Unit 14 Hemotherapy and Organ Transplantation

1. Unit 14 Hemotherapy and Organ Transplantation Terry Kotrla, MS, MT(ASCP)BB

2. Hemotherapy Introduction • Indications for transfusion must be defined. • Transfuse appropriate product. • Products most frequently used: • Red blood cells • Apheresis platelets • Fresh frozen plasma • Cryoprecipitate • Additional considerations: • Irradiated • CMV negative

3. Red Blood Cells • Used to treat symptomatic anemia. • Criteria for selection • ABO compatible • Negative for antigens that patient has clinically significant, alloantibodies to. • Infant – compatible with baby and mother and lack antigens to which mother has clinically significant antibodies.

4. Red Blood Cells • Indications for use: • Oncology patients • Trauma victims • Cardiac, orthopedic and other selected surgeries. • End-stage renal disease • Premature infants • Diseases such as sickle cell, thalassemia, aplastic anemia, etc. • Additional considerations • Immunosuppressed give CMV negative • Risk of TA-GVHD give irradiated

5. Apheresis Platelets • Used to treat thrombocytopenia • Function includes • Maintenance of vascular integrity • Initial arrest of bleeding by platelet plug formation. • Stabilization of hemostatic plug through contribution to fibrin formation. • Criteria for selection • ABO compatible if possible • If ABO compatible not available limit exposure. • D negative for D negative recipients, can give RhIG

6. Apheresis Platelets • Indications for use: • Chemotherapy or radiation therapy patients. • Post-hematopoietic progenitor cell transplant recipients • Peri- or post-operative bleeding • Thrombocytopenic purpura • Thrombocytopenia due to other causes • Additional considerations • Immunosuppressed give CMV negative • Risk of TA-GVHD give irradiated

7. Fresh Frozen Plasma • Used to replace clotting factors including labile factors V and VIII. • Criteria for selection • MUST be ABO compatible. • Crossmatching NOT necessary. • ABO selection • Think of ABO antibodies in PATIENT. • AB universal donor. • Group O universal recipient, WHY?

8. Fresh Frozen Plasma • Preparation • NEVER thaw until order to give is confirmed. • Thaw at 37C for 30-45 minutes – several methods available. • Must use protective overwrap to protect ports from contamination. • Expiration • 24 hours • After 24 hours can be relabeled “thawed plasma” and used for 5 days if not needed for Factor V or VIII.

9. Fresh Frozen Plasma • Indications for use • Clotting factor concentrates not available. • Massive transfusion. • Patients on warfarin who are bleeding. • Plasmapheresis • Severe liver disease • DIC • Rare specific plasma protein deficiencies. • Two units frequently ordered.

10. Cryoprecipitate • What is it? • Insoluble precipitate which forms when FFP is thawed at 1-6C. • Contains concentrated levels of Factor VIII and fibrinogen. • Criteria for selection • Due to small volume ABO group does not matter UNLESS patient is an infant or small child. • ABO compatibility considerations same as FFP.

11. Cryoprecipitate • Preparation • NEVER thaw until order to give is confirmed. • Must be thawed at 37C. • Protect ports. • For adult patient pool 6-10 units for therapeutic dose • Expiration • Frozen 1 year. • Thawed 6 hours • Pooled 4 hours

12. Cryoprecipitate • Indications for use: • Massive transfusion • DIC • Fibrinogenemia • VonWillebrand’s disease

13. Massive Transfusion Protocol • Massively bleeding patients need EVERYTHING. • Massive transfusion protocols have been studied and are proven to reduce mortality rates. • Numbers will vary according to institution but standardizes the protocol to transfuse components. • Example for adult: • 6 units RBCs • 4 units FFP • 1 unit apheresis platelets • Continue until lab results are within normal limits.

14. Transplantation • Solid organs • Kidney • Liver • Lungs • Intestine • Pancreas • Heart • Living donor tissue and cell allografts • Hematopoietic progenitor cells: bone marrow or peripheral blood • Cord blood • Tissue Allografts: bone, heart valves, tendons, etc.

