BLOOD TRANSFUSION

Suprhamanyam Evali

QUIZ

What is your blood

group? How
common is it in this
room? is it the same
as the world population?

RECESSIVE but most common??

ANSWER: it is the ancestral form.
The A and B mutations
appeared in the last 20,000 years
and haven't spread
through the population yet.

TOPICS

Blood Components
Pre-transfusion Testing
Transfusion Reactions

1665 1st Documented

Animal-to-Animal Transfusion
Dog-to-dog
transfusion
by Richard
Lower.
From Petz and Swishers Clinical Practice of
Transfusion Medicine, 2nd ed., 1989.

16671st Documented
Animal-to-Human Transfusion
Jean Baptiste
Denis infuses
15-year-old
boy with
lambs blood.

From Zmijewskis Immunohematology.

18181st Documented
Human-to-Human Transfusion
Following a 150-year
transfusion hiatus,
James Blundell
transfuses patient with
blood from a human
donor.
From Petz and Swishers Clinical Practice of
Transfusion Medicine, 2nd ed., 1989.

1800sAll Manner of Blood

Collection Devices Utilized
(You think presentday donor centers
sometimes face
challenges in
recruiting repeat
blood donors?)
From Petz and Swishers Clinical Practice of
Transfusion Medicine, 2nd ed., 1989.

1900
ABH Blood Group System IDd
Karl Landsteiner
discovers ABH system
when he types
individuals as (what we
now call) group A, group
B, and group O. In 1902,
his proteges identify a
group AB individual for
the first time.
From Transfusion, Vol. 1, p. 2 (1961)

The Discovery of Many Other

Red Cell Antigens Followed

Rh (C, c, D, E, e, )
Kell (K, k, )
Kidd (Jka, Jkb, )
Duffy (Fya, Fyb, )
MNSs,
Lewis (Lea, Leb)

How We Make Blood Components

Collection Process
(1) Via Whole Blood Donation:
Whole
blood
TAKE
ALLis collected from
healthy blood donors into sterile
blood bags that contain
anticoagulant-preservative.
(2) Via Apheresis: Machines with
internal
centrifuges
TAKE
WHAT YOUseparate a donors
bloodWANT
into individual components (e.g.,
platelets, plasma, RBCs, etc.). The
desired components are retained,
while the remainder is returned to the
donor.

Blood products

Whole blood

Cellular
PRBCs
Platelets

Plasma
FFP
Cryoprecipitate
Other proteins

You may donate

every 56 days

Blood Component Preparation

A little goes a long way
450ml
Slow centrifuge
200-250ml
Fast centrifuge
180-200ml
50-70ml
10-15ml

The plasma from your donation is replaced

within about 24 hours. Red cells need about
four to six weeks for complete replacement.
Thats why at least eight weeks are required
between whole blood donations

Blood component

Whole Blood Separation

Typical values of the density of blood

plasma and blood cells are
1025 kg/m^3 and 1125 kg/m^3,
respectively."

Differential Centrifugation
First Centrifugation
Closed System

Whole Blood
Main Bag

RBCs

Satellite
Bag
1

Satellite Bag
2

First

Platelet-rich
Plasma

Differential Centrifugation
Second Centrifugation

RBCs

Platelet-rich
Plasma

Second

RBCs

Platelet
Concentrate

Plasma

Collection of Blood Products

Apheresis

(TAKE WHAT U WANT-RETURN WHAT U DONT)

Plateletpheresis- may donate up to 24x/year

Leukapheresis-granulocytes donor given
dexamethasone? G-CSF?
Erythrocytapheresis may donate every 16 weeks
Plasmapheresis
Stem Cell collection

Blood products

Cellular Components:

Red blood cells

- Leukocyte-reduced RBCs purified

- Washed RBCs plasmaless RBC

- Irradiated RBCs smash the DNA of WBC to prevent
GVHD

Platelets
- Whole blood derived platelets

- Single-donor platelets (Apheresis Platelets)

Granulocytes

Blood products

Acellular Components:

Fresh-frozen plasma (FFP), Thawed plasma

Cryoprecipitate
Factor concentrates (VIII, IX)
Albumin

Blood Component Manufacture from Whole

Blood
Leukoreduce
Possibly irradiate
Other

RBCs

+
Platelet-Rich
Plasma

ge
Centrifu es)
forc
g
r
e
h
(hig

Platelets

or

Plasma

Fre
ez
e

Fresh Frozen Plasma (FFP)

or
Plasma Frozen with 24 hours

Blood Component Manufacture from

Whole Blood
Fresh
Frozen
Plasma
(FFP)

Cryoprecipitate
Thaw (4 C)
Centrifuge

+
Cryo-Reduced
Plasma

Using the Leftovers Wisely

a d)
m
s kin
a
l
P ny
a
f
(o

Sent for

further processing

Plasma Derivatives

Albumin
Factor VIII
Immune globulin
etc.

