Beitrage zur Infusionstherapie = Contributions to infusion therapy最新文献

Transfusion-associated graft-versus-host disease (TA-GVHD) resulting from the engraftment of competent lymphocytes contained in blood products has been well described in immunocompromised patients and more recently in immunocompetent patients. Prophylactic irradiation of blood products prior to transfusion is the most efficient way to prevent TA-GVHD. Standard blood bank measures to reduce mononuclear cell contamination in red blood cell units, such as freezing, washing and filtration, may reduce the number of viable lymphocytes to prevent immunizations. However, it is unknown whether the depletion of leukocytes with these techniques would decrease the risk of TA-GVHD. In this report we describe the first case of TA-GVHD following transfusion of filtrated red blood cells given to a patient receiving cytotoxic therapy for Hodgkin's disease.

In my opinion, the problem of a 'critical hematocrit' can be summarized in five contentions: First, it is inadmissible to label any single hemoglobin or hematocrit value as being generally acceptable, the reason being, second, that the adequate values differ between patients and sometimes also between various stages of their individual course--for instance during the intra- and the postoperative period. Third, a hemoglobin or hematocrit within the normal range constitutes a natural buffer against encroachments upon the oxygen supply from non-Hb causes. Intentional manipulation of this buffer requires a careful assessment of potential benefits vs. risks. Fourth, a patient in otherwise perfect condition tolerates a hemoglobin or hematocrit below 10 g/dl or 30%, respectively, down to approximately 8 g/dl or 25%- but tolerance is not necessarily equivalent to an optimum. And fifth, the patient most dependent on his 'hemoglobin buffer' is the individual who has to overcome troubles without the monitoring facilities of an intensive care unit, for instance in the peripheral hospital equipped only for primary care.

The preparation of platelet concentrates (PC) from pooled buffy coats has raised concern as to whether activation of lymphocytes might take place during the period of storage. Therefore it appears to be essential to investigate the degree of leukocyte contamination and identify the subtypes of these cells. Especially lymphocytes are of relevance as they may induce either a mixed lymphocyte reaction (MLR), the production of cytokines or a graft-versus-host reaction. As the number of leukocytes is very low we adopted the alkaline phosphatase-antialkaline phosphatase (APAAP) technique to determine the composition of leukocytes. We used mouse monoclonal antibodies to specifically stain T lymphocytes, B lymphocytes, monocytes, HLA-DR-positive cells and NK cells. All subtypes could easily be identified and their relative amounts were determined. In samples from 15 PCs the percentages of T lymphocytes, B lymphocytes, monocytes, NK cells and HLA-DR-positive cells was 40.3, 6.4, 18.9, 7.2 and 17.1% of total leukocytes, respectively. The standard deviation ranged between 2 and 5%. We highly recommend this technique, which is a very sensitive method to determine leukocyte contamination in PC.

The diagnosis and management of HDN relies on measurement of maternal anti-D, amniotic fluid analysis and fetal blood sampling by chordiocentesis. However, amniocentesis and chordiocentesis have substantial risks of fetomaternal hemorrhage and subsequent increase in maternal anti-D. In addition to quantitation the functional activity of maternal anti-D has been determined by measuring the interaction of red blood cells sensitized by maternal serum in monocyte-monolayer assays. We assessed the functional activity of anti-D by titration of the sensitized red blood cells using selected sera with rheumatoid factor (RF) as human anti-IgG. First experiments using monoclonal anti-D showed a good correlation between erythrophagocytosis and RF titers. The bilirubin-protein ratio in amniotic fluid may be of great value in predicting the severity of HDN, as shown in 94 cases with severe and 39 cases with moderate disease. Amniotic fluid analysis is complicated by the presence of hemoglobin; we developed a computer program to solve this problem. To improve the serological diagnosis of ABO incompatibility, we measured IgG-anti-A, B in 1,392 maternal and newborn sera applying a sensitive gel test with Coombs serum. Furthermore, we determined the hemolytic activity of anti-A, B by microscopic observation of the morphological changes of red blood cells.

