BLOOD TRANSFUSION

ASSISTANT PROFESSORDr. Talib Hussein Kamoona

Karl Landsteiner: ABO Blood Group

1900 :Agglutination of RBCs from some individuals by serum from other individuals

On basis of this agglutination, assigned individuals to groups: A, B, C (O)

1907 :Reuben Ottenberg introduced pretransfusion compatibility testing

1930 :Nobel Prize in Physiology or Medicine

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BLOOD GROUPS

Red blood cells (rbc’s) can contain surface A & B antigens .There are four principal blood groups in humans: O, A, B and AB

Group Oanti-A

anti-B

Group O rbc’s have no surface A & B antigens: antibodies anti-A

& anti-B are present in the plasma

anti-B

Group A rbc’s have surface antigen A and antibody B.

Group A

anti-A

Group B rbc’s have surface antigen B and antibody A.

Group AB rbc’s have surface antigens A & B and no antibodies.

Group AB

Group B

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The Rhesus (Rh) antibody group is of great clinical importance, especially of women of child-bearing age.

The most common Rh antigen is called D and the antibody is called

anti-D .Rhesus negative (Rh-) people have no D antigen and generally no D antibody in their plasma (15% Caucasians, 1% Orientals).

If a Rh- person is transfused with Rh+ blood they will raise D

antibodies .A second transfusion with Rh+ blood will then result in red cell destruction.

BLOOD GROUPS - THE RHESUS FACTOR

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BLOOD GROUPS

When giving a blood transfusion it is important that the blood groups of the donor and recipient are known, otherwise the red cells may clump together - a process known as agglutination.e.g.

If group B blood cells were mixed with group O blood the anti-B antibody of the group O blood would bind to the B-antigen

Group B Group B

Group BGroup B anti-B

anti-B

anti

-B

anti

-B

Group O is a universal donor as group A, B or AB have no antibodies to group OGroup AB is a universal recipient because its plasma has no antibodies to other groups.

More Blood GroupsA few more blood groups discovered with direct agglutination

1945 :Robin Coombs described indirect agglutination using secondary anti-IgG to detect IgG-coated RBCs

Improved Platforms for Hemagglutination

ISBT Human Blood Group Systems Number/Name Abbreviation

001ABOABO002MNSMNS003P1P1004RhRH005LutheranLU006KellKEL007LewisLE008DuffyFY009KiddJK010DiegoDI011CartwrightYT012XGXG013SciannaSC014DombrockDO015ColtonCO016Landsteiner-WienerLW017Chido/RodgersCH/RG018HhH019KxXK020GerbichGE021CromerCROM022KnopsKN023IndianIN024OkOK025RaphRAPH026JMHJMH027II028PP

29GILGIL30RhAGRHAG

• 30 blood group systems

• 308 blood group antigens

• 1140 blood group alleles

Immunohematology: Operational

Two core serological tests based on RBC agglutination Type: phenotype Ags on RBC

Reagent is Ab of known specificity Screen: detect (and identify) RBC Abs in serum

Reagent is RBC of known phenotype

ABO: Ag-negative RBCs to prevent acute hemolysis Pre-formed Ab to non-self A and/or B antigens

D: Ag-negative RBCs to prevent alloimmunization

K, C(c), E(e): in sections of Europe and in sickle cell disease patients in US, Ag-negative RBCs to prevent alloimmunization

All other Ags: Ab screen to determine need for Ag-negative RBCs to prevent hemolysis

Crossmatch: Major (patient’s serum vs. donor RBCs) or immediate spin or electronic

ABO Population Frequencies

DAT Test Results

Warm AIHA: IgG, +/- C3CAD: C3PCH: +/- C3; positive Donath-Landsteiner test

Elution to remove the autoantibody from red cells. Once removed, can test eluate against a panel for specificity, if anyTiterThermal amplitude

Volunteer Blood Donor Eligibility

Age 16 or olderTypically 110 lbsIn good healthTemperature ≤37.5°C (99.5°F)Pulse 50-100Blood Pressure ≤ 180/100Hb/HCT 12.5 g/dl / 38%No skin lesions or signs of IV drug use

Volunteer Donations

•Medical History•Mini physical exam•Hb determination•Phlebotomy •Eat and Drink

Blood Bank

•Compatibility testing–ABO/Rh–Screening–Crossmatching

•Antibody identification

Blood Collection and Manufacturing

R e d B lo o d C e llsS h e lf L ife 35 - 4 2 d a ys

~ 2 5 0 - 3 1 0 cc ,1 -6C

P la te le t C o n ce n tra te5 d a y sh e lf life~ 5 0 cc,2 0 -2 4C

P la sm aF re sh F ro ze n

O n e ye ar sh e lf life~ 2 5 0 cc ,-1 8C

C e n trifu ge

P la te le t R ich P la sm a

C e n trifu ge

W h o le B o o d D o n a tion4 5 0 - 5 0 0 cc , 1 -6C

Plasma/Red Cell Separation

Centrifugation Plasma expression

Plateletpheresis donation

•1-2 products•Takes ≈ 2 hours•No aspirin for 36

hours

Blood Bank: Storage

Platelet Components

Platelets

•We use only apheresis platelets at our Hospital•Stored at room temperature/ continuous agitation•5 day shelf-life•Volume 200 mL-400mL•QC for apheresis platelets: 3 X 1011 platelets/unit in

at least 90% of units•In absence of decrease platelet survival, a unit should

raise 30,000-50,000/µL

Cryoprecipitated AHF

•Contains –Fibrinogen–Factor VIII–Von Willebrand Factor–Factor XIII–Fibronectin

Direct Antiglobulin Test (DAT)

What causes a positive DAT?

