In vitro Characteristics of 'Undercollected' Units of Whole Blood in CP2D-A

Blood donation volumes less than 350 ml are classified as 'undercollected' at the NSW Red Cross Blood Transfusion Service (BTS) and are discarded. This study evaluated the in vitro characteristics during storage of both undercollected units and units of acceptable volume. Thirty-two units of whole blood were each collected into 63 ml of CP2D-A, with blood volumes ranging from 180 to 456 ml. The units were stored between 4 and 6°C for 35 days and in vitro measurements were performed weekly. Biochemical parameters measured included ATP, extracellular pH, total haemoglobin, haematocrit, mean cell volume, plasma sodium and potassium, plasma haemoglobin, 2,3-DPG and lactate levels. All parameters were within the BTS acceptable quality control limits for whole blood. Thus, it appears feasible to transfuse undercollected units with volumes between 180 and 350 ml. However, routine transfusion of undercollected homologous units is undesirable. In contrast, it may be preferable to transfuse an autologous unit, even if it was undercollected. The performance of in vivo survival studies would provide confirmatory data on this proposition.     

Superiority of minipool nucleic acid amplification technology for hepatitis B virus over chemiluminescence immunoassay for hepatitis B surface antigen screening

BACKGROUND AND OBJECTIVES: The Japanese Red Cross (JRC) have developed a fully automated multiplex (MPX) nucleic acid amplification technology (NAT) system for hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus 1 (HIV-1). This is used to test serologically negative blood units from volunteer, non-remunerated donors. The system utilizes a 50-sample pool for NAT screening with an input volume of each pool. This results in a significantly higher sensitivity for hepatitis B than that seen with highly sensitive hepatitis B surface antigen (HBsAg) testing. MATERIALS AND METHODS: From 1 February 2000 to 15 October 2001, over 11 million donations, which were serologically negative, were tested using the MPX NAT system. Donations found to be HBV DNA positive were further tested by using the chemiluminescence immunoassay (CLIA). RESULTS: Out of 181 HBV DNA-positive donations, 96 (53%) and 76 (42%) were negative by individual enzyme immunoassay (EIA) and CLIA testing, respectively. CONCLUSIONS: The sensitivity of the 50-sample pool MPX NAT system was higher than that of individual HBsAg screening by CLIA. By adopting this NAT-screening system, the JRC has improved the safety of the blood supply and maintained supply across Japan.     

How Much Blood for the World?1

Based on data from 96, and estimates from 32 countries with populations of over 1 million, it was calculated that the total amount of whole blood collected annually in the world in the early 1980s was about 75 million units. Of this, one-third was collected by Red Cross and Red Crescent blood programmes. The index of donations per 1,000 population was on average 50.2 in industrial market countries, 9.5 in middle-income countries and 1.1 in low-income countries. For planning purposes donation rates in relation to health services are better than the population index. It seems that roughly 10 annual donations per acute hospital bed, or 0.40 donation per patient admission to these hospitals would be sufficient to provide adequate quantities of blood and blood products for modern haemotherapy.     

Restoration of red blood cell volume following 2-unit red blood cell apheresis

BACKGROUND AND OBJECTIVES: Blood donors who weigh at least 130 lbs (59 kg) and have a haematocrit of at least 40 V per cent can donate 2 units of blood, from which a 360-ml volume of red blood cells (RBC) can be isolated. This study was carried out in seven healthy male blood donors to assess the restoration of the RBC volume 1 month following a 2-unit RBC apheresis procedure. MATERIALS AND METHODS: RBC volumes were measured prior to donation and 4 weeks after the 2-unit RBC apheresis procedure without oral iron supplementation. RESULTS: Four weeks after the removal of 2 units of RBC from the male donors not supplemented with oral iron, the RBC volume was restored to 92% of the precollection value. The 360-ml volume of RBC collected represented 12-19% of the donor's original RBC volume. CONCLUSIONS: Male donors can safely donate 2 units of RBC and will restore a mean of 92% of their RBC volume within 1 month without iron supplementation.     

