We have recently had an "effeciency expert" inhouse to try to determine ways in which we can cut costs. One of the recommendations was to decrease the use of CMV negative products since in their opinion leukoreduction by filtration filters CMV essentially making the unit CMV negative. My question is is this a true statement, and what justification can be found to agree with or disagree with this? Also, how many of you all out in BB land agree with this and do you use CMV seronegative products or rely on the filtration to "clean" the units?:confused:

It is true (ish)!

Pall, who make the filters we use within the NHSBT, have shown that, actually, when serology is used to show CMV (as opposed to the newer molecular methods), the filters are more reliable, because there is an innate false negativity in the serological test. So, for "normal" patients, we use just filtered blood.

However, when the patient is immunocompromised (such as a newborn or a patient who has undergone a BMT or SCT) we use components that are leukodepleted and CMV- (these days by molecular methods).

I will be very interested to see the responses to this question. (Thanks, MAGNUM!)

I remember reading several articles a few years ago about this topic (basically promoting the use of leukoreduced blood products and dropping the CVM Neg requirements.) Since we use only leukoreduced red cell and platelet products, I sent the articles to our Oncology group asking if we could drop the requests for CMV Negative products. Their answer was "No." I don't know if they responded "No" because they didn't accept the research findings or if they just didn't feel knowledgable or confident enough to be "trailblazers" for the change of practice.

Donna

So Malcolm you mentioned immunocompromised patients, but what about our oncology patients who have never tested as CMV positive do we give them leukoreduced products or CMV seronegative products?

Personally, as a scientist, rather than a clinician, I would give leukodepleted, but, as I scientist, I don't have to take that decision (thank goodness)

Over to Liz?????????????????????????????????

From what I have seen in the literature, pre-storage leukodepleted blood products were found statistically to be no more likely to transmit CMV to a recipient than CMV seronegative blood products. Bedside filters were not found to be as effective. Remember that the test we are relying on here is an *antibody* test, so there is a wider window period in which CMV would not be detected than in an antigen test. The practice here is to use pre-storage leukodepleted blood products for neonates and oncology patients and to use products that are both pre-storage leukodepleted and CMV seronegative for intrauterine transfusions and transplant patients (regardless of their CMV status).

So can anyone point me to a reference for this.

While CMV is in the WBCs, and it would make perfectly logical sense that pre-storage leukoreduced blood could be considered CMV negative, he hasn't found studies proving that fact that meet his strict standards.... we continue treating CMV+ blood products as CMV+ regardless of their leukoreduction standards.

Personally, as a scientist, rather than a clinician, I would give leukodepleted, but, as I scientist, I don't have to take that decision (thank goodness)

Over to Liz?????????????????????????????????

Hi I see my name

Pre-storage leukocyte reduction, reduces the WBCs, they are not depleted. The filtered unit is called CMV-safe. As safe as if we serologically tested the unit and it tested negative (Ab).

If your oncology patient is CMV negative I would give CMV serologically negative blood (it is required to test the unit) and, if possible, preferably by NAT, as well as pre-storage leukocyte-reduced through filtration. The pre-storage leukocyte-reduced through filtration will be for CMV and for the other benefits of leukocyte-reduction.

I want to add that I agree with Adiecast.

Please note that when a unit is CMV positive, leuko-reducing it does not change its status; it remains CMV positive.

We also consider pre-storage leukoreduced products to be "CMV neg equivalent". The only patients that we recommend CMV neg for are neonates, bone marrow/stem cell transplants (6 months pre and 6 months post transplant). Getting our oncologists not to order it on everyone is always a challenge.

I believe Julie Staves at the John Radcliffe in Oxford has stopped using CMV negative units but I don't have a reference (if there is one).

Here in the good old middle east (Abu Dhabi to be precise) I have no choice but to treat leucoreduced units as CMV negative. Our local blood supplier does not test any of the units it supplies for CMV. My hospital is a maternity hospital with a specialist 50 bed NICU unit. All difficult maternity cases and premature babies are referred here. So I have to end up giving ELBW babies (<750g) leucoreduced blood with an unknown CMV status. We do about 50 top-ups per month, and in four years here I have only been told of 2 or 3 neonates that got a CMV infection. Of course the doctors suspect it has come from the blood units transfused but I believe the mother can also be the cause if she is CMV positive and is supplying infected milk through breastfeeding (please correct me if I`m wrong!)