15. Transplantation • Solid Organ Compatibility testing • MUST be ABO compatible for solid organ transplants. • MUST be HLA compatible • Progenitor cells or bone marrow • ABO doesn’t matter. • MUST be HLA compatible • Other tissues (bone, etc.) only stored, no compatibility testing necessary – bone and cornea most common. • Transfusion service role • Accurate ABO typing of donor • Supply blood appropriate blood components.

16. Human Leukocyte Antigens (HLA) • Complex array of genes and their molecular products involved in immune regulation and cellular differentiation. • HLA antigens found on surface membranes of all NUCLEATED cells. • Second in importance to only ABO for solid organ transplant survival.

17. Human Leukocyte Antigens (HLA) • HLA found on surface of nucleated cells which includes WBC. • Function of HLA is to help identify and in turn, fight “foreign stuff” • 2 types of HLAsome for MHC I and MHC II (MHC genes are on chromosome 6) • Most important HLA are types A, B (MHC I) and DR (MHC II) • MHC I present antigens to cytotoxic T cells and MHC II use antigen-presenting cells for helper T cells • For this reason, it is important to have closely matched HLA between donor and recipient to avoid rejection, i.e., to avoid donor cells being presented to recipient immune system by MHC for destruction.

18. Recipient Qualifications • List of individuals waiting for organs far exceeds supply. • Most cases <60 yr old • Disqualified if: • Recent MI • Active infection • Malignancy • Substance abuse • Limited life expectancy from unrelated disease

19. Time Factors - FYI • Once harvested organs must be transplanted quickly • Kidney – 48 hours • Pancreas – 24 hours • Liver – 12 hours • Corneas – 8 hours • Heart and lungs – 6 hours • Recipients closest to location of donor and who “match” are first ones offered organ. • United Network for Organ Sharing (UNOS) is clearing house http://www.unos.org/

20. Transfusion Support • Liver transplant require the most blood components. • Problem if patient has alloantibodies • Use antigen negative first 5-10 units • Switch to unscreened or partially matched units. • Use antigen negative last 5-10 units. • Requires close communication between physician and transfusion service. • May use preop plasmapheresis to reduce titer of clinically significant antibodies.

21. Transfusion Support • Transfusion support for other types of transplants usually not a problem. • Follow protocol at your institution. • Products • Irradiated • CMV negative

22. Marrow Transplantation • Types • Autologous hematopoietic progenitor cells (HPC)(not really a transplant but a “rescue”). • Allogeneic hematopoietic progenitor cells. • Bone marrow • Purpose is to reconstitute patient’s heamtopoietic system after destruction of the recipient’s. • Procedure • Destroy patient’s bone marrow totally. • Infuse HLA matched HPC or bone marrow. • Monitor for engraftment.

23. Marrow Transplantation • Indications • Hematologic malignancies • Severe immunodeficiency • Aplastic anemia • Hemoglobinopathies • Malignant diseases are the most common indication. • Success rate depends on • Patient’s disease and stage of disease • Degree of prior treatment • Age and condition of patient • Degree of HLA match between patient and donor.

24. Transfusion Support for Marrow Transplant • Refer to page 310 in textbook. • Transfusion service staff must carefully follow protocol and determine phase patient is in. • Phase I compatible with recipient. • Phase II compatible with recipient and donor. • Phase III compatible with donor.

25. Marrow Transplantation – Transfusion Service Challenges • Challenges for transfusion service after successful transplant with ABO marrow different than original. • During transition mixed field results and ABO discrepancies will occur, indicates successful engraftment. • Historical type will be one type, current sample will be another after successful engraftment. • History is CRUCIAL in these situations. • Must have patient redrawn to verify no collection error occurred. • Must document from medical records when transplant was performed.

26. References • AABB Technical Manual 16th edition, 2008 • Basic & Applied Concepts of Immunohematology, Blaney and Howard, 2009 • Massive Transfusion Protocols, 2009, http://www.cinj.org/documents/MTP.pdf • Massive Transfusion for Trauma is Appropriate, 2005, http://www.itaccs.com/traumacare/archive/05_03_Summer_2005/appropriate.pdf • Transfusion Support in Solid-Organ Transplantation, 2001, http://www.itxm.org/tmu/tmu2001/tmu4-2001.htm • Role of Transfusion Services in Organ and Tissue Transplantation http://tinyurl.com/3ojbr9l

27. End of Unit 14