Predictive Value of Screening Tests for Persistent Hepatitis C Virus Infection Evidenced by Viraemia: Japanese Experience

In November 1989, Japanese Red Cross Blood Centres started screening for heaptitis C virus (HCV) with enzyme-linked immunosorbent assay (Elisa) for the C100-3 viral peptide as the first such nationwide programme in the world. Thereafter post-transfusion non-A non-B hepatitis (PTNANBH) was reduced by 61–80%, but this was not as complete a success as our programme to prevent post-transfusion hepatitis B by screening for high titer hepatitis B core antibody, which we began in the same period. In order to acquire more effective control of PTNANBH, the HCV core-related antigen (GOR, N14) and second-generation Elisa (Ortho2, Abbott2)and second-generation antigen agglutination (PA, PHA) tests have been employed. Among 16,500 donors in 11 blood centers, 365 were serologically positive by at least one of these tests. Among these, HCV RNA was detected in 138 units and the remaining 227 were HCV RNA negatives. The effectiveness of these serological tests to detect HCV RNA-positive status were analyzed. Passive haemagglutination and particle agglutination (PHA and PA) tests were highly effective to predict HCV viraemia among blood donors. Also, these tests can easily determine antibody titre. By either PHA or PA, all units with ≧2¹² agglutination titre (120 and 122 units) were HCV RNA positive and all agglutination-positive units with serum alanine aminotransferase level higher than 35 Karmen units were HCV RNA positive. These results have formed the basis for implementing a more effective screening for HCV viraemia in blood donors, where effectiveness is defined as enhancing the protection of patients from post-transfusion hepatitis C and providing higher quality information to achieve more effective donor counselling.     

Human Parvovirus B19 Infection in Blood Donors

Using an immunodiffusion assay, we tested all of the blood units donated at the Fukuoka Red Cross Blood Center from June 1991 to July 1994 for B19 antigen. Over this 3-year trial period, we detected 16 viremic cases out of approximately 560,000 blood donors. Interestingly, most of the viremic donors (15 out of 16) were detected between February 1992 and January 1993, which coincided with a local erythemia infectiosum epidemic in the Fukuoka area (December 1991 to August 1992). In particular, we detected 4 cases of viremia in March 1992, which was the peak of the erythema infectiosum epidemic. The incidence of B19 viremia in this peak period was approximately 1/4,000. The viremic donors ranged in age from 17 to 45 years, and most (11/16) were between 31 and 39 years old. By ELISA, using virus particles purified from viremic donor plasma as antigen, we analyzed the prevalence of B19-specific antibody among blood donors. The antibody-positive rate was approximately 40% in donors 16–30 years old, gradually increased in middle age, and reached a peak of 92% in donors more than 61 years old.     

Prospective assessment of donor blood screening for antibody to hepatitis C virus by first- and second-generation assays as a means of preventing posttransfusion hepatitis

In November 1989, the Japanese Red Cross began screening blood donors for the hepatitis C virus antibody (anti-HCV) by first-generation assay and high-titer hepatitis B virus core antigen antibody. A significant reduction in the incidence of acute posttransfusion hepatitis was reported; however, the incidence still ranged from 2 percent to 4 percent. The Red Cross changed to the second-generation assay in February 1992, the objective being the complete elimination of potential posttransfusion hepatitis. The aim was to elucidate the advantage of second-generation assay as a blood-donor screening test. The incidence of posttransfusion hepatitis after the introduction of second-generation assay was compared with that before the introduction of the first-generation assay and with that during its use. The incidence of posttransfusion hepatitis was 9.6 percent (216/2,240) before anti-HCV-s donor screening. It was 3.7 percent (24/655) and 0.9 percent (3/326) after the introductions of the first-and second-generation hepatitis C virus (HCV) assays, respectively (chi² = 50.0, P < .01). Blood-donor screening by second-generation anti-HCV provided a significant benefit compared with the first-generation assay. (Hepatology 1996 Apr;23(4):708-12)     

Red cell antibodies in frequently transfused patients with myelodysplastic syndrome

Therapy for myelodysplastic syndrome (MDS) is often restricted to lifelong support with red blood cell units (RBCU). A variety of immune phenomena associated with antibody production have been reported in MDS patients. Therefore, we hypothesized that red cell antibodies are more frequent in patients with MDS compared to other regularly transfused patients. Red cell antibodies were determined in 42 MDS patients, in 28 patients with other hematological disorders, and in a historical group of 129 patients with end-stage renal failure. All of these patients received frequent red cell substitution therapy, at least two RBCU in biweekly intervals. Red cell antibodies were detected in 9 of 42 patients with MDS, in 3 of 28 patients with other hematological disorders, and in 4 of 129 patients with end-stage renal failure. Evidence of red cell antibodies was displayed by 6 of 27 MDS patients treated with prestorage leukocyte-depleted RBCU and 3 of 15 MDS patients transfused with bedside leukocyte-filtered RBCU. Red cell antibodies are frequent in patients with hematological disorders who require repetitive red cell transfusions. The formation of alloantibodies to red cell antigens is as frequent in MDS patients as in other patients with hematological disorders.     

