松浦 秀哲

BACKGROUND AND OBJECTIVES: Reports on the changes in plasma fibrinogen levels in patients receiving cryoprecipitates synthesized using different methods are lacking. Therefore, we investigated these changes in patients who underwent cardiovascular surgery. MATERIALS AND METHODS: We included 309 patients who underwent cardiovascular surgery and received 12 cryoprecipitate units between February 2020 and March 2024 and 204 patients were selected by propensity score matching. The cryoprecipitates were prepared using two methods. Fresh frozen plasma (FFP) was thawed at 2 to 6°C for 24 h and centrifuged to remove the supernatant in the one-step method, whereas FFP was thawed, refrozen at -20°C, and subsequently rethawed in the two-step method. We investigated the association between different cryoprecipitate preparation methods and ICU admission for ≥ 1 week, with in-hospital mortality considered as a competing risk in the analysis. In addition, we evaluated the changes in plasma fibrinogen levels before and after cryoprecipitate administration. RESULTS: Baseline plasma fibrinogen levels were significantly higher in the two-step method group than in the one-step method group. Differences in cryoprecipitate preparation methods were not significantly associated with ICU admission for ≥ 1 week, in the analysis that considered in-hospital mortality as a competing risk (P = 0.93). The increase in plasma fibrinogen levels after cryoprecipitate administration was significantly higher with the two-step method than with the one-step method (36 mg/dL vs. 51 mg/dL, P = 0.020). CONCLUSION: The cryoprecipitates synthesized using the two-step method showed a higher increase in plasma fibrinogen levels than those prepared using the one-step method. These findings may help guide appropriate transfusion protocols by confirming intraoperative plasma fibrinogen levels.

This study investigated the anti-tumor effects of andrographolide, a diterpene lactone derived from Andrographis paniculata, on T-cell acute lymphoblastic leukemia (T-ALL) cells. Andrographolide induced dose-dependent cytotoxicity and morphological changes in the T-ALL cell line Jurkat cells, including cell shrinkage and chromatin condensation. Mechanistically, andrographolide triggers apoptosis through reactive oxygen species (ROS) generation, mitochondrial membrane depolarization, and cytochrome c release. These effects were reversed by the ROS inhibitor N-acetyl-L-cysteine (NAC), indicating that andrographolide induces apoptosis through a ROS-dependent apoptotic pathway. In contrast, NAC treatment did not reverse cytarabine- and vincristine-induced apoptosis or the ROS-dependent apoptotic pathway in Jurkat cells. Intriguingly, andrographolide also induced ferroptosis, as evidenced by increased expression of the ferroptosis marker fatty acid-CoA ligase 4 and ultrastructural changes such as reduced mitochondrial area and disappearance of cristae. These effects were likewise reversed by NAC, further implicating ROS in the ferroptotic process. In MOLT-4 cells, where andrographolide suppressed viability, increased Annexin V positivity and ROS levels, and upregulated FACL4 expression in a NAC-sensitive manner. Unlike cytarabine and vincristine, andrographolide did not significantly alter cell cycle distribution. In conclusion, andrographolide induces both apoptosis and ferroptosis in T-ALL cells via ROS-dependent mechanisms that are distinct from those of conventional chemotherapeutic agents. These dual actions position andrographolide as a candidate for standalone or combination therapy in T-ALL.

Abstract Background Ethylenediamine tetraacetate/glycine acid (EGA) and chloroquine diphosphate (CDP) are used in transfusion testing to dissociate IgG antibodies from red blood cells (RBCs). However, the ability of these reagents to dissociate IgM antibodies sensitized to RBCs has not been comprehensively elucidated. We investigated whether EGA and CDP could dissociate cold‐reactive antibodies from RBCs and their effect on RBCs after dissociation treatment. Study Design and Methods Cold‐reactive antibody‐sensitized RBC samples were prepared by mixing group A RBCs and group B plasma and treated with EGA, CDP, and dithiothreitol (DTT). Before and after the dissociation treatment, changes in the agglutination of these RBCs were assessed using the test tube method. Flow cytometric analysis was used to confirm the nature of antibodies bound to RBCs. Additionally, RBC morphology was evaluated using scanning electron microscopy. This study utilized off‐label use of EGA and CDP. Results Flow cytometric analysis showed that antibodies sensitized to RBCs were mainly IgM antibodies. After antibody dissociation, agglutination disappeared in the EGA‐treated samples to the same degree as in the DTT‐treated samples. However, IgM antibodies remained in the CDP‐treated samples. Regarding RBC morphology, RBC surface appeared coarser in both EGA‐ and CDP‐treated samples, and RBC area was significantly smaller in the CDP‐treated samples than in the EGA‐treated samples. Discussion EGA could dissociate cold‐reactive antibodies, whereas CDP had a higher residual antibody content. This difference in dissociation ability appears to correlate with the antibody pH of the dissociation reagent. EGA treatment may be useful in cases of sensitization by high‐titer cold‐reactive antibodies.

