Factors affecting clinical outcomes of continuous and intermittent plasmapheresis in patients with severe hypertriglyceridemia.

INTRODUCTION: Acute hypertriglyceridemia is considered a category III indication for plasmapheresis. The use of plasma as replacement fluid (RF) has been suggested to replace the consumed lipoprotein lipase. Heparin when used as an anticoagulant could possibly release lipoprotein lipase, thereby increasing triglyceride clearance. METHODS: The impact of RF (albumin vs fresh frozen plasma (FFP) and anticoagulant (ACD-A vs. heparin) on triglycerides following plasmapheresis in 27 patients with severe hypertriglyceridemia (SHTG) was investigated. A paired study of four patients with recurrent SHTG was conducted, evaluating continuous (Optia) versus intermittent flow plasmapheresis (Haemonetics). RESULTS: Shorter procedures positively impacted triglycerides (TG) drop post-sessions p < 0.05. In albumin sessions, patients who used heparin demonstrated significantly greater drop in TG and required less sessions than did those with citrate p < 0.05. In heparin sessions, patients who used albumin demonstrated significantly greater drop in triglycerides and required less sessions than did those with FFP p < 0.05. Three of six patients who used FFP and heparin showed a triglyceride drop of 11.7% following three sessions and a 50% drop with one albumin session. Compared with Haemonetics, Optia removed comparable volumes of plasma in less time, processing smaller blood volumes and using less citrate p < 0.05. Patients demonstrated significantly lower drop in TG and required more sessions with Haemonetics than they did with Optia p < 0.05. CONCLUSION: Shorter procedure was the main predictor for effective TG clearance. This can be achieved by continuous apheresis technology, particularly when using albumin as RF. TG removal via Optia seems to be optimized by using heparin.

Quality Assessment and Clinical Utility of Plasma Obtained Via Apheresis vs That Obtained from Whole Blood.

OBJECTIVE: We studied the impact of storage of thawed plasma (TP) on the in vitro coagulation quality and posttransfusion outcomes of apheresis plasma (AP) vs whole blood plasma (WBP). METHODS: One hundred units of each product were analyzed. In vitro assays were performed on TP on day 0, day 2, and after refreezing, evaluating international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen, and factors V and VIII. Transfusion of TP on day 2 was studied in 70 patients with liver cirrhosis and 25 patients with thrombotic thrombocytopenic purpura (TTP). RESULTS: Refrozen specimens from both products showed a significant decline of all values, although AP had a considerably greater coagulation profile (P < .05).On day 0 and day 2, we observed significant decreases in coagulation values (except fibrinogen) with WBP, compared with AP (P < .05). The WBP, however, provided similar INR for patients with liver cirrhosis and TTP, as compared with AP. The AP resulted in a significant correction of aPTT following plasma exchange in TTP (P < .05). CONCLUSION: AP demonstrated considerably greater factor activity. This would be beneficial when manufacturing clotting factor concentrates. Large scale clinical trials are needed to further address the hemostatic outcomes of both products in massively transfused patients.

Idiopathic TTP in the Middle East: Epidemiology and clinical outcomes in infection associated episodes.

INTRODUCTION: Literature on epidemiology of thrombotic thrombocytopenic purpura (TTP) in the Middle East is scarce. MATERIALS AND METHODS: We prospectively examined the association between infection and clinical outcomes in 44 patients with idiopathic TTP, with severely deficient ADAMTS13. We also investigated seasonality of the disease, hoping to better understand the epidemiology of idiopathic TTP. RESULTS: Summer demonstrated significantly lower incidence for idiopathic TTP, compared with other seasons P = 0.0003. Fourteen patients had 15 episodes with a suspected concomitant infection. Five initial episodes were triggered by an infection (33.3 %), all presenting in winter, six episodes were associated with an exacerbation (40 %) and infection triggered a relapse in the other four episodes (26.7 %), with 2 episodes presenting in winter. TTP associated infections included: central line infection, urinary tract infection and post-operative infection. One patient had respiratory tract infection, on both his initial and relapsing episodes. Refractoriness to treatment was demonstrated in 4 patients (28.6 %) and it was associated with dental abscess (one patient), septic shock (one patient) and Mycoplasma pneumonia (2 patients). All 4 patients had markedly elevated CRP values with a median of 335 mg/L. CONCLUSION: Most of the infection associated episodes developed in winter (77.8 %). In patients with idiopathic TTP refractory to conventional treatment, infection should be seriously considered as an additional contributing factor for their initial and /or recurrent episodes, particularly when CRP is markedly elevated.