Un nouveau cas d'allo-anti-LWab

A patient admitted to hospital for hip replacement was found incompatible in pretransfusion testing due to allo-anti-LW^ab antibody, as well as anti-JK^b, anti-E and anti-IH antibodies. The patient had a rare phenotype LW(a-b-ab-). The antibodies were acquired though pregnancy and/or transfusion. This newly discovered anti-LW^ab allowed us to study and emphasize the relevant serological and transfusional aspects related to incompatibility caused by « publicantibodies in association with other alloantibodies.We attempted to update the LW system in the light of Sistonen and Tippett's recent discoveries ^[10]. We collected the required compatible units of blood through autologous donations and a Central Canadian Red Cross Registry for rare donors.     

A Decade of Rare Donor Services in the United States

Between 1981 and 1990, the American Red Cross Rare Donor Registry supplied 9,872 units of red cell components with rare phenotypes to blood centers in the United States and abroad. Approximately 51% were from donors with high-frequency antigen-negative phenotypes and 49% were from donors with multiple antigen-negative phenotypes. Since 1989, the disease category requiring the largest number of units has been sickle cell disease. Strategies to ensure that the Registry will have adequate resources to meet future requirements include testing selected donors for rare phenotypes and blood conservation programs, such as intraoperative salvage and the treatment of anemia of chronic renal failure with recombinant erythropoietin.     

Cost-effectiveness of the introduction of home blood pressure measurement in patients with office hypertension

OBJECTIVE: Cost-effectiveness of hypertension treatment is an important social and medical issue in Western as well as in Eastern countries, including Japan. Home blood pressure (HBP) measurements have a stronger predictive power for cardiovascular events than casual clinic blood pressure (CBP) measurements. Therefore, the introduction of HBP measurement for the diagnosis and treatment of hypertension should lead to a decrease in medical expenditure. This study presents calculations of the cost savings likely to take place when HBP is implemented for newly detected hypertensive subjects in Japan. DESIGN AND METHODS: We estimate the cost savings from the perspective of a Japanese healthcare system. To estimate the costs associated with changing from CBP to HBP measurement as the diagnostic tool, we constructed a simulation model using data from the Ohasama study. These calculations are based on current estimates for cost of treatment, prevalence of white-coat hypertension at baseline, and varying the incidence of new hypertension after the initial screening. RESULTS: When HBP measurement is not incorporated into the diagnostic process, the medical cost is estimated at US$10.89 million per 1000 subjects per 5 years. When HBP measurement is incorporated, the medical cost is estimated at US$9.33 million per 1000 subjects per 5 years. The reductions in medical costs vary from US$674,000 to US$2.51 million per 1000 subjects per 5 years for treatment of hypertension, when sensitivity analysis is performed. CONCLUSIONS: The introduction of HBP measurement for the treatment of hypertension is very useful for reducing medical costs.     

Oka: An Erythrocytic Antigen of High Frequency

Clinically significant antibodies to a 'new' high-frequency antigen on red blood cells have been detected in the serum of a Japanese woman. The notation Oka has been given to this antibody and its corresponding antigen. Two of the patient's siblings are Ok (a--) but a large number of red cell samples lacking common antigens were tested and found to be Ok (a+). The antibody reacted by the antiglobulin test with blood samples from random blood donors and with more than 4,000 red cell samples from Oriental blood donors and patients.     

