Subcutaneous administration (s.c.) of erythropoietin is more effective for preoperative autologous blood collection than intravenously administration of erythropoietin. However, pain at the injection site is a clinical problem. This study sought to evaluate two different on-patent recombinant human erythropoietins in autologous blood donation for gynecological surgery.
A total of 50 patients undergoing preoperative autologous blood donation were randomly assigned to s.c. injections of epoetin alfa or beta (24,000IU) at intervals of 1 week, and were then crossed over to the alternative treatment.
Local pain was evaluated primarily using a Visual Analog Scale (VAS), and secondarily using the Wong-Baker Face Pain Rating Scale (FS) and duration of pain immediately after s.c. injection. VAS score of epoetin alfa and beta were 39.2±26.8mm and 27.3±26.8mm, respectively (p=0.0285). VAS scores by the Linear Mixed Model of epoetin alfa and beta were 40.1 [29.5-50.7] mm and 28.0 [17.4-38.6] mm, respectively (p=0.0308). As for FS, there was no significant difference in the degree of pain between treatments with epoetin alfa and beta (p=0.1513). However, the duration of pain was shorter in a treatment with epoetin beta (1.3±1.7sec) than epoetin alfa (3.2±3.5sec)(Wilcoxon Test; p<0.0001).
In conclusion, s.c. injection of epoetin beta is significantly less painful and may provide a lower burden compared with epoetin alfa in patients undergoing preoperative autologous blood donation.

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Introduction: Fibrinogen concentrate or cryoprecipitate is currently administered to patients with acquired fibrinogen (Fib) deficiency associated with conditions such as hemorrhage, and the use of these products reportedly reduces not only blood loss but also transfusion requirements of red cells concentrate (RCC) and fresh frozen plasma (FFP). In Japan, however, only FFP is available for use with such patients. Here, we investigated Fib levels and blood transfusion volumes in patients requiring massive transfusion (MT).
Subjects and Methods: Subjects comprised patients who received ≥10 units of red blood cells in 1 calendar day at our institution between September 2010 and August 2011. Transfusion volumes of blood products administered on the day of MT and minimum Fib levels on the day before MT were assessed.
Results: Total volumes of RCC and FFP transfused to patients during the study period were 16,146 units (to 5,125 patients) and 10,120 units (to 1,547 patients), respectively. RCC totaling 3,294 units (20.4% of total transfusion volume) was administered to 188 patients (3.7%), and FFP totaling 3,092 units (30.6%) was administered to 177 patients (11.4%). RCC and FFP transfusions in MT patients with Fib <150mg/dl totaled 1,840 units (11% of RCC total transfusion volume) and 1,918 units (19% of total transfusion volume), respectively.
Discussion: Large volumes of FFP are required if selected as a treatment for acquired hypofibrinogenemia, leading to a risk of pulmonary edema. For patients potentially requiring MT, Fib levels should be measured and subsequent consideration given to administration of Fib preparations for patients with severe deficiency, in an effort to help reduce RCC and FFP usage.

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Background: Recent reports have shown that the prophylactic use of high-dose intravenous immunoglobulins (IVIG) does not benefit patients undergoing hematopoietic stem cell transplantation (HSCT). However, the efficacy of moderate-dose IVIG in HSCT settings has not been well examined. We retrospectively studied the impact of weekly 0.1g/kg IVIG administration on HSCT outcome.
Patients and Methods: Transplant outcomes were compared between 20 patients (6 with myeloid malignancy and 14 with lymphoid malignancy) who received prophylactic IVIG at 17.5g/month(Group 1) and 21 patients (12 with myeloid malignancy, 8 with lymphoid malignancy, and 1 with mixed phenotype malignancy) who did not receive prophylactic IVIG (Group 2). There were no significant differences between the two groups in the ratio of myeloablative to reduced-intensity conditioning regimens (10 : 10 vs. 13 : 8, respectively); ratio of cyclosporine to tacrolimus prophylaxis (17 : 3 vs. 18 : 3, respectively); proportion of unrelated bone marrow, related bone marrow, and related peripheral blood transplants (16 [80%], 2 [10%], and 2 [10%] vs. 12 [57%], 7 [33%], and 2 [10%], respectively); or degree of HLA one allele mismatch (1/20 vs. 3/21, respectively).
Results: Grade II to IV acute GVHD occurred significantly less frequently in Group 1 (20%) than in Group 2 (57%, P=0.025). There were no significant differences in the incidence of veno-occlusive disease; viral, bacterial, or fungal infections; transplant-related mortality; or overall survival between the two groups.
Conclusion: Weekly 0.1g/kg IVIG administration may reduce the incidence of grade II to IV acute GVHD in Japanese patients undergoing HSCT.