Evaluation of post-thaw CFU-GM: clinical utility and role in quality assessment of umbilical cord blood in patients receiving single unit transplant.

BACKGROUND: The CFU assay is considered the only in vitro assay that assesses the biologic function of hematopoietic stem and progenitor cells (HSPC). STUDY DESIGN AND METHODS: To investigate the impact of post-thaw CFU-GM counts on the quality of umbilical cord blood (UCB), we studied transplant outcomes in 269 patients receiving single UCB transplant. We also correlated the post-thaw CFU-GM counts of 1912 units with the pre-freeze and post-thaw graft characteristics, hoping to optimize selection criteria of UCB. Data analysis included: total nucleated cells, viability, CD34+, nucleated red blood cells (NRBC), hematocrit, frozen storage time, and cord blood bank (CBB). RESULTS: We demonstrated an association between post-thaw CFU-GM dose and the speed of neutrophil and platelet engraftment (p < 0.01). Higher post-thaw CFU-GM dose showed an increased benefit for neutrophil and platelet engraftment (p < 0.01). Post-thaw CD34+ cell dose and CFU-GM dose were strongly correlated (r = 0.78). However, CFU-GM dose showed additional benefit for patients receiving the lowest quartile of CD34+ dose. HLA disparity did not adversely impact either neutrophil or platelet engraftment. Post-thaw CFU-GM/million nucleated cells plated showed moderate correlation with pre-freeze and post-thaw CD34+ and weak correlation with other parameters. Post-thaw CFU-GM was not influenced by storage time, but was impacted by the CBB from which the unit is obtained (p < 0.01). CONCLUSION: Post-thaw CFU-GM is an effective measure of the quality and efficacy of the UCB graft, particularly adding valuable clinical information when the CD34+ cell dose is low. Consideration of pre-freeze CD34+ cell content and CBB as additional selection criteria is warranted.

Therapeutic Plasma Exchange Performed Via 2 Apheresis Devices and its Impact on the Blood Profile of Hematological and Neurological Patients.

BACKGROUND: An efficient apheresis device performs therapeutic plasma exchange (TPE) sessions in short times, while avoiding significant potential cell losses in the removed plasma. METHODS: To evaluate TPE performed via Optia (hereinafter, Optia) and COBE Spectra (hereinafter, COBE) apheresis devices, a paired randomized comparison study was conducted. We evaluated the device performance and its impact on cell loss in the removed plasma, as well as blood counts of patients. RESULTS: In patients with thrombotic thrombocytopenic purpura (TTP), the median platelet content of the extracted plasma was 9.5 × 1000 per µL for Optia and 33.5 × 1000 per µL for COBE (P <.001). This finding resulted in a median drop in patient platelet count of 2.4% with with Optia, compared with 5.6% with the COBE instrument (P = .04). When using albumin as replacement fluid, the median platelet content of the waste bag was comparable with both machines. However, the drop in patient platelet count with COBE was significantly higher (17.5%) compared with Optia (8.3%; P = .04). Minimal changes were observed in the hemoglobin and white blood cells of patients, undergoing sessions on both machines. CONCLUSION: The Optia device seems to reduce significant platelet losses in patients undergoing TPE.

Serologic findings of RhD alleles in Egyptians and their clinical implications.

