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PREVENTION OF THE POST-TRANSFUSION SYNDROME
849 tions of living in a modern society are more relevant to the aetiology of diverticulosis than the amount of roughage in the diet. Evangelismos Hospital, O. N. MANOUSOS. Athens, Greece.
TERATOGENICITY OF LITHIUM IN MICE in lithium expressed during the past several months in your columns, the following preliminary report of its teratogenicity for mice may be of interest. Timed matings of female mice (Charles River HaM/ICR) were obtained, and the pregnant animals received 200, 300, and 465 mg. per kg. lithium carbonate daily from days 6 to 15 of gestation. Control animals received 0-5% tragacanth alone in identical volumes during the same period. Gestation was terminated on the 18th day, and the fetuses were removed by caesarean section and examined for viability and malformations. At dosage levels of 465 and 300 mg. per kg., cleft palate occurred in approximately 30% and 6% of the fetuses respectively. The incidence of resorption of fetuses was also dose-related. None of the control fetuses had cleft palate. The occurrence of cleft palate was not associated with any other type of malformation. Pathology and Toxicology Department, Smith Kline & French Laboratories, KALMAN T. SZABO. Philadelphia, Pennsylvania.
SIR,-In view of the interest
PREVENTION OF THE POST-TRANSFUSION SYNDROME SIR,-In a leading article (Sept. 6, p. 526) you state that patients whose immunological function is impaired, and pregnant women, should be protected as far as possible from the post-transfusion syndrome. This syndrome, presumably caused in the majority of cases by cytomegalovirus (c.M.v.), has never been reported after transfusion of blood more than 24 hours old. This is true for twelve patients seen by us. Clearly, therefore, the use of stored blood is preferable in the above-mentioned high-risk groups, for intra-uterine transfusions, and for transfusions in the neonatal periodand in the puerperium. Since virxmia is more apt to occur in primary infections, transfusion of blood from donors with longstanding C.M.v. antibodies is sometimes advocated as a safe alternative. Our objections to this procedure may possibly be supported by the following case-history. The patient, a 17-year-old girl, is one of a series of four with post-transfusion C.M.v. mononucleosis described elsewhere. She received one unit of fresh blood during a splenectomy. Subsequently she developed a typical posttransfusion syndrome, accompanied by a rise of complement-fixing c.M.v.-antibody titre from less than 8 to 32. c.mt.v. was isolated from the urine. The donor was seen 21 days after donation. This was a healthy woman of 25 who had no history of recent illness. c.M.v. could not be isolated from urine or mouth-swab. The complementfixing c.M.v.-antibody titre was 16, and the IgM c.M.v.antibody titre was less than 8. IgM antibodies were determined by an indirect-immunofluorescence technique, differing in some details3 from the test used by Hanshaw et al.4 1. 2. 3. 4.
Foster, K. M., Jack, I. Australas. Ann. Med. 1968, 17, 135. Langenhuysen, M. M. A. C., Kapsenberg, J. G. Ned. Tijdschr. Geneesk. 1968, 112, 2125. Langenhuysen, M. M. A. C., The, T. H., Nieweg, H. O., Kapsenberg, J. G. Clin. exp. Immun. (in the press). Hanshaw, J. B., Steinfeld, H. J., White, C. J. New Engl. J. Med. 1968, 279, 566.
This result of
IgM-antibody titration is, in our experiargument against a primary infection of the donor at the time of donation. Virxmia possibly may occur in latent infections. Investigations of another ence,3
an
herpes-group virus demonstrated E.B. virus antigen in cultures of peripheral leucocytes from individuals with a history of infectious mononucleosis as long as 20 years ago.ó Although it cannot be proved that the infection in our patient was brought about by the transfused blood, we are inclined to use only blood which has been stored, for high-risk recipients, until more is known about viraemic states in donors. When the use of fresh blood or blood components cannot be avoided, y-globulin can be given in addition.
Division of Hæmatology,
University Department of Medicine, Gronigen, Netherlands.
