Optimizing a fully automated and closed system process for red blood cell reduction of human bone marrow products.

BACKGROUND AIMS: Hematopoietic stem cell transplantation using bone marrow as the graft source is a common treatment for hematopoietic malignancies and disorders. For allogeneic transplants, processing of bone marrow requires the depletion of ABO-mismatched red blood cells (RBCs) to avoid transfusion reactions. Here the authors tested the use of an automated closed system for depleting RBCs from bone marrow and compared the results to a semi-automated platform that is more commonly used in transplant centers today. The authors found that fully automated processing using the Sepax instrument (Cytiva, Marlborough, MA, USA) resulted in depletion of RBCs and total mononuclear cell recovery that were comparable to that achieved with the COBE 2991 (Terumo BCT, Lakewood, CO, USA) semi-automated process. METHODS: The authors optimized the fully automated and closed Sepax SmartRedux (Cytiva) protocol. Three reduction folds (10×, 12× and 15×) were tested on the Sepax. Each run was compared with the standard processing performed in the authors' center on the COBE 2991. Given that bone marrow is difficult to acquire for these purposes, the authors opted to create a surrogate that is more easily obtainable, which consisted of cryopreserved peripheral blood stem cells that were thawed and mixed with RBCs and supplemented with Plasma-Lyte A (Baxter, Deerfield, IL, USA) and 4% human serum albumin (Baxalta, Westlake Village, CA, USA). This "bone marrow-like" product was split into two starting products of approximately 600 mL, and these were loaded onto the COBE and Sepax for direct comparison testing. Samples were taken from the final products for cell counts and flow cytometry. The authors also tested a 10× Sepax reduction using human bone marrow supplemented with human liquid plasma and RBCs. RESULTS: RBC reduction increased as the Sepax reduction rate increased, with an average of 86.06% (range of 70.85-96.39%) in the 10×, 98.80% (range of 98.1-99.5%) in the 12× and 98.89% (range of 98.80-98.89%) in the 15×. The reduction rate on the COBE ranged an average of 69.0-93.15%. However, white blood cell (WBC) recovery decreased as the Sepax reduction rate increased, with an average of 47.65% (range of 38.9-62.35%) in the 10×, 14.56% (range of 14.34-14.78%) in the 12× and 27.97% (range of 24.7-31.23%) in the 15×. COBE WBC recovery ranged an average of 53.17-76.12%. Testing a supplemented human bone marrow sample using a 10× Sepax reduction resulted in an average RBC reduction of 84.22% (range of 84.0-84.36%) and WBC recovery of 43.37% (range of 37.48-49.26%). Flow cytometry analysis also showed that 10× Sepax reduction resulted in higher purity and better recovery of CD34+, CD3+ and CD19+ cells compared with 12× and 15× reduction. Therefore, a 10× reduction rate was selected for the Sepax process. CONCLUSIONS: The fully automated and closed SmartRedux program on the Sepax was shown to be effective at reducing RBCs from "bone marrow-like" products and a supplemented bone marrow product using a 10× reduction rate.

An outcome-based review of an accredited Specialist in Blood Banking (SBB) program: 25 years and counting.

CONCLUSIONS: Specialist in Blood Banking (SBB) programs play an important role in preparing technologists to become leaders and contributors to the field of transfusion medicine through dedicated education and training. The SBB program at the National Institutes of Health (NIH) Clinical Center has graduated 55 students since 1994 with an overall pass rate of 96 percent for the American Society for Clinical Pathology (ASCP) SBB examination. Graduates hold positions in a variety of transfusion medicine-related fields, with hospitals, blood centers, and Immunohematology Reference Laboratories being the most common categories of employer. Projects completed as part of the program added to transfusion medicine knowledge as evidenced by publications and awards. Almost half of all projects completed led to publications (49%), and greater than 50 percent of submissions have been selected for the AABB Future Leaders Scholarship (previously known as AABB Fenwal Scholarship Award). The students have completed over 40 program value-added opportunities. This information was available for retrieval and review. In this review, we analyzed data for the last 25 years from the SBB program at the NIH Clinical Center on program statistics, student accomplishments (such as publications in peer-reviewed journals), program value-added opportunities (such as other publications and audits performed with our Quality Assurance office), and job procurement. The collected, reviewed, and organized data provided a useful internal self-assessment to review the history of our program and head into the future.

