMP1, lysosomal-associated membrane protein 1; MAP1LC3/LC3, microtubule-associated protein 1 light chain 3; J, flux; MEF, mouse embryonic fibroblast; MTOR, mechanistic target of rapamycin kinase; nA, number of autophagosomes; nAL, number of autolysosomes; nL, number of lysosomes; p-MTOR, phosphorylated mechanistic target of rapamycin kinase; RFP, red fluorescent protein; siRNA, small interfering RNA; τ, transition time; TEM, transmission electron microscopy.

Cytomegalovirus-safe blood: the unclear effect of sickle hemoglobin

Cytomegalovirus-safe blood: the unclear effect of sickle hemoglobin Transfusion-transmitted cytomegalovirus (CMV) remains a significant concern for at-risk patients, especially transplant recipients. CMV has been associated with increased morbidities that include graft-versus-host disease, rejection, and susceptibility to secondary infection as well as increased mortality. Antiviral medications are available, but they are not without side effects, nor do they completely prevent sequelae. For previously CMV-negative patients, transfusion is rarely confirmed as the source of infection, but it is often suspected. Seronegative and leukoreduced blood products have residual CMV transmission rates of 1 to 2% and 2 to 3%, respectively. Of these two approaches, prestorage leukoreduction is most widely used to provide “CMV-safe” blood products, because it is logistically easier to implement and decreases the rate of febrile nonhemolytic transfusion reactions and human leukemic antigen (HLA) alloimmunization. However, at least one major prospective study showed significantly higher rates of CMVassociated disease in patients who received leukoreduced versus seronegative transfusions. Interestingly, preclinical data suggest that sickle trait (HbAS) donor red blood cells (RBCs) decrease leukoreduction efficacy, which has not been taken into account in clinical studies to date. Given the widespread use of leukoreduction, the effect of sickle hemoglobin on the rate of transfusion-transmitted CMV deserves consideration and further study. Blood collection centers use statistical process control to detect leukocyte reduction failures, typically testing approximately 1% of units. Factors that increase the binding of RBCs to the filter may decrease sites available for leukocyte binding and, thus, leukoreduction efficacy. The same process can also completely occlude the filter. This problem has been reported for HbAS RBCs, in which the efficacy of leukoreduction seems to be related to filtration time. Because of this issue, US Food and Drug Administration guidance requires additional testing in certain scenarios. For instance, if filtration requires longer than the filter manufacturer’s stated maximum filtration time, then that unit must be individually tested. There are problems with this approach: studies demonstrate that, although about one-half of HbAS units filter within the allowed time, many of these units show suboptimal leukoreduction. CMV DNA has been detected in 0.004 to 0.01% of circulating mononuclear cells from CMV seropositive individuals (50%-70% of the healthy donor population) after granulocyte colony-stimulating factor-mobilization. CMV DNA has also been detected in some seronegative individuals. CMV infects marrow progenitor cells, but monocytes are the primary circulating mononuclear cell type infected by CMV. The number of CMV DNA copies per 10,000 monocytes varies by age, from 8.6 (standard deviation, 38) for individuals younger than 70 years to 249 (standard deviation, 59) for those older than 70 years. Assuming a normal peripheral blood monocyte count, a unit collected from a latently infected donor and reduced to 5 3 10 white blood cells could contain from 86 to 430 copies of CMV DNA or more. In mice, the minimum infectious dose appears to be approximately 1000 murine CMV genomes, with a dose-dependent increase in transmission rates above that level. Thus, even a 10% decrease in leukoreduction efficiency (as previously reported in some HbAS-positive units) may lead to a significant increase in the CMV transmission rate. With an estimated sickle trait prevalence of approximately 0.8% in US blood donors and marked geographic variation, these units may account for a non-negligible percentage of CMV transmissions when using leukocyte-reduced products. The current response to this potential risk is inconsistent. At least one large US blood center tests donors for sickle hemoglobin if they self-identify as being of African descent and voluntarily opt to join a “sickle cell program.” If they are positive, then the donor is deferred for RBC donation. Another large US blood supplier only defers known sickle trait donors if their donated blood does not reliably filter, which can be advantageous, because these donors might provide hard to find antigen-negative blood for alloimmunized patients of African descent. Large clinical studies would be needed to determine whether HbAS increases the transmission risk when leukoreduction is used to provide CMV reduced-risk units to patients; in vitro and animal studies may be more tractable approaches to further address this question. Similar approaches could be used for a preliminary assessment of whether febrile nonhemolytic transfusion reactions or HLA alloimmunization rates may also be increased in recipients who received leukoreduced units from sickle trait donors. Until additional data become available, and depending on what is deemed an acceptable level of risk for transfusion-transmitted CMV, it may be necessary to implement additional testing of leukocyte-reduced units from HbAS donors. An alternative approach to ensure a low risk of CMV transmission would be pathogen inactivation (once available for RBC units). doi:10.1111/trf.14138

Remote emergency release of blood products using a custom iPad application: IPAD APPLICATION FOR REMOTE EMERGENCY RELEASE

Hennepin County Medical Center (HCMC) is a Level I trauma hospital with approximately 160 massive transfusions annually, most initiated in the emergency department (ED). Although emergency release red blood cell (RBC) units are always available from the blood bank, it may take 15 to 20 minutes to reach the ED by runner. While there are commercial solutions (e.g., Hemosafe, Haemonetics) to remotely issue blood products, their cost can be prohibitive. We developed a novel software and hardware system to control and monitor the emergency release of RBCs in the HCMC ED (see figure, schematic workflow shown). The system utilizes the access control features on an Omnicell, Inc. medication dispensing cabinet to release the lock on a blood refrigerator door. To obtain emergency release blood, trained ED staff unlock the refrigerator using the Omnicell by entering their identification (ID) and a patient ID and selecting blood products, like they would for dispensing medication. If no patient ID is available (e.g., before patient arrival), release can occur to an unidentified

Mechanical hemolysis in pediatric patients associated with rapid transfusion and one-way valve: MECHANICAL HEMOLYSIS WITH ONE-WAY VALVE

Four similar transfusion reactions involving infants were reported in less than 1 year. After transfusion of red blood cells (RBCs) via syringe in the operating room, each patient experienced discolored urine, laboratory evidence of hemolysis, and acute kidney injury. Clerical and serologic investigations were unremarkable. Mechanical hemolysis was considered.

