Background Post-transplant cyclophosphamide (PTCy) was developed to allow the use of haploidentical donors for allogeneic stem cell transplantation (alloHSCT), then tested with matched donors. Cedars-Sinai Medical Center Blood and Marrow Transplant was an early adopter of PTCy for matched alloHSCT in 2016. Purpose of the Research We retrospectively analyzed 15-year outcomes of patients who underwent alloHSCT with matched donor stem cells prior to 2016 (n = 252), with the outcomes of patients who were transplanted in the PTCy era, post-2016 (n = 99), to assess the impact of the switch to PTCy, while controlling for other differences between the cohorts. Principle Results Overall Survival (OS) was better in the PTCy group (at 1 year, 90% vs 62%, P < .0001), and the difference persisted in OS at 2 years and 3 years. There was no difference in relapse (26% non-PTCy vs 19% PTCy; P = .3560). Non-relapse mortality was lower with PTCy, 7% vs 22% without, P = .0002. Acute GVHD was lower in the PTCy group (16% PTCy vs 33% non-PTCy, P = .0013). Chronic GVHD was similar between the two groups, 35% in the PTCy group and 42% in the non-PTCy group (P = .1235), but the rate of extensive cGVHD was lower, 15% with PTCy vs 29% without; P = .0078. Post-transplant hospital stay was shorter, 23 ± 13.1 days in the non-PTCy group and 18 ± 7.0 days with PTCy, P < .0001. Conclusions Long-term follow up of patients transplanted using PTCy with matched donors has demonstrated superiority of PTCy compared to tacrolimus methotrexate.

Immune thrombotic thrombocytopenic purpura (iTTP) is characterized by microangiopathic hemolytic anemia, thrombocytopenia, and microvascular occlusion secondary to acquired ADAMTS13 deficiency. Contemporary data regarding iTTP treatment practices in the US, including the use of caplacizumab, are lacking. We aimed to characterize the demographics and therapies, including medications and apheresis practices, in patients with iTTP in the US. We retrospectively analyzed iTTP cases at 15 sites in the US that provide comprehensive care for patients with iTTP. The time-period assessed was from January 1, 2017 to December 31, 2021. Our primary objective was to analyze data by iTTP episode, inclusive of initial episodes and relapses. A total of 390 iTTP episodes were reported for 280 unique individuals (187 females, 93 males). Thirty-day mortality was 3.7% (14/374), and 6-month mortality was 7.4% (27/367). TPE details were reported for 343 episodes, among which 261 underwent at least one procedure (median 6, IQR 3-11). Among the 261 episodes with at least one therapeutic plasma exchange (TPE) performed, 82.0% (214/261) used only plasma. Caplacizumab was used either alone or in combination with other agents in 43 (11.0%) episodes. Management strategies for iTTP remain varied across centers in the US, with a variety of combinations for TPE replacement fluids and therapeutic agents, as well as limited use of caplacizumab. Further research and standardization of treatment regimens may further reduce mortality in this condition.

Mushroom (amatoxin) poisoning from ingestion is a rare but life-threatening medical emergency characterized by gastrointestinal symptoms before progression to multisystem organ failure in severe cases. Many therapies of amatoxin intoxication have been described, including supportive care, medical therapies, detoxification strategies, and liver transplant. The evidence supporting these therapies remains limited due to the rarity of amatoxin poisoning and challenge of a timely diagnosis. We report a case of amatoxin poisoning in Los Angeles causing severe liver injury without acute liver failure treated successfully using medical therapies, gallbladder drainage, and plasma exchange.

Prior studies have suggested that immune thrombotic thrombocytopenic purpura (iTTP) may display seasonal variation; however, methodologic limitations and sample sizes have diminished the ability to perform a rigorous assessment. This 5-year retrospective study assessed the epidemiology of iTTP and determined whether it displays a seasonal pattern. Patients with both initial and relapsed iTTP (defined as a disintegrin and metalloprotease with thrombospondin type motifs 13 activity <10%) from 24 tertiary centers in Australia, Canada, France, Greece, Italy, Spain, and the US were included. Seasons were defined as: Northern Hemisphere-winter (December-February); spring (March-May); summer (June-August); autumn (September-November) and Southern Hemisphere-winter (June-August); spring (September-November); summer (December-February); autumn (March-May). Additional outcomes included the mean temperature in months with and without an iTTP episode at each site. A total of 583 patients experienced 719 iTTP episodes. The observed proportion of iTTP episodes during the winter was significantly greater than expected if equally distributed across seasons (28.5%, 205/719, 25.3%-31.9%; p = .03). Distance from the equator and mean temperature deviation both positively correlated with the proportion of iTTP episodes during winter. Acute iTTP episodes were associated with the winter season and colder temperatures, with a second peak during summer. Occurrence during winter was most pronounced at sites further from the equator and/or with greater annual temperature deviations. Understanding the etiologies underlying seasonal patterns of disease may assist in discovery and development of future preventative therapies and inform models for resource utilization.

[This corrects the article DOI: 10.14309/crj.0000000000001246.].

BACKGROUND:Within component therapy of massive transfusion protocol (MTP) in trauma, thawed plasma is particularly susceptible to expiring without use given its short 5-day shelf life. Optimizing the number of thawed products without compromising safety is important for hospital resource management. The goal is to examine thawed plasma utilization rates in trauma MTP events and optimize the MTP cooler content at our Level I trauma center. METHODS:Trauma MTP activations from 01/2019 to 12/2022 were retrospectively reviewed. During the study period, blood products were distributed in a 12:12:1 ratio of packed red blood cells (pRBC): plasma: platelets per cooler, with up to 4 additional units of low-titer, group O whole blood (LTOWB) available. The primary measure was percent return of unused, thawed plasma. RESULTS:There were 367 trauma MTP activations with a median (IQR) activation call-to-first cooler delivery time of 8 (6-10) minutes. 73.0% of thawed plasma was returned to the blood bank unused. In one third of MTP activations, all dispensed plasma was returned. The majority (74.1%) of patients required 6 or fewer units of plasma. In 81.5% of activations, 10 or fewer units of plasma and 10 or fewer units of pRBC were used. DISCUSSION:The majority of trauma MTP requirements may be accommodated with a reduced cooler content of 6 units pRBC, 6 units plasma, and 1 pheresis platelets, buffered by up to 4 units LTOWB (approximates 4 units of pRBC/4 units plasma), in conjunction with a sub-10min cooler delivery time. Follow-up longitudinal studies are needed.