Inhibition of blood group antibodies by soluble substances.

CONCLUSIONS: The presence of multiple alloantibodies or an antibody to a highprevalance antigen in a patient sample can pose challenges in antibody identification. The pattern of reactivity seen on an antibody panel may show various strengths of reactivity by different methods of testing or same strength of reactivity at one or more phases of testing. To ensure proper identification, multiple investigative tools may be used. We review one of these methods-inhibition by soluble substances-which has become an expansion of our toolbox within the past 10 years. Alloantibodies can be inhibited using specific soluble substances. These soluble substances occur naturally in various fluids or can be manufactured. When a patient sample contains multiple antibodies, clinically significant or not, inhibition of one may help determine specificities of others. Specific inhibition of a particular antibody will also help to confirm its presence.

Red blood cell sedimentation of Apheresis Granulocytes.

Sedimentation of Apheresis Granulocyte components removes red blood cells. It is used to increase the blood donor pool when blood group-compatible donors cannot be recruited for a patient because of a major ABO incompatibility or incompatible red blood cell antibodies in the recipient. Because granulocytes have little ABO and few other red blood cell antigens on their membrane, such incompatibility lies mostly with the contaminating red blood cells. Video Clip S1 shows the process of red blood cell sedimentation of an Apheresis Granulocyte component. This video was filmed with a single smart phone attached to a commercial tripod and was edited on a tablet computer with free software by an amateur videographer without prior video experience.

Critical Value Reporting in Transfusion Medicine: A Survey of Communication Practices in US Facilities.

OBJECTIVES: While critical value procedures have been adopted in most areas of the clinical laboratory, their use in transfusion medicine has not been reviewed in detail. The results of this study present a comprehensive overview of critical value reporting and communication practices in transfusion medicine in the United States. METHODS: A web-based survey was developed to collect data on the prevalence of critical value procedures and practices of communicating results. The survey was distributed via email to US hospital-based blood banks. RESULTS: Of 123 facilities surveyed, 84 (68.3%) blood banks had a critical value procedure. From a panel of 23 common blood bank results, nine results were selected by more than 70% of facilities as either a critical value or requiring rapid communication as defined by an alternate procedure. CONCLUSIONS: There was overlap among results communicated by facilities with and without a critical value procedure. The most frequently communicated results, such as incompatible crossmatch for RBC units issued uncrossmatched, delay in finding compatible blood due to a clinically significant antibody, and transfusion reaction evaluation suggestive of a serious adverse event, addressed scenarios associated with the leading reported causes of transfusion-related fatalities.

Following the Rules Set by Accreditation Agencies and Governing Bodies to Maintain In-Compliance Status: Applying Critical Thinking Skills When Evaluating the Need for Change in the Clinical Laboratory.

Maintaining an in-compliance clinical laboratory takes continuous awareness and review of standards, regulations, and best practices. A strong quality assurance program and well informed leaders who maintain professional networks can aid in this necessary task. This article will discuss a process that laboratories can follow to interpret, understand, and comply with the rules and standards set by laboratory accreditation bodies.

They're Here! How to Prepare Your Blood Bank for Inspection.

The importance of an inspection ready blood bank cannot be overemphasized. Various agencies perform inspections to ensure that facilities are compliant with federal and state regulations, as well as with standards defined by professional organizations. Inspections may strike fear into the staff members of the organizations being inspected. When a laboratory is in a state of constant readiness, such anxiety is likely to be lessened. Facilities may differ in structure and size and yet be held to the same standards. This article discusses the who, when, and why of laboratory safety inspections. We share helpful information gathered from various resources, including interviews with a quality assurance specialist, a blood bank manager, and an assessor, to help facilities work towards an inspection ready state.