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A questionnaire-based survey on chemotherapy-induced anemia (CIA) in cancer patients was conducted between September and November 2010. The number of patients treated with chemotherapy, rate of blood transfusion, volume of blood transfused, severity of anemia, and factors affecting blood transfusion were analyzed according to the type of cancer, in an attempt to clarify the current status of CIA in Japan. During the survey period, among the eight types of cancer analyzed (breast, lung, stomach, colorectal, liver, gynecologic, and urologic cancer and malignant lymphoma), chemotherapy was given to 5.4-13.6% (mean=9.2%) of patients, among whom 1.6-24.0% (mean=7.5%) required blood transfusion. The number of units of red blood cells transfused was 3.9-7.3 units (mean=5.9 units) per patient.
According to a nationwide patient survey conducted by the Ministry of Health, Labour and Welfare, it is estimated that approximately 146,000 units of red blood cells, which account for 2.2% of the annual total supply of red blood cell products, are transfused to cancer patients with CIA yearly. In addition, it is estimated that annually approximately 172,000 cancer patients with CIA, accounting for 40% of patients receiving chemotherapy, have hemoglobin (Hb) levels below 10g/dL. Possible factors affecting blood transfusion included a history of chemotherapy and radiotherapy, as well as the use of platinum agents.
In patients who received red blood cell transfusions, the average Hb level prior to chemotherapy was 9.5g/dL, and the average lowest Hb level after starting chemotherapy was 6.9g/dL, whereas in patients who did not receive transfusion, these values were 11.6g/dL and 10.4g/dL, respectively. Furthermore, in all cancer types, almost no red blood cell transfusion was performed in patients with an Hb level of 8.0g/dL or higher, but also many patients with an Hb level of 6.9g/dL or lower did not receive red blood cell transfusions. There was no significant difference in the ratio of adverse events following blood transfusion in this survey compared with that in the nationwide survey. The present results demonstrated the strict restriction of red blood cell transfusion to cancer patients with CIA. Therefore, there is need to consider the use of alternative therapies to allogeneic blood transfusion, such as erythropoiesis-stimulating agents, to increase Hb levels, and consequently improve the quality of life in cancer patients with CIA.

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Since 2010, the collection of peripheral blood hematopoietic stem cells (PBHSC) from an unrelated donor and transplantation with PBHSC have been performed according to the Japanese medical insurance system. Subsequently, the certification system for the collection of PBHSC by Japan Marrow Donor Program has been introduced. Our institution was certified for this system in 2011. Since then, apheresis nurses certified by the Japan Society of Transfusion Medicine and Cell Therapy have subsequently played an active role in the collection of PBHSC from unrelated donors, because highly safe apheresis is required in such situations. The role of apheresis nurses includes provision of information to the donor or patient before apheresis, safety management during the procedure, and provision of information to nurses in the ward after collection. Apheresis nurses currently play a coordinating role in a highly professional health care team, such as provision of information concerning the donor or patient to physicians, medical engineers, or clinical technologists in the team, and program planning regarding the apheresis. Thus, PBHSC apheresis itself is a typical health care team activity, and the presence of the apheresis nurse is now indispensable in this system.

