【正文】 n fo u n d ing v a ri a b lesx x v i su ch a s a g e o f b lo o d p rod u cts. T RA L I may b e d u e , in p a rt, t o lipid s d e ri v e d f r o m w h ite c e ll s a n d p re sto rag e leu ko red u ctio n ma y re d u ce th e tra n s f u sio n b u rde nx x v i i L ike CMV, o th e r c e ll a sso ciat e d v ir u se s a re remo v e d b y le u ko f i ltrat ion , s u ch a s HT L V 1x x v i i i L e u k o red u c tio n f il t e rs h a v e b e e n sh o w n to re m o v e b a c te ri a in cl u d ing Y e rsi n ia sp .x x i x, co a g n e g a tiv e S ta p h yloco cc u sxxx a s w e ll a s p a rasite s like Trypa n o s o m e sxxxi, to so me e x te n t a n d p e rha p s L e ishma n iax x x i i. Inta ngib le B e ne fits A s soc ia te d w i th ULR ? ? En dors ed by both BP ACx x x i i i adv i sin g t he FDA an d B SA Cx x x i v adv i sin g DH HS , 15 count r i es hav e ado pt ed UL Rxxxv as w el l as bei ng 80 % i m pl em ented i n t he USx x x vi wi t h g r ow i ng i m pl i cat i ons r eg a r di ng issues o f st and ar d o f ca r e ? ? M ana g i ng dua l i nv entor i es i s l abo r i nt ensi v e and pr esent s t he r i s k o f pa t i ents r ecei v i ng non LR bl ood w hen t hey nee d i t ? ? Co st s o f i m pl em entin g UL R hav e bee n j us t i f i ed b y som e m aj o r i ns t i t ut i ons suc h a s Ya l e Un i v er sity Ho spi t al 13 46 7 8 913 14 1518 1920 21,22 23,24 25 26 27 28 29 30 31 32 33 34 35 36 Known effects of Leucocytes ? Alloimmunization leading on to Refractoriness ? Infection transmission viruses and bacteria ? Immunomodulation higher incidence of post op. Infection ? Immunosuppression higher AND increased incidence of solid tumour reformation ALLOIMMUNISATION AND REFRACTORINESS Antigen Presenting Cell BLymphocyte Plasma Cell Memory Cell TLymphocyte Donor Recipient Transfusion Antibody Production * The production of HLA antibodies is a 2 signal process requiring the presence of both Class I and Class II antigens Location of HLA * HLA Class I Present on ALL nucleated cells (white cells) and platelets * HLA Class II Present ONLY on Monocytes, Macrophages, BLymphocytes, activated TLymphocytes, dendritic cells NB: red cells do not express HLA Alloimmunisation ALLOIMMUNISATION % 05101520253035404550Killick, 1997Adamzik, 1995Williamson, 1994Oksanen, 1994Saarinen, 1993BedfordRussel, 1993Control Groups Filter Groups ANALYSIS OF UTILIZATION AND COST OF PLATELET TRANSFUSION IN REFRACTORY HEMATOLOGY / ONCOLOGY PATIENTS 020406080100120140160180RefractoryNon Refractory0246810121416020224000600080001000012022Number of Average Platelets Average Admissions Transfused Platelet Costs ($) Lill et al., . 