Red blood cell preservation by droplet freezing with polyvinylpyrrolidone or sucrose-dextrose and by bulk freezing with glycerol.

BACKGROUND: Red blood cell (RBC) preservation is essential to transfusion medicine. Many blood group reference laboratories need a method to preserve rare blood samples for serologic testing at a later date. This study offers a comparison of three common cryoprotective agents and protocols used today: bulk preservation with glycerol and droplet freezing with sucrose-dextrose (S+D) or polyvinylpyrrolidone (PVP). STUDY DESIGN AND METHODS: Human blood from 14 volunteers was collected and frozen at set intervals over 2 weeks with PVP, S+D, or glycerol. The frozen RBCs were later thawed and the percentage of surviving RBCs was determined. Detailed protocols and an instructional video are supplied. RESULTS: Over a 2-week period, RBCs preserved with glycerol and thawed with a widely used protocol showed a recovery of 41 ± 16% (mean ± standard deviation) while those thawed with a modified glycerol protocol showed a recovery of 76 ± 8%. RBCs preserved by droplet freezing with S+D showed a recovery of 56 ± 11% while those preserved by droplet freezing with PVP showed a recovery of 85 ± 6%. Recovery values were similar with ethylenediaminetetraacetic acid or heparin anticoagulants, differing freezing rates, and varying droplet volumes. CONCLUSION: Droplet freezing with PVP offered the greatest recovery. While bulk freezing with glycerol can also be effective, droplet freezing may be a more convenient method overall. It requires less effort to thaw, needs much less storage room, and allows blood group laboratories to be frugal with thawing rare samples.

Organization and management of an accredited specialist in blood bank (SBB) technology program.

BACKGROUND: Specialists in blood bank (SBBs) technology play important roles in blood banks, transfusion services, regulatory agencies, educational institutions, and other facilities where expertise in blood banking, transfusion medicine, cellular therapy, and tissue transplantation is required. STUDY DESIGN: Review of pathways that qualify applicants for a national examination administered by the American Society of Clinical Pathology (ASCP) to become a certified specialist and outcomes of accredited programs. Description of a face-to-face, accredited program including review of management topics included in curriculum. RESULTS: The first examination was administered in 1954. As of December 2009, the total number of certified SBBs was 5124. There are currently 16 accredited SBB programs in the United States. The programs vary in mode of delivery, length of program, number of students accepted, and organization of program officials and faculty, but all must follow specific standards and guidelines in order to be accredited. CONCLUSION: Students who successfully complete SBB programs have a higher passing rate than those who attempt the certification examination and have not participated in a program. Students can choose among a variety of programs that differ widely in the way they are managed. The role of management in an SBB program ranges from attracting and retaining individuals and maintaining an accredited program to finally graduating individuals who not only pass the certification examination but who also confidently contribute to the field.

Another example of a KEL1 variant red cell phenotype due to a threonine to serine change at position 193 of Kell glycoprotein.

BACKGROUND: Healthy subjects whose red blood cells (RBCs) react variably with anti-KEL1, but strongly express other Kell blood group antigens, have been described and called KEL1 variant. A 53-year-old Caucasian blood donor was identified whose RBCs reacted with three monoclonal and two polyclonal anti-KEL1 and did not react with two monoclonal and one polyclonal anti-KEL1. The molecular basis of this phenotype was investigated. STUDY DESIGN AND METHODS: Genomic white blood cell DNA was analyzed for KEL*1/2 genotype by utilizing sequence-specific primers and polymerase chain reaction. In addition, the region of the KEL*1/2 polymorphism at position 578 of KEL was analyzed by DNA sequencing. RESULTS: Genotyping of the donor with the KEL1 variant phenotype revealed that he was KEL*2 homozygous. Sequencing revealed one typical KEL*2 allele and a KEL*2 allele with an adenosine (A) to thymidine (T) substitution at position 577 that predicted a threonine to serine change at position 193. CONCLUSION: It is not known if this phenotype is clinically relevant, but for at least some genotyping applications probes that identify this polymorphism should be used and anti-KEL1 should be tested for reactivity to this allele.