Abstract Background Donor-specific antibodies (DSAs) targeting human leukocyte antigens (HLAs) substantially reduce the longevity of transplanted organs. Desensitization of DSA-positive renal transplant recipients is achieved through intravenous administration of immunoglobulin (IVIg). However, the presence and detectability of anti-HLA antibodies in IVIg preparations following administration are not fully understood. We aimed to assess whether immunoglobulin preparations contain anti-HLA antibodies that can be detected as passive antibodies when administered into the body. Methods We evaluated 3 immunoglobulin preparations from different pharmaceutical companies, using anti-HLA class I and II antibody specificity tests and immunocomplex capture fluorescence analysis (ICFA). Results Direct testing for anti-HLA antibodies resulted in high background errors, particularly for Venoglobulin. Diluting Venoglobulin to physiological concentrations revealed the presence of anti-HLA class I antibodies; however, no common alleles were found between the specificity identification test and ICFA. For Glovenin and Venilon, anti-HLA class I and II antibodies were detected; however, variability was observed across different test reagent lots. Moreover, dilution of the globulin formulation revealed a prozone phenomenon. Conclusion The administration of IVIg complicates the accurate detection of anti-HLA antibodies, underscoring the need for careful interpretation of test results post-IVIg administration.

Abstract Background Despite several reports on red blood cell (RBC) alloimmunization, the actual prevalence and factors contributing to RBC alloimmunization in transfused patients remain poorly investigated. We examined the association between clinical factors and the development and evanescence of RBC antibodies after transfusion. Study Design and Methods Each participating institution performed antibody screens before and after RBC transfusion. A survey including patient characteristics, results of antibody screen and identification, antibody screen methods, total amount of RBC transfused, and adverse reactions, was conducted. Results Between October 2018 and March 2023, 1194 patients were registered at five institutions. Overall, 958 patients underwent at least one follow‐up RBC antibody screen after transfusion, revealing new antibody development in 44 (4.6%). Anti‐E was identified in 25 patients, anti‐Jk^a in 5, and anti‐c in 4. The number of RBC units transfused was significantly associated with antibody development after transfusion (p < .001). Among 55 patients in whom antibodies were identified after transfusion, including historical antibodies, antibodies evanesced in 18 (33%); anti‐E in 7, anti‐Jk^a in 4, and anti‐Le^a in 2. Evanescent antibodies were identified more frequently by saline and/or enzyme methods than persistent antibodies (p = .012). Discussion The number of RBC units transfused can impact antibody development, and antibodies identified only by saline and/or enzyme methods, deemed clinically insignificant, are likely to have a high evanescence rate. Antibody screen should be carefully performed, especially in those receiving a large number of RBC units. Confirming previous antibody screen results should be performed to prevent omitting evanesced antibodies regardless of clinical relevance.

体外式膜型人工肺（extracorporeal membrane oxygenation; ECMO）を使用する重症新型コロナウイルス感染症（COVID-19）症例は血液製剤を要するが，その使用状況についての報告は少ない。2019年11月から2021年8月までに当施設でECMO治療を受けた重症COVID-19患者19名の患者背景，血液製剤の使用量，ECMO稼働時間，臨床検査値，転帰を調査し，解析を行った。同時期にECMOを稼働した虚血性心疾患（IHD）患者18名を対照とした。ECMO稼働中，両群ともに臨床検査値の低下時とECMO離脱に際して輸血が行われていた。IHD症例ではECMO導入早期に各血液製剤が使用されていた。一方で，COVID-19症例では血液製剤が連日使用されており，特に新鮮凍結血漿（fresh frozen plasma; FFP）使用量がIHD症例と比較して有意に多かった。輸血療法の目安として臨床検査値が一般的であるが，ECMO稼働症例では両群ともにECMO離脱時にも輸血が実施されており，治療の進捗状況に留意する必要がある。輸血管理部門としては臨床検査値，治療状況を把握し輸血要請に迅速に対応できる製剤管理を行う必要がある。