Background: Posttransplant cyclophosphamide (PTCy) graft-versus-host disease (GVHD) prophylaxis was developed to enable the use of haploidentical donors for patients undergoing allogeneic stem cell transplantation (alloHSCT), then used for matched-donor transplants. In 2016, we transitioned from utilizing calcineurin inhibitor/methotrexate-based GVHD prophylaxis to PTCy, for all patients undergoing alloHSCT (using haploidentical, matched-related, and matched-unrelated donors). Objective: Statistically evaluate the change in alloHSCT outcomes that occurred after adoption of universal PTCy, to assess the effect of the GVHD prophylaxis strategy, as well as other programmatic changes (graft source, conditioning regimens, donor selection). Study Design: This is a single-center retrospective cohort study of adult patients who underwent alloHSCT at Cedars Sinai Medical Center between January 2010 and September 2021. We compared outcomes in the pre-PTCy era (2010 - 2016) to outcomes in the era of PTCy (2016 - 2021). 432 patients were included; 180 received PTCy-based GVHD prophylaxis, and 252 patients received non-PTCy GVHD prophylaxis. Kaplan-Meier estimates and Cox regression models were built to compare outcomes based on the type of GVHD prophylaxis received (Tac/MTX pre-2016 versus PTCy-tacrolimus-mycophenolate post-2016). Results: Hospital stay was 29 ± 15.9 days (Median ± Std) in the pre-PTCy era, and 26 ±9.9 days in the PTCy era (p < 0.001). Post-transplant hospital stay was 23 ± 13 in the pre-PTC and 19 ± 8.5 days with PTCy (p < 0.001). The number of patients requiring opioids after transplant was greater in the pre-PTCy era compared to the post-PTCy era (94.12 % vs 81.01%, p <0.0001). Overall Survival increased in the PTCy era compared to the pre-PTCy era (at 1 year, 87% versus 62%; p <0.0001), and the difference in OS persisted at 2 years and 3 years. Relapse-free survival was higher in the PTCy era (HR: 0.55, 95% CI (0.42-0.71); p<0.0001). There was no difference in the cumulative incidence of relapse at 1 year between the two groups (17% PTCy versus 26% pre-PTCy, p=0.0661). Non-Relapse Mortality at 1 year was lower in the PTCy group (10% PTCy versus 22% non-PTCy; p=0.0020). Acute GVHD was lower in the PTCy group: grade II-IV at day 100 was 20% in PTCy, versus 33% in the non-PTCy group (p=0.0016); grade III-IV at day 100 was 5% versus 15% (p=0.0008). The 1-year cumulative incidence of cGVHD with peripheral-blood stem cell transplants was similar between the two groups, 39% in the PTCy era and 42% in the PTCy group (p=0.3321), but there was a difference in the rate of extensive cGVHD favoring use of PTCy (23% with PTCy versus 33% without, which approached significance; p = 0.053). Patients in the PTCy era achieved higher one-year GVHD and relapse-free survival (GRFS) compared to patients in the pre-PTCy era (37%: PTCy versus 19%: non-PTCy, p <0.0001). In the multivariate Cox regression model, PTCy was associated with better OS [HR: 0.40, 95% CI (0.46-0.96); p=0.0001], better RFS [HR: 0.66, 95% CI (0.46-0.96); p=0.0300], and lower NRM [HR: 0.33, 95% CI (0.16-0.69); p=0.0034]. No difference in Relapse between the two groups was shown [HR:1.12, 95% CI (0.73-1.72); p=0.6053]. Conclusion: Patients who underwent alloHSCT utilizing PTCy displayed significantly improved overall survival at 1 year compared to patients treated with predominantly methotrexate and calcineurin inhibitors, significantly improved relapse-free survival (RFS), lower rate of NRM, lower rates of acute GVHD, with no difference in rates of cGVHD. Hospital stay was 6 days shorter and fewer patients required opiates (less mucositis with PTCy). These data support the utilization of PTCy for GVHD prophylaxis for all HLA donor match grades and graft sources.

