To prevent delays in transfusion and the development of hemolytic transfusion reactions at the emergency room of a local hospital, we implemented a Type O blood usage program for life-threatening bleeding patients in August 2001 according to Japanese government guidelines for transfusion. To better understand actual conditions for urgent blood transfusion before and after implementation of this program, we surveyed the time between ordering to the start of transfusion, shock index at the start of transfusion, total volume of transfused blood, causes of death, irradiation of blood, side effects, and reasonable adaptation of transfusion. Results showed the time between ordering to the start of transfusion shortened to 9.3 minutes from 62.2 minutes after implementation. There was no case in which non-irradiated blood unit, was transfused, nor of incompatible blood transfusion following cross matching. Further, there was no increase in workload following implementation of the Type O blood usage program. In conclusion, Type O blood usage programs can dramatically save time between ordering to the start of transfusion. However, they carry risks such as Rh-positive blood transfusion to Rh-negative patients (about 0.5%) and antigen-positive blood transfusion to patients positive for irregular antibodies (about 1.3%). Adaptation of this transfusion must be carefully controlled. All patients receiving type O blood transfusion should be investigated for suitability after transfusion.
「安全な血液製剤の安定供給の確保等に関する法律」に医療関係者の責務と明記された「安全かつ適正な輸血」の実施状況及び課題を把握するため, 輸血管理体制及び輸血療法委員会に関する調査を含む輸血関連総括的アンケート調査を2004年度に実施した.300床以上で血液製剤使用量が3,000単位以上の全医療機関777を含む1,355病院を対象とし, 829施設 (61.2%) より回答を得た. 輸血部または検査部による輸血検査・輸血用血液の一元管理体制は, 各々164施設 (19.9%), 513施設 (62.1%) において確立し, 輸血療法委員会あるいは同様の機能を持つ委員会が733施設 (88.7%) に設置されていたが, 同委員会の中心となるべき専任の輸血責任医師が任命されている施設は86施設 (10.5%) と少なかった (表2, 表4).医療機関の病床数及び輸血責任医師の専任, 兼任, 不在により分類した5群 (表1) における血液製剤の使用量, 廃棄率を比較した結果, 輸血責任医師不在の300床以上の医療機関において, 濃厚赤血球液 (RBC) 及び新鮮凍結血漿 (FFP) の廃棄率が多く, FFP使用単位数/RBC使用単位数が統計学的有意差はないものの, より多い傾向が認められた (表6).以上より, 輸血療法委員会を活用し, [安全かつ適正な輸血医療] を実践するために, 専任の輸血責任医師が重要な鍵を握るものと考えられた.
We evaluated the feasibility and safety of red cell collection by apheresis technology. Red cells corresponding to 600ml of whole blood were collected with two types of apheresis machine (Trima and CCS). Healthy male donors whose (circulating) blood volume was 4, 100ml or more were entered into the trial. Mean time for the entire process was 32.4min. All procedures were completed without interruption, although one case of vaso-vagal reaction was noted during collection. No sign of serious side effects was reported after collection. Red cell counts and hemoglobin values of the donors recovered to the baseline 2-3 months after collection, although serum ferritin remained at 64.4% of predonation values after 6 months.It was concluded that red cell collection by apheresis technology equivalent to 600ml of whole blood is feasible and safe. However, a large scale clinical trial will be necessary to affirm the safety of this procedure.
Nagasaki Prefecture is a highly endemic area for hepatitis B virus (HBV). In recent years, we have identified a decrease in the incidence of positivity for hepatitis B surface antigen (HBsAg). In 1985, the Government of Japan started a nationwide prevention program for mother-to-infant infection by HBV. As blood donor is acceptable from age 16, a portion of the people who owed this program became to age with approval of blood donation. We screened 291, 587 serum samples from voluntary blood donors (170, 366 males and 121, 221 females) between 16 and 69 years of age who first visited Nagasaki and Sasebo Red Cross Blood Center from June 1990 to December 2004.The positive rate for HBsAg among blood donors by year of birth decreased from 1.67 to 0% over the years 1929 to 1988 (test of trend; p<0.001).No donor born from 1986 to 1988 was positive, although a decrease in the positive rate was recognized before 1985. This may be because in 1985, the Government of Japan started a prevention program for mother-to-infant infection by HBV. Shiraki has reported that this program was very effective. The present study involving the analysis of data among blood donors provides further evidence for the high efficacy of this program.
