Inappropriate use of fresh frozen plasma (FFP) and albumin products has been a serious problem in Japan. The continuous monitoring of blood use and feedback on transfusions can effectively decrease inappropriate blood transfusions. We proposed a method to assess hospital-level use of FFP and albumin products using administrative data (DPC data).
First, we conducted a retrospective audit of blood utilization at two hospitals to examine the underlying conditions for blood utilization and the appropriateness of blood transfusion in each hospital. Next, using DPC data from 587,045 cases provided by 73 acute-care hospitals, we developed case-mix-adjustment models to predict hospital-wide use of albumin and FFP. In order to assess case-mix adjusted blood products use, the expected total use of albumin or FFP at the hospital was compared with the observed values, by calculating observed to expected ratios (O/E ratios) for each hospital. The assessment by O/E ratio was compared with the proportion of appropriate blood products use.
The proportions of appropriate use of FFP and albumin were quite low (range from 20% to 30%). Model goodness-of-fit assessed using R² for linear regression was 0.77 for albumin use, and 0.78 for FFP use. High O/E ratios calculated using the case-mix adjustment models tended to be relative to low proportions of appropriate transfusions. It was suggested that DPC data can be used for the evaluation of appropriate blood use.

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As of March 2009, 67 lung transplants, including 52 from living donors and 15 from cadaveric donors, have been carried out since the first lung transplantation in Japan in 1998 at Okayama University Hospital. We analyzed the preparation and actual usage of blood products in lung transplantation during this period.
The average number of units of prepared and transfused red cells were 57.4 and 33.5, respectively, with a C/T ratio of 1.73. Average number of units of prepared and transfused fresh frozen plasma were 43.3 and 19.4, and those of platelet concentrate were 27.7 and 19.8, respectively. In double- and single-lung transplantation, the average number of units of transfused red cells, fresh frozen plasma and platelet concentrate were 37.9 and 11.5 (p<0.05), 21.8 and 7.0 (p<0.05), and 22.8 and 4.5 (p<0.05), respectively. In 5 double-lung transplants, more than 100 units of red blood cells were prepared, of which 3 were from cadaveric donors.
It is difficult to predict bleeding volume during lung transplantation due to factors including the degree of adhesion between visceral and parietal pleura. Our analysis suggested that the number of units of blood products required might depend on whether transplantation is single-lung or double-lung, probably indicating that cardiopulmonary bypass usage is a major determinant. Our analysis confirmed that it is important for both transfusion and clinical departments to communicate with each other on a routine basis, and to be prepared to use ABO-mismatched but compatible blood products in order to handle emergency surgery for cadaveric lung transplantation with demand for a large amount of blood products.

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A number of studies have shown the formation of various sizes of aggregates during storage of red cells concentrate (RC-MAP) supplied by the Japanese Red Cross until 2007. Among aggregates, macroaggregates are known to cause the clogging of transfusion filters at the bed side, and microaggregates are suggested to induce transfusion-related pulmonary embolism. Since the introduction of a prestorage leukocyte reduction system containing a CPD solution instead of an ACD-A solution as anticoagulant, and the supply of Red Cells Concentrate-Leukocyte Reduced (RCC-LR) in the blood program in Japan, the formation of macroaggregates and microaggregates has not been reported. We evaluated the formation of macroaggregates and microaggregates during storage of RCC-LR containing CPD solution. In addition, since the criteria for the use of a microaggregate screen filter have not been determined, we measured the number of microaggregates in RCC-LR before and after use of a microaggregate screen filter. Our results showed that no macroaggregates were formed in the storage of RCC-LR, and that the number of microaggregates in RCC-LR was significantly lower than that in RC-MAP. No significant change in the number of microaggregates was observed between pre- and post-filtered RCC-LR using a microaggregate screen filter. From our results, it is expected that transfusion of RCC-LR without using a microaggregate screen filter in adult patients with chronic anemia and related conditions may not cause adverse effects due to microaggregates, although the possibility cannot be ruled out that a small amount of microaggregates in RCC-LR still may be harmful in patients during massive transfusion or pediatric transfusion.

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The red cell antigens Do^a and Do^b are encoded by a pair codominant alleles (DOA, DOB) at the Dombrock locus. Both antigens are weakly immunogenic and the corresponding alloantibodies are rare. Anti-Do^a and anti-Do^b are usually weakly reactive and coexist with other alloantibodies. Furthermore, the serologic identification of anti-Do^a and anti-Do^b is notoriously difficult. Therefore, Do^a and Do^b typing antisera are not readily available for screening antigen-negative RBC units, and the selection of compatible blood is frequently based on crossmatch results. However, inaccurate selection can put patients at risk for hemolytic transfusion reactions.
Here, we used DOA/DOB PCR-SSP assay as an alternative to serologic typing for selecting RBC units for a patient with anti-Do^a. The patient received 2 units of DOA-negative (DOB/DOB) RBC and had no symptoms or laboratory evidence of hemolysis. The Dombrock gene frequencies in blood donors in Hokkaido (n=235) were 0.109 for DOA and 0.819 for DOB.
DNA-base typing appeared useful for screening for Dombrock-compatible donors.