Over 400 red cell antigens described

Each antigen is defined by a specific
antibody
Antigens are divided into blood group
systems > 25 systems

The most important blood group

system ABO!

Incompatibilities

ABO
Rh
Lewis (oligosaccharide)
Kell
Duffy
Kidd
MNSsU
I/I (carbohydrate)

ABO System
The ABO system is defined by the presence of
A, B., H (0) antigens (sugars) on surface of red
cells

Determined by allelic genes A, B, O, and Hh

Genes code for specific glycosyltransferases

that add sugars to oligosaccharide chains

H substance is the precursor on which A and B

antigens are built

O gene is a silent allele which does not encode a

functional enzyme - the structure of H substance
is not altered

Precursor Substance
(Hh gene)
(Se gene)
H antigen
(A gene)
A antigen

(B gene)
B antigen

ABO Antigen System

H antigen only = Blood group O

COMPATIBLE
Patient's
ABO
Group

Antigen
Antibody
on Red
in
Cells
Serum

Whole
Blood

Red Blood
Plasma
Cells

No A or B

Anti-A
Anti-B

Anti-B

A
O

O
A
B
AB
A
AB

Anti-A

B
O

B
AB

AB

AB
A
B
O

AB

AB

A and B

None

RBC Compatibility

Plasma Compatibility

The Rhesus System

The Rh or Rhesus blood system is the second most important

system.
The major antigen in this system is D
Rh positive ( D+)
Rh negative ( D-)

85%
15%

D Ag is highly immunogenic
Antibodies are "unexpected" and are immune - they result from
previous transfusion or pregnancy

Rh factor blood grouping system

Many people also have a so called Rh factor

on the red blood cell's surface.
This is also an antigen and those who have it
are called Rh+.
Those who haven't are called Rh-.
A person with Rh- blood does not have Rh
antibodies naturally in the blood plasma (as
one can have A or B antibodies, for instance).

Cont.

But a person with Rh- blood can develop Rh antibodies in the

blood plasma if he or she receives blood from a person with
Rh+ blood, whose Rh antigens can trigger the production of
Rh antibodies.
A person with Rh+ blood can receive blood from a person with
Rh- blood without any problems.

Rh COMPATIBILITY

Rh Positive Patient

Rh positive or
Rh negative Components

Rh Negative Patient

Only Rh negative Components

WHAT IS AN ANTIGLOBULIN TEST ?

The antiglobulin test is either "direct"
or "indirect". The "direct antiglobulin
testor DAT is often called the
__________".

DIRECT ANTIGLOBULIN TEST

In a direct antiglobulin test (DAT), red cells
are taken from the patient, extensively washed
and then "directly" tested with anti IgG or anti
complement. Agglutination indicates a positive
test.
A DAT evaluates whether a patients red cells are
coated in vivo with IgG or complement.

Direct Antiglobulin Test

USE OF THE DAT:

Diagnosis of:
Haemolytic Disease of the Newborn (HDN)
Autoimmune Haemolytic Anaemia (AIHA)
Drug related Haemolysis

Haemolytic Transfusion Reaction

INDIRECT ANTIGLOBULIN TEST

Detects in vitro sensitization
Plasma added to screening red cells
If antibodies to red cell antigens are
present, the antibodies will coat the red
cells
Anti IgG added and agglutination will occur

Plasma with antibodies

and reagent red cells

Sensitization

Anti IgG

USE OF THE IAT:

Detection of unexpected antibodies
Phenotyping or detection of red cell
antigens
Crossmatching

conclusion

HOW TO FIGURE IT OUT

RECOMMENDATION

RH COMMENTS

COMPATIBLE
Patient's
ABO
Group

Antigen
Antibody
on Red
in
Cells
Serum

Whole
Blood

Red Blood
Plasma
Cells

No A or B

Anti-A
Anti-B

Anti-B

A
O

O
A
B
AB
A
AB

Anti-A

B
O

B
AB

AB

AB
A
B
O

AB

AB

A and B

None

Pre-Transfusion Testing

ABO/Rh type 5 minutes

Antibody screen 25 minutes
Antibody identification 1 hour or much more

Testing

ABO
Rh
RBC Antibody Screen
Infectious Diseases

Syphilis
HBsAg
Anti-HIV-1/2
Anti-HBc

Testing

Infectious Diseases (cont.)