Introduction: Moderate iron deficiency anemia(IDA), defined as a hemoglobin below 11 g/dl, occurs in 1.5% of the United States population and is overrepresented in minority populations. IDA is known to cause permanent structural and function damage in children, but IDA's cognitive and neurovascular phenotype in adults is poorly characterized. We performed brain MRI and cognitive testing in 34 otherwise healthy women with IDA to determine whether oxygen delivery and metabolism are preserved as well as the association of IDA with brain volumes and cognitive function. Methods: We recruited potential blood donors from four hospital-based donor centers, Children's Hospital Los Angeles, University of California Los Angeles, Cedar's Sinai, and City of Hope, whose point-of-care hemoglobin values were less than 10.5 g/dl. We also recruited individuals from the community using social media advertisements, with anemia documented by screening hemoglobin assessment. All participants were free from inflammatory, infectious, or malignant diseases that may impact blood counts and iron metabolism. IDA was confirmed by laboratory assessment of CBC, reticulocyte count, iron indices, methyl malonic acid, hemoglobin electrophoresis, homocysteine, and high-sensitivity C-reactive protein. Patients underwent a four-hour neurocognitive assessment consisting of subsets from the Weschler Abbreviated Scale of Intelligence (WASI-II), the California Verbal Learning Test (CVLT), the Rey Complex Figure Test (RCFT), and the NIH Cognitive Toolkit. MRI was performed on a 3T Philips Achieva using a 32-element head coil. Anatomic imaging consisted of 3D T1, 3D T2, 3D T2*/QSM, and 2D multishell diffusion imaging. Phase contrast and arterial spin labeling measured total and regional brain blood flow, respectively. Cerebral venous oximetry was performed using T2 relaxation under spin tagging. Results: The study population demonstrated a classic IDA phenotype characterized by low ferritin and transferrin saturation, high iron binding capacity, decreased MCV and MCHC, and hypochromic microcytosis on blood smear (not shown). Neurocognitive function was impaired across multiple domains for women having hemoglobin values less than 10.0 g/dl (Figure 1, left), with Cohen's D values ranging from 0.7 - 1.5. Cerebral blood flow (CBF) rose slightly as oxygen content declined (Figure 1, right), but much less than predicted based on historical controls 1,2 leading to impaired brain oxygen delivery. Oxygen extraction fraction was independent of hemoglobin concentration, thus cerebral metabolic rate was also decreased. Grey matter volume was smaller in the right temporal lobe and correlated with 2/3 of the abnormal cognitive indices (in Figure 1, left). White matter volume was decreased in the right cingulate gyrus, corpus callosum, and cerebellum, correlating with the remaining abnormal cognitive indices. Discussion: Our study demonstrates that iron deficiency has serious effects on cognitive performance; individuals with hemoglobin less than 10.0 g/dl scored more than one standard deviation below their peers with milder anemia. Poor cognitive performance was correlated with demonstrable brain shrinkage whose reversibility is unknown. The failure of the brain to upregulate CBF in response to IDA was striking because most patients with chronic anemia preserve cerebral oxygen delivery through compensatory hyperemia 1,2. While both anemia and iron deficiency can impair brain function on their own, it is likely that iron deficiency is the primary contributor to the cognitive and neurovascular effects. We will test this hypothesis in subsequent work by reexamining women with IDA shortly after intravenous iron administration, thus creating a window where the iron deficiency has been corrected but the anemia persists(NCT05929729). We will also determine whether the cerebrovascular, anatomic, and functional deficits are reversible with iron repletion. References 1. Brown MM, Marshall J. Regulation of cerebral blood flow in response to changes in blood viscosity. Lancet. 1985;1(8429):604-609. 2. Bush AM, Borzage MT, Choi S, et al. Determinants of resting cerebral blood flow in sickle cell disease. Am J Hematol. 2016;91(9):912-917.

BACKGROUND:Bacterial contamination of hematopoietic stem cell (HSC) products is most commonly due to normal skin flora. Salmonella in HSC products is rare, and to our knowledge safe administration of an autologous HSC product containing Salmonella has not been reported.STUDY DESIGN AND METHODS:We describe two patients undergoing autologous HSC transplant: peripheral blood HSC collection was performed by leukapheresis, and samples were cultured according to standard institutional protocol. Subsequent microorganism identification was performed using MALDI-TOF (Bruker Biotyper). Strain-relatedness was investigated by infrared spectroscopy using the IR Biotyper (Bruker).RESULTS:The patients were asymptomatic throughout the collection process; however, HSC products collected on two consecutive days from each patient were positive for Salmonella. Isolates from both cultures were further characterized as Salmonella enterica serovar Dublin by the local public health department. Antibiotic susceptibility testing revealed different sensitivity patterns for the two strains. IR Biotyper demonstrated significant discriminatory power among the clinically significant Salmonella enterica subspecies, serogroups B, C1, and D. The patient strains were similar as both belonged to Group D Salmonella enterica serovar Dublin but were not identical. The Salmonella positive autologous HSC products were infused to both patients following administration of empiric antibiotic therapy. Both patients successfully engrafted and did well.CONCLUSION:Salmonella is rarely seen in cellular therapy products and positivity may be the result of asymptomatic bacteremia at the time of collection. We present two instances of autologous HSC products containing Salmonella that were infused, along with prophylactic antimicrobial therapy without significant adverse clinical effects.

There are subtypes within blood type A, termed non-A1, that have reduced expression of A antigen on cell surfaces. This can result in the development of anti-A1 antibodies. There is limited information regarding the impact of this in heart transplant (HTx) recipients. We conducted a single-center cohort study of 142 Type A HTx recipients in which we compared outcomes of a match group (an A1/O heart into an A1 recipient or a non-A1/O heart into a non-A1 recipient) with a mismatch group (an A1 heart into a non-A1 recipient or a non-A1 heart into an A1 recipient). At one year post-transplant, there were no differences between the groups in survival, freedom from non-fatal major adverse cardiovascular events, freedom from any treated rejection, or freedom from cardiac allograft vasculopathy. There was an increased hospital length of stay in the mismatch group (13.5 vs. 17.1 days, p = 0.04). Our study showed that A1 mismatch was not associated with worse outcomes at one year post-HTx.

There is a small but growing number of thrombotic thrombocytopenic purpura (TTP) cases attributed to immune checkpoint inhibitor therapy, with nivolumab and ipilimumab therapy being the most frequently described in the literature.