Comparison of proteomic profiles of serum, plasma, and modified media supplements used for cell culture and expansion.

BACKGROUND: The culture and expansion of human cells for clinical use requires the presence of human serum or plasma in culture media. Although these supplements have been extensively characterized in their chemical composition, only recently it has been possible to provide by high throughput protein analysis, a comprehensive profile of the soluble factors contributing to cell survival. This study analyzed and compared the presence of 100 proteins including chemokines, cytokines and soluble factors in six different types of media supplements: serum, plasma, recalcified plasma, heat inactivated serum, heat inactivated plasma and heat inactivated recalcified plasma. METHODS: Serum, plasma, recalcified plasma, and heat inactivated supplements were prepared from ten healthy subjects. The levels of 100 soluble factors were measured in each sample using a multiplexed ELISA assay and compared by Eisen hierarchical clustering analysis. RESULTS: A comparison of serum and plasma levels of soluble factors found that 2 were greater in plasma but 18 factors were greater in serum including 11 chemokines. The levels of only four factors differed between recalcified plasma and plasma. Heat inactivation had the greatest effect on soluble factors. Supervised Eisen hierarchical clustering indicated that the differences between heat inactivated supplements and those that were not were greater than the differences within these two groups. The levels of 36 factors differed between heat inactivated plasma and plasma. Thirty one of these factors had a lower concentration in heat inactivated plasma including 12 chemokines, 4 growth factors, 4 matrix metalloproteases, and 3 adhesion molecules. Heat inactivated decalcified plasma is often used in place of heat inactivated serum and the levels of 19 soluble factors differed between these two supplements. CONCLUSION: Our report provides a comprehensive protein profile of serum, plasma recalcified plasma, and heat inactivated supplements. This profile represents a qualitative and quantitative database that can aid in the selection of the appropriate blood derived supplement for human cell cultures with special requirements.

KEL6 and KEL7 genotyping with sequence-specific primers.

BACKGROUND: Although antibodies to Js(a) and Js(b) are clinically significant, reagent-quality anti-Js(a) and anti-Js(b) are not readily available. A sequence-specific primer-polymerase chain reaction (SSP-PCR) genotyping assay was tested that makes use of two single-nucleotide polymorphisms (SNPs) at positions 1910 and 2019 of KEL. These SNPs distinguish the gene encoding Js(a), KEL6; and Js(b), KEL7. STUDY DESIGN AND METHODS: Four primer sets that selectively amplified KEL6 and KEL7 from genomic DNA were developed. Two sets detected the SNP at bp 1910 and two sets detected the bp 2019 SNP. KEL6 and KEL7 genotyping and Js(a) and Js(b) phenotyping results were compared among 64 subjects. RESULTS: The SSP-PCRs were specific for KEL6 and KEL7 when testing DNA for three donors of known Js phenotype: Js(a+b-), Js(a-b+), and Js(a+b+). Genotyping results for the 1910 SNP were identical to the phenotyping results in all 64 subjects, but for the 2019 SNP, the genotyping and phenotyping results were identical for only 49 subjects. In 12 subjects with the Js(a-b+) phenotype, the 2019 SNP was heterozygous KEL6, KEL7; in 2 with Js(a-b+) and in 1 with Js(a+b+), the 2019 SNP was homozygous KEL6. CONCLUSION: KEL 2019-bp SNP does not always correlate with the Js phenotype owing to the presence of an atypical KEL gene with a KEL7 polymorphism at 1910 and a KEL6 polymorphism at 2019. The KEL polymorphism at 2019 is silent and this allele yields a Js(a-b+) phenotype. Only analysis of the 1910-bp SNP can be used to genotype KEL6 and KEL7.

In vitro variables of red blood cell components collected by apheresis and frozen 6 and 14 days after collection.