本研究では, 新しく開発された全自動型血液成分分離装置 Baxter Amicus の末梢血幹細胞採取機能を評価するために, COBE Spectra の手動プログラムと比較した. 連続した自己末梢血幹細胞移植患者を対象に Amicus 群と Spectra 群に交互に振り分け, CD34陽性細胞回収率や採取物の特徴を比較検討した.最初の比較試験では, Amicus の設定をデフォルトのまま, すなわちMNCオフセットを2.3ml, 処理血液量は1,400ml×7cyclesで行った. 症例数は各群それぞれ5例, 採取回数は Amicus 群7回, Spectra 群9回であった. CD34陽性細胞回収率は Amicus 群で33.20±12.23%, Spectra 群で54.51±12.07%と後者で有意に良好であった. 血小板の混入量は Amicus 群で4.57±1.93×1010/bag, Spectra 群で17.71±15.55×1010/bagと前者で有意に少なかった.次に Amicus のCD34陽性細胞回収率を向上する目的でMNCオフセットを2.1ml, 血液処理量を1.800ml×5cycles に変更し, 同様の比較試験を行った. 症例数は各群それぞれ5例, 採取回数は Amicus 群7回, Spectra 群7回であった. CD34陽性細胞回収率は23.09±11.53%, Spectra 群で50.66±15.15%と後者で有意に良好であり, Amicus のCD34陽性細胞回収率を向上することはできなかった.Amicus は自動型の利点があるものの, CD34陽性細胞回収率が Spectra 手動プログラムより劣っていると考えられたが, 回収率の差をより明確にするために, 症例数を増やして更なる検討の必要性があるものと思われた.
HLAクラスI抗体が血小板輸血不応状態 (platelet transfusion refractoriness: PTR) に関与することについては数多くの報告があるが, IgM型のHLAクラスI抗体 (IgM-HLA抗体) のPTRへの関与についての報告はほとんどない. そこで, PTR患者121人の凍結保存血清のHLA抗体スクリーニングを, 磁性粒子を用いた Mixed passive hemagglutination assay (M-MPHA) 法, Flow cytometric reagents for detection of panel-reactive antibody against HLA Class I antigens (FlowPRA) 法, Anti-human immunoglobulin lymphocyte cytotoxity test (AHG-LCT) 法により行い, IgM-HLA抗体のPTRへの関与については, 輸血24時間後の補正血小板増加数 (CCI24hours) による血小板輸血効果から推測した. その結果, M-MPHA法により121症例中48症例からIgM-HLA抗体が検出された. 一方, FlowPRA法により検出できたIgM-HLA抗体は, それら48例中35例, AHG-LCT法では20例のみであった. 血小板輸血効果は, IgM-HLA抗体を保有する, 48症例中7症例74輸血において判定できた. IgM-HLA抗体の特異性に対応する抗原を持たない輸血では, CCI24hoursが19.7±4.7(×109/L) を示し輸血効果を得ることができたが, 対応する抗原を持つ輸血では, CCI24hoursが2.0±19(×109/L) を示し輸血効果を得られなかった. PTR患者に高頻度に存在するIgM-HLA抗体は, PTRの原因になると考えられ, その半数以上はAHG-LCT法により検出できなかった. M-MPHAをHLA抗体スクリーニング, 血小板輸血の際の交差試験に用いることで, PTR症例の原因解析と輸血効果の向上に貢献できる可能性がある.
【背景】静注用免疫グロブリン (IVIG) に関しては未だ明確な使用基準がなく, 適正使用を推進するには使用指針の作成が急務である. 我々は指針作成を最終的な目標とし, 先ずIVIGについて全国の中・大規模病院における疾患別の使用実態を調査, 検討した.【方法】全国の400床以上の732病院を対象に, 平成15年7月から9月までの3ヵ月間におけるIVIG使用状況をアンケート形式で調査した. 調査内容は疾患別の使用患者数および使用量である.【成績】本調査の有効回答率は36.6% (268/732病院) であった. 総使用患者数 (8,570例) 中の小児群は1,955例で自己免疫疾患が38%, 術後感染症を含めた感染症が33%であり, 成人群は6,615例で自己免疫疾患が10%, 感染症が73%と両群間に有意差が認められた. 総使用量 (171,018g) では, 小児群 (28,684g), 成人群 (142,334g) での自己免疫疾患の占める割合は各々60%, 35%であり, 感染症は各々15%, 45%であった. 感染症以外の患者数をみると, 小児群では川崎病が44.5%と高頻度であり, 成人群では特定の疾患に多く使用される傾向は認められなかった. 感染症に関しては両群とも細菌感染症に多く使用されていた. また, 重症感染症の指標として設定したCRP値の境界値 (小児群: 10mg/dl, 成人群: 15mg/dl) 以上での使用例は小児群では28%と低率であり, 成人群でも51%と約半数に過ぎなかった.【結論】本調査から自己免疫疾患ならびに感染症が今後のIVIG需要量を規定する主な疾患であると判断された. 特に, 感染症のうち, 重症と考え難く, 不適正と考えられる症例にもかなり使用されている実態が明らかになった.