Objectives The goal of this study was to explore the incidence of overtransfusion in trauma patients requiring massive transfusion protocol (MTP) activation and identify modifiable risk factors. We hypothesized that overtransfusion is common after MTP activation. Methods Patients admitted to a level I trauma center from July 2016 to December 2019 and who required MTP activation were selected. The primary outcome was overtransfusion, defined as a hemoglobin (Hg) ≥11 g/dL at 24 hours (±2 hours). A Cox regression model was used to identify independent risk factors for overtransfusion. Results 140 patients met inclusion criteria. The median age was 39.0 years, with the majority (74.3%) being male. The median (IQR) Injury Severity Score (ISS) was 24.0 (58.0) and 38.4% had a penetrating mechanism. The median (IQR) admission Hg was 12.6 (11.7) g/dL. Overall, 71.4% of patients were overtransfused by the conclusion of MTP, 43.6% 24 hours later, and 29.5% at discharge. Overtransfusion did not correlate with the number of units of blood transfused nor with the duration of MTP. Overtransfused patients at 24 hours after the conclusion of MTP were significantly more likely to present with a penetrating injury (52.5% vs. 27.3%, p=0.003) and have a significantly lower ISS (median (IQR) 18.5 (44.0) vs. 26.0 (58.0), p=0.035.) In a Cox regression model, penetrating mechanism (adjusted HR (AHR): 2.93; adjusted p=0.004) and admission base excess (BE) (AHR: 1.15; adjusted p=0.001) were the only variables independently associated with overtransfusion. Conclusions Overtransfusion of trauma patients requiring MTP activation is highly common, leading to overutilization of a limited resource. Penetrating trauma and BE may be modifiable risk factors that can help limit overtransfusion. Overtransfusion should be tracked as a data point by blood banks and trauma centers and be further studied as a potential quality metric for the resuscitation of massively transfused trauma patients. Level of evidence III.

Introduction: Cold-stored low titer group O whole blood (LTOWB) is increasingly utilized in the initial resuscitation of exsanguinating trauma patients. We report on our early experience with LTOWB, focusing on logistics, implementation challenges, and outcomes. Methods: In February, 2019, LTOWB was incorporated into the massive transfusion protocol (MTP) activated for trauma patients in the emergency department (ED.) Up to 4 units of LTOWB were included in the MTP cooler, depending on availability, and were transfused prior to transfusion of any other blood products from the MTP cooler. Demographics, injury characteristics, and outcomes were obtained, and the logistics of LTOWB availability were reviewed. Results: Over a 12-month period, MTP was activated for 74 trauma patients. Of those, 38 (51%) MTP included at least one unit of LTOWB, with 19/38 (50%) including 4 LTOWB units. A total of 177 units of LTOWB were purchased during the study period, and of those, 74 (42%) expired before use. Patients who received LTOWB had a similar mortality compared to those who received component therapy (39% vs. 47%; Odds Ratio [95% CI]: 0.7 [0.3, 2.0]; p = 0.72,) however, they were able to achieve a significantly higher plasma:pRBC ratio during the duration of MTP activation (mean [SD] 0.8 [0.2] vs. 0.4 [0.4]; mean difference [95% CI]: 0.4 [0.2, 0.5]; p < 0.01.) Conclusions: Our early experience with LTOWB transfusion demonstrates feasibility, but also highlights challenges with inventory management. These findings triggered changes to our protocol aiming at minimizing wastage. The use of LTOWB may yield a higher plasma:pRBC ratio early during the resuscitation period. Further investigation is required to explore whether this may yield a survival advantage. (C) 2022 Elsevier Ltd. All rights reserved.

To the Editor:A renewed interest in convalescent plasma (CP) was triggered by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Based on the historical use of CP during prior viral outbreaks, a small number of case series and observational studies were conducted early in the pandemic to evaluate the therapeutic role of CP in coronavirus disease 2019 (COVID-19) [[1]Wooding D.J. Bach H. Treatment of COVID-19 with convalescent plasma: lessons from past coronavirus outbreaks.Clin Microbiol Infect. 2020; 26: 1436-1446Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar]. Though the results were mixed, in April 2020, the Mayo Clinic received permission from the US Food and Drug Administration (FDA) to start an Expanded Access Program (EAP) for the use of CP as treatment for COVID-19. The EAP increased access to CP and facilitated investigation of its safety and efficacy [[2]Joyner M.J. Carter R.E. Senefeld J.W. Klassen S.A. Mills J.R. Johnson P.W. et al.Convalescent Plasma Antibody Levels and the Risk of Death from Covid-19.The New England J Med. 2021; 384: 1015-1027Crossref PubMed Scopus (253) Google Scholar]. In August of 2020, the FDA granted an emergency use authorization (EUA) for CP [[3]Hinton DM. Emergency Use Authroization of Convalescent Plasma for COVID-19, Letter of Authorization, 2020. 〈http://www.wellspanlabs.org/media/15813/FDA_-EUA_Convalescent-PlasmaLOA_FINAL_web_82320.pdf〉.Google Scholar]. When the EUA was granted, the efficacy of CP in COVID-19 was still unknown, and important questions about timing of treatment, patient selection, dosing, and antibody testing remained unanswered. There is now a better understanding of the serological response to SARS-CoV-2, “high-titer” thresholds for different anti-SARS-CoV-2 antibody assays have been defined [[3]Hinton DM. Emergency Use Authroization of Convalescent Plasma for COVID-19, Letter of Authorization, 2020. 