MT-IMMUNOHEMA LEC (Finals)  ABO antibodies

- IgM
ABO Blood Group  Naturally occurring form
 Cold-reacting
Blood Groups  Binds complement
 Major blood groups  Doesn’t cross placenta
- ABO - IgG and IgA
- Rh  Immune forms
 Minor blood groups  Results from foreign red cell stimulation by
transfusion or pregnancy
ABO Blood Group System  Forward (RBC) and Reverse (Serum) Blood Typing
 Discovered by Landsteiner, von Descatello and
Sturle
- Drew blood from himself and 5 colleagues
- Separated serum from the red cells and mixed
them up
- Unknowingly performed the first ever forward
and reverse blood typing
 Landsteiner’s experiment
Sera from A Sera from B
Red cells
person (Anti-B) person (Anti-A)
O person (no NEG NEG
Ag)
A (A Ag) NEG +
B (B Ag) + NEG
AB (A and B + +
Ags)
- Individuals have “naturally occurring” antibodies
in their serum directed against the missing
- Forward is usually used
antigens on the surface of their RBCs
 The reagent where it agglutinates is the blood
- Sensitization of the missing antigen is no longer type (Reacts with A, is A)
needed to produce an antibody
- Reverse is for checking
 Blood type A doesn’t have to be exposed to B  The reagent where it doesn’t agglutinate is the
to produce Anti-B
blood type (Reacts with B, is A)
- Naturally occuring antibodies are IgM
- 4+ large clumps
- Universal donor – O
- 3+ medium clumps
- Universal recipient – AB
- 2+ small clumps
- Receiving of any blood type (in case of AB) is only
- 1+
done when no same type is available
- No aggulutination is negative (read as O)
- Universal donor and recipient only used packed - Reagent is put first before the sample
RBCs because serum has antibodies
 ABO (ABH) antigens
 What we know today
- Glycoproteins or glycolipids
- ABO antibodies ae not really “naturally occurring.”
- Present in all organs of the body (histoblood
Their production is stimulated by ubiquitois
group antigens)
substances such as
- Phenotypic expression affected by several
 Bacteria
factors:
 Pollen
 Age – develop as early as 37th day of fetal life,
 Other substances
newborn red cells have only 25-50% of the
- Production of ABO antibodies starts at birth but number of antigenic sites found on adult red
titers are too low for detection until 3 to 6 months
cells
of age  Race
 Reverse blood-typing in neonates is useless
 Genetic interaction
because there will be no reaction due to low
 Disease states
titer
- Inheritance
 Forward – antigen
 Alleles involved – A, B, O, H, and Se
 Reverse – antibodies - Formation
- Antibody roduction peaks at 5-10 years but
 Precursor substance – paragloboside
decreases with age o Red cell surface
- Persons above 65 have low titers for detection

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 o Type 2 (terminal galactose and N-  Differences between red cell and soluble A, B, and
acetylglucosamine in beta 1  4 linkage) H antigens
glycolipid Red cell A, B, Soluble A, B,
o Body fluids and secretions and H antigens and H antigens
o Type 1 (terminal galactose and N- Biomolecule Glycolipids Glycoproteins
acetylglucosamine in beta 1 3 linkage) First sugar Glucose N-acetyl-
glycoprotein galactosamine
 Addition of sugars determines antigen Chain Type 2 Type 1
o Glycosyltransferases are added to Gene FUT 1 FUT2
paragloboside
o Type of glycosyltransferase depends on ABO Subgroups
inherited alleles  A subgroups
Glycosyl Transferases - Main subgroup (2 schemes)
Gene Enzyme Nucleotide Sugar Ag  A1 and A2
(sugar o First described by von Dungern in 1911
donor) o Quantitative and qualitative
H α-2-L- fucosyl GDP-Fuc L-fucose H differences
transferase  Concentration of α-3-N-acetyl-
A α-3-N-acetyl- UDP- N-acetyl-D- A galactosaminyltransferase
galactosaminyl GalNAC galactos  Number of antigen sites on red cell
transferase amine  Antibodies produced
B α-3-D- UDP-Gal D-galactose B  Aa, Ab, Ac, and Adantigens
galactosyl - Weak subgroups
transferase  Occur in 1% of the population
h None None None h  A3, Am, Ax, Ay, Aend, and Ael
o Every individual has antigen, even if
blood type is O (H antigen) A Subgroups
o If there is no H antigen, there will be no  A1and A2
phenotypic expression AB - A1
o If there are gene for A and B, if there is no  A1 gene elicits production of high
H gene, there will be no phenotypic concentrations of α-3-N-acetyl-
exression (h – recessive; Bombay blood galactosaminyltransferase
type)  Production of 810,000 to 1,170,000 antigen
o For blood type O, there is H antigen sites
o For A and B, there is still H antigen,  Presence of A and A1 antigens
because it is the base antigen  Production of anti-H cold agglutinin
o Even if an individual has alleles or - A2
genotypes to express A or B, in the end,  Less activity of α-3-N-acetyl-
the result will be O, because A or B galactosaminyltransferase than A1
antigens will not be formed in the  Production of 240,000 to 290,000 antigen
absence of H antigen sites
o GDP-Fuc – guanosine-diphosphate L-  Presence of only the A antigen
fucose  Production of Anti-A1
o UDP-GalNAC – uridine diphosphate-N-  Aa, Ab, Ac, and Ad antigens
acetyl-D-galactose - Based on the four different forms of the H antigen
o UDP-Gal – uridine diphosphate galactose - H antigen forms: H1, H2, H3, and H4
 Soluble A, B, and H antigens  H1 and H2 are unbranched straight chains
- Secretion  H3 and H4 are complex branched chains
 Secretor status (Sese or SeSe) – α-2-L-  H1 and H2 can be converted to Aa and Ab by
fucosyl transferase expression in tissues both A1 and A2 enzymes
related to exocrine secretions  H3 and H4 can only be converted to Ac and Ad
 Non-secretors (sese) by A1 enzyme, and very poorly by A2 enzyme
- Fluids in which A, B and H substances can be  A1 – has Aa, Ab, Ac, and Ad
detected in secretors  A2 – has Aa, Ab, low Ac, and no Ad
 Saliva, urine, bile, amniotic fluid, tears,  Reagents used to detect A subgroups
digestive juices, milk, and pathologic fluids - Anti-A
 Extracted from sera of type B persons
 Contains both Anti-A and Anti-A2

