BLOOD TRANSFUSION

1. BLOOD TRANSFUSION ASSISTANT PROFESSOR Dr. Talib Hussein Kamoona

2. 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

3. Group B anti-B 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 O anti-A anti-A Group O rbc’s have no surface A & B antigens: antibodies anti-A & anti-B are present in the plasma Group B rbc’s have surface antigen B and antibody A. Group A Group AB anti-B Group A rbc’s have surface antigen A and antibody B. Group AB rbc’s have surface antigens A & B and no antibodies.

4. BLOOD GROUPS - THE RHESUS FACTOR 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.

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

6. More Blood Groups A few more blood groups discovered with direct agglutination 1945: Robin Coombs described indirect agglutination using secondary anti-IgG to detect IgG-coated RBCs

7. Improved Platforms for Hemagglutination

8. Number/Name Abbreviation 001 ABO ABO 002 MNS MNS 003 P1 P1 004 RhRH 005 Lutheran LU 006 Kell KEL 007 Lewis LE 008 Duffy FY 009 Kidd JK 010 Diego DI 011 Cartwright YT 012 XG XG 013 Scianna SC 014 Dombrock DO 015 Colton CO 016 Landsteiner-Wiener LW 017 Chido/Rodgers CH/RG 018 Hh H 019 Kx XK 020 Gerbich GE 021 Cromer CROM 022 Knops KN 023 Indian IN 024 Ok OK 025 RaphRAPH 026 JMH JMH 027 I I 028 P P GIL GIL 30 RhAGRHAG ISBT Human Blood Group Systems • 30 blood group systems • 308 blood group antigens • 1140 blood group alleles

9. 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

10. ABO Population Frequencies

11. DAT Test Results Warm AIHA: IgG, +/- C3 CAD: C3 PCH: +/- C3; positive Donath-Landsteiner test Elution to remove the autoantibody from red cells. Once removed, can test eluate against a panel for specificity, if any Titer Thermal amplitude

12. Volunteer Blood Donor Eligibility Age 16 or older Typically 110 lbs In good health Temperature ≤37.5°C (99.5°F) Pulse 50-100 Blood Pressure ≤ 180/100 Hb/HCT 12.5 g/dl / 38% No skin lesions or signs of IV drug use

13. Volunteer Donations • Medical History • Mini physical exam • Hb determination • Phlebotomy • Eat and Drink

14. Blood Bank • Compatibility testing • ABO/Rh • Screening • Crossmatching • Antibody identification

15. Blood Collection and Manufacturing

16. Plasma/Red Cell Separation Centrifugation Plasma expression

17. Plateletpheresis donation • 1-2 products • Takes ≈ 2 hours • No aspirin for 36 hours

18. Blood Bank: Storage

19. Platelet Components

20. 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

21. Cryoprecipitated AHF • Contains • Fibrinogen • Factor VIII • Von Willebrand Factor • Factor XIII • Fibronectin

22. Direct Antiglobulin Test (DAT)

23. 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)

24. 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

25. 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

26. 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.

27. 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

28. 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)

29. Immunologic Hemolytic Febrile Allergic Anaphylactic TRALI Non-immunologic Circulatory Overload Hemolytic Physical Bacterial contamination Air embolus Metabolic reaction Categories of Transfusion ReactionsAcute (<24h)

30. 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. Categories of Transfusion ReactionsDelayed (> 24 hours)

31. 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

32. Transfusion Medicine Reviews 2005;19: 2-31

33. 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.)

34. Acute Hemolytic Transfusion Reaction Key points 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 • 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

35. Acute Shortness of breath in a transfusion recipient • Allergic • Circulatory Overload • TRALI

36. 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

37. Circulatory Overloadoccurs in • Patients with diminished cardiac reserve • Setting of chronic anemia • Setting of massive transfusion • Transfusion small infants

38. 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

39. 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

40. 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

41. LUNG LUNG LIVER BRAIN BRAIN Am J Clin Pathol 2008;129:287-297

42. Intra-alveolar granulocytes Am J Clin Pathol 2008;129:287-297

43. 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

44. GOOD LUCK WISH YOU ALL THE BEST