【はじめに】公益社団法人愛知県臨床検査技師会輸血検査研究班では愛知県内の輸血検査技術向上および標準化を図るため，毎年実技研修会を開催してきた．今回，コロナ禍で実施した新しい実技研修会の内容およびその効果について報告する． 【方法】2021年度は開催形式をWebに変更した．2022年度は事前に検体を送付し検査を実施してもらうことにした．いずれの研修会でもグループワークの時間を設け，受講生全員が発言できるように工夫した． 【結果】アンケートの結果，2021年度と2022年度はそれぞれ「満足」が81%，85%であった．また実技研修会に対しては好意的な意見が多数寄せられた． 【考察】コロナ禍において感染拡大を防ぐ社会の要請と輸血検査技術の維持，向上への貢献という狭間で新様式での研修会を開催した．既存の形にとらわれない柔軟な発想をもって受講生に有益な実技研修会のあり方を継続して検討していきたい．

クリオプレシピテート（以下，クリオ）はフィブリノゲン（以下，Fib）等の凝固因子を高濃度に含むため，大量出血時に使用することで凝固能を早期に回復させ，出血量や輸血量の減少に繋がるとされている。当院でも心臓血管外科（以下，心外）からの要望でクリオの院内作製を開始したので導入経緯と使用実績及び課題について報告する。対象はクリオを使用した心外の手術51症例（以下，投与群）とクリオ未使用の心外の手術94症例として，術式を大血管手術とそれ以外（以下，非大血管手術）に分けて比較検討した。調査内容は出血量，赤血球液（RBC）・新鮮凍結血漿（FFP）の投与量，濃厚血小板（PC）投与量，RBCとFFPの投与比（R/F比），ICU在室日数とした。クリオ投与患者には投与前後のFib値を測定し，統計学的解析を行った。クリオ投与前後のFib値は有意な上昇を認めた。大血管・非大血管手術の両者ともに投与群の方が非投与群と比較して，出血量が多かった。RBCおよびFFPの投与量は大血管手術の投与群で低い傾向があるが，非大血管手術の投与群では有意に多かった。クリオ導入当初，クリオの投与により血液製剤の使用量が削減できると期待したが現状では明確な輸血量削減効果は得られていない。輸血量を削減するためには，クリオを使用できる環境を整えるだけではなく，クリオを効果的に投与するために使用者の意識を変える必要がある。

SARS-CoV-2 infection has been reported to be associated with a positive direct antiglobulin test (DAT). In this study, an analysis of 40 consecutive coronavirus disease 2019 (COVID-19) cases from December 2020 to September 2021 in Japan revealed that patients of 70 years and over were predisposed to a positive DAT. DAT positivity was related to a decrease in the hemoglobin level. Anemia in DAT-positive COVID-19 patients was attributed to hemolysis, which was corroborated by high reticulocyte counts and an increase in the red blood cell distribution width. Human leukocyte antigen (HLA)-DRB1*12:01 and DRB1*12:02 were exclusively found in DAT-positive COVID-19 patients. In silico assays for the Spike protein of SARS-CoV-2 predicted several common core peptides that met the criteria for a B cell epitope and strong binding to both HLA-DRB1*12:01 and DRB1*12:02. Among these peptides, the amino acids sequence TSNFR, which is found within the S1 subunit of SARS-CoV-2 Spike protein, is shared by human blood group antigen Rhesus (Rh) CE polypeptides. In vitro analysis showed that the expression of HLA-DR in CD4+ T cells and CD8+ T cells from a DAT-positive patient was increased after pulsation with TSNFR-sequence-containing peptides. In summary, positive DAT is related to enhanced anemia and to HLA-DR12 in the Japanese population. A peptide sequence within SARS-CoV-2 Spike protein may act as an epitope for IgG binding to RBCs in DAT-positive COVID-19 patients.

