Volkmar Sachs

Autologous Transfusion Practice Controversies about Current Fashions and Real Needs

Autologous transfusions, frequently termed ‘autotransfusions’, generally refer to the use of patients’ own blood to meet their blood transfusion needs either fully or partially. By salvaging blood from postpartum hemorrhages in 10 women in 1818, Blundell [1] is considered to have been the first physician to employ autologous transfusion systematically. Although their use was reported sporadically in many different settings during the 19th and early 20th centuries [for a historical review see Kuban, 21, it was not until the late 1960s and early 1970s that autologous transfusions to large numbers of patients were reported [3-81. Their popularity during that period can be attributed, at least in part, to concerns about transmission of hepatitis by transfusions [6-81; paid blood donors were still widely used in the United States and testing of donated blood and plasma for the hepatitis B surface antigen was in its infancy. A second wave of popularity €or autologous transfusions both on the part of patients and their physicians appears to have been stimulated by the emergence of AIDS [9, 101. Concerns about transfusion-transmitted AIDS have grown even though the risks of hepatitis transmission by blood transfusion greatly exceed those of AIDS [ll]. A survey of transfusion services and donor centers conducted in 1974 indicated that 35% offered autologous donation programs but that very little blood was collected for this purpose 1121. A similar survey conducted in 1982 indicated that 49% of institutions offered autologous programs at that time [13]. They were most common in hospitals as only 12% of responding regional centers had established autologous programs. In January 1986, less than 1% of red cells transfused during a cooperative study in 18 tertiary care hospitals was autologous [14]. However, autologous donations have increased in our center from less than 1% of collections in 1985 to more than 4% in 1988, and are projected to be greater than 6% in 1990 [unpubl. data, Carey P, Zuck T, 19881. We believe our experience mirrors nationwide trends in the United States. The current interest in autologous transfusions has reawakened various controversies about some programs and practices. Many of these issues were discussed recently at a meeting of the Blood and Blood Products Advisory Committee meeting of the United States Food and Drug Administration (FDA) [15]. In this communication we review the current practice of autologous transfusion, principally in the United States, and discuss those areas on which the controversies have focused.

Immunologic Aspects of Plasminogen

* Presented at the Tenth Annual Meeting of The International College of Angiology, New York, in Geneva, Switzerland (July 23-28, 1968), second scientific session, Peripheral Vascular Diseases, July 24, 1968. † Department of Immunohematology and Blood Transfusion, Institute of Hygiene, University of Kiel, Kiel, Germany. ‡ Department of Nuclear Hematology and Biology, Institute of Nuclear Energy, University of Stuttgart, Stuttgart, Germany. Although inhibition of the fibrinolytic activity of human plasma by immune antibodies against plasminogen has been assumed,’ it has not been proven. In order to test the hypothesis that immune antiplasminogen inhibits the streptokinase-activated fibrinolytic activity of plasma, we prepared immune antiplasminogen sera by immunization of rabbits either with plasminogen of human plasma or with euglobulin fraction adsorbed on rabbit fibrinogen or fibrin. The specificity of the rabbit immune antisera was shown by immunoelectrophoresis and in agar gel diffusion tests by comparison with a wellknown specific antiplasminogen serum. (Immunoelectrophoresis of our antiplasminogen with plasminogen and the results of the comparing diffusion tests are shown in figures 1, 2, and 3.) For the inhibition tests we did not use the rabbit antiserum itself, but the antibody-containing y-globulin fraction, prepared according to the method of Horejsi and Smetana.’ The special inhibition tests were performed as follows. Constant volumes (0.5 ml) of a 2-fold diluted antiplasminogen y-globulin fraction were added to equal volumes of a plasma pool. After a reaction time

Introduction of a standardized “paternity index” for the statistical evaluation of blood group findings in paternity testing

The introduction of a standardized paternity index (PI) for the statistical evaluation of blood group findings in cases of disputed paternity is proposed and explained. By using the PI X/Y as parameter, it is not necessary to give the information of the probability of paternity in percent. The PI includes the full information of the blood group findings. In addition to that, by using the suggested standardization based on the probabilities of error according to Schulte Mönting and Walter the test volume is also taken into account. The interpretation of the mathematical result is given by verbal predicates, the limitations of which are orientated by the verbal predicates for the probabilities of error according to Schulte Mönting and Walter, published by us elsewhere. Besides the essential fact that the test volume is taken into account, the most important advantage of this procedure is that the mathematical result is involved in the court decision only by the PI (which is free of any valuation) and its verbal predicate and not by sometimes relatively high percentages, which may be misunderstood by laymen.