Long-term survival of transfused patients was studied at a single institution. This study, to our knowledge the first such report in Japan, compared long-term survival before (Group 1: 1986-1987, 1, 781 patients) and after implementation (Group 2:1992-1993 1, 326 patients) of HCV antibody screening. Unexpectedly, post-transfusion survival rate by Kaplan-Meier analysis showed no significant difference between the two groups. Female-s had a greater survival rate than male-s in both group 1 (1-year survival; male 74.1%, female 79.9%; p<0.05) and group 2 (1 year survival; male 73.7%, female 82.9%; p<0.01). There was no difference in survival between those aged 65 or more and under 65. Internal medicine patient-s had markedly lower survival than surgical patient-s (Group 2, 1-year survival; internal medicine group 58.2%, surgical patient group 84.3%; p<0.001). Transfused patients had a very high risk of death, with almost 1/4 of all patients dying within 1 year after the first transfusion.
We encountered an apheresis donor with a suspected case of mosaicism. The donor, K. A., was a 46-year-old Japanese female registered as an HLA-compatible platelet concentrate (HLA-PCs) donor. In her HLA serological typing for HLA-PCs donor registration, three antigens, HLA-B55, -B61 and -B62, were assigned in the HLA-B locus. She was not a twin and had never undergone transfusion or transplantation. Flow cytometric analysis using platelets and lymphocytes indicated that HLA-B55, -B61 and -B62 antigens were simultaneously expressed on the surface of platelets and lymphocytes. HLA-B allele typing with the polymerase chain reaction restriction fragment length polymorphism technique using genomic DNA from peripheral blood and nails as a somatic sample was carried out to establish HLA-B mosaicism. Three alleles, HLA-B*5502, -B*4002 and B*1501, were assigned in both exon 2 and exon 3. HLA-B mosaicism was observed in both her peripheral blood and nails. The HLA-B*4002 and -B*1501 alleles were inherited by her son, who carried three HLA-B alleles, HLA-B*4002, -B*1501 and -B*4001. No other sign of chimerism or mosaicism was observed in other HLA loci antigens or red cell antigens. These results suggest that this donor has a chimeric allele consisting of a mixture of the nucleotide sequences of HLA-B*4002 and -B*1501 alleles.
The First WHO International Standard for HCV RNA for Nucleic Acid Amplification Technology (NAT) Assay (96/790) was established in 1997. The aim of our collaborative study was the establishment of the Japanese National Standard for HCV RNA calibrated against the WHO International Standard. The candidate materials were evaluated in the following two steps. First, titers of two HCV positive plasma (119 and 122) diluted in cryosupernatant were evaluated, and plasma 122 was chosen as the source plasma for the candidate for the national standard. Then, candidate 122 was prepared by diluting the source plasma to approximately 105 international units (IU)/ml in cryosupernatant. The relative potency of the candidate was measured against the International Standard by the end-point method. Seven laboratories from three countries participated in the collaborative study. Four laboratories used the Roche Amplicor assay (Version 1) and 3 laboratories used in-house PCR methods. There was reasonable agreement among the mean estimates from the laboratories. The overall mean potency of the candidate relative to the International Standard was 105.00 (104.80-105.20) IU/ml. The sample was accepted as the first Japanese national standard and assigned a titer of 100, 000IU/ml. Each vial of the National Standard contains 0.5ml of HCV plasma (genotype 1b) diluted in cryosupernatant and should be stored at-80°C.
We report here a rare case of delayed hemolytic transfusion reaction (DHTR) probably caused by a primary immune response. The patient was a 69-year-old Japanese female who underwent neurosurgery for subarachnoid hemorrhage. For treatment of post-operative hemorrhage, she received 2 units of packed red cells (Ir-RC-MAP) per day for 6 days, for a total of 12 units. On day 33 after the first transfusion, she showed symptoms of hemoglobinuria, anemia, thrombocytopenia, elevated levels of serum LDH and total bilirubin, and a decreased level of serum haptoglobin. Her blood was typed as A, ccDEE. Partial coagulation was observed on Rh blood-type examination for C and e but disappeared on day 37 after the first transfusion. On irregular antibody screening of patient serum collected 37 days after the first transfusion, IgM type anti-C+e was detected by MTS-Pap. We found that the immunoglobulin class of anti-C+e switched from IgM to IgG during the clinical course. These findings suggest that the DHTR was probably due to anti-C+e caused by a primary immune response.