INTRODUCTION: Quantitative measurement of anti-A/-B antibody titers is important during ABO-incompatible living kidney transplantation (ABOi-LKT). METHODS: We conducted a multi-institutional study to measure the antibody titers using the automated column agglutination technique (auto-CAT) and tube test (TT) method in ABOi-LKT recipients. Statistical analysis was performed to evaluate the two methods. RESULTS: We examined 111 samples from 35 ABOi-LKT recipients at four institutions. The correlation coefficient of the two methods was >0.9; the concordance rate and clinically acceptable concordance rate for the IgG titers were 60.4% and 88.3%, respectively. Perioperative status did not influence the statistical significance. Parallel changes were observed in the IgG antibody titers measured using the auto-CAT or TT technique by desensitizing therapy in time-course monitoring. CONCLUSION: Auto-CAT is comparable with the TT technique and is feasible for IgG anti-A/B antibody titration in ABOi-LKT recipients.

A 43-year-old Japanese male, who had undergone open liver surgery for tumor resection, presented with decreased hemoglobin levels on Day 13 post-emergency-release transfusion of 16 units of Fy(a +) red blood cells. As the anemia was accompanied by increased lactate dehydrogenase, indirect bilirubin, and reticulocytes, as well as decreased haptoglobin, it was attributed to hemolysis. In the diagnostic workup for hemolytic reaction, the direct antiglobulin test result for IgG was positive and the antibody dissociated from the patient's peripheral red blood cells was identified as anti-Fya (titer, 4). The hemolytic reaction was transient (approximately 10 days), of moderate severity, and did not result in any obvious organ damage. However, a single compatible red blood cell transfusion of 2 units was required on Day 17 after the causative transfusion. Notably, HLA typing revealed that the patient carried the HLA-DRB1*04:03 allele, which has been implicated in immunogenicity and induction of anti-Fya response in Caucasian populations. In summary, this is the first documented case of definitive anti-Fya-mediated delayed hemolytic transfusion reaction associated with HLA-DRB1*04:03 in the Japanese population.

BACKGROUND: The occurrence of transfusion-transmitted hepatitis B virus (HBV) infection has fallen dramatically due to continuous improvements in pre-transfusion laboratory testing. However, the characteristics of transfusion-transmitted HBV infection caused by individual donor nucleic acid amplification test (ID-NAT)-negative blood products are unclear. CASE PRESENTATION: A 76-year-old woman with acute myeloid leukemia was diagnosed with transfusion-transmitted HBV infection after receiving apheresis platelets derived from an ID-NAT-negative blood donation. This case was diagnosed definitively as transfusion-mediated because complete nucleotide homology of a 1556 bp region of the HBV Pol/preS1-preS2-S genes and a 23 bp region of the HBV core promoter/precore between the donor and recipient strains was confirmed by PCR-directed sequencing. The case is uncommon with respect to the unexpectedly prolonged HBV-DNA incubation period of nearly 5 months after transfusion (previously, the longest period observed since the recent implementation of ID-NAT pre-transfusion laboratory testing in Japan was 84 days). Slow-replicating HBV genotype A2 may contribute to the prolonged incubation period; also, the quantity of apheresis platelets delivered in a large volume of plasma, and/or the immune response of the recipient suffering from a hematological neoplasm, may have contributed to establishment of HBV infection in the recipient. This was supported by analysis of three previously documented cases of transfusion-transmitted HBV infection by blood products derived from ID-NAT-negative donations in Japan. CONCLUSION: Continuous monitoring of HBV infection for longer periods (>3 months) may be required after transfusion of blood components from an ID-NAT-negative HBV window donation.