Distributed ledgers in transfusion medicine: an opportunity for standards to accelerate innovation: LETTER

Distributed ledgers in transfusion medicine: an opportunity for standards to accelerate innovation A distributed ledger is a generic data storage model that can contain anything from currency transaction information (e.g., Bitcoin) to health care information. Copies of the data are stored in many places, with access and data security protected by encryption-controlled permissions and synchronization. Additionally, distributed ledgers allow for full auditing of data entry and data access events as well as “smart contracts” (preprogrammed, self-executing transactions triggered by the occurrence of certain events and conditions being met, even if all the details involved in the transactions are not visible to users of the system). The US Food and Drug Administration (FDA), IBM, and other private companies are exploring this technology to develop tomorrow’s health care information technology (IT) applications. They promise secure health care data (for research or clinical care) available and modifiable worldwide, with appropriate permissions that can be completely controlled by the patient. Now is the moment for the blood banking community to define clear standards for data stored and transmitted via distributed ledger.

Optimal Storage Conditions for Apheresis Research (OSCAR): a Biomedical Excellence for Safer Transfusion (BEST) Collaborative study: STORAGE OF CELL PRODUCTS

Cell therapy products are often stored and transported between sites. The aim of this study was to determine the effect of storage temperature, solution, and cell concentration on nonmobilized, peripheral blood–derived mononuclear cells (MNCs).

A 43-year-old woman with unexplained elevation of hCG

OBJECTIVE This case report investigates an unusual hCG result in a woman who is not pregnant. PATIENT AND METHODS A 43-year-old woman was admitted for recurrence of thrombotic thrombocytopenic purpura (TTP) and therapeutic plasma exchange (TPE) was initiated. Prior to transitioning the patient from TPE to immunosuppressive therapy, a serum qualitative hCG test was performed and was positive. Several etiologies for elevated hCG were considered and investigated, including heterophile antibody interference, endogenous hCG from pituitary or malignancy, and exogenous hCG. RESULTS Retrospective measurement of hCG levels in remnant samples, including a sample obtained prior to TPE initiation, demonstrated that the hCG elevation occurred with plasma administration for TPE. Further investigation with the American Red Cross confirmed that a plasma donor was unknowingly pregnant and in the latter half of the first trimester at the time of donation, when hCG levels peak. CONCLUSION In plasma recipients with unexplained hCG elevation, passive transfer of hCG from plasma should be considered in the differential diagnosis. Retrospective measurement of hCG in remnant samples obtained prior to plasma exchange can assist in confirming the source.

Traveling treatment: medical tourism in the emerging era of potentially transmissible therapeutics

blood donors among their ID patients was estimated to be low, and only 28% (14/50) reported to usually know if a patient is a repeat blood donor. Our online survey raises suspicion that the awareness for blood donation as primary cause for ID and iron-deficient anemia is low, supporting Mast’s assumption. Two to three percent of the generally healthy population donates blood, and up to 40% of male and 60% of female donors are iron deficient. Given these high numbers of potentially affected individuals, the direct medical and indirect socioeconomic costs for unnecessary medical workups including endoscopy in irondeficient blood donors may be notable but need to be verified, since most donors are referred to their physician by the blood donation services due to low hemoglobin (Hb) counts. In many cases further investigations would likely be waived. However, the anticipated costs of widespread ferritin screening are not trivial either and need to be weighed against them. It seems surprising that in our survey, less than 10% of the participating physicians were aware of the association between blood donation and ID, but donors are generally considered to be healthy and are therefore not typical patients. We suggest that blood donor status should be recorded in patients’ files and donors should be informed about the potential adverse effects of blood donation. Sixty years ago, Schumann and colleagues reported that ID is highly prevalent in blood donors and should be prevented with the following recommendations: maximal volume of 400 to 500 mL per donation, ID screening for donors (and exclusion of affected donors), blood donation only after (Hb and iron store) recovery, and oral iron therapy between donations. To date, only one of these recommendations (maximal volume of 400-500 mL) is widely implemented in transfusion medicine services worldwide. In 2015, Kiss and colleagues showed that iron status or Hb recovery is very slow without iron supplementation and takes longer than the minimum donation interval even with iron supplementation in many donors. Without iron supplements, 67% of participants did not recover iron stores by 168 days (with oral iron intake recovery took a median of 76 days [IQR, 20–126 days], without oral iron intake more than 168 days [IQR, 147 to >168 days]), questioning the current standard 8-week minimum interval between whole blood donations in the United States and many other countries. In summary, it appears that blood donation as a causative factor in assessing ID is rarely considered and physicians may not be aware if their patients are regular blood donors. In their recent article, Goldman and colleagues give us convincing evidence that all of Schumann’s four 1956 recommendations hold true—but three still need to be discussed for routine implementation to mitigate health concerns in volunteer blood donors. CONFLICT OF INTEREST