BACKGROUND: An automated cell processing system (ACP 215, Haemonetics Corp.) can be used for the glycerolization and deglycerolization of RBC components, but the components must be 6 or fewer days old. Depending on the anticoagulant (CP2D)/additive solution (AS) used, deglycerolized RBCs can be stored at 1 to 6 degrees C for up to 14 days. This study evaluated in vitro variables of apheresis RBC stored for 6 and 14 days at 1 to 6 degrees C before glycerolization and 14 days after deglycerolization. STUDY DESIGN AND METHODS: Two units of CP2D/AS-3 leukoreduced RBCs were collected by apheresis from seven donors. One unit was glycerolized and frozen 6 days and the other 14 days after collection. All units were deglycerolized with the ACP 215 and stored at 1 to 6 degrees C for 14 days in AS-3. Several in vitro variables were evaluated during postdeglycerolization storage. RESULTS: All components had postdeglycerolization RBC recoveries greater than 81 percent and osmolalities of less than 400 mOsm per kg. No significant differences were noted in potassium and supernatant hemoglobin after 14 days of postdeglycerolization storage between RBCs frozen at 6 and 14 days after collection. After 14 days of postdeglycerolization storage, however, the pH, lactate, and ATP levels were slightly lower in RBCs frozen after 14 days. CONCLUSION: The ACP 215 can be used to glycerolize and deglycerolize apheresis RBC components that are up to 14 days of age. It is likely that apheresis components glycerolized at 14 days of age or less can be stored up to 14 days in AS-3 after deglycerolization, but this should be confirmed with in vivo survival studies.

Factors affecting the formation of white particulate matter in red blood cell components.

BACKGROUND: Recently white particulate matter (WPM) in red blood cell (RBC) components has received increased attention. The nature and causes of WPM formation were investigated. STUDY DESIGN AND METHODS: Whole-blood units were collected from 18 healthy subjects with three different types of collection sets. Six units were collected into each type. Units were divided into four equal parts and stored for 4 hours: two parts at room temperature and two at 4 degrees C. RBCs were prepared from each quarter-unit: two by heavy centrifugation (5000 x g) and two by light centrifugation (2000 x g). Whole blood was inspected for WPM over 4 hours and RBCs over 1 hour. RESULTS: No WPM was detected in whole blood, but WPM was detected in at least one RBC component from 9 of the 18 donations. The 36 components prepared by heavy centrifugation were more likely to contain WPM than the 36 prepared by light centrifugation (50% vs. 19%; p < 0.02). The incidence of WPM was similar among RBCs stored at room temperature and 4 degrees C. Donors of RBCs with WPM had higher total cholesterol levels than donors of components without WPM (191 +/- 20 mg/dL vs. 163 +/- 32 mg/dL; p < 0.04), but there was no difference in triglyceride levels between the two groups. CONCLUSIONS: WPM is an expected consequence of standard RBC manufacturing methods, but it is more frequent in RBCs prepared by heavy centrifugation and from donors with higher cholesterol levels.

Increasing hemoglobin oxygen saturation levels in sickle trait donor whole blood prevents hemoglobin S polymerization and allows effective white blood cell reduction by filtration.

UNLABELLED: BACKGROUND Red blood cell (RBC) components from donors with sickle cell trait (Hb AS) often occlude white blood cell (WBC) reduction filters. Techniques were investigated to successfully filter Hb AS donor blood by increasing the Hb oxygen saturation with storage bags and conditions suitable for transfusion products. STUDY DESIGN AND METHODS: Oxygenation kinetics were measured over 3 days in whole-blood units stored in standard-sized 600-mL polyvinylchloride (PVC) bags and whole-blood units divided into three equal parts and stored in standard-sized blood bags made from PVC, tri-2-(ethylhexyl)trimellitate (CLX) plastic, or Teflon. The filterability of Hb AS blood stored for 3 days was tested with whole-blood filters. RESULTS: Oxygen saturation levels did not increase in full whole-blood units from donors without sickle cell trait during 3 days of storage in 600-mL PVC bags. In divided Hb AS whole-blood units stored for 3 days, oxygen saturation levels increased from baseline levels of 45 to 56, 66, and 94 percent after storage in 600-mL PVC, CLX, and Teflon bags, respectively (n = 5, p < 0.02), and all components filtered completely. When full Hb AS whole-blood units from eight donors were stored for 3 days in 1.5-L CLX bags, all units filtered completely, but one had a high residual WBC count. CONCLUSION: Storage of Hb AS whole blood in large-capacity oxygen-permeable bags increases oxygen tension and allows more effective WBC reduction by filtration.