1997 IN P A T IE N T P L A T E L E T U S E amp。 C OS T S :A C OM P A R IS O N B E T W E E N R E F R A C T OR YA N D N ON R E F R A C T OR Y P A T IE N T SG or d on e t al . , A S H 19 960102030405060708090P at i e n tN u m b e rP l at e l e tU n i t sT r an s f u s e dL e n gt h ofS t ayP l at e l e tC o s t sT o t al C o s t sR ef r a ct o ryN o n R ef r a ct o ry%N = 24 5N = 48 0$2 3, 51 0$3,126$5 9, 42 6$1 5, 89 7Author Patient Group Alloimmunisation Refractoriness Blood Product Reduction Standard Leucodepleted Standard Leucodepleted Red Cells Platelets HLA Matched . Study, 1997 AML 45% 17% 13% 3% 0% 0% Killick et al ., 1997 Aplastic 50% 12% 0% Anaemics Novotney et al ., 1995 Aplastic 12% 5% Thrombocytopenics Adamzik et al ., 1995 Cancer 27% 0% 27% 0% % AML % Blumberg et al ., 1995 AML 0% % * Lymphoma % % * Williamson et al ., 1994 Cancer % % 31% 24% AML 63% 31% Oksanen et al ., 1994 AML 38% 17% 21% 3% % % * Saarinen et al ., 1993 Leukaemics 30% 0% 10% 0% % % BedfordRussell et al ., 1993 Neonates % 0% Myllyla et al ., 1993 Renal 67% 19% Leukaemics 52% 0% AML 18% % AlMomen et al ., 1992 Leukaemics % van Prooijen et al ., 1991 Leukaemics % % 82% van Marwijk Kooy et al ., Leukaemics 42% 7% 46% 11% 1991 Overall Means: % % % 6% % % 82% * Authors found additional cost savings in terms of length of hospital stay (2341% reduction) and total charges (1041% reduction) in the leucocyte depleted arm ? 造成血小板減少的病人出血之原因，除了血小板數(shù)目外，很多其它的臨床癥狀也要考慮，例如敗血癥，尿毒癥，凝血功能異常，以及藥物的影響等。不之疾病造成血小板之減少癥，對(duì)輸血小板之反應(yīng)不盡相同，如敗血癥，脾腫大，免疫性血小板減少癥，則對(duì)輸血小板之反應(yīng)不佳。因此，除了血小板的數(shù)目外，引起血小板減少之原因及疾病亦應(yīng)注意，才能掌握血小板輸注的正確時(shí)效。 ? 治療性血小板輸注呢？一般而言，是只對(duì)正在出血的血小板減少之病人之治療方法。這時(shí)在輸血小板之前及之后，對(duì)血中血小板數(shù)量的監(jiān)測(cè)與比較是很重要的，因?yàn)檫@樣可以評(píng)估血小板的存活數(shù)量，以及預(yù)測(cè)未來對(duì)輸血小板的需求。如果血小板的數(shù)量沒有爬升，即使是反覆的輸血，可能對(duì)病人并沒有什么好處。通常此時(shí)醫(yī)師必須積極去追查造成頑固性血小板減少的原因。 ? 有一些疾病所導(dǎo)致的血小板減少癥對(duì)輸血小板的反應(yīng)良好，特別是針對(duì)骨髓抑制所造成的頑固性血小版減少癥。如化學(xué)治療后，放射線治療后，維持生活素缺乏，或是再生性不良性貧血等。 ? 另外有一些疾病所導(dǎo)致的血小板減少癥則對(duì)輸血小板反應(yīng)不好，如：敗血癥 (sepsis)，脾臟腫大(splenectomy)，以及免疫性血小板減少癥，包括自體免疫性血小板減少癥 (immuhrombocytopenia)，藥物引起之血小板減少癥，或是淋巴增生性疾病等。相對(duì)的，有一些疾病所導(dǎo)致的血小板減少癥，輸血小板則為其禁忌癥。如血栓性血小板減少性紫斑癥(thromboticthrombocytopenic purpura，可能會(huì)因輸血小板而導(dǎo)致血栓更加惡化。 ? 頑固性 (refractory)的血小板減少癥： ? 頑固性 (refractory)的血小板減少癥包含了： ? (nonimmune)的頑固性的血小板減少癥 ? (alloimmunization)的頑固性的血小板減少癥 ? 非免疫性的頑固性血小板減少癥的原因包含：敗血癥 (sepsis)，彌漫性血管內(nèi)凝血癥 (DIC)，以及脾臟腫大 (splenomegaly)等。 對(duì)于非免疫性的頑固性的血小板減少癥的處理方法有： ABO血型相符之血品 (splenectomy)的病人則應(yīng)增加血小板的劑量 (sepsis)及彌漫性血管內(nèi)凝