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To clarify the infection dynamics of HIV-1 found in blood donors, the subtypes and drug resistant mutations of past and present HIV-1 positive specimens were examined comparatively. After analyzing 237 cases of HIV-1 positive specimens "past" specimens in blood donated nationwide from 1992 to December 2001 and 212 cases "present" specimens from September 2009 to December 2011, we found that the subtypes of "past" specimens included 86.5% B, 10.1% CRF01_AE, 0.8%CRF02_AG, and 0.8% others. As for "present" specimens, B accounted for 90.6%, CRF01_AE for 5.2%, and CRF02_AG for 2.4% of subtypes. Drug resistant mutations were present in 8.6% of past specimens and 21.4% of present specimens. The proportion of revertant T215X in drug resistant mutations was 12.5% in past specimens and 12.9% in present specimens. These results suggest that no increase in HIV-1 subtype recombinant has occurred in the blood of donors on the whole within Japan. We also noted more drug-resistant mutations among present specimens than among past ones, suggesting the prevalence of drug-resistant mutations even among infected carriers, excluding people undergoing HIV-1 treatment.

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We discuss the importance and issues of post-transfusion viral marker tests after experiencing a patient with transfusion-transmitted HBV fulminant hepatitis. The patient received 3 units of red blood cell transfusion (RCC-LR) derived from 2 donors in the perioperative period. No viral infection markers were detected just before transfusion. However, 95 days after transfusion, the patient's condition rapidly deteriorated with rapidly elevated transaminase levels and detection of HBs antigen (Ag), HBe Ag, HBc antibody (Ab), and HBV-DNA. Despite aggressive therapy, including a plasma exchange, the patient died. The result of DNA sequence analysis of the HBV showed a homologous pattern, which suggested transfusion-transmitted HBV hepatitis.
After this case, the importance of post-transfusion viral marker tests was realized in our institute, and we attempted to increase the rate of implementation. Members of the transfusion unit earnestly informed doctors of the timing and items of the tests for each transfused case, and clearly explained to patients the importance of these tests. We also summarized the data of patients who visited other hospitals for post-transfusion viral marker tests. As a result, the implementation rate improved to around 70%.
It is necessary to make efforts to improve the implementation rate of post-transfusion viral marker tests, and we will continue to explain the importance of these tests to both physicians and patients.

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Frequent blood transfusion causes iron overload and leads to failure of various organs in patients with anemia related to chronic hematopoietic dysfunction, such as aplastic anemia and myelodysplastic syndrome. Deferasirox (DFX), an oral iron chelating agent, was recently developed, and has resulted in improvements in iron chelation therapy compliance with medication and in overall survival in patients with transfusional iron overload. In addition, medical guidelines for the treatment of transfusional iron overload were promulgated after July 2008, providing criteria for the diagnosis of transfusional iron overload and iron chelation therapy.
We assessed compliance with iron chelation therapy according to the guidelines for treatment of transfusional iron overload during the five-year period from January 2007 to December 2011 at Saga University Hospital. Four hundred and nineteen patients who received over 20 units of total erythrocyte transfusion annually were enrolled in this study. Patients' serum ferritin values measured at least once during the period in the patients in hematological and pediatric patients out of proportion was 28%, 45%, 71%, 66% and 72% respectively, toward the 2011 from 2007. Also, average serum ferritin value measured at the first time exceeded 2,500ng/ml and total red blood cells transfusion of average was more than 40 units up to half. Fifteen people received chelation therapy with DFX during the study period, and only four patients received chelation therapy according to the medical guideline for transfusional iron overload.
These results indicate that management of transfusional iron overload in our Hospital is insufficient, probably due to the difficulty in precisely understanding the total units of erythrocytes transfused to patients and the delay in recognition of the status of iron overload. In this regard, a new component of the electronic medical record system in our hospital has been developed to support clinicians seeking support with transfusion management.

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