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 - Adsorbed Anti-A Red cell testing
 Sera from Type B persons are adsorbed with Phenotypes Anti-
Anti-A Anti-B Anti-H
A2 cells A,B
 Contains only Anti-A2 B 0 ++++ ++++ ++
- Dolichos biflorus lectin/Anti-A1 lectin B3 0 mf ++ ++ mf +++
 Seed extract that agglutinates A1 cells Bx 0 wk/0 + +++
 Similar to Anti-A1 Bm 0 0 0 +++
 A subgroup typing Bel 0 0 0 +++
Anti-A (from B Adsorbed Anti-A/
sera) Anti-A1 lectin Naturally occurring antibodies in
A1 + + Phenotypes serum
A2 + NEG Common Unexpected
 Weak A subgroups B Anti-A None
Red cell testing B3 Anti-A None
Phenotypes Anti-
Anti-A Anti-B Anti-H Bx Anti-A Weak Anti-B
A,B
Bm Anti-A None
A3 ++ mf 0 ++ mf +++
Bel Anti-A Sometimes
Ax wk/0 0 ++ ++++
weakAnti-B
Aend wk mf 0 wk mf ++++
Am 0 0 0 ++++
Substances Presence of “B”
Ay 0 0 0 ++++
Phenotypes present in saliva transferase in
Ael 0 0 0 ++++
of secretors serum
B B,H Pos
Naturally occurring antibodies in
B3 B,H Weak pos
Phenotypes serum
Bx H Neg
Common Unexpected
Bm B,H Weak pos
A3 Anti-B Sometimes Anti-A1
Bel H Neg
Anti-B Almost always
Ax
Anti-A1 AB Subgroups
Aend Anti-B Sometimes Anti-A1  Related to A subgroups
Am Anti-B No Anti-A1  A1B and A2B
Ay Anti-B No Anti-A1
Anti-B Usually Anti-A1 Bombay Phenotypes
Ael
Sometimes Anti-A  Lack A, B, and H antigens
 No phenotypic expression
Substances Presence of “A”  Production of anti-H that react at 37°C
Phenotypes present in saliva transferase in  Two types
of secretors serum - Classic Bombay
A3 A,H Weak pos  hh
Ax H Very weak pos  O is the usual result
Aend H Neg - Para-Bombay
Am A,H Pos  Ah, Bh, and ABh
Ay A,H Weak pos  Weak expression of A and B
Ael H Neg  Mutant H (FUT) gene results in low levels of H
antigen
B Subgroups
 Main subgroup Anti-H
- α-3-D-galactosyl transferase  A1 and A1B Anti-H are cold agglutinins
 Requires Mn2+ as cfactor  Bombay Anti-H react strongly at 37°C
 Optimum pH 6.5  Reactivity – O > A2> B > A2B > A1> A1B
 Two types – pl’s 4.8-5.2, and 8.2-8.8  The more converted H antigen, the lesser the reaction
- Also based on the four different forms of the H
antigen – BI, BII, BIII, BIV Disease States and Conditions that Alter ABH Antigen
 Weak subgroups – B3, Bm, Bx, Bel Condition Alteration
Leukemia Weakened A and B antigen
Conditions related to expression
stress hematopoiesis (e.g.,
thalassemia)
Hodgkin’s disease