Development of permanent national register of blood component use utilizing electronic hospital information systems

BACKGROUND AND OBJECTIVES: We wanted to establish a permanent national database system, which can be utilized to study transfusion recipients and blood use in Finland. MATERIALS AND METHODS: A regularly updated register for permanent use was developed. To study the usability of the database, years 2002 and 2003 were further analysed. Database included all transfused patients in major blood-transfusing hospitals from four university and five central hospital districts managing altogether 63% of Finnish inpatient hospital episodes. RESULTS: Audit of gathered data reveal 96.8% match in adult blood components with Finnish Red Cross, Blood Service sales figures. Model data set includes 59,535 transfused patients (44.3% men and 55.7% women) having received 529,104 blood components. Half of all blood units were transfused in connection with surgical operations. Most of the blood recipients were elderly (51.6% are over 64 years of age). Blood-component use and transfusion-related costs varied widely between hospitals. CONCLUSION: Hospital data managing systems can be useful for creating a population-based database system to monitor and compare transfusion practices. This record provides information about transfusion epidemiology for transfusion professionals, hospital management, and hospital administration.     

Flow cytometry as a diagnostic tool for hereditary spherocytosis

Flow cytometric analysis of eosin-5'-maleimide-labeled red blood cells has been proposed as a new method of identifying hereditary spherocytosis (HS). The aim of the present study was to analyze sensitivity and specificity of this method. Red blood cells from patients with HS (n = 58) revealed significantly lower mean channel fluorescence values than red blood cells from normal subjects (n = 110), unaffected HS family members (n = 8), and patients with other anemias (n = 44). Taking a mean channel fluorescence of 400.0 units as the threshold value identified by logistic regression, sensitivity and specificity of the test for HS were 96.6 and 99.1%, respectively. Flow cytometric analysis is a valuable screening test for the diagnosis of HS.     

Red-blood-cell alloimmunization and number of red-blood-cell transfusions

Background Patients receiving red‐blood‐cells may form antibodies against the alloantigens expressed by red‐blood‐cells, with the risk of serious morbidity and the need for extensive phenotype‐matching in subsequent transfusions. The incidence of alloimmunization is considered variable for specific patient groups and for first time antibody formation. We therefore studied the cumulative incidence of the first formed alloantibody as a function of red‐blood‐cells exposure. Methods We performed a new‐user cohort among all previously non‐transfused non‐alloimmunized patients that received non‐extended matched (ABO and RhD) red‐blood‐cells transfusions from January 2005 to December 2009 in our university medical centre. Alloimmunization incidences were estimated by Kaplan–Meier survival‐analysis. Results A total of 3002 previously non‐transfused patients received 31 103 red‐blood‐cell units. A first time alloantibody forming event was experienced by 54 (1·8%) patients. The cumulative incidence of alloimmunization was 1·0% at 5 units, 2·4% at 10 units, 3·4% at 20 units and 6·5% at 40 units of red‐blood‐cells transfused. Conclusion The risk to develop a first red‐blood‐cells alloantibody increases up to the 40th transfusion and is similar for men and women. More data are needed to examine the risk after 40th transfusion.     

Réaction transfusionnelle hémolytique retardée due à un anti-U

Delayed hemolytic transfusion reactions due to anti-U are rare, only two (2) cases having been reported in the literature. We now report a third case : a multiparous black woman without any transfusion history was admitted to hospital for severe microcytic anemia (31 g/l). The patient was group AB negative, the direct antiglobuline test was negative and an anti P₁ cold allo-antibody was present in her serum. Five A, Rh negative, P₂ packed red cells were cross-marched with the sample obtained at admission on January 8, 1988. She was transfused on January 8, 9, 10, 11 and 12. On the 12th of January her hemoglobin level reached 125 g/l. On January 13, the patient presented clinical signs of hemolysis and her hemoglobin fell to 60 g/l within 24 hours. On january 15, the direct antiglobulin test was positive and an antibody found in her serum was reactive with all the red cells of the commercial panel. The sample was referred to our red cell serology reference laboratory. The phenotype of the pre-transfusion sample was found to be Fy(a-b-) M, N, S-s-U-. An anti-U was detected in the eluate and the serum. The patient was transfused with two (2) units of O-P₂, U-red cells obtained from the American Red Cross, Syracuse, and her hemoglobin reached 90 g/l within 48 hours. This is the third reported case of a delayed hemolytic transfusion reaction due to anti-U. This case illustrates the need to perform cross-matches with samples obtained within 48 hours of the scheduled transfusion for patients who have been transfused with blood in the preceding 3 months. Also, this case emphasises the need to recruit U negative blood donors for the Canadian rare donor file.     