INTRODUCTION: Serologic discrepancies caused by various reactivity of D variants can only be resolved by the use of RhD genotyping. However, this strategy cannot be applied routinely due to the cost and feasibility. It has been documented that D variants are demonstrated among individuals with positivity for at least C or E antigens. It is considered to be affordable for some countries to test D negative donors who are C or E positive for D variants. It was proposed that an algorithm could be found based on distinct serologic features that matches the Egyptian genetic frequency data, and correctly assigns donors and patients, using the least possible expenses. MATERIALS AND METHODS: Samples with the most prevalent weak D and partial D were investigated for their RhCE phenotype. Routine D typing by immediate spin (IS) tube method was performed in parallel with an automated gel test, and the reactivity results of D variants with both techniques were compared. RESULTS: Among 31 D variants, only 5 were C or E positive (16.1 %). R0r phenotype was associated with the remaining 26 samples (83.9%) and constituted weak D types 4.2 (38.5%), and 4.0/4.1 (11.5%), partial DIII (34.6%), and partial DV (15.4%). Gel reacted strongly with partial DIII and DV. Ten samples with DIII and DV typed as D positive with IS. All weak D were positive by indirect antiglobulin test (IAT), while all partial D were positive by gel and IAT. CONCLUSION: Guidelines for RhD workup should be adjusted to match population data. Detection of D variants among C or E positive donors may not be an optimal strategy for Egyptians. Serology cannot discriminate weak D from partial D, but may provide a clue about the probable D variant to be tested molecularly with the appropriate kit. Reagent selection is important to correctly assign donors and patients with the DIII and DV types.

Clinical and quality evaluation of red blood cell units collected via apheresis versus those obtained manually.

To evaluate the impact of collection procedure on the in vitro quality of red blood cells (RBC), we studied 30 units of apheresis-prepared RBC (ARBC) and 30 units of manually collected RBC (MRBC). We performed assays on day 1 and day 21 of the study, evaluating red cell mass volume (RCM); rate of hemolysis; pH, and levels of sodium, potassium, adenosine triphosphate (ATP), 2,3-diphosphoglycerate (2,3-DPG) and glucose. Eight patients with aplastic anemia received RBC transfusions of both components and their post-transfusion hematocrit (HCT) levels were compared. On day 21, we observed a significant drop of sodium and glucose levels in the ARBC group, compared with the MRBC group (P <.05). ARBC group demonstrated higher RCM that provided significantly higher HCT values to our group of anemic patients (P <.05). Hemolysis was significantly lower in the ARBC group, compared with the MRBC group (P <.05). At day 21, both groups had no detectable 2,3-DPG. Specimens from both groups retained ATP in sufficiently healthy amounts. The ARBC group demonstrated higher RCM and lower hemolysis levels compared with the MRBC group.

Predictors of red cell alloimmunization in multitransfused Egyptian patients with ß-thalassemia.

CONTEXT: Thalassemia is a major health problem in Egypt. Red blood cell alloimmunization is an important complication in transfusion-dependent patients. OBJECTIVES: To determine alloimmunization prevalence in Egyptian patients with ß-thalassemia and to evaluate risk factors that could influence alloimmunization, with the hope of minimizing transfusion-associated risks in those patients. DESIGN: Records of 272 patients with ß-thalassemia who are receiving regular blood transfusions, matched for ABO-Rh(D), were analyzed. Alloantibody identification was performed by DiaMed-ID microtyping system. Autoantibodies were detected by direct Coombs test. RESULTS: Alloimmunization incidence was 22.8% with 123 alloantibodies detected in 62 patients. The most common alloantibody was Rh-related (37.4%; 46 of 123), comprising anti-E (14.6%; 18 of 123), anti-D (8.9%; 11 of 123), anti-C (8.9%; 11 of 123), and anti-c (4.9%; 6 of 123), followed by anti-Kell (26%; 32 of 123), → anti-MNS (9.8%; 12 of 123), → anti-Kidd (8.9%; 11 of 123) → anti-Duffy (8.1%; 10 of 123), → anti-Le (5.7%; 7 of 123), → anti-Lu (2.4%; 3 of 123), and → anti-P1 (1.6%; 2 of 123). Anti-D antibodies developed in 34.5% of all Rh-negative patients. Eighty percent of all anti-D antibodies developed in patients older than 18 years. Males had the highest alloimmunization incidence. Alloimmunization incidence increased with the number of units transfused (P = .01). Patients who received unfiltered blood had a higher alloimmunization rate than did those who always received leukoreduced blood (P < .001). Splenectomized patients had a higher alloimmunization rate (32%; 40 of 125) than did those who did not have a splenectomy (16.3%; 24 of 147; P = .003). Autoantibodies occurred in 1.5% (4 of 272) of all patients. CONCLUSION: Transfusion of leukoreduced and phenotypically matched cells for selective antigens may help reduce expenses and risks of alloimmunization in patients with thalassemia.