M. M. A. C. LANGENHUYSEN.
EFFECT OF NEPHRECTOMY ON TRANSFUSION REQUIREMENTS OF DIALYSIS PATIENTS SiR,ŃThe article on this subject by Dr. van Ypersele de Strihou and M. Stragier (Oct. 4, p. 705) was interesting, but I feel that they have neglected to comment on an alternative explanation as to why their bilaterally nephrectomised patients received more blood. It appears that their indication for transfusion was an arbitrary measurement of the haematocrit and hxmoglobin, and if one assumes that the blood from which these observations were made was obtained before each dialysis, there was obviously a more rapid fall in hxmatocrit in the bilaterally nephrectomised group. This fall in hxmatocrit could have been due to a greater dilution effect with an apparent lowering of hxmatocrit and hxmoglobin. Since they do not present data on whether the nephrectomised patients retained more fluid between the dialyses than the non-nephrectomised subjects, I would suggest that this may be the explanation for their increase in transfusion requirements. I should like to add my own experiences on this matter. Since 1965 I have not found it necessary to use routine blood-transfusion in patients receiving maintenance hasmodialysis, and I have personally been responsible for the treatment of over 100 patients since this time. In the past year I have reviewed the average haemoglobin levels of 20 patients who have been on dialysis for periods varying between 6 months and 4 years. 17 of these patients still have their kidneys and 3 have had bilateral nephrectomies. The average hsematocrit for the nephrectomised group was 30%, and the average for the non-nephrectomised group was 30%. No patient in either group has received a blood-transfusion in the past year. I accept that the atrophic kidney of the chronic-dialysis patient may contribute to erythropoiesis, but probably, given time, the bilaterally nephrectomised patient would develop extrarenal sites of erythropoietin formation and eventually achieve adequate levels of haemoglobin without transfusion. In my experience the single most important factor in the elimination of transfusion requirements, and ultimately the achievement of higher levels of haemoglobin, in chronic-dialysis patients is the avoidance of transfusions completely, since transfused blood probably depresses endogenous erythropoiesis. The value of parenteral iron in raising the hxmoglobin level in some patients is well documented, 6, and recently we have seen striking improvements in hxmoglobin levels after administration of parenteral testosterone. 5. 6.
7.
Diehl, V., Henle, G., Henle, W., Kohn, G. J. Virol. 1968, 2, 663. Crocket, R. E., Baillod, R. A., Lee, B. N., Moorhead, J. M., Stevenson, C. M., Vorghese, Z., Shaldon, S. Proc. Europ. Dial. Transpl. Ass. 1967, 4, 17. Wright, F. K., Goldsmith, H. J., Hill, S. M. ibid. 1968, 5, 179.
TERATOGENICITY OF LITHIUM IN MICE in lithium expressed during the past several months in your columns, the following preliminary report of its teratogenicity for mice may be of interest. Timed matings of female mice (Charles River HaM/ICR) were obtained, and the pregnant animals received 200, 300, and 465 mg. per kg. lithium carbonate daily from days 6 to 15 of gestation. Control animals received 0-5% tragacanth alone in identical volumes during the same period. Gestation was terminated on the 18th day, and the fetuses were removed by caesarean section and examined for viability and malformations. At dosage levels of 465 and 300 mg. per kg., cleft palate occurred in approximately 30% and 6% of the fetuses respectively. The incidence of resorption of fetuses was also dose-related. None of the control fetuses had cleft palate. The occurrence of cleft palate was not associated with any other type of malformation. Pathology and Toxicology Department, Smith Kline & French Laboratories, KALMAN T. SZABO. Philadelphia, Pennsylvania.
SIR,-In view of the interest
PREVENTION OF THE POST-TRANSFUSION SYNDROME SIR,-In a leading article (Sept. 6, p. 526) you state that patients whose immunological function is impaired, and pregnant women, should be protected as far as possible from the post-transfusion syndrome. This syndrome, presumably caused in the majority of cases by cytomegalovirus (c.M.v.), has never been reported after transfusion of blood more than 24 hours old. This is true for twelve patients seen by us. Clearly, therefore, the use of stored blood is preferable in the above-mentioned high-risk groups, for intra-uterine transfusions, and for transfusions in the neonatal periodand in the puerperium. Since virxmia is more apt to occur in primary infections, transfusion of blood from donors with longstanding C.M.v. antibodies is sometimes advocated as a safe alternative. Our objections to this procedure may possibly be supported by the following case-history. The patient, a 17-year-old girl, is one of a series of four with post-transfusion C.M.v. mononucleosis described elsewhere. She received one unit of fresh blood during a splenectomy. Subsequently she developed a typical posttransfusion syndrome, accompanied by a rise of complement-fixing c.M.v.-antibody titre from less than 8 to 32. c.mt.v. was isolated from the urine. The donor was seen 21 days after donation. This was a healthy woman of 25 who had no history of recent illness. c.M.v. could not be isolated from urine or mouth-swab. The complementfixing c.M.v.-antibody titre was 16, and the IgM c.M.v.antibody titre was less than 8. IgM antibodies were determined by an indirect-immunofluorescence technique, differing in some details3 from the test used by Hanshaw et al.4 1. 2. 3. 4.