〈http://www.wellspanlabs.org/media/15813/FDA_-EUA_Convalescent-PlasmaLOA_FINAL_web_82320.pdf〉.Google Scholar], and a large cohort study suggests that “high-titer” CP may be effective in reducing progression of COVID-19 in some hospitalized patients [[2]Joyner M.J. Carter R.E. Senefeld J.W. Klassen S.A. Mills J.R. Johnson P.W. et al.Convalescent Plasma Antibody Levels and the Risk of Death from Covid-19.The New England J Med. 2021; 384: 1015-1027Crossref PubMed Scopus (253) Google Scholar].Early in the pandemic, we were interested in strategies that would increase a patient’s chances of receiving the quantity (i.e.; titer) and type (i.e.; neutralizing) of antibodies needed to suppress SARS-CoV-2 viral injury. We anticipated this could be done safely via serial transfusions of CP given the low risk of plasma transfusion [[4]Bloch E.M. Shoham S. Casadevall A. Sachais B.S. Shaz B. Winters J.L. et al.Deployment of convalescent plasma for the prevention and treatment of COVID-19.J Clin Investig. 2020; 130: 2757-2765Crossref PubMed Scopus (470) Google Scholar]. Based on this premise, we conducted a pilot study to evaluate the feasibility of repeated dosing of anti-SARS-CoV-2 CP in critically ill mechanically ventilated patients. Key parameters included access to CP and provider willingness to transfuse multiple units of CP to profoundly hypoxemic, mechanically ventilated patients. Additional areas of interest included the antibody content of the transfused CP and measures of safety.In this single-arm, open-label, pilot study conducted at two academic medical centers (NCT04353206), 10 hypoxemic (PaO2/FiO2 < 300) mechanically ventilated adults (age > 18 years) with acute respiratory failure due to COVID-19 were enrolled within 72 h of intubation. Patients were transfused with up to six units of CP (2 units of CP on day 0, 3, and 6), or until significant clinical improvement (PaO2/FiO2 > 300), extubation, futility (i.e., as determined by the treating physician), or death (whichever occurred first). Plasma transfused to enrolled patients at Cedars Sinai was sourced from donors via the Blood Donor Service of the Cedars Sinai Transfusion Medicine Program. These units were then screened using a lateral flow assay to detect the presence or absence anti-SARS-CoV-2 antibodies (Haelgen COVID-19 IgG/IgM Rapid Test). By contrast, at Johns Hopkins, CP was sourced via an expanded access resource to which individuals donate after recovery from COVID-19, but no assessments for antibody presence were made before use. Vital signs, laboratory studies, and assessment of clinical status (including ventilatory requirements) were performed on days 0, 3, and 6 of plasma administration. Additional follow-up was performed on days 14, 28, and 60, which included assessments of respiratory and overall clinical status. Antibody levels of the transfused units of CP were measured retrospectively at both sites using commercially available enzyme-linked immunosorbent assays (ELISAs).The baseline demographics and clinical outcomes of the 10 patients are reported in Table 1. The median age was 59 years; 7 patients were male, and 8 met criteria for obesity (BMI > 30). The median time between date of onset of respiratory symptoms and mechanical ventilation and first CP infusion was 11 and 12.5 days, respectively. All patients received concomitant SARS-COVID-2 therapy with remdesivir and dexamethasone. Six patients were extubated by day 60. Among the eight patients who were discharged alive, the median time on mechanical ventilation was 22.5 days. The median length of stay for these survivors was 35 days. Two patients died before discharge. Neither death was attributed to the use of CP. In fact, none of the 10 patients in the pilot had any adverse events attributable to CP.Table 1Baseline demographics and clinical outcomes of enrolled patients with COVID-19 who received multiple doses of CP.Patient Number12345678910Age (years)51656949403374537072Sex (M/F)FMMMMMMMFFRace/EthnicityHispanicAfrican-AmericanCaucasianHispanicHispanicCaucasianCaucasianHispanicAfrican-AmericanAfrican-AmericanBMI38333336283028384046ComorbidityObesity, HLD, pre-diabetesCAD, DM, CKD, HLD, HTN, ObesityCAD, HTN, ObesityObesityNoneHIV/AIDS, ObesityHLD, HTN, OSADM, HLD, HTNDM, GERD, HTN, Obesity, OSAAsthma, CKD, ObesityTime to MV1151216113211159Time to CP2161318135241269Other TherapyDex, RemdesivirDex, RemdesivirAzithro, Dex, RemdesivirDex, RemdesivirDex, RemdesivirDex, RemdesivirAzithro, Dex, Remdesivir, Vit CDex, RemdesivirDex, RemdesivirDex, RemdesivirExtubatedNYYNYYNYNYMV Days7321821274643675Adverse Events0000000000Discharged AliveNYYNYYYYYYHospital Days8443523711364 *108022Azithro = Azithromycin, BMI = body mass index, CAD = coronary artery disease, CKD = chronic kidney disease, CP = convalescent plasma, Dex = Dexamethasone, DM = diabetes mellites, GERD = gastroesophageal reflux disease, HLD = hyperlipidemia, HTN = hypertension, MV = mechanical ventilation, OSA = obstructive sleep apnea, Vit C = Vitamin. *Discharged alive to vent rehabilitation unit Open table in a new tab Table 2 shows severity of disease based on APACHE II and SOFA Scores [5Knaus W.A. Draper E.A. Wagner D.P. Zimmerman J.E. APACHE II: a severity of disease classification system.Crit Care Med. 1985; 13: 818-829Crossref PubMed Scopus (13147) Google Scholar, 6Vincent J.L. Moreno R. Takala J. Willatts S. De Mendonca A. Bruining H. Reinhart C.K. Suter P.M. Thijs L.G. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine.Intensive Care Med. 1996; 22: 707-710Crossref PubMed Scopus (6932) Google Scholar]. The median APACHE II score was 22 on day 0, which correlates to an approximated 40% likelihood of in-hospital death [[5]Knaus W.A. Draper E.A. Wagner D.P. Zimmerman J.E. APACHE II: a severity of disease classification system.Crit Care Med. 1985; 13: 818-829Crossref PubMed Scopus (13147) Google Scholar]. The median SOFA score on day 0 was 9, and for those who remained alive and in hospital at day 28 (n = 5), the median SOFA score was 8.Table 2Severity of disease based on APACHE II and Modified SOFA.Patient number12345678910APACHE IIDay 019413424162428201818mSOFADay 0813117107108710Day 391210811311368Day 6N/A1798838274Day 14N/A12794212DC62Day 28N/A81N/A6DC9DC9DCNote: Patient 4 expired by Day 28. Patient 6 did not follow-up on Day 28.DC: patient discharged alive and SOFA not calculated. Open table in a new tab Table 3 displays the antibody content of each plasma unit administered to the 10 patients enrolled at the two sites. Antibodies were measured using the Abbott Architect or the Euroimmun anti-SARS-CoV-2 IgG assays at site 1 (patients 1 – 6; Cedars Sinai) and site 2 (patients 7−10; Johns Hopkins), respectively [7Klein S.L. Pekosz A. Park H.S. Ursin R.L. Shapiro J.R. Benner S.E. et al.Sex, age, and hospitalization drive antibody responses in a COVID-19 convalescent plasma donor population.J Clin Investig. 