Evaluation of infectious disease markers in multitransfused Egyptian children with thalassemia.

In an attempt to evaluate blood supply safety and the potential effect of the screening tests performed in our center, the frequency of hepatitis C virus (HCV) antibody, hepatitis B surface antigen (HBsAg), and human immunodeficiency virus (HIV) antibody were evaluated among multi- transfused Egyptian children with thalassemia. Samples from 200 children with ß thalassemia were tested for HCV antibody, HBsAg, and HIV-1 and 2 antibodies. ELISA was used for all tests. HCV positive samples were confirmed by RT-PCR. The study included 96 males and 104 females. Their mean age was 9.2±4.5. Forty-eight patients were positive for HCV antibody (24%); all were confirmed positive by PCR. Four HCV-positive patients were also HBsAg-positive. Six patients (3%) were HBsAg-positive. No patient was HIV-positive. Older ages were significantly associated with an increased incidence of positive infectious markers (p<0.05). The frequency of HCV infection is considerably high among Egyptian children with thalassemia. It is therefore important to implement measures to improve blood transfusion screening; nucleic acid testing, which could help reduce transmission of HCV during the window period, should be considered.

Blood donor recruitment strategies and their impact on blood safety in Egypt.

INTRODUCTION: Because of the high incidence of HCV, blood safety presents a serious challenge in Egypt. Given the constrained economy which limits the implementation of nucleic acid amplification technology, proper recruitment of blood donors becomes of paramount importance. To evaluate the effectiveness of blood donor recruitment strategies, the seroprevalence of positive infectious markers among blood donors was studied. MATERIALS AND METHODS: Donors' records covering the period from 2006-2012 were reviewed. Blood donations were screened for HCV antibodies, HBs antigen (HBsAg), HIV-1 and 2 and syphilis antibodies. RESULTS: Of 308,762 donors, 63.4% were voluntary donors (VD). VD of 2011-2012 were significantly younger than family replacement donors (RD) .The overall prevalences of HCV antibodies, HBsAg, HIV and syphilis antibodies were 4.3%, 1.22%, 0.07%, and 0.13%, respectively. All tested markers (except HIV) were significantly higher among RD, when compared to VD (P<0.0001). A consistent steady trend for decrease in HCV seropositivity was observed in RD and VD from 8.9% and 4.2% to 3.8% and 1.5%, respectively. A trend for decrease in HBsAg was demonstrated in VD from 1.2% to 0.53%. CONCLUSION: The decreasing trends in HCV antibody and HBs antigen is promising and may reflect the improved donor selection criteria.

Weak D types in the Egyptian population.

Patients with the most common weak D types 1, 2, and 3 can be safely considered D positive. We evaluated 1,113 Rh-negative Egyptian samples for weak D expression to propose a cost-effective strategy related to D variant testing. D variants were tested using polymerase chain reaction with sequence-specific priming. Fifty samples were D variants (4.5%): weak D type 4.2 (32%), weak D type 4.0/4.1 (16%), and weak D type 15 (2%). Fifteen (62.5%) of 24 samples were identified serologically as partial D. We also studied the probability of the development of anti-D in 52 Rh-negative children with thalassemia who were receiving units for which weak D was not tested. Anti-D alloimmunization was observed in 63.5% of patients with thalassemia. It is prudent to implement weak D typing in Egyptian donors. Weak D variants of Egyptians are significantly different compared with Caucasians. Ethnicity must be taken into consideration when developing clinical and prenatal strategies related to D variants.

Non-myeloablative bone marrow transplant and platelet infusion can transiently improve the clinical outcome of mitochondrial neurogastrointestinal encephalopathy: a case report.