The measurement of anti-blood group A/B (anti-A/B) IgG antibody levels is important for ABO unmatched-organ recipients because the effective removal of the antibodies improves their prognosis. However, currently existing methods to detect anti-A/B IgG antibodies suffer limitations due to high costs, low throughput, and poor adaptability to automation. We have developed a rapid means to quantitate anti-A/B IgG antibodies by surface plasmon resonance (SPR). The change in titers when the same plasma was diluted was precisely reflected by the SPR method. The coefficients of correlation between SPR and test tube (TT) methods for anti-A and -B IgG antibodies were 0.85 and 0.56, respectively. The SPR values also paralleled the TT values that showed a decline in titers after the removal of antibodies by double filtration plasma apheresis or plasma exchange.**This article is partly based on a study first reported in the Transfusion (Kimura, S., Yurugi, K., Yuasa, T., Tsuji, H., Segawa, H., Kuroda, J., Sato, K., Nogawa, M., Egawa, H., Tanaka, K., Maekawa, T.: Rapid quantitation of IgG antibodies specific for blood group antigens A and B by surface plasmon resonance. Transfusion, 45 (1): 56-62, 2005.)
HIV-infected voluntary blood donors have increased to more than 80 a year in the last 5 years. There are concerns that blood donation is being used for HIV testing by persons with high-risk behaviors, whose blood in the window period might result in HIV infection of recipients.A questionnaire was sent to 366 AIDS Care Core Hospitals, asking them to report the number of consultation by and characteristics of HIV-positive blood donors found by testing donations over the last 3 years. There were 185 HIV-positive donors reported, 158 (85%) of whom were male. Only 22 donors sought testing (12%), which increased to 13% over the last 5 years compared to 8% in previous years (not significant). However, 132 donors (71%) had high-risk behaviors including men who have sex with men (MSM: 57%) and multiple heterosexual partners (15%), but no intravenous drug users. Among the male donors, irrespective of whether they agreed to, denied or were undecided about donation for the purpose of HIV testing, MSM were the highest in each group (90%, 59%, and 77%, respectively), showing a remarkable increase to 71% over the last 5 years compared to 55% in 1993-1997 and 27% in 1986-1992. In addition, the fact that most infected donors did not approve of donation for the purpose of testing but revealed high-risk behavior once consulted a doctor in the hospitals shows a clear contradiction to their attitude at donation, at which time they ignored notices against donations for HIV testing or by those with high-risk behaviors before, at the time of, and after donation. Therefore, it should be considered that most but not all HIV-positive donors, particularly MSM, donated in order to obtain a HIV test.To ensure safety, it is recommended that MSM should be denied donating blood, and that donor recruitment should be focused on repeat donors, since HIV infection rates in first-time donors were three times higher than those in repeat donors.
Norimi Niwa, Takeshi Yuasa, Shinya Kimura, Hiroaki Tsuji, Kimiko Yurugi, Ryoko Takegawa, Rie Hishida, Hiroto Egawa, Koichi Tanaka, Hiroaki Asano, Tomoko Kawamura, Shigeki Yokoyamaand Taira Maekawa Department of Transfusion Medicine and Cell Therapy, Laboratory Medicine, Center for Cell and Molecular Therapy, and Transplantation and Immunology, Kyoto University Hospital, Kyoto Prefectural University of Medicine, School of Nursing, and Kyoto Blood Center
Refractoriness to platelet transfusions is considered one of the major obstacles in treating patients with hematological disorders. Although various transfusion procedures have been tried to prevent HLA alloimmunization, some patients still develop HLA and/or HPA antibodies and become refractory to platelet transfusions. We investigated the AHG-LCT, MPHA, LIFT and FlowPRA methods for detecting HLA antibodies and MPHA using chloroquine-treated platelets for HPA antibodies to analyze immunological factors in platelet transfusion-refractory (PTR) patients. Results showed that HLA antibodies were detected in 55 patients, HPA antibodies in 2 and both HLA and HPA antibodies in 2 patients. HLA-A and -B-compatible platelet transfusions were successful in boosting platelet levels in 27 of the patients. Nine patients developed not only HLA-A and/or -B antibodies but also HLA-C antibodies and became refractory to HLA-A and -B-compatible platelet transfusions. Matching of the HLA-C antigens was required in these patients to ensure the effectiveness of platelet transfusions. In some patients, ABH incompatibility reduced the effectiveness of transfusions. In these patients, platelet crossmatching was useful for predicting platelet survival. Of the 68 ABH-incompatible transfusions evaluated at 24 hours post-transfusion, 20 with positive crossmatches had corrected platelet count increments of 3.1±4.1 (×109)/L. In contrast, 48 transfusions with negative crossmatches had corrected platelet count increments of 18.1±7.6 (×109)/L. Other weak HLA antibodies in ten patients were not detected by the conventional methods but were detected by the FlowPRA method. Owing to screening and crossmatch tests, platelet transfusion efficacy was improved in 59 immunological PTR patients.