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Hypogammaglobulinemia Weakened Anti-A and B  Fisher-Race and Wiener depend on genetics, alleles,
Agammaglobulinemia and genes
Very young and old  Fisher-Race (DCE)
populations - Theory
Polysaccharides from E. Acquired B antigen  Antigens produced by three closely linked
Coli (due to any condition alleles (D, C/c, and E/e)
that increases  One antigen per allele
permeability of intestinal  Codominant expression (like ABO)
wall) - Antigen designations – D, d, C, c, E, and e
Excessive amounts of Absence of antigens  d is only a representation of the absence of D,
blood group-specific during forward typing; it is not recognized as an antigen
soluble substances (due to patients appear to be - Rules
gastric and pancreatic blood type O  Antigens have same designations as genes.
cancers) Genes are italicized
 “d” – absence of D antigen
Rh Blood Group  “-“ – other missing antigens (e.g., DC-/dc-)
 Rh- (Rhnull) – no expressed antigen (e.g., -/-)
Rh Antigens  Haplotypes are inherited from each parent
 Nonglycosylated transmembrane proteins - Example
 Started out with just 5 antigens (D, C, c, E, and e)  Genotype – DCe/dce
 51 antigen specificities  Phenotype (antigens produced) – D, C, c,
 Immunogenicity – D (greatest) > c > E > C > e (least) and e
 Genetics still unclear  Wiener (Rh-Hr)
 Production due to sensitization - Theory – three antigens produced by single gene
 Synthesized, not naturally occurring (Rh0)
 Antibodies are only seen in Rh- individuals - Antigens – Rh0, Rh1, Rh2, Rhz, rh, rh’, rh’’, rhy
- For Rh-, there are no antibodies and antigens at (shorthand designations, have equivalent genes
first, but once something that can sensitize the of Fischer-Race)
antibodies happens (e.g., transfusion, pregnancy, - Longhand and shorthand designations
etc), antibodies will be synthesized  Longhand – contents of Rh0
- 1st exposure is not yet critical since there are no - Rules for writing genes
antibodies. Once an Rh- person is exposed to a  Antigens have same designations as genes
Rh+ blood, antibodies will be produced, minimal  Genes are italicized, with subscripts written
transfusion reaction will take place as superscripts (Rh0, Rh1, Rh2, Rhz, rh, rh’, rh’’,
- 2nd exposure will be critical and might produce rhy)
adverse reactions in either transfusion or - Rules for longhand
pregnancy  Rh0 refers to “D”
- If an Rh- individual is given Rh+ blood, acute  Single prime (‘) refers to “C or c”
hemolytic reaction might happen  Double prime (‘’) refers to “E or e”
 If “r” precedes “h” (rh’ or rh’’), we are
 IgG (subclasses 1 to 4)
referring to uppercase “C and E”
- Main antibody
 If “h” precedes “r” (hr’ or hr’’), we are
- Do not usually bind complement
referring to the lowercase “c and e”
- Extravascular hemolysis
 Example
- IgG1 and IgG3 subclasses are of greatest clinical
o Dce converts to Rh0hr’hr’’
significance
- Rules for shorthand
- React optimally at 37°C or after antiglobulin
 “R” denotes presence of “D”, “r” denotes
testing
absence
- Can cross placenta
 “C” denoted by subscript “1 (one)” or by a
 IgA and transient IgM forms
single prime (‘)
- To differentiate IgM to IgG, note that IgM reacts at
 “E” denoted by subscript “2 (two)” or by a
room temperature
double prime (‘’)
 When both “C and E” are uppercase, the
Nomenclature
subscript “z” or superscript “y” is used
 4 schemes
 Subscripts are used with uppercase “R”, while
- Fisher-Race – basic scheme
superscripts and primes with lowercase “r”
- Wiener – modified Fischer-Race
 Example
- Rosenfield – states whether antigen id present or
o R1 converts to DCe
absent
- ISBT – used for automatization of testing

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 - Summary of Wiener Terminology Mechanisms of Antigen Expression
Antigen Longhand Shorthand Fisher-Race  Giblett model
Rh0 Rh0hr’hr’’ R0 Dce X1r genes
Rh1 Rh0rh’hr’’ R1 DCe Precursor substance 1 ---- Precursor substance 2
Rh2 Rh0hr’rh’’ R2 DcE DCE genes LW genes
Rhz Rh0rh’rh’’ Rz DCE ---- DCE antigens ---- LW antigens
rh hr’hr’’ r dce  Rosenfield model
rh’ rh’hr’’ r’ dCe Operator gene  messenger  structural gene 
rh’’ hr’rh’’ r’’ dcE antigen
rhy rh’rh’’ ry dCE
 Rosenfield (Alpha/Numeric) Variations on D Antigen Expression
- Theory  Genetic weak D
 No genetic basis - D antigen are expressed and complete but few in
 Simply states presence or absence of Rh numbers
antigens - Indirect antiglobulin test (IAT) will be tested
- Rules positive
 Minus sign (-) before the number designates  C in Trans to D
absence - Position effect or gene interaction effect
 If an antigen hasn’t been tested for, its - Dce/dCe
number will not appear - Will produce weak D or a varation on D antigen
 Designations because an interference took place due to their
o D – Rh1 positions
o C – Rh2 - C in cis to D – D and C are next to each other = no
o E – Rh3 adverse effects
o c – Rh4 - C in trans to D – has an effect
o e – Rh5  Partial D
 Example - One or few D antigen is missing
o D+, C+, E+, c-, e- converts to Rh: 1, 2, 3, -4, - Can produce anti-D
-5 - Once anti-D is present, it can no longer receive
- Drawback – other blood groups such as Kell, Rh+ because there will be HTR of HDFN
Duffy, Kidd, Lutheran, Sciana, etc. have similar - Detected through molecular test to check if
nomenclature scheme variation is caused by partial D
 ISBT - Once partial D is present, Rh- is needed to be
- Six digit numbers transfused
- 004 was assigned to Rh blood group system (e.g.,  Not detected by normal tests for blood typing. Results
Rh1  “D”  004001) will be Rh-
- Similar to Rosenfield, only difference  To different weak D from real Rh-, indirect
 RH instead of Rh antiglobulin test is used
 Takes genetics into account  C in Trans to D and Partial D needed to undergo
 Characters are italicized, followed by a space molecular test because Partial D is critical
or an asterisk, and then numbers of the
antigens are separated by commas Rh Subgroups
- Example  Rhnull
 Rh1 converts to DCe and RH 1,2,3 or RH*1,2,5 - Individuals do not have Rh antigen (possible
sensitization of Rh)
Proposed Genetic Pathways - Must be given Rh- (if given Rh+, might result to
 Fisher and Race theory HDR)
 Wiener theory - Regulator/inhibitor
 Currently accepted model  Genes – homozygous X0r/X0r
- Two linked genes on chromosome 1 control Rh  Precursor 1 not converted to precursor 2
expression  No DCE or LW antigens (needed for
 Codes for presence or absence of “D” conversion of precursor 1 to precursor 2)
 Codes for Ce, cE, ce, and CE  Individuals may produce antibodies to any of
- Codominant expression the Rh antigens
- Amorphic
 Genes – homozygous recessive rr
 Precursor 1 converted to precursor 2
 Unaltered precursor 2 (won’t produce
antigens DCE/LW because of recessive trait)