Postpartum sera of 1,016 unselected women were examined for granulocyte-specific and HLA antibodies. A total of 11 out of 1,016 sera (1.1%) were only reactive with neutrophils. Cytotoxic HLA antibodies were detected in 24%, noncytotoxic HLA antibodies in 4.8% of the sera. All antibodies belonged to the IgG 1 and IgG 3 subclasses. NA1 and NB1 specificity were each determined in one serum, two sera contained NA2-specific antibodies. After 1 year all antibodies were no more detectable. As none of the newborns from immunized mothers developed neutropenia, the incidence of alloimmune neonatal neutropenia seems to be lower than 0.1%.

Diagnosis of HAT type II and treatment of thromboembolic complications in these patients are difficult. Recently we have developed the heparin-induced platelet activation (HIPA) assay which allows a rapid confirmation of the tentative diagnosis of HAT type II. In vitro studies with sera of 25 patients revealed cross-reactivity to the LMW heparins Fragmin, Fraxiparin and Clexane whereas a LMW heparinoid, Org 10172 (Orgaran), did not. In a prospective study this heparinoid was selected for 10 HAT patients, for whom further parenteral anticoagulation was required. In 7 of these patients who received LMW heparins prior to laboratory investigations low platelet counts persisted under treatment with LMW heparins and 2 patients developed additional thromboembolic complications. Upon treatment with Org 10172 platelet counts normalized in 9 patients, in 1 patient thrombocytopenia was unrelated to parenteral anticoagulation, in 1 patient platelet count normalized after discontinuation of Org 10172. We conclude that the HIPA assay allows the laboratory diagnosis of HAT type II and the selection of a compatible heparin or heparinoid for further parenteral anticoagulation.

Presampling determination for hemoglobin has been pursued for a long time, but now it is becoming possible to examine further parameters such as SGPT (ALT). The SGPT predonation testing is best performed with the Reflotron system (Fa. Boehringer Mannheim) since whole blood samples drawn into capillary tube can be used. Between 1985 and 1988 1.35-1.75% of an average of 22,000 whole blood donations were found to have SGPT levels above the accepted cutoff (> 30 IU/l, 25 degrees C). The cost per test using the UV kinetics and the overall expenses of unusable collections were compared with the cost of SGPT predonation testing. An average of DM 20,000.-per year has been saved. Therefore prescreening of SGPT in blood banking is a highly cost-effective approach.

DNA fragments coding for a variety of different viral antigens have been cloned and expressed in Escherichia coli. Selected purified recombinant antigens were used for detection of specific antibodies by means of the ELISA technique. This approach has been used for the development of four different ELISAs for the detection of HIV- and EBV-specific antibodies.

One thousand regular blood donors of the Department of Transfusion Medicine at the University Hospital in Hamburg were screened for antibodies against the Lyme disease spirochete, B. burgdorferi. 7.2% were initially reactive in the enzyme immunoassay, 37.5% of which were confirmed by immunoblot. The seroprevalence of anti-B. burgdorferi antibodies thus is 2.7% in Hamburg blood donors. 25 of 27 positive donors received a physical exam, which did not reveal any symptoms of acute or chronic Lyme disease. 24 of these 25 donors were tested for B. burgdorferi-specific DNA in urine by polymerase chain reaction, which came out negative in all cases. Introduction of B. burgdorferi antibody screening is not regarded an effective means to prevent transfusion-transmitted Lyme disease.

Hepatitis C virus (HCV) is responsible for the majority of cases of transfusion-related hepatitis. We performed a first-generation anti-HCV EIA in 665 repeat and 168 first-time blood donors from Berlin. 4.7 and 4.2%, respectively, showed at least one indeterminate or positive result. We further looked for HCV genome in the plasma of 20 donors with reactive anti-HCV-EIA doing a polymerase chain reaction (nested PCR). The control group consisted of 20 patients with chronic hepatitis C. The PCR was negative in all examined blood donors, but was positive in 17 of 20 controls. These findings raise the question, if a positive anti-HCV test correlates with infectiosity.