•Autoantibody to intrinsic RBC antigens•Alloantibodies in recipient circulation to transfused

cells•Alloantibodies in donor plasma to recipients RBC•Alloantibodies in maternal circulation which cross the

placenta and coat fetal or newborn cells•Antibodies against certain drugs which bind RBC

membrane (e.g. Pencillin)

What causes a positive DAT ?(Cont’d)

•Adsorbed proteins which attach to RBC modified by drugs (e.g. cephlasporin)

•Complement components bound to RBC after drugs (e.g. quindine)

•Non RBC immunoglobulins in hypergamma patients or after IVIG

•Antibodies produced by passenger lymphocytes in transplant organs and HPC

What does a positive DAT mean?

•Positive DAT does not necessarily mean shortened RBC survival

•-Positive DAT without clinical problems occur in 1:1000-1:14,000 blood donors and in 1-15%

of hospital patients•DAT can detect 100-500 molecules of IgG/ red

cell

What does a positive DAT mean?

•-Immune-mediated hemolysis is the shortening of RBC survival by immune mechanisms

•-If marrow can compensate, it may not result in anemia

•-Blood bank must rely on other lab data to determne if ‘hemolytic anemia” is occurring- e.g Hb, Retic

count, RBC morphology, bilirubin, haptoglobin, LD levels

•-Serologic findings suggest only whether hemolysis has an immune basis.

Determing the cause of positive DAT

•Complement only–Drug–Paroxymal Cold Hemglobinuria

• +Donath Landsteiner test

•Ig G alone or with complement–Elution to determine pattern of reaction

Defining the cause of a DAT with elution

•Positive eluate–Autoantibody – usually panagglutin–Alloantibody- RBC Ag specific

•Negative Eluate–Drug– anti-A or anti-B (unless test with A or B cells)

Categories of Transfusion Reactions Acute (<24h)

•Immunologic–Hemolytic–Febrile–Allergic–Anaphylactic–TRALI

•Non-immunologic–Circulatory Overload–Hemolytic

•Physical•Bacterial

contamination

–Air embolus–Metabolic reaction

Categories of Transfusion ReactionsDelayed (> 24 hours)

•Immunologic–Alloimmunization

•RBC•HLA

•Hemolytic•GVHD•Post-transfusion

Purpura•Immunomodulation

•Non-immunologic–Iron overload–Viral infections

•HCV•HBV•HIV•HTLV

–Other organisms•Malaria, Chagas,

Babesiosis, etc.

Protocol for ALL acute transfusion reactions

•STOP THE TRANSFUSION immediately•Maintain IV assess with 0.9% NaCl•Check blood component for patient ID•Notify Blood Bank(BB)•Send blood sample and urine to BB•Keep blood unit in case culture becomes

necessary•Support patient as necessary

Transfusion Medicine Reviews 2005;19: 2-31

Febrile Non-hemolytic Transfusion Reaction (FNHTR)

•Defined as a ≥1 C rise in temperature that cannot be explained by the patients clinical

condition•Usually accompanied by chills, rigors or

discomfort•4-5% fever is only symptom•5-10% of time symptoms occur after

transfusion completed (usually within 1-2 hr.)

Acute Hemolytic Transfusion Reaction

Key points •Transfused RBC react with

preformed antibody•Most severe caused by ABO

incompatibility•Most caused by clerical error

rather than laboratory error•About 10% of ABO incompatible

will be fatal

Laboratory Investigation–Clerical check–DAT (may be negative if all

cells destroyed)–Visual check for hemolysis–Repeat other serologic test–Helpful in diagnosing

hemolysis -haptoglobin, serum hemoglobin, urine

hemoglobin, LDH, Indirect Bilirubin

Acute Shortness of breath in a transfusion recipient

•Allergic•Circulatory Overload•TRALI

Allergic and Anaphylactic Transfusion Reaction

•Assumes interaction between allergen and preformed IgE antibody

•Allergen is usually plasma protein of donor•Mild urticaria in 1-3% of plasma transfusions•Anaphlaxsis1:20K to 47K units of blood or

components•In general the shorter the time before reaction

the more severe the reaction•Tendency for reactions to get worse when

repeated infusions

Circulatory Overloadoccurs in

•Patients with diminished cardiac reserve•Setting of chronic anemia•Setting of massive transfusion•Transfusion small infants

Circulatory Overload

•Occurs in approximately 1:700 transfusions•9% of Transfusion-related fatalities reported

to FDA•Single unit consider cause in 20% of cases•SLOW DOWN THE TRANSFUSION

Incidence of TRALI

•Unknown•0.014%–0.08% per unit of allogeneic blood or• 1 in 5000 transfusions has frequently been

quoted•A case fatality rate of 1%–10% has been

reported•Most common cause of fatal transfusion

reaction

Transfusion-related Lung InjuryClinical Features

•Timeline: Symptoms from onset of transfusion*

–>90% of cases within 1-2 hours–100% of cases within 6 hours

•Plasma-containing transfusions+ *•Female antibody-pos donor involved in 75% of

cases+

*Popovsky MA, Transfusion 1985;28:573-577

+Eder,A Transfusion 2007;47:599-607

LUNG LIVER

BRAIN

Am J Clin Pathol 2008;129:287-297

BRAIN

LUNG

Intra-alveolar granulocytes

Am J Clin Pathol 2008;129:287-297

Incidence of HIV and HCV increased between 2005-2006 and 2007-2008

•Increase HIV incidence primarily among 16-19

years old male (accounted for 60% of increase)

•Increase in HCV incidence primarily among Caucasian

males >50 years old

Zou S, Dosey KA, Notari EP. Et.al. Transfusion 2010;50:1495-1504

GOOD LUCK

WISH YOU ALL THE BEST