Increasing oxygen tension improves filtration of sickle trait donor blood.

A major cause of filter failure of red cell (RBC) components from donors with sickle cell trait (HbAS) is the polymerization of haemoglobin. The oxygen saturation (sO2) of blood stored in various plastics and different volumes of air was assessed. Blood from 10 HbAS donors was collected and divided into two bags, one with air added, one without. Bags with added air had increased sO2 levels (from 49 +/- 10% to 76 +/- 6%). Filtration was successful for nine of 10 components with air, and one of 10 without air. Successful filtration of RBC components occurs when sO2 is increased.

Sickle Hb polymerization in RBC components from donors with sickle cell trait prevents effective WBC reduction by filtration.

BACKGROUND: RBC components collected from donors with sickle cell trait frequently occlude WBC-reduction filters. In vitro, sickle trait RBCs have the potential for sickle Hb (Hb S) polymerization at low oxygen saturations and high Hb concentrations. STUDY DESIGN AND METHOD: To determine if the low pH and high osmolarity of the CP2D used in the collection contributed to filter failures, the filterability of sickle trait donor RBCs collected in CP2D was compared with RBCs from the same donors collected in heparin. RESULTS: Five of six sickle trait components collected in CP2D did not complete filtration, but all six RBC components collected in heparin filtered completely. RBC components collected in CP2D from four other sickle trait donors were divided in two, and one-half was treated with carbon monoxide to convert Hb S to its liganded form to prevent Hb S polymerization. All four carbon monoxide-treated components filtered within 9 minutes, but only one untreated component filtered completely. RBC components collected by apheresis contained less CP2D, and five of seven sickle trait apheresis components filtered completely; four of the five filtered rapidly (<15 min) and one filtered in 100 minutes. Hb oxygen saturation was greater in the four rapidly filtering apheresis RBC components (68 +/- 9%) than in the three that filtered slowly or incompletely (37 +/- 5%, p = 0.03). CONCLUSIONS: Hb S polymerization appears responsible for RBC WBC-reduction filter failures. Citrate anticoagulant and low oxygen saturation are responsible in part for Hb S polymerization in this setting.

Detection of antibodies in acid eluates with the gel microcolumn assay.

BACKGROUND: Gel microcolumns can be used to detect unexpected serum antibodies and to determine ABO blood group and Rh phenotype. DATs can also be performed with this system. The purpose of this study was to compare the gel microcolumn to the tube IAT using anti-IgG for the detection of antibodies eluted from RBCs. STUDY DESIGN AND METHODS: Acid eluates were prepared from 30 peripheral blood and 41 umbilical cord blood samples. Twelve of the 71 eluates made were from control samples (known DAT negative). Specificities of eluted antibodies were determined by both tube and gel assays with a three-cell screen plus A1 and B cells, as determined by blood type. RESULTS: Ten of 30 peripheral blood eluates were reactive in both assays. Eighteen were nonreactive in both assays, and two from patients with autoimmune hemolytic anemia were reactive by gel assays and nonreactive by tube assays. Thirty three of the 41 cord blood eluates were reactive in both assays. Eluates from 2 of the 35 DAT-positive samples reacted with A1 and B cells by the tube method but were nonreactive by the gel method. Of the 33 cord blood eluates that were reactive by both assays, antibody specificity differed for two samples. When tested by tube assay, these eluates reacted with both A1 and B cells, whereas the same eluates tested by gel assay showed one reacting with only A1 cells and the other with only B cells. CONCLUSIONS: Results of testing eluates in gel assays were similar to those obtained in tube assays. The gel assays may be better at detecting antibodies eluted from RBCs from patients with autoimmune hemolytic anemia, and tube assays may be better at detecting isohemagglutinins eluted from umbilical cord blood.