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  Individuals may produce antibodies to any of  Antibody specificity – D has the highest
the Rh antigens immunogenicity
 No LW antigen  ABO group influence – ABO incompatibility
 Rhmod
- Genes – homozygous XQr/XQr Antigenic Exposure
- Limited amount of precursor 1 converted to  Fetomaternal hemorrhage – significantly increases
precursor 2 maternal antibody titer; the more antibodies
- Weak expression of CDE or LW antigens produced, the more severe the HDN will be
- Individuals may produce antibodies to Rh - Pregnancy (transplacental)
antigens they lack - Delivery
- Conversion is possible, but since precursor 1 is  As little as 1 mL of fetal RBC can already immunize
limited, the antigens will be incomplete. The mother
missing antigens will produce antibodies  Approximately 16% only gets sensitization
 Conditions that promote fetomaternal
Clinical Considerations hemorrhage
 Transfusion reactions - Amniocentesis
- Circulating Rh antibodies appear within 120 days - Chorionic villus sampling
of primary exposure and 2-7 days after secondary - Abortion
exposure - Ectopic pregnancy
- On first exposure, there is low chance of HTR, - Abdominal trauma
since there are no sensitized anti-D, but there - Accidental or inadvertent transfusion
would be antibodies against D antigen. If there is a - Greater than 40 weeks gestation
second exposure/transfusion, in 2-7 days, there  Host factors
would be HTR - Depends on complex genetic factors
- Unexplained fever, mild bilirubin elevation and  Immunoglobulin class
decreased hemoglobin and haptoglobin - IgG starts crossing the placenta during the second
- Positive direct antiglobulin test (DAT) trimester
 HDN - IgG1 and IgG3 are more efficient in RBC
- RhoGAM (IM injection) hemolysis
- The mother should have a sensitization to Rh - IgG half-life – 25 days
antibodies
- Sensitization is prevented by injection of RhoGAM Antibodies that cause HDN
 Common
Hemolytic Disease of the Newborn (HDN) - Anti-D
- Anti-D+C
Definition - Anti-D+E
 Destruction of fetal red blood cells by maternal - Anti-C
antibodies - Anti-E
 Mother is stimulated to produce antibodies by - Anti-c
previous pregnancy or during 2nd or 3rd trimester of - Anti-e
pregnancy - Anti-K – other blood groups; second to anti-D in
 Occurs in Rh- mother to Rh+ baby in secondary immunogenicity
pregnancy; only develops antibodies during the first  Rare – other blood groups
 Two common types - Anti-Fya
- Rh HDN - Anti-s
- ABO HDN - Anti-M
- Anti-N
HDN - Anti-S
 Cause – usually antibodies (IgG) to the Rh(D) antigen - Anti-JKa
 Couples usually affected  Antibody specificity
- Rh- female - Anti-D is most potent
- Rh+ male - Other Rh antibodies
 Second child is usually affected  Anti-E and anti-c causes severe HDN
 Prevention – Rh immune globulin (RhIg or Rhogam) - Other blood group antibodies
 Anti-Kell is most potent
Factors Affecting Immunization and Severity
 Antigenic exposure ABO Group Influence
 Host factors – variable between person to person  ABO incompatibility between mother and fetus
(complex genetic factors) prevents mother from being sensitized
 Immunoglobulin class – IgG (crosses placenta)