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The Kanagawa Prefecture Joint Meeting of Hospital Transfusion Committees conducted a questionnaire study of adult cardio-vascular surgeries performed in the 2006 fiscal year. Answers were received from 22 (57.9%) of the 38 hospitals to which the questionnaire was sent. Intra-operative transfusion decisions were made mainly by consensus between the anesthesiologist and chief surgeon (81.8%): 7 of 22 (31.8%) were at a hemoglobin concentration level between 7 to 8g/dl and 5 of 22 (22.7%) were under 7g/dl. The red cell concentrates (RCC) transfusion rates for artificial graft replacement for thoracic aortic aneurysm (TAA) was 85.2%, valve replacement for valvular diseases (valve replacement) was 67.2%, and coronary artery bypass graft (CABG) was 45.6%. Transfusion rates of fresh frozen plasma (FFP), platelet concentrate (PC), and albumin solution (ALB) were in the same order. Average RBC usage for TAA was 16.1±17.6 units (U), valve replacement was 10.4±11.1U, and CABG was 7.3±5.2U. FFP, PC, and ALB were in the same order. The usage difference between hospitals was studied using the formula 90% value/50% value (90/50 ratio). The 90/50 ratios of RBC, FFP and PC usage did not exceed 2.0, except for the RBC for valve replacement and TAA, and for the FFP for TAA. Although there were several hospitals at which no ALB was used, several hospitals regularly used more than 20U of ALB. Significant statistical differences were found between the FFP/RBC ratio and ALB/RBC ratio for TAA (p=0.0106), valve replacement (p<0.0001), and CABG (p<0.0023). Autologous predeposition was done at 13 (59.1%) of the 22 hospitals. The rates of autologous predeposition were 22 of 149 TAA (14.8%), 48 of 183 valve replacements (26.2%), and 24 of 195 CABG (12.3%), with avoidance rates for homologous transfusion for TAA of 40.9% (9/22), valve replacement 54.2% (26/48), and CABG 75.0% (18/24). Our results showed little difference in the usage of RCC, FFP, and PC between hospitals, but a large difference in the usage of ALB. Reducing the usage of ALB in our prefecture is important, and a program to achieve this goal is now being developed.

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A nationwide questionnaire survey on transfusion medicine conducted in fiscal year 2008 revealed that the majority (3/4) of institutions performing blood transfusion were small-scale hospitals (<300 beds), whereas most (>85%) domestically transfused blood products was used in large-scale hospitals (≥300 beds). Thus, a detailed analysis of the transfusion management system and use of blood products in small-scale hospitals in Japan was performed. Results showed that numerous hospitals had not established a unified transfusion management system appropriately, and that transfusion testing was not centralized to the blood transfusion service. Additionally, most hospitals had no assigned transfusionists or laboratory technologists responsible for blood transfusion. Further, a hospital transfusion committee was established in only 65% of the institutions. Although the ratio of transfused blood units per number of beds in small-scale hospitals was lower than in large-scale hospitals, the wastage rate was higher. As expected, the wastage rate, as well as the albumin/red cell product usage rate, was lower in hospitals where transfusionists or laboratory technologists responsible for transfusion were assigned. To solve these problems, there is need to incentivize hospitals to assign medical and co-medical staff responsible for transfusion, and also to establish an active joint regional transfusion committee to help improve transfusion management systems in small-scale hospitals to ensure the performance of appropriate blood transfusion.

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Results concerning cellular therapy from the Comprehensive Questionnaire Surveys on Transfusion Medicine for 2008 by the Japanese Society of Transfusion Medicine and Cell Therapy were collected and analyzed. Questionnaires were sent to 7,857 hospitals, of which 3,208 (40.8%) replied. Full-time nurses were posted to transfusion departments in 53 hospitals. Autologous blood stem cells, allogeneic blood stem cells, unrelated bone marrow, related bone marrow, donor lymphocytes, and granulocytes were harvested at 108, 75, 28, 26, 24 and 10 institutions, respectively. As for autologous peripheral blood stem cells, 48 hospitals conducted harvests at transfusion departments, 70 had standard operating procedures, 54 recorded working processes, 59 labeled containers for defined items, 52 identified and verified cell products according to procedures designed for blood products, 70 carried out flow-cytometric analyses at their own facilities, and 63 used dedicated clean benches for open-system processing. Pre-storage and post-storage sterility tests were conducted at only 7 and 1 facilities, respectively. In aphereses, veins were punctured by patient-care physicians in 82 hospitals, and cell-separators were operated by medical technologists and engineers in 35 and 31 hospitals, respectively. Processing, freezing, storage and issuance of the cells were assumed by medical technologists in most hospitals. This survey for 2008 revealed that medical technologists and engineers play important roles, and that process and quality control in cell processing in hospitals require improvement.

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