An auto-anti-B in an A1B person. Serological studies

SummaryThe serum of a patient (Mr. Lat) with the regular blood group A1B contains an anti-B reacting with all cells having a B antigen except bx and cis AB. The anti-B reacts at 4° C and occasionally at room temperature as shown by agglutination, absorption-elution and by thermo-dynamic assays. The antibody is regarded as an irregular autoantibody belonging to the group of the so called “suppressed” or “latent” antibodies.ZusammenfassungDas Serum eines Patienten (Mr. Lat) mit der normalen Blutgruppe A1B enthält Anti-B, das mit allen Zellen reagiert, die ein B-Antigen aufweisen, ausgenommen Bx und cis AB. Das Anti-B reagiert bei 4° C und gelegentlich bei Zimmertemperatur, was durch Agglutination, Absorption-Elution und durch thermodynamische Unter-suchungen gezeigt wurde. Der Antikörper wird als irregulärer Autoantikörper angesehen, der zur Gruppe der „supprimierten“ oder „latenten“ Antikörper gehört.

Serologische Untersuchungen mit enzymbehandelten Erythrozyten zur Frage partieller Antigen-gemeinschaften im Rh-System

ZusammenfassungVorläufiger Bericht über Versuche, durch Enzymbehandlung von Erythrozyten Hinweise auf die Struktur der Rh-Antigene und mögliche partielle Antigengemeinschaften zu erhalten.Sukzessiv mit Bromelin und ß-Glucuronidase behandelte rote Blutzellen werden durch verschiedene gruppenspezifische Antiseren agglutiniert, die mit den unbehandelten oder nur mit einem von beiden Enzymen behandelten Erythrozyten nicht reagieren. Durch Ansatz gegen andere, von Antikörpern gegen Blutgruppen freie Substrate und durch Absorption mit doppeltfermentiertem Erythrozytenstroma, kann gezeigt werden, daß es sich bei der beobachteten Agglutination um eine Antigen-Antikörper-Reaktion handelt, die jedoch nicht mit der T-Agglutination identisch ist.Das läßt vermuten, daß durch die sukzessive Enzymbehandlung am Erythrozyten Strukturen zugänglich gemacht werden, die mit gruppenspezifischen Antiseren reagieren, weil diese über entsprechende Reaktionsorte verfügen. Obwohl die determinante Struktur weiter abgeklärt werden muß, ist das bisherige Ergebnis ein neuerlicher Hinweis auf die Existenz pattieller Gemeinschaften zwischen den Gruppenantigenen.SummaryErythrocytes successively treated with bromelin and β-glucuronidase (DET: double enzyme treated) are agglutinated by anti-Rh and anti-ABO sera of different specificities although the same antisera do not react with untreated or only with bromelin respectively ß-glucuronidase treated red blood cells. Additional agglutination tests with sera plasma fractions and seed extracts containing no blood group antibodies and absorption tests with DET erythrocyte stroma show that the observed agglutination reactions of DET red blood cells are true antigen-antibody reactions not identical with a known group specific or the well known T-agglutination. This and the further results allow the tentative conclusion that double enzyme treatment makes accessible determinant not yet identified structures that are able to react with blood group specific antisera because these antisera have the corresponding reaction sites. This is a mainly preliminary report but the results are a further indication that partial cross reactivity does exist between certain blood group antigens.

Anti-C as a sole autoantibody in autoimmune hemolytic anemia.

associated with blood product choice that would bias group selection; we therefore performed a prospective randomized study. The study was not designed to quantitate precisely the degree of immunization associated with leukocyte counts in a variety of blood products; that is a related but clearly distinct question. Since there already is a general reluctance in the renal transplant community to use blood totally depleted of leukocytes (e.g., frozen products) due to the reported diminished benefit of such pretransplant transfusions on graft survival: we examined the effect of washed and other leukocyte-poor blood products in comparison to packed RBC, a question most nephrologists, transplant surgeons, and, as Dr. Chaplin points out, transfusionists consider important and controversial. The leukocytedepleted products available to our referral population were felt to be reasonably similar to each other and significantly lower in leukocyte counts than packed RBC products, such that the inability to control completely for this variable was not considered critical. In our own blood bank, packed RBC units yield a mean leukocyte count of 7.0 X lo9 per 1, compared to a range of 0.8 (washed) to 2.5 (inverted spin) X lo9 per 1 for the various leukocytedepletion methods identified as acceptable in this study. The clinical protocol called for washed blood for patients in the leukocyte-poor group, with the other leukocytedepleted products to be used only if washed blood was unavailable. More than 90 percent of transfusions given to this group were of washed blood, most of the remainder were with inverted spin units. Although the data we presented reflected the entire patient population and were not subdivided by prior history of transfusion or transplant, we mentioned in the text that the changes in sensitization observed were more strongly associated with a history of prior graft loss than type of blood product used. This is more clearly demonstrated in Table I where protocol patients receiving only packed RBC or leukocyte-poor blood transfusions were separated into those with no prior history of transfusion or transplant (not immunized) versus those with prior graft loss. As shown, no patient who entered the protocol without previous transfusions or transplant had a level of immunization (panel reactive antibody, PRA) considered significant (260%) by the South-Eastern Organ Procurement Foundation or United Network for Organ Sharing and only 1 of 22 patients in each transfusion group (<5%) was immunized to the 60 percent PRA level following transfusion. Likewise, there were no significant differences in the average change in immunization or transplant rate between groups. In comparison, the number of patients who were highly immunized (PRA 2 60%) on entering the protocol was significantly higher for those with prior graft loss in both the packed RBC and leukocyte-poor blood transfusion groups (53 and SO%, respectively), as was the average PRA (58.8 f 10.5, 41.9 f 10.3, respectively). Again, for these groups with prior graft loss, no differences in transplant rate or change in immunization were found to be related to blood product used. The average number of transfusions given per patient were similar: 3.87 f 0.74 (packed RBC group) versus 3.54 f 0.55 (leukocyte-poor group). Certainly, poorly designed studies that yield misleading results are worse than no studies a t all. However, we disagree with Dr. Chaplin that the design of this study precludes all but the most qualified conclusions and reiterate that the use of leukocyte-poor blood products provides no discernible clinical advantage in reducing immunization or increasing the rate of transplantation regardless of prior history of patient immunization. We feel the real pity is that some clinicians and transfusionists may persist in this costly and time-consuming practice which has no documented added benefit for renal transplant candidates. FRED SANFILIPPO, MD, P h D Director, Irnrnunopathology JOHN A. KOEPKE, M D Director, Transfusion Services Duke University Medical Center Durham, North Carolina 27710