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Pathology  Newborn transfusions – aliquoted blood
 Erythroblastosis fetalis - Purpose
- Red cell destruction  overworked bone marrow  Removal of bilirubin
 spleen and liver produces red cells   Removal of sensitized RBCs and incompatible
hepatosplenomegaly  hypoproteinemia  antibody
hydrops fetalis  Suppression of erythropoiesis
- Hepatosplenomegaly - Blood must be
 Enlargement of spleen and liver  CMV-negative
 Might lead to hypertension and hepatocellular  Hematocrit – 70%
damage
 Severe anemia leading to hypoproteinemia Prevention
- Hypoproteinemia  Dose – volume of fetomaternal hemorrhage divided by
 Liver couldn’t produce protein due to damage 30
- Hydrops fetalis  Fetomaternal hemorrhage volume
 Cardiac failure with edema 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑓𝑒𝑡𝑎𝑙 𝑐𝑒𝑙𝑙𝑠 𝑥 𝑀𝑎𝑡𝑒𝑟𝑛𝑎𝑙 𝑏𝑙𝑜𝑜𝑑 𝑣𝑜𝑙𝑢𝑚𝑒
 The protein that should maintain the balance 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑚𝑎𝑡𝑒𝑟𝑛𝑎𝑙 𝑐𝑒𝑙𝑙𝑠
of the body is absent, so albumin leaks,
causing edema ABO vs. Rh HDN
 High output cardiac failure Characteristics ABO Rh
 Bilirubin elevation First pregnancy Yes Rare
- Newborn liver unable to conjugate bilirubin Disease
- This results in elevated indirect (unconjugated) predicted by No Yes
bilirubin titers
- Kernicterus – permanent brain damage IgG Yes Yes
Bilirubin at
Diagnosis: Serologic and Clinical Tests Normal Elevated
birth
 Serologic tests Anemia at birth No Yes
- ABO and Rh typing Phototherapy Yes Yes
- Antibody screen – 37°C and potentiator (PEG or
Exchange
LISS, enhances reaction) Rare Sometimes
transfusion
- Treatment with dithiotreitol or 2-
Intrauterine
mercaptoethanol destroys J-chain of IgM; and None Sometimes
transfusion
differentiates IgG from IgM
Spherocytosis Yes Rare
 Clinical tests
- Amniocentesis and cordosentesis
Minor Blood Groups
 Amniotic fluid is read spectrophotometrically
at 450 nm
Location of Blood Group Genes
 Readings are plotted in a Liley graph
 Bilirubin causes a change in optical density Blood group Location of genes
 In cases where bilirubin readings don’t Duffy and Rh Chromosome 1
change as the pregnancy proceeds, it is MNSsU Chromosome 4
possible that there is worse HDFN Kell Chromosome 7
 New diagnostic techniques I Chromosome 9
- Ultrasonography Kidd Chromosome 18
- Doppler assessment of middle cerebral artery Lutheran, Lewis and Chromosome 19
peak velocity Secretor
- Percutaneous umbilical blood sampling P Chromosome 22
- Allele-specific gene amplification studies on fetal Kx (Kell antigen precursor) X chromosome
cells
- Intrauterine infusion Phenotypes
 Most of the blood groups have antithetical antigens
Treatment (e.g., Jsa is antithetical to Jsb)
 Intrauterine transfusion - Antithetical – divided into A and B
- Amniotic fluid change in OD450 results are high in  Usually expressed inside parentheses, with “+” sign
zone II or zone III denoting presence and “-“ sign absence (e.g., Fy
- Cordocentesis blood sample has hemoglobin less (a+b+))
than 10 g/dL  Dosage effect
- Fetal hydrops is noted on ultrasound examination - Exhibited when red cells of homozygous people
 Early delivery – alternative to transfusions possess more antigens than red cells from
 Phototherapy – exposure to light reduces jaundice heterozygous people
because bilirubin is light-sensitive - MNSsU, Rh, Kell, Kidd, Lutheran and Duffy
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Antigens  Anti-U
 Certain blood group antigens have similar molecular - Rare but can be formed in S- s- individual
structures and differ only by a few amino acids - Implicated with HTR and HDN
- “M” antigen has serine and glycine in the 1st and - Enhanced with enzyme
5th positions of glycophorin A, while “N” antigen
has leucine and glutamic acid in the same P System
positions, respectively  Antibodies of this blood group may cause spontaneous
- “S” antigen has methionine as its 29th amino acid, abortions and graft rejection
unlike “s” which has threonine  P1 antigen
- Fya has glycine as its 44th amino acid, in contrast - Found on fetal red cell as early as 12 weeks
to Fyb which has asparagines - Deteriorates rapidly on storage
- Expressed on neuroepithelial cell surface used by
Lewis System E. coli to cause UTI
 They are not manufactured directly by erythrocytes  Anti-P1
and are only adsorbed from the plasma - IgM antibody in sera of P2 individuals
 Antigens are water soluble, hence seen in body fluids - Cold reactive
 They also have the same precursor substance as ABO, - Observed in infected individual with hydatid
P and I antigens disease
 Antigen - Associated with fascioliasis, Clonorchis sinensis,
- Cord blood and newborn RBC phenotype as Le(a- and Opistorchis viverrini infection
b-)  Anti-PP1Pk
 No antigen - Predominant IgM
- Decrease expression on pregnant - Wide thermal range reaction (both cold and warm
 Antibodies (Anti-Lea and Anti-Leb) reactions)
- Considered naturally occurring - Associated with spontaneous abortion in early
- IgM (cold agglutinin) pregnancy
- Activate complement  Anti-P
 Associated with CA 19.9 - Alloantibody in the sera of Pk individuals
 Reactions are non-significant as long as cross- - Alloanti-P is rare but significant due to thermal
matching is compatible change
- IgG autoantibody in patient with paroxysmal cold
MNSs System hemoglobinuria
 U comes out at certain conditions - Can also be seen in spontaneous abortion
 MN antigen  Anti-Pk
- Location – glycophorin A or MN sialoglycoprotein - Some are isolated from anti-PP1Pk by selective
- Differ in their amino acid adsorption with P1 cells
- Well developed at birth - Present in serum of P1 individual with biliary
- Easily destroyed by enzymes cirrhosis and autoimmune hemolytic anemia
- Loss of MN antigen
 Risk for Plasmodium falciparum I System
 UTI caused by E. coli  Ii Antigens
 Ss antigen - i on infant
- Location – glycophorin B or SS=sialoglycoprotein  Well developed at birth
- S – methionine - I on adult (converted i)
- s – threonine  If not converted, it will be “i adult” or “I
- Well developed at birth negative”
- Less easily degraded by enzymes  I negative
 Cause both HTR and HDN - Hereditary
 Anti-M and Anti-N - Erythoblastic
- Cold reactive - Multinuclearity with positive acidified serum
- IgM (cold) or IgG (warm)  Anti-I
- Don’t bind complement - Common autoantibody
- Don’t react with enzyme-treated cell (only Anti-M) - Strong reaction on adult cell and weak on cord
- Rarely cause HDN cells
 Anti-S and Anti-s  Only reacts with I antigen, not with “i”
- Most are IgG - Not associated with HDN
- React at 37°C and AHG  Benign Anti-I
- Implicated with severe HTR with hemoglobinuria - Possible present at normal healthy individual
and HDN - Not associated with red cell destruction
- Weak IgM