Foster, K. M., Jack, I. Australas. Ann. Med. 1968, 17, 135. Langenhuysen, M. M. A. C., Kapsenberg, J. G. Ned. Tijdschr. Geneesk. 1968, 112, 2125. Langenhuysen, M. M. A. C., The, T. H., Nieweg, H. O., Kapsenberg, J. G. Clin. exp. Immun. (in the press). Hanshaw, J. B., Steinfeld, H. J., White, C. J. New Engl. J. Med. 1968, 279, 566.
This result of
IgM-antibody titration is, in our experiargument against a primary infection of the donor at the time of donation. Virxmia possibly may occur in latent infections. Investigations of another ence,3
an
herpes-group virus demonstrated E.B. virus antigen in cultures of peripheral leucocytes from individuals with a history of infectious mononucleosis as long as 20 years ago.ó Although it cannot be proved that the infection in our patient was brought about by the transfused blood, we are inclined to use only blood which has been stored, for high-risk recipients, until more is known about viraemic states in donors. When the use of fresh blood or blood components cannot be avoided, y-globulin can be given in addition.
Division of Hæmatology,
University Department of Medicine, Gronigen, Netherlands.
M. M. A. C. LANGENHUYSEN.
EFFECT OF NEPHRECTOMY ON TRANSFUSION REQUIREMENTS OF DIALYSIS PATIENTS SiR,ŃThe article on this subject by Dr. van Ypersele de Strihou and M. Stragier (Oct. 4, p. 705) was interesting, but I feel that they have neglected to comment on an alternative explanation as to why their bilaterally nephrectomised patients received more blood. It appears that their indication for transfusion was an arbitrary measurement of the haematocrit and hxmoglobin, and if one assumes that the blood from which these observations were made was obtained before each dialysis, there was obviously a more rapid fall in hxmatocrit in the bilaterally nephrectomised group. This fall in hxmatocrit could have been due to a greater dilution effect with an apparent lowering of hxmatocrit and hxmoglobin. Since they do not present data on whether the nephrectomised patients retained more fluid between the dialyses than the non-nephrectomised subjects, I would suggest that this may be the explanation for their increase in transfusion requirements. I should like to add my own experiences on this matter. Since 1965 I have not found it necessary to use routine blood-transfusion in patients receiving maintenance hasmodialysis, and I have personally been responsible for the treatment of over 100 patients since this time. In the past year I have reviewed the average haemoglobin levels of 20 patients who have been on dialysis for periods varying between 6 months and 4 years. 17 of these patients still have their kidneys and 3 have had bilateral nephrectomies. The average hsematocrit for the nephrectomised group was 30%, and the average for the non-nephrectomised group was 30%. No patient in either group has received a blood-transfusion in the past year. I accept that the atrophic kidney of the chronic-dialysis patient may contribute to erythropoiesis, but probably, given time, the bilaterally nephrectomised patient would develop extrarenal sites of erythropoietin formation and eventually achieve adequate levels of haemoglobin without transfusion. In my experience the single most important factor in the elimination of transfusion requirements, and ultimately the achievement of higher levels of haemoglobin, in chronic-dialysis patients is the avoidance of transfusions completely, since transfused blood probably depresses endogenous erythropoiesis. The value of parenteral iron in raising the hxmoglobin level in some patients is well documented, 6, and recently we have seen striking improvements in hxmoglobin levels after administration of parenteral testosterone. 5. 6.
7.
Diehl, V., Henle, G., Henle, W., Kohn, G. J. Virol. 1968, 2, 663. Crocket, R. E., Baillod, R. A., Lee, B. N., Moorhead, J. M., Stevenson, C. M., Vorghese, Z., Shaldon, S. Proc. Europ. Dial. Transpl. Ass. 1967, 4, 17. Wright, F. K., Goldsmith, H. J., Hill, S. M. ibid. 1968, 5, 179.