Vergleichende Untersuchungen zwischen Serum- und Gewebssaftalkohol

ZusammenfassungBei gleichzeitiger Bestimmung des Alkoholgehaltes im Serum und in dem von der freigelegten Grundfläche einer Cantharidenblase mittels Unterdruck abgesaugten Gewebssaft (Intercellularflüssigkeit) liegen die Gewebssaftwerte stets unter den Serumspiegeln. Während die Abstände beider Kurven im ansteigenden Kurventeil infolge der unübersichtlichen Resorptionsverhältnisse meist unregelmäßig sind, laufen die Kurven im absteigenden Teil fast parallel. Der Gipfelwert wird gleichzeitig erreicht.Die geringeren Saftwerte lassen sich durch Verdampfen größerer Alkoholmengen infolge der Absaugung durch Unterdruck, womit im Prinzip eine Vakuumdestillation nachgeahmt wurde, erklären.Das wiederum läßt die Vermutung gerechtfertigt erscheinen, daß die Gewebssaftwerte in Wirklichkeit höher als festgestellt liegen und daß die resultierenden Kurven in Übereinstimmung mit den bisher bekannten experimentellen Ergebnissen zumindest in der Abbauphase nicht wesentlich von den Serumkurven abweichen, wobei es offen bleiben muß, ob eine geringe zeitliche Verspätung der Saftkurven statt hat.Trotz der methodischen Schwächen unserer Untersuchung, wird man vor allem auch im Hinblick auf das gleichzeitige Erreichen der Gipfelwerte beider Kurven den Schluß ziehen dürfen, daß sich der Diffusionsausgleich zwischen Blut und Gewebe nach abgeschlossener Resorption recht schnell vollzieht und daß demzufolge ein Blutalkoholgehalt auch für den Gewebsalkoholspiegel repräsentativ ist.

Frequencies of the red cell uridine-5-monophosphate kinase groups (UMPK),E.C.2.7.4.14 in Schleswig-Holstein

In order to compare the frequencies of red cell UMPK groups in Schleswig-Holstein with the frequencies of samples of other investigators we have determined UMPK groups by starch gel electrophoresis according to GIBLETT et al. (1974) and MARTIN (1982) in a random sample of 1003 blood doners.

Evidence for a "new" allele at the phosphoglycolate phosphatase locus.

SummaryAn obviously new phosphoglycolate phosphatase (PGP) gene product (PGP*Sumatra) was detected by use of horizontal starch gel electrophoresis (SGE). The observed phenotype PGP (1-Sumatra) can be distinguished from any known PGP type.

Zur gelchromatographischen Trennung von kompletter (IgM-) und inkompletter (IgG-)Antikörperaktivität blutgruppenspezifischer Antiseren

Die chromatographische Fraktionierung humaner Seren mit Sephadex-Gelen erm6glicht eine mehr oder minder scharfe Trennung der Serumproteine voneinander [2,3]. Unter bestimmten Voraussetzungen gelingt es mit einfachen Mitteln, auch die Immunglobuline IgM und IgG verschiedener Blutgruppenantiseren so voneinander zu trennen, dab sie frei yon gegenseitiger Verunreinigung eluiert werden kSnnen. Dies ist fiir die Untersuchung yon gruppenspezifischen Antiseren, insbesondere wenn es die Zuordaung der Spezifit~t und das serologische Verhalten zu bestimmten Immunglobulinen betrifft, yon groBer Bedeutung.