2020; 130: 6141-6150Crossref PubMed Scopus (226) Google Scholar, 8Patel E.U. Bloch E.M. Clarke W. Hsieh Y.H. Boon D. Eby Y. Fernandez R.E. Baker O.R. Keruly M. Kirby C.S. Klock E. Littlefield K. Miller J. Schmidt H.A. Sullivan P. Piwowar-Manning E. Shrestha R. Redd A.D. Rothman R.E. Sullivan D. Shoham S. Casadevall A. Quinn T.C. Pekosz A. Tobian A.A.R. Laeyendecker O. Comparative Performance of Five Commercially Available Serologic Assays To Detect Antibodies to SARS-CoV-2 and Identify Individuals with High Neutralizing Titers.J Clin Microbiol. 2021; : 59Google Scholar]. Antibodies were measured in the plasma of all but one donor; one patient did not receive CP on day 3, and four patients did not did not receive CP on day 6. Based on the EUA-defined thresholds for high-titer using the Abbott Architect assay (specimen/calibrator [S/C] > 4.5) or Euroimmun assay (Arbitrary Unit [AC] > 3.5), all patients at Cedars Sinai and one patient at Johns Hopkins received at least 1 unit of high-titer CP. Overall, 20 of the 50 (40%) CP units administered met criteria for high-titer. Notably, review of transfusion records demonstrated that some patients received more than one unit of CP from the same donor (e.g. units 1–2 in patient 2, units 1, 3, and 5 in patient 7). This had the potential to provide serial doses of high-titer CP to some patients (patient 2), while in others it resulted in serial transfusions of non-high-titer CP (patient 7). Moreover, 53% of units administered at Cedars Sinai met criteria for high-titer CP compared to only 11% of units at Johns Hopkins. Indeed, it appears that the practice at Cedars Sinai of using a lateral flow assay to identify units as having some detectable anti-SARS-CoV-2 antibodies was of value in identifying units with a higher likelihood of being high-titer. Notably, lateral flow assays are easy to use, portable, provide a rapid result, and do not require the laboratory infrastructure and technical expertise necessary to conduct ELISA assays [[9]Conklin S.E. Martin K. Manabe Y.C. Schmidt H.A. Miller J. Keruly M. et al.Evaluation of serological SARS-CoV-2 lateral flow assays for rapid point-of-care testing.J Clin Microbiol. 2021; : 59Google Scholar].Table 3Abbott and Euroimmun anti-SARS-CoV-2 IgG Serum/Calibrator per unit of plasma administered.IgG S/CPatient 1Patient 2Patient 3Patient 4Patient 5Patient 6Patient 7Patient 8Patient 9Patient 10AssayAbbottAbbottAbbottAbbottAbbottAbbottEuroimmunEuroimmunEuroimmunEuroimmunDay 0Unit 14.637.385.263.077.184.330.20.190.841.03Unit 22.467.38Not tested9.176.267.50.321.61.063.59Day 3Unit 10.615.267.744.27.031.660.2N/A0.843.17Unit 22.637.950.572.8121.660.32N/A1.068.37Day 6Unit 1N/A7.746.886.887.46N/A0.2N/A0.38N/AUnit 2N/A0.576.883.118.03N/A0.32N/A0.38N/ASum of Titer10.3336.28> 27.3329.2437.7615.551.561.794.5616.16S/C = specimen/calibratorNote: EUA-defined high-titer CP is an index (S/C) > 4.5 for the Abbott assay & > 3.5 for EuroimmunN/A = Not applicable because not transfused on this day Open table in a new tab Our study also suggests that administering multiple units of CP is feasible. Among patients receiving units pre-screened with a lateral flow assay, the cumulative antibody delivered overall was much greater than had a single unit been transfused. CP was readily accessible and clinical providers were supportive of a multi-dosing strategy, whereby concerns related to volume overload and the potential for transfusion associated lung injury did not impact enrollment. Further, no adverse events were attributed to CP infusion.There are limitations of this study. First, while we did not observe any transfusion associated adverse events, the small sample size and non-randomized design limit this observation. Second, we did not measure pre- and post-infusion anti-SARS-CoV-2 endogenous antibody titers, so whether the infusion of the convalescent plasma changed antibody levels in the recipients is unknown.In conclusion, a strategy that employs a qualitative assay and transfusion of multiple units can be used to increase the amount of antigen specific antibody transfused overall. This strategy may be especially valuable in resource-limited settings where ELISA assays and monoclonal antibodies are scarce. We encourage continued enrollment into clinical trials to better understand CP as treatment, both for COVID-19 as well as to inform the response to emerging infectious diseases. To the Editor: A renewed interest in convalescent plasma (CP) was triggered by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Based on the historical use of CP during prior viral outbreaks, a small number of case series and observational studies were conducted early in the pandemic to evaluate the therapeutic role of CP in coronavirus disease 2019 (COVID-19) [[1]Wooding D.J. Bach H. Treatment of COVID-19 with convalescent plasma: lessons from past coronavirus outbreaks.Clin Microbiol Infect. 2020; 26: 1436-1446Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar]. Though the results were mixed, in April 2020, the Mayo Clinic received permission from the US Food and Drug Administration (FDA) to start an Expanded Access Program (EAP) for the use of CP as treatment for COVID-19. The EAP increased access to CP and facilitated investigation of its safety and efficacy [[2]Joyner M.J. Carter R.E. Senefeld J.W. Klassen S.A. Mills J.R. Johnson P.W. et al.Convalescent Plasma Antibody Levels and the Risk of Death from Covid-19.The New England J Med. 2021; 384: 1015-1027Crossref PubMed Scopus (253) Google Scholar]. In August of 2020, the FDA granted an emergency use authorization (EUA) for CP [[3]Hinton DM. Emergency Use Authroization of Convalescent Plasma for COVID-19, Letter of Authorization, 2020. 