Mitochondrial neurogastrointestinal encephalopathy (MNGIE) is caused by deficiency in thymidine phosphorylase (TP), that regulates thymidine (dThd) and deoxyuridine (dUrd). Toxic levels of dThd and dUrd can lead to mitochondrial dysfunction by impairing mitochondrial DNA replication, causing GI and neurologic deterioration. We studied the impact of bone marrow transplant (BMT) and platelets, as a source of TP on the clinical outcome of MNGIE. We report a case of MNGIE, who presented with severe vomiting. Over time, he was non-ambulatory and his GI symptoms got progressively worse with severe dysphagia, abdominal pain episodes, persistent vomiting and diarrhea. Being unfit for intense conditioning regimen, he received a mini BMT, with mild conditioning regimen. Bone marrow was obtained from his HLA fully matched brother. One month after transplantation, donor chimerism in peripheral blood was 33%. Excellent clinical responses were achieved 3 months after transplantation and circulating donor cell chimerism decreased to 24% with a significant increase in platelet TP activity. Ten months post transplant the patient's symptoms recurred and fresh single donor platelets were infused, with a significant increase in platelet TP activity. Mini BMT and platelet transfusion can transiently increase circulating TP activity and might prevent progress of this fatal disease.

HLA alloimmunization in Egyptian aplastic anemia patients receiving exclusively leukoreduced blood components.

BACKGROUND: The aim of the work was to detect the presence of anti-human leukocyte antigens (anti-HLAs) class I and II antibodies in sera of multitransfused aplastic anemia pediatric patients using two different techniques. The effect of the implemented transfusion practice on the frequency of these antibodies was studied as well as their effect on the patient's clinical condition. METHODS: Flowcytometry panel reactive antibodies (FlowPRAs) for HLA class I and II were determined and compared to the results obtained by Complement-dependent-cytotoxicity (CDC) assay. RESULTS: Over the past 3years, 20 aplastic anemia patients received leukoreduced blood components, 5/20 patients received leukoreduced products exclusively throughout their disease (group1), 15/20 patients had received non-leukoreduced components previously (group2). None of the patients in group1 was FlowPRA positive. Six patients from group2 (40%) were FlowPRA positive, only four out of these six patients showed positive CDC test. Positive and negative predictive values of CDC were 44.4 and 81.4% respectively, with 65% accuracy. Platelet refractoriness was encountered in 13/20 patients; only 3 out of these 13 patients (23%) were FlowPRA I positive (38±18%). One refractory patient died from intracranial hemorrhage. His FlowPRA I was 65.7% and CDC assay failed to detect it. CONCLUSION: Leukoreduction of blood components minimizes the incidence of HLA alloimmunization. Further investigations for other immune causes of platelet refractoriness are recommended. FCM is a simple and reliable technique for detection of anti-HLA antibodies, while CDC assay lacks sensitivity and specificity.

Evaluation of blood supply operation and infectious disease markers in blood donors during the Egyptian revolution.

BACKGROUND: The Egyptian revolution took place on January 25, 2011. Millions of protesters demanded the overthrow of the Egyptian president's regime. Many people suffered from life-threatening injuries after violent clashes between police and protesters. STUDY DESIGN AND METHODS: The overall management of the blood bank operation at Cairo University Hospital was described, in an attempt to evaluate blood safety and establish a standard effective plan to manage blood supply during crisis. RESULTS: Three days after the uprising, thousands of Egyptians rushed to the hospital to alleviate the blood shortage. A total of 3425 units were collected in 3 days and thousands of donors were turned away. An error delayed processing of 1000 units and they were used as stored whole blood. Apheresis platelets were donated by protesters who were particularly motivated to donate for two victims with liver injury. The usual positive rate of hepatitis C virus (HCV) antibody in Egyptian donors is 3.8%. However, the positive rate of HCV markers in the collected units was only 1.6%. The mean age of donors during the revolution was 31.7±10.4 years while the usual mean age of donors is 39.2±8.5 years. Operating theaters were used only for emergencies. A blood surplus developed that met the hospital needs for 1 month. CONCLUSION: Revolution resulted in an influx of first-time donors with a relatively low positive rate of HCV antibody. To be prepared for disasters, a systematic approach to spread donors evenly on a daily basis is needed.