At our institution, only 22% of patients receiving blood transfusions between May and October, 2002, were subsequently screened for HIV infection. To improve this rate, we prepared lists of all patients undergoing transfusion on a monthly basis and distributed them to the attending department. We changed the principle of the system to further improve the rate in May of 2003 by the use of new individual forms programmed using commercial database software (FileMaker Pro) for each patient. The new forms featured an easily readable design and were distributed to the attending department even after discharge. The frequency of screening after blood transfusion remarkably increased between May and October, 2003, to 77%. We concluded that form design, particularly readability for individual patients, and method of notification are important for effective verification of transfusionassociated HIV infection.
We introduced an automated instrument for pretransfusion testing during off-hours based on column agglutination technology. As the time required for testing ABO group and Rh type is at least 20 minutes, we also prepared manuals regarding emergency transfusion of uncrossmatched blood. During a two-year period, 25 patients received 209 units (8.4 units per patient) of group O blood, and 19 patients received 289 units (15.2 units per patient) of group-specific blood. Additionally, 5 patients received 98 units of group-specific blood following group O blood. Fourteen patients (26.9%) required massive transfusion (20 or more units of blood within 24 hours). Accurate blood typing was carried out by using a blood sample drawn from the patient prior to infusion of group O blood. Antibody screening was carried out using this specimen the next day, and if a patient was positive for an antibody, complete compatibility testing was also performed. All patients were followed clinically and for any signs of transfusion reactions or crossmatching difficulties, but none developed. Although one patient had anti-E antibody present on admission and received E antigen-positive blood, no elevation of antibody level or delayed hemolytic reaction occurred. Two near-miss incidents associated with clerical errors were experienced with group-specific blood transfusion. We conclude that urgent transfusion of uncrossmatched blood is safe, and that group O blood transfusion may be safer than group-specific blood transfusion in some emergency situations. Off-hour manuals based on the time required for blood preparation will avoid transfusion errors.
The performance of platelet concentrates (PCs) for transfusion is greatly limited by their short shelf life. A highly oxygen-permeable container (PO-80, Kawasumi, Tokyo) was developed as an approach to extending the shelf-life of PCs. Here, we compared PCs containing a high number of platelets (4×1011/250mL plasma/bag) stored in a PO-80 container with those stored in a standard bag (control) (PL2410, Baxter Healthcare, USA) by monitoring platelet biochemical and functional parameters for up to 9 days.Three of six bags in the control bags had a pH below 6.2 by day 7. These PCs also showed the disappearance of swirling, a rapid drop in glucose combined with a marked increase in lactic acid, accelerated P-selectin expression on platelets and an earlier decrease in both %HSR and aggregation of platelets in the observation period. In contrast, only one of six bags had a pH below 6.2 by day 9 in the PO-80 container. Further, there was no disappearance of swirling. Other biochemical and functional parameters of PCs in PO-80 showed a slower change compared with those in the control bag. Overall, the in vitro characteristics of PCs showed a lower level of deterioration over 9 days when stored in a higher oxygen-permeable container than in a conventional bag. It is suggested that this newly developed highly oxygen-permeable PO-80 container will preserve adequate platelet function for longer storage periods and with higher PC yields.
The automated blood group testing system based on column agglutination technology (CAT) does not provide a standard for reversed typing. If the tube test (TT) method standard is introduced into automated the CAT method, the frequency of confirmation testing with the TT method will increase. In this study, we compared the results of the CAT and TT methods using samples which produced weak results with the automated CAT method (reactivity<3+; AutoVue System, Ortho).Forty-five percent of weak samples showed an increase in agglutination reactivity after a fixed 3-minute incubation time with the manual CAT method (Bio Vue, Ortho). All 481 weak samples had greater than 3+ reactivity with the TT method. Eighty percent of weak samples possessed IgM antibody. Titration and scoring results with the TT method were greater than with the manual CAT method for all samples. Titration and scoring of the weak samples were low with all methods for all samples. In conclusion, we propose that 1+ reactivity in the automated CAT method requires a confirmation test with the TT method because CAT 2+ samples can present as 3+ with the TT method.