So if we say we have done 2400 top-ups over 4 years and only had 2 or 3 CMV infected babies during that time, can we say that leucoreduced blood has been shown to be as good as CMV negative blood - or is 2 or 3 infections still 2 or 3 too many?

just a thought on this, I had a high school friend who started chemotherapy. She had a history of a low HCT to the point she was rejected as a blood donor. A few weeks after the chemo was started we started transfusing her with leukodepleted red cells. Shortly after her 3rd transfusion visit, she became gravely ill and died from a CMV infection. The question at that time was did she have a previous infection to come back or was it from the blood?

Sadly, it could be either.

As I understand it, the patient can either get a primary infection (not necessarily the same strain of CMV with which they were originally infected) or can get a sort of secondary infection with the original strain that, clinically, can be far more severe than the original infection.

NOTE: I am no expert on this area of Blood Transfusion.

See this article In Transfusion Magazine:

Issue Dodd, R. (2010), Direct assessment of cytomegalovirus transfusion-transmitted risks after universal leukoreduction. Transfusion, 50: 776–786.

Basically after studying baseline sero-negative patients, the risk of CMV-TTD is around 6.5% after universal leukoreduction.

Although I could not find the article, I seem to remember (but I am as old as dirt) that the term used when universal leukoreduction was being considered as an FDA requirement was "CMV safe." Much of the literature at that time was from University of Rochester, Strong Memorial Hospital and Rochester Region Red Cross Blood Services. They stated that with leukoreduction, the need to test for CMV would be eliminated except for Bone Marrow transplant patients. Note: I do not necessarily agree with any of these statements, this is what I recall as arguements for universal leukoreduction of packed red cells.

We switched to cmv safe (pre-storage leukodepleted products) more than 10 years ago.We use CMV safe products on all oncology, BMT and NICU patients and so far we have not had any sero-convention.

We use pre-storage leuko-reduced products for all patients except for CMV neg recipients of a CMV neg transplant or those with an immunodeficiency disorder such as deGeorge's. In addition these patients are also getting irradiated products.

We had a policy WAY, WAY back when to give CMVN, irradiated products to all potential transplant candidates regardless of the type of transplant. Since most of the transplants occur somewhere else, I do not have access to the CMV status of the patient. When I request that the patient be tested, I get a lot of push back from the physicians. When I ask if they still want this product based on past protocols, most of them just answer yes without any idea what or why I am asking. We have had charges rejected by Medicare/Medicaid because they do not meet the criteria for use of that particular product.

The Circular of Information, revised Dec 2009, states: " Transfusion of CMV-negative blood is indicated in CMV-seronegative recipients who are at risk for severe CMV infections. These at-risk groups include pregnant women and their fetuses, low birthweight infants, hematopoietic progenitor cell transpland recipients, solid-organ transplant recipients, severely immunosuppressed recipients, and HIV-infected patients. Leukocyte-reduced components may be an alternative to CMV-seronegative transfusion in some clinical conditions." Unfortunately, it DOES NOT say what the 'some clinical conditions' are..... In addition to the cases stated above, we continue to give CMV-negative product to those who have tested CMV-negative. Their CMV status is entered in to our computer system so there is no question when they come in for transfusion.

hi dear friends of BBTalk

i am back, being away for a while for not receiving Pathtalk for a few months. Now i have it but somehow they are sent to " spam" .It's ok, i just go from there.

Thanks for the clarification of " CMV negative and leukopoor products"

Just want to mention a little bit about CMV neg at our facility:

- when being asked "is the unit CMV neg, " our answer is : the unit is leukopoor, CMV neg is taken care.All units are leukopoor here.

- our blood supply (blood and platelets) has some units that are CMV neg , we never order or request CMV neg

-for oncology patients, we use irradiated products if the dr orders

Also thanks to Cliff for helping me to restore Pathtalk

For all that option we are using irradiated blood for transplant and neonatal and all other. we irradiat the blood just when we recive call for transfusion . ( coz it takes less time to irradiat)

So can anyone point me to a reference for this.

Try these for starters:

Transfusion 2001;41:419-426

Blood 2004 Feb 1;103(3):1137-9

Blood 1995; 86: 3598-3603

Question 1: Smith et al (Vox Sanguinis 2010;98:29-36) published a survey of current practices among 183 hospitals that showed variability in practices to reduce the risk of transfusion-transmitted CMV. The authors noted that, “Lack of a consensus approach may reflect the conflicting data that exist in the literature as well as adherence to longstanding practice.”

Question 2: CMV DNA detection does not appear to correlate well with CMV seropositivity or infectivity. In 2003, Roback et al (Transfusion 2003;43:314-321) reported that CMV is only rarely detectable in seropositive donors and the use of CMV PCR assays does not increase the detection of potentially infectious blood components beyond current serologic screening assays.