Anti-HTLV-I/II
Anti-HCV
HIV Nucleic acid testing (NAT)
HBV NAT
HCV NAT
WNV NAT
T. cruzi antibody (Chagas Disease)
(On some units) Anti-CMV
Future ??? Parvovirus B19, malaria, etc.

Infectious Transfusion Risks

HIV: 1 in 2,135,000 units

HBV: 1 in 205,000-to-488,000 units
HCV: 1 in 1,935,000 units
HTLV-I/II: 1 in 514,000-2,993,000 units
CMV: << 1: 100 (when leukoreduced or CMVnegative blood used)
WNV: ? (region-specific; very low)
vCJD: ? (risk very, very loweven in U.K.)
Infectious Risks of Blood Transfusion. Blood Bulletin
(Americas Blood Centers). December 2001.

Time required for units

Uncrossmatched Group O-neg RBCs - < 5

minutes
Uncrossmatched type specific RBCs ~ 15
minutes
Crossmatched RBCs 30-45 minutes
Full ABO type, screen & crossmatch 1 hour
Patient with multiple alloantibodies may take
many hours!
FFP 30-45 minutes for thawing
Cryo 15 minutes for thawing

Whole Blood

Storage

Indications

4 for up to 35 days
Massive Blood Loss/Trauma/Exchange Transfusion

Considerations

Use filter as platelets and coagulation factors will not be

active after 3-5 days
Donor and recipient must be ABO identical

RBC Concentrate

Storage

Indications

4 for up to 42 days, can be frozen

Many indicationsie anemia, hypoxia, etc.

Considerations

Recipient must not have antibodies to donor RBCs (note:

patients can develop antibodies over time)
Usual dose 10 cc/kg (will increase Hgb by 2.5 gm/dl)
Usually transfuse over 2-4 hours (slower for chronic
anemia

Platelets

Storage

Indications

Up to 5 days at 20-24
Thrombocytopenia, Plt <15,000
Bleeding and Plt <50,000
Invasive procedure and Plt <50,000

Considerations

Contain Leukocytes and cytokines

1 unit/10 kg of body weight increases Plt count by 50,000
Donor and Recipient must be ABO identical

Plasma and FFP

ContentsCoagulation Factors (1 unit/ml)

Storage

Indications

FFP--12 months at 18 degrees or colder

Coagulation Factor deficiency, fibrinogen replacement, DIC, liver
disease, exchange transfusion, massive transfusion

Considerations

Plasma should be recipient RBC ABO compatible

In children, should also be Rh compatible
Account for time to thaw
Usual dose is 20 cc/kg to raise coagulation factors approx 20%

Cryoprecipitate

Description

Storage

After collection, refrozen and stored up to 1 year at -18

Indication

Precipitate formed/collected when FFP is thawed at 4

Fibrinogen deficiency or dysfibrinogenemia

vonWillebrands Disease
Factor VIII or XIII deficiency
DIC (not used alone)

Considerations

ABO compatible preferred (but not limiting)

Usual dose is 1 unit/5-10 kg of recipient body weight

Granulocyte Transfusions

Prepared at the time for immediate transfusion (no

storage available)
Indications severe neutropenia assoc with infection
that has failed antibiotic therapy, and recovery of BM
is expected
Donor is given G-CSF and steroids or Hetastarch
Complications

Severe allergic reactions

Can irradiate granulocytes for GVHD prevention

Leukocyte Reduction Filters

Used for prevention of transfusion reactions

Filter used with RBCs, Platelets, FFP,
Cryoprecipitate
Other plasma proteins (albumin, colloid expanders,
factors, etc.) do not need filtersNEVER use filters
with stem cell/bone marrow infusions
May reduce RBCs by 5-10%
Does not prevent Graft Verses Host Disease (GVHD)

Transfusion Complications
Acute Transfusion Reactions (ATRs)
Chronic Transfusion Reactions
Transfusion related infections

Acute Transfusion Reactions

Hemolytic Reactions (AHTR)

Febrile Reactions (FNHTR)
Allergic Reactions
TRALI
Coagulopathy with Massive transfusions
Bacteremia
Fluid overload

Frequency of Transfusion Reactions

Adverse Effect

Frequency

Comments

Acute Hemolytic Rxn

1 in 25,000

Red cells only

Anaphylactic hypotensive 1 in 150,000 Including IgA

Febrile Nonhemolytic

1 in 200

Common

Allergic

1 in 1,000

Common

Delayed Hemolytic

1 in 2,500

Red cells only

RBC alloimmunization

1 in 100

Red cells only

WBC/Plt
alloimmunization

1 in 10

WBC and Plt only

Acute Hemolytic Transfusion

Reactions (AHTR)