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 Pathologic Anti-I - Associated with infrequent and mild cases of HDN
- Potent IgM - IgG (warm reactions)
- Cause autoagglutination and vascular occlusion or - Induced production of Anti-Jkb is caused by
intravascular hemolysis Enterococcus faeceum or Proteus mirabilis
 Auto anti-I
- May be stimulated by I-like antigen on Lutheran System
microorganism  Lua and Lub antigens
- Associated with Mycoplasma pneumoniae - Poorly developed at birth
 Anti-i - Production at approximately age 15
- Mostly IgM  Anti-Lua
- Reacts with saline suspended cell - Most are IgM but can be IgA and IgG
- Associated with - Wide thermal range
 IM - May react at 37°C and AHG
 Alcoholic cirrhosis  Anti-Lub
 Myeloid leukemia - Most are IgG
- IgG associated HDN - Reactive at 37°C and AHG
- Can also cause HTR - Made in response to pregnancy and transfusion
(HDN and HTR)
Kell System - Cause post transfusion jaundice
 Antigens of this group are essential for normal
phagocyte function and erythrocyte morphology Antibody Identification
 Absence of antigen is associated with chronic
granulomatous disease (CGD) Antibody Screens
 Kell antigen  Test donor/patient serum (unknown) with reagent
- Immunogenic (second to D antigen) RBCs (known)
- Well developed at birth  Use 2 or 3 screening cells to detect if antibodies are
- Mcleod phenotype cells present in the serum
 Very weak expression or absent Kell antigen  If antibodies are detected (at least 1 cell), they must be
 Acanthocytosis, muscular dystrophy, and CDG identified
is present
 Anti-K Reagent RBCs
- Common antibody  Screening cells
- IgG - Antibody detection
- Synthesized in response to pregnancy and - Sets of 2 or 3 vials
transfusion (HTR and HDN)  Panel cells
- Antibody identification
Duffy System - At least 10 vials per set
 Fya and Fyb antigen - Last row (autocontrol/patient typing) – red cell
- Well developed at birth and serum from the patient are mixed
- If absent (a- b-) – resistance to Plasmodium (esp. - Group O red blood cells
vivax and knowlesi), mostly seen in Africans
- Destroyed by common proteolytic enzymes
 Anti-Fya and Anti-Fyb
- IgG
- Enhanced by LISS
- Do not react to enzyme treated cells
- Associated with HTR, possible cause mild HDN

Kidd System
 Jka and Jkb antigen
- Well developed at birth
- Not altered by enzyme, but enhanced  Arrangement depends on manufacturer
- Jkb is detected around 7 weeks - Each of the panel cells has been antigen-typed
- Jka is detected around 11 weeks (showed on antigram)
 Anti-Jka and Anti-Jkb  + refers to the presence of the antigen
- Synthesized in response to pregnancy and  o refers to the absence of the antigen
transfusion
- Detected in AHG
- Common cause of HTR and delayed HTR (120
days)

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 - An autocontrol should also be run with ALL  Indirect antiglobulin test (IAT) phase (or AHG)
panels - Anti-human globulin reagent (AHG)
 Polyspecific
 Anti-IgG
 Anti-complement
 Some will have reactions with autocontrol, - Wash cells 3 times with saline
but most of the time, it has no reactions - Add 2 drops of AHG and gently mix
- The same phases used in an antibody screen are  Centrifuge
used in a panel
 Read
 Record reactions

- A tube is labeled for each of the panel cells plus

one tube for AC

 Interpretation of results

 IS phase
- Perform immediate spin (IS) and grade
agglutination; inspect for hemolysis
- Record the results in the appropriate space as
shown
- “Ruling out” means crossing out antigens that did
not react

 LISS 37°C phase

- 2 drops of LISS are added, mixed and incubated
for 10-15 minutes
- Centrifuge and check for agglutination  Cross out antigens that show no reaction in
- Record results any phase
 Don’t cross out heterozygous antigens that
show dosage

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 - Circle the antigens that are not crossed out could be used or antigen typing on red cells can be
performed, provided no recent transfusion
occurred