Incidence of Red Cell Alloantibody among the Transfusion Recipients of Universiti Kebangsaan Malaysia Medical Centre

Red blood cell alloimmunization is a common complication among the transfusion recipients. In Malaysia, multiple ethnicity causes genetic heterogeneity among the population which in turn can cause a wide variation of antibody. The objective of this study was to analyse the red cell alloantibody detected during the pre-transfusion testing. This was a cross-sectional study done in the blood bank of Universiti Kebangsaan Malaysia Medical Centre during the period of January–December 2010. The data was retrieved from the hospital laboratory information system. A total of 24,263 patients’ blood samples were subjected for pre-transfusion testing. Antibody screening was done using an indirect antiglobulin test method. The positive samples were further identified for antibody specificity. Antibody screening tests were positive in 184 patients out of 24,263 samples with the incidence of 0.76 %. Autoantibodies and alloantibodies were detected in 39/184 (21.2 %) and 140/184 (76.1 %) of the patients respectively. In five patients (2.7 %) the antibody specificity remained undetermined. Total 161 alloantibodies were identified. The suspected Anti-Mia alloantibody was observed most frequently (49/161, 30.4 %) followed by anti-E (30/161, 18.6 %) and anti-D (22/161, 13.7 %). Anti-E and anti-c were the most common combination of multiple alloantibodies. In view of the high incidence of suspected Anti-Mia antibodies, more efforts are needed to look into the techniques for confirmation of the Anti-Mia antibodies. Besides that, we suggested that all multiply transfused patients should be phenotyped for the Rh system and to supply Rh phenotype specific blood in order to limit alloimmunization.     

Management of a Severe Transfusional Problem in a Patient with Alloantibody to Kpb (K4)

The case of a 58-year-old male with severe anemia after hemicolectomy is described. The patient proved to be Kp(b-), and the serum contained anti-Kpb. Because no Kp(b-) donors were available, two incompatible units are administered after intravenous gammaglobulin (400 mg/kg/day) and hydrocortisone (500 mg). The tolerance was good, without signs of increased red cell destruction. Pending the arrival of compatible blood from the American Red Cross, the hematocrit reached 18%, and the direct antiglobulin test remained negative.     

The epidemiology of red cell transfusion

Background and Objectives Understanding of the clinical usage of red cells is limited despite its importance in transfusion practice improvement and planning for blood supply requirements. Previous studies have described red cell use based upon ICD and hospital discharge codes; however, such approaches are open to misclassification. This study addresses this limitation by undertaking an epidemiological analysis of red cell use using case note review. Materials and Methods Patient, disease and contextual factors were extracted from the medical records of a randomly selected sample of hospital patients in Northern Ireland who received a red cell transfusion during 2005 (n = 1474). Results Transfused patients received a total of 3804 units (median of two units per transfusion episode). Most transfusions occurred in a medical setting (71%). Patients undergoing treatment for gastrointestinal conditions were responsible for the majority of the demand (29% of transfusion episodes; 34% of red cell units). The presence of bleeding and abnormal tests of coagulation were associated with receiving larger transfusions (≥ 3 units), while patients undergoing orthopaedic surgery and those with a haemoglobin level over 7 g/dl had the lowest risk of receiving ≥ 3 units in any one transfusion episode. Conclusion The majority of red cells are now prescribed in a medical setting. With an ageing population and increasing therapeutic interventions, the demand for blood is likely to increase despite efforts to reduce usage by eliminating inappropriate transfusions through education and behaviour change. The post‐transfusion target (and therefore the number of units to transfuse) for any given clinical situation as well as guidance on a ‘safe’ transfusion threshold should be considered in future guidelines.     

Cost-effectiveness of introducing a third-generation test for HBsAg in Danish blood donors

Owing to the low incidence of hepatitis B in Denmark, screening of blood donors for HBsAg has mostly been done by immunoelectroosmophoresis (IEOP). The purpose of the present study was to carry out a cost-effectiveness analysis prior to the introduction of a third-generation test for HBsAg in Danish blood donors. The analysis was performed on data from a subsequent screening of 48 750 blood units by radioimmunoassay (RIA) 3 weeks after donation. The RIA-pos., IEOP-neg. blood donors identified in the study were evaluated by a follow-up examination, and the recipients of RIA-pos., IEOP-neg. blood units were monitored for up to 9 months as to the development of acute hepatitis B. The study shows that the estimated cost for each prevented case of transfusion-associated hepatitis B in Denmark is US$ 1100 when screening donors not previously tested by a third-generation technique, and US$ 240 000 when screening donors tested before by this technique.