Immune and non immune hemolysis

Occurs when incompatible RBCs are transfused into a
recipient who has pre-formed antibodies (usually ABO or Rh)
Antibodies activate the complement system, causing
intravascular hemolysis
Symptoms occur within minutes of starting the transfusion
This hemolytic reaction can occur with as little as 1-2 cc of
RBCs
Labeling error is most common problem
Can be fatal

Symptoms of AHTR

High fever/chills
Hypotension
Back/abdominal pain
Oliguria
Dyspnea
Dark urine
Pallor

What to do?
If an AHTR occurs

STOP TRANSFUSION
ABCs
Maintain IV access and run IVF (NS or LR)
Monitor and maintain BP/pulse
Obtain blood and urine for transfusion reaction
workup
Send remaining blood back to Blood Bank

Labs found with AHTR

Hemoglobinemia
Hemoglobinuria
Positive DAT
Hyperbilirubinemia
Abnormal DIC panel

Monitoring in AHTR

Monitor patient clinical status and vital signs

Monitor renal status (BUN, creatinine)
Monitor coagulation status (DIC panel
PT/PTT, fibrinogen, D-dimer/FDP, Plt,
Antithrombin-III)
Monitor for signs of hemolysis (LDH, bili,
haptoglobin)

Febrile Nonhemolytic Transfusion

Reactions (FNHTR)

Definition--Rise in patient temperature >1C

(associated with transfusion without other fever
precipitating factors)
Occurs with approx 1% of PRBC transfusions and
approx 20% of Plt transfusions
FNHTR caused by alloantibodies directed against
HLA antigens
Need to evaluate for AHTR and infection

What to do?
If an FNHTR occurs

STOP TRANSFUSION
Use of Antipyretics
Use of Corticosteroids for severe reactions
Use of Narcotics for shaking chills
Future considerations

May prevent reaction with leukocyte filter

Use single donor platelets
Use fresh platelets
Washed RBCs or platelets

Washed Blood Products

PRBCs or platelets washed with saline

Removes all but traces of plasma (>98%)
Indicated to prevent recurrent or severe reactions
Washed RBCs must be used within 24 hours
RBC dose may be decreased by 10-20% by washing
Does not prevent GVHD

Allergic Nonhemolytic Transfusion

Reactions

Etiology

Presents with urticaria and wheezing

Treatment

May be due to plasma proteins or blood

preservative/anticoagulant
Best characterized with IgA given to an IgA deficient
patients with anti-IgA antibodies

Mild reactionsCan be continued after Benadryl

Severe reactionsMust STOP transfusion and may require
steroids or epinephrine

PreventionPremedication (Antihistamines)

TRALI
Transfusion Related Acute Lung Injury

Clinical syndrome similar to ARDS

Occurs 1-6 hours after receiving plasma-containing
blood products
ANTIBODY HYPOTHESIS & NEUTROPHIL
PRIMING (magnet) HYPOTHESIS
Caused by WBC antibodies present in donor blood
that result in pulmonary leukostasis pulmonary
edema
Treatment is supportive
High mortality

Massive Transfusions

Coagulopathy may occur after transfusion of

massive amounts of blood (trauma/surgery)
Coagulopathy is caused by failure to replace
plasma
See electrolyte abnormalities

Due to citrate binding of Calcium

Bacterial Contamination

More common and more severe with platelet

transfusion (platelets are stored at room
temperature)
Organisms

PlateletsGram (+) organisms, ie Staph/Strep

RBCsYersinia, enterobacter

Risk increases as blood products age (use fresh

products for immunocompromised)

Chronic Transfusion Reactions

Alloimmunization
Transfusion Associated Graft Verses Host
Disease (GVHD)
Iron Overload
Transfusion Transmitted Infection

Alloimmunization

Can occur with erythrocytes or platelets

Erythrocytes

Antigen disparity of minor antigens (Kell, Duffy, Kidd)

Minor antigens D, K, E seen in Sickle patients

Platelets

Usually due to HLA antigens

May reduce alloimmunization by leukoreduction (since
WBCs present the HLA antigens)

Transfusion Associated GVHD

Mainly seen in infants

EtiologyResults from engraftment of donor
lymphocytes of an immunocompetent donor
into an immunocompromised host
SymptomsDiarrhea, skin rash, pancytopenia
Usually fatalno treatment
PreventionIrradiation of donor cells

Transfusion Associated Infections

Hepatitis C
Hepatitis B
HIV
CMV

CMV can be diminished by leukoreduction, which

is indicated for immunocompromised patients