- Consider antibody’s usual reactivity

Multiple Antibodies
 More than 1 antibody present
 Reaction strengths can vary
 Matching the pattern is difficult
 Multiple antibody identification
- Selected cells
- Neutralization
- Chemical treatment
 Proteolytic enzymes
 Lea is normally a cold-reacting antibody (IgM),  Sulfhydryl reagents
so it makes sense that we see the reaction in  ZZAP
the IS phase of testing  Selected cells
 The E antigen will usually react at warmer - Selected cells are chosen from other panel or
temperatures screening cells to confirm or eliminate the
- Look for a matching pattern antibody
- The number of selected cells needed depends on
how many antibodies are identified
- Every cell should be positive for each of the
antibodies and negative for the remaining
antibodies
- Example: You ran a panel and identified 3
different antibodies: anti-S, anti-Jka, and anti-P1

 Possible results and interpretation

- Autocontrol
 Negative – alloantibody
 Positive – autoantibody or DTR (i.e.,
alloantibodies)  These results show that instead of 3
- Phases antibodies, there are actually 2: anti-S and
 IS – cold (IgM) anti-Jka
 37° - cold (some have higher thermal range)
 Neutralization
or warm reacting
- Some antibodies may be neutralized as a way of
 AHG – warm (IgG)
confirmation
- Reaction strength
- Commercial “substances” bind to the antibodies in
 Consistent strength – one antibody
the patient serum, causing them to show no
 Different strengths – multiple antibodies or
reaction when tested with the corresponding
dosage
antigen (in panel)
 Rule of three - Common substances
- The rule of three must be met to confirm the
 P1 substance (sometimes derived from
presence of the antibody hydatid cyst fluid)
 Positive with 3 cells with the antigen  Lea and Leb substance (soluble antigen found
 Negative with 3 cells without the antigen in plasma and saliva)
- If there are not enough cells in the panel to fulfill  I substance can be found in breast milk
the rule, then additional cells from another panel

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  Sda substance derived from human or guinea  Cold autoantibodies
pig urine - React at room temperature with most (if not all) of
 Proteolytic enzymes the panel cells and give a positive autocontrol
- Can be used to enhance or destroy certain blood - The DAT is usually positive with anti-C3 AHG
group antigens (detects complement)
- Examples - Could be due to Mycoplasma pneumoniae,
 Ficin (pigs) infectious mononucleosis, or cold agglutinin
 Bromelin (pineapple) disease
 Papain (papaya)  Warm autoantibodies
 Trypsin - More common than cold autoantibodies
- Enzyme procedures may be - Positive DAT due to IgG antibodies coating the
 One-step – enzyme is added directly to the red cell
serum/cell mixture - Majority of panel or screening cells will be
 Two-step positive
o Panel cells are pre-tested with enzyme, - The Rh system (e antigen) seems to be the main
incubated and washed target although others occur
o Patient serum is added to panel cells and - Causes of warm antibody
tested  Idiopathic
- Enzymes remove the sialic acid from the RBC  Known disorder (SLE, RA, leukemias,
membrane, thus destroying it, and allowing other ulcerative colitis, pregnancy, infectious
antigens to be enhanced diseases, etc)
- Antigens destroyed – M, N, S, s, Duffy  Medications
- Antigens enhanced – Rh, Kidd, Lewis, I, and P
- If there is no agglutination after treatment, then it Component Therapy
is assumed the enzymes destroyed the antigen
 Sulfhydryl reagents Component Therapy
- Cleave the disulfide bonds of IgM molecules and  Transfusion of specific blood components depending
help differentiate between IgM and IgG antibodies on what is required by the patient
- Good to use when you have both IgG and IgM  Helps prevent volume overload
antibodies (warm/cold)  Maximizes the use of blood since several patients may
 Diothiothreitol (DTT) is a thiol and will benefit from the blood of a single donor
denature Kell antigens  Blood products
 2-mercaptoethanol (2-ME)
 ZZAP Whole Blood
- A combination of proteolytic enzymes and DTT  Contains all blood plasma and cellular elements
- Denatures Kell, M, N, S, Duffy and other less  Increases RBC and plasma volume (hematocrit by 3-
frequent blood group antigens 5%, hemoglobin by 1-1.5 g/dL)
- Does not denature the Kx antigen  Should not be given to patients with severe chronic
- Good for adsorption techniques anemia
 Frees autoantibody off patient’s cell, so that - Already compensated by water retention
autoantibody can then be adsorbed onto - Volume overload and lung edema
another RBC
Packed Red Blood Cells (PRBCs)
Autoantibodies  Given to patients who require increased O2 carrying
 Can be cold or warm reacting capacity
 There is an antigen, and also an antibody - Respiratory rate of >30/minute
 A positive autocontrol or DAT may indicate that an - Pulse rate of >100/minute
auto-antibody is present - Hemoglobin
 Sometimes, the autocontrol may be positive, but the  Disease states – 8 g/dl
antibody screening may be negative, meaning  Intact compensatory mechanisms – 6 g/dL
antibody is already coating the RBC  Same effect as whole blood
 Direct antiglobulin test (DAT)
- Tests for the in vivo coating of RBCs with Leukocyte Reduced RBCs
antibody  Prevent
- AHG is added to washed patient red cells directly - Viral infections
- Used in cases of HDN, HTR, autoimmune and drug- - Certain conditions that may be triggered by
induced hemolytic anemia, whereas IAT is used in leukocytes and cytokines
weak D testing, compatibility testing, screening  Leukocyte content of
cell antibody - 5x108 prevents febrile non-hemolytic transfusion
reactions