〈http://www.wellspanlabs.org/media/15813/FDA_-EUA_Convalescent-PlasmaLOA_FINAL_web_82320.pdf〉.Google Scholar]. When the EUA was granted, the efficacy of CP in COVID-19 was still unknown, and important questions about timing of treatment, patient selection, dosing, and antibody testing remained unanswered. There is now a better understanding of the serological response to SARS-CoV-2, “high-titer” thresholds for different anti-SARS-CoV-2 antibody assays have been defined [[3]Hinton DM. Emergency Use Authroization of Convalescent Plasma for COVID-19, Letter of Authorization, 2020. 〈http://www.wellspanlabs.org/media/15813/FDA_-EUA_Convalescent-PlasmaLOA_FINAL_web_82320.pdf〉.Google Scholar], and a large cohort study suggests that “high-titer” CP may be effective in reducing progression of COVID-19 in some hospitalized patients [[2]Joyner M.J. Carter R.E. Senefeld J.W. Klassen S.A. Mills J.R. Johnson P.W. et al.Convalescent Plasma Antibody Levels and the Risk of Death from Covid-19.The New England J Med. 2021; 384: 1015-1027Crossref PubMed Scopus (253) Google Scholar]. Early in the pandemic, we were interested in strategies that would increase a patient’s chances of receiving the quantity (i.e.; titer) and type (i.e.; neutralizing) of antibodies needed to suppress SARS-CoV-2 viral injury. We anticipated this could be done safely via serial transfusions of CP given the low risk of plasma transfusion [[4]Bloch E.M. Shoham S. Casadevall A. Sachais B.S. Shaz B. Winters J.L. et al.Deployment of convalescent plasma for the prevention and treatment of COVID-19.J Clin Investig. 2020; 130: 2757-2765Crossref PubMed Scopus (470) Google Scholar]. Based on this premise, we conducted a pilot study to evaluate the feasibility of repeated dosing of anti-SARS-CoV-2 CP in critically ill mechanically ventilated patients. Key parameters included access to CP and provider willingness to transfuse multiple units of CP to profoundly hypoxemic, mechanically ventilated patients. Additional areas of interest included the antibody content of the transfused CP and measures of safety. In this single-arm, open-label, pilot study conducted at two academic medical centers (NCT04353206), 10 hypoxemic (PaO2/FiO2 < 300) mechanically ventilated adults (age > 18 years) with acute respiratory failure due to COVID-19 were enrolled within 72 h of intubation. Patients were transfused with up to six units of CP (2 units of CP on day 0, 3, and 6), or until significant clinical improvement (PaO2/FiO2 > 300), extubation, futility (i.e., as determined by the treating physician), or death (whichever occurred first). Plasma transfused to enrolled patients at Cedars Sinai was sourced from donors via the Blood Donor Service of the Cedars Sinai Transfusion Medicine Program. These units were then screened using a lateral flow assay to detect the presence or absence anti-SARS-CoV-2 antibodies (Haelgen COVID-19 IgG/IgM Rapid Test). By contrast, at Johns Hopkins, CP was sourced via an expanded access resource to which individuals donate after recovery from COVID-19, but no assessments for antibody presence were made before use. Vital signs, laboratory studies, and assessment of clinical status (including ventilatory requirements) were performed on days 0, 3, and 6 of plasma administration. Additional follow-up was performed on days 14, 28, and 60, which included assessments of respiratory and overall clinical status. Antibody levels of the transfused units of CP were measured retrospectively at both sites using commercially available enzyme-linked immunosorbent assays (ELISAs). The baseline demographics and clinical outcomes of the 10 patients are reported in Table 1. The median age was 59 years; 7 patients were male, and 8 met criteria for obesity (BMI > 30). The median time between date of onset of respiratory symptoms and mechanical ventilation and first CP infusion was 11 and 12.5 days, respectively. All patients received concomitant SARS-COVID-2 therapy with remdesivir and dexamethasone. Six patients were extubated by day 60. Among the eight patients who were discharged alive, the median time on mechanical ventilation was 22.5 days. The median length of stay for these survivors was 35 days. Two patients died before discharge. Neither death was attributed to the use of CP. In fact, none of the 10 patients in the pilot had any adverse events attributable to CP. Azithro = Azithromycin, BMI = body mass index, CAD = coronary artery disease, CKD = chronic kidney disease, CP = convalescent plasma, Dex = Dexamethasone, DM = diabetes mellites, GERD = gastroesophageal reflux disease, HLD = hyperlipidemia, HTN = hypertension, MV = mechanical ventilation, OSA = obstructive sleep apnea, Vit C = Vitamin. *Discharged alive to vent rehabilitation unit Table 2 shows severity of disease based on APACHE II and SOFA Scores [5Knaus W.A. Draper E.A. Wagner D.P. Zimmerman J.E. APACHE II: a severity of disease classification system.Crit Care Med. 1985; 13: 818-829Crossref PubMed Scopus (13147) Google Scholar, 6Vincent J.L. Moreno R. Takala J. Willatts S. De Mendonca A. Bruining H. Reinhart C.K. Suter P.M. Thijs L.G. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine.Intensive Care Med. 1996; 22: 707-710Crossref PubMed Scopus (6932) Google Scholar]. The median APACHE II score was 22 on day 0, which correlates to an approximated 40% likelihood of in-hospital death [[5]Knaus W.A. Draper E.A. Wagner D.P. Zimmerman J.E. APACHE II: a severity of disease classification system.Crit Care Med. 1985; 13: 818-829Crossref PubMed Scopus (13147) Google Scholar]. The median SOFA score on day 0 was 9, and for those who remained alive and in hospital at day 28 (n = 5), the median SOFA score was 8. Note: Patient 4 expired by Day 28. Patient 6 did not follow-up on Day 28. DC: patient discharged alive and SOFA not calculated. Table 3 displays the antibody content of each plasma unit administered to the 10 patients enrolled at the two sites. Antibodies were measured using the Abbott Architect or the Euroimmun anti-SARS-CoV-2 IgG assays at site 1 (patients 1 – 6; Cedars Sinai) and site 2 (patients 7−10; Johns Hopkins), respectively [7Klein S.L. Pekosz A. Park H.S. Ursin R.L. Shapiro J.R. Benner S.E. et al.Sex, age, and hospitalization drive antibody responses in a COVID-19 convalescent plasma donor population.J Clin Investig. 