OBJECTIVE: The JT interval of the myocardial repolarization time can be divided into Jpoint to T-peak interval (JTp) and T-peak to T-end interval (Tpe). It is well known that the JT interval is dependent on the heart rate, but little is known regarding heart rate dependence for JTp and Tpe. The aim of the present study was to clarify the heart rate dependence of JTp and Tpe and to elucidate the interference of autonomic nervous activity with these parameters. METHODS: We evaluated 50 prepubertal children (mean age: 6.4 ± 0.5 years; male:female, 22:28) without heart disease. JTp, Tpe, and the preceding RR intervals were measured using 120 consecutive beats (lead CM5). First, the relationships between the RR interval and JTp and Tpe were evaluated by Pearson's correlation coefficient. Second, to evaluate autonomic interference with JTp and Tpe, the degree of coherence between RR interval variability and JTp or Tpe variability was calculated using spectral analysis. RESULTS: Significant positive correlations were observed between the RR interval and JTp (y = 0.116x + 105.5; r = 0.594, p < 0.001) and between the RR interval and Tpe (y = 0.037x + 44.7; r = 0.432, p < 0.001). Tpe variability had a lower degree of coherence with RR interval variability (range: 0.039-0.5 Hz) than with JTp variability (0.401 [interquartile range, 0.352-0.460] vs. 0.593 [0.503-0.664], respectively; p < 0.001). CONCLUSIONS: Tpe had lower heart rate dependence and a lower degree of autonomic nervous interference than did JTp.

輸血副反応に対し看護師が行う患者観察の実態を明らかにすることを目的に、学会認定・臨床輸血看護師が在籍する施設を対象にアンケート調査を行い、413施設(回収率84%)より回答を得た。その結果、98%の施設で輸血前に看護師が患者のバイタルサイン測定を行ってから輸血を開始しており、輸血開始後5分間では95%の施設で看護師がベッドサイドで患者の状態を観察していた。さらに、輸血開始15分後には99%、輸血終了時は100%、輸血後は88%の施設で、看護師が断続的に輸血副反応の出現有無などを観察していた。一方、輸血開始後5分間、および輸血後に患者観察が行われていない施設がそれぞれ5%、12%あり、輸血開始から終了後まで一貫した患者観察が可能な体制を整備する必要があると考えられた。

輸血チーム医療の現状を把握するために行ったアンケート調査を踏まえて、輸血チーム医療を推進していくための方略について検討した。アンケートは医療スタッフ164名のうち142名(86.6%)から回答が得られた。アンケート結果からは「他職種との相互理解不足」が輸血医療チームの推進を妨げる主な要因であることが示唆された。また、職種によって現状のチーム医療に対する認識は異なることが明らかになった。以上、今回の調査結果から各施設においてコミュニケーション不足や相互理解不足によりミスマッチが生じやすい緊急輸血等の場面を想定したシミュレーションを実施し、輸血医療チームにおける他職種との相互理解や他職種の協力を得る努力を行っていく必要があると考えられた。

【目的】乳幼児から二次性徴前の児童における心周期と心室筋再分極過程の変動を variability ratio（VR）から評価し，年齢による変化について検討した．【対象】心疾患を有さない乳児から就学時までの児童176名を， I群（生後0～6ヵ月，17名），II群（生後7～11ヵ月，21名），III群（1歳，28名），IV群（2～3歳，37名），V群（4～5歳，36名），VI群（6～7歳，37名）の6群に分類し比較検討した．【方法】安静時心電図から 120心拍の RR間隔と QT時間の計測を行い，RR間隔の標準偏差（SDRR）とQT時間の標準偏差（SDQT）から VRを算出し，月齢との関係を求めた．【結果】各群でVR，SDRR，SDQTに性差を認めず，VRは年齢とともに減少し就学時には一定の値となった．年齢別基準値を用いることにより，自律神経系の生後発達を評価できる可能性が示唆された．

早産低出生体重児13例を対象に,脳波,眼球運動電位図,心電図,呼吸波を記録・解析し,日齢0と生後1ヵ月で比較した.日齢0から生後1ヵ月にかけて洞結節興奮周期(PP間隔)は有意な短縮を示し,房室結節伝導時間(PR間隔)は延長した.周波数特性をみると,PP,PRともに低周波数領域(LF)と高周波数領域(HF)の成分が増加し,呼吸周波数領域(RSA)の成分も増加していた.PP間隔の周波数解析で,LF/HFは日齢0の7.56から生後1ヵ月には3.28へと有意に低下し,RSA/全周波数領域(TF)は0.015から0.048に有意に増加していた.生理的な心周期に対する自律神経活動の増加と,呼吸性迷走神経活動の発現が示唆された.PRではLF/HFが0.86から1.37へと有意に増加したが,RSA/TFは0.138から0.125と有意な変化はなかった.房室伝導に対する交感神経活動は亢進していたが,呼吸迷走神経入力は微弱であり,房室伝導は呼吸以外の迷走神経系により優位に支配されていることが示唆された