2020; 130: 6141-6150Crossref PubMed Scopus (226) Google Scholar, 8Patel E.U. Bloch E.M. Clarke W. Hsieh Y.H. Boon D. Eby Y. Fernandez R.E. Baker O.R. Keruly M. Kirby C.S. Klock E. Littlefield K. Miller J. Schmidt H.A. Sullivan P. Piwowar-Manning E. Shrestha R. Redd A.D. Rothman R.E. Sullivan D. Shoham S. Casadevall A. Quinn T.C. Pekosz A. Tobian A.A.R. Laeyendecker O. Comparative Performance of Five Commercially Available Serologic Assays To Detect Antibodies to SARS-CoV-2 and Identify Individuals with High Neutralizing Titers.J Clin Microbiol. 2021; : 59Google Scholar]. Antibodies were measured in the plasma of all but one donor; one patient did not receive CP on day 3, and four patients did not did not receive CP on day 6. Based on the EUA-defined thresholds for high-titer using the Abbott Architect assay (specimen/calibrator [S/C] > 4.5) or Euroimmun assay (Arbitrary Unit [AC] > 3.5), all patients at Cedars Sinai and one patient at Johns Hopkins received at least 1 unit of high-titer CP. Overall, 20 of the 50 (40%) CP units administered met criteria for high-titer. Notably, review of transfusion records demonstrated that some patients received more than one unit of CP from the same donor (e.g. units 1–2 in patient 2, units 1, 3, and 5 in patient 7). This had the potential to provide serial doses of high-titer CP to some patients (patient 2), while in others it resulted in serial transfusions of non-high-titer CP (patient 7). Moreover, 53% of units administered at Cedars Sinai met criteria for high-titer CP compared to only 11% of units at Johns Hopkins. Indeed, it appears that the practice at Cedars Sinai of using a lateral flow assay to identify units as having some detectable anti-SARS-CoV-2 antibodies was of value in identifying units with a higher likelihood of being high-titer. Notably, lateral flow assays are easy to use, portable, provide a rapid result, and do not require the laboratory infrastructure and technical expertise necessary to conduct ELISA assays [[9]Conklin S.E. Martin K. Manabe Y.C. Schmidt H.A. Miller J. Keruly M. et al.Evaluation of serological SARS-CoV-2 lateral flow assays for rapid point-of-care testing.J Clin Microbiol. 2021; : 59Google Scholar]. S/C = specimen/calibrator Note: EUA-defined high-titer CP is an index (S/C) > 4.5 for the Abbott assay & > 3.5 for Euroimmun N/A = Not applicable because not transfused on this day Our study also suggests that administering multiple units of CP is feasible. Among patients receiving units pre-screened with a lateral flow assay, the cumulative antibody delivered overall was much greater than had a single unit been transfused. CP was readily accessible and clinical providers were supportive of a multi-dosing strategy, whereby concerns related to volume overload and the potential for transfusion associated lung injury did not impact enrollment. Further, no adverse events were attributed to CP infusion. There are limitations of this study. First, while we did not observe any transfusion associated adverse events, the small sample size and non-randomized design limit this observation. Second, we did not measure pre- and post-infusion anti-SARS-CoV-2 endogenous antibody titers, so whether the infusion of the convalescent plasma changed antibody levels in the recipients is unknown. In conclusion, a strategy that employs a qualitative assay and transfusion of multiple units can be used to increase the amount of antigen specific antibody transfused overall. This strategy may be especially valuable in resource-limited settings where ELISA assays and monoclonal antibodies are scarce. We encourage continued enrollment into clinical trials to better understand CP as treatment, both for COVID-19 as well as to inform the response to emerging infectious diseases. NM’s effort is supported in part by NCI ( 1U54CA260591–01 , sub-project ID 8248). EMB’s effort is supported in part by the NHLBI ( 1K23HL151826 ). The study also had support from Bloomberg Philanthropies and the State of Maryland .

Patients with sickle cell disease (SCD) have a high prevalence of RBC alloimmunization. However, underlying mechanisms are poorly understood. Given that proinflammatory type 1 interferons (IFNα/β) and interferon stimulated genes (ISGs) promote alloimmunization in mice, we hypothesized that IFNα/β may contribute to the increased frequency of alloimmunization in patients with SCD. To investigate this, expression of ISGs in blood leukocytes and peripheral blood mononuclear cells (PBMCs) of previously transfused SCD patients with or without alloimmunization and race-matched healthy controls were quantified, and IFNα/β gene scores were calculated. IFNα/β gene scores of SCD leukocytes and plasma cytokines were elevated, compared to controls (gene score, p < 0.01). Upon stimulation with IFNβ, isolated PBMCs from patients with SCD had elevated ISGs and IFNα/β gene scores (p < 0.05), compared to stimulated PBMCs from controls. However, IFNβ-stimulated and unstimulated ISG expression did not significantly differ between alloimmunized and non-alloimmunized patients. These findings indicate that patients with SCD express an IFNα/β gene signature, and larger studies are needed to fully determine its role in alloimmunization. Further, illustration of altered IFNα/β responses in SCD has potential implications for IFNα/β-mediated viral immunity, responses to IFNα/β-based therapies, and other sequelae of SCD.