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 - 5x106 prevents HLA alloimmunization, (HELLP) syndrome get better after transfusion with
transfusion-related acute lung injury (TRALI), FFP
TAGVHD, and viruses (CMV, EBV, HIV, and HTLV)  FFPs thawed at 1-6°C can be used to prepare liquid
 Leukocytes are inactivated by irradiation or removed plasma and cryoprecipitate
through the use of leukocyte depletion filters
 Low shelf life Plasma
 Expensive  Also known as liquid plasma or cryoprecipitate plasma
 Contains small amounts of labile factors and is usually
Washed RBCs indicated for patients with HUS, TTP, and HELLP
 PRBCs are washed with sterile isotonic saline solution
to remove all traces of plasma Cryoprecipitated Antihemophilic Factor (AHF)
 Prevents allergic response (anaphylactic shock) due to  Also known as factor VIII
plasma proteins  Contains fibrinogen, Von Willebran factor, and fibrin
 Also indicated for patients with anti-IgA due to IgA stabilizing factor
deficiency  Used primarily for fibrinogen replacement but can be
 Must be transfused right away because the blood bag used to treat deficiencies in other factors it contain
will have lesions (because it is punctured with needle Clotting factor Concentration
during washing) Factor VIII 80-120 U/conc.
Fibrinogen 150-250 mg/conc.
Frozen RBCs vWF 40-70% of original FFP
 Autologous or rare blood types Factor XIII 20-30% of original FFP
 Glycerol in 40% weight per volume serves as anti-
freeze agent Factor VIII Concentrate
 Deglycerolization  Intended primarily for patients with Hemophilia A
- Removes toxic glycerol (by washing blood bag;  Preparation is by fractionation and lyophilization of
becomes washed RBC) pooled plasma
- Removes plasma proteins so these units can also  Final products are sterilized using pasteurization or
be given to patients who are allergic to plasma solvent-detergent treatment
proteins
Factor IX (Prothrombin) Complex
Platelet Concentrate  Contains vitamin K dependent factors (II, VII, IX, and
 For patients with platelets that are low in number or X)
functionally abnormal  Recommended only for patients with Hemophilia B,
 From one unit of whole blood – 5.5x1010/µL platelets factor VII or X deficiencies or factor VIII inhibitors
 Plateletpheresis – 3x1011/µL
 Indicated for patients whose platelet count is Antithrombin III
<20,000/µL  Protease inhibitor that inhibits clot formation
 Increases patient platelet count by 5,000 to 10,000/µL  Antithrombin III activity is enhanced by heparin, and
is indicated for patients with hereditary antithrombin
Granulocyte Concentrate III deficiency and disseminated intravascular
 Indicated in cases of neutropenia (WBC ct. <500/µL) coagulation (DIC)
with infection and poor response to antibiotics
 Should be administered within 24 hours of collection Protein C
to maintain viability of cells  A serine protease inhibitor that inactivates factors V
 Recommended dose and VIII
- One unit daily for 4 or more days in adults
- Administered once or twice in neonates Alpha-1 Protease Inhibitor
 Heat-treated product used for patients with alpha-1
Fresh Frozen Plasma antitrypsin deficiency
 Contain all clotting factors
 Should be separated from whole blood and frozen Albumin (5-25% solution)
within 24 hours  Prepared from chemical fractionation of pooled
 Used to treat factor XI and multiple coagulation plasma
deficiencies (liver failure DIC, vitamin K deficiency,  Heat-treated to remove infectious agents
warfarin toxicity or massive transfusion), as  Used for volume replacement/expander
replacement fluid during plasmapheresis
 Patients with thrombotic thrombocytopenic purpura Plasma Protein Fraction (5% solution)
(TTP), hemolytic uremic syndrome (HUS), and high  Similar to albumin, the only difference is in
fever, elevated liver enzymes and low platelet count composition: 83% albumin, 17% globulin

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Immune Globulin - Blood should be warmed evenly and never above
 Contains primarily IgG but may contain small amounts 41°C
of IgM and IgA
 Indicated for patients with congenital Irradiated Blood Components
hypogammaglobulinemia and exposure to diseases  Prevent TAGVHD
 Half-life of immune globulin in the bloodstream is 22 - Recipient should be immunocompromised
days - Immunocompetent donor T cells
- HLA haplotype sharing between donor and host
Transfusion Practices - Skin rash, fever, diarrhea, and liver damage with
or without jaundice
Red Cell Transfusion Guidelines  Expiration
 Symptomatic anemia in a euvolemic patient - 28 days
 Acute blood loss of <15% of estimated blood volume - Original expiration date if it comes earlier
 Preoperative Hb <9.0 g/dL with unexpected blood
loss >500 mL FFP Transfusion
 Hb <7.0 g/dL in a critically ill patient  Thawed at 37°C
 Hb <8.0 g/dL in a patient with an acute coronary  Must be transfused within 24 hours, if not, relabel as
syndrome “plasma”
 Hb <10.0 g/dL with uremic or thrombocytopenic  Thawed plasma can be kept at refrigerator
bleeding temperatures up to 5 days and still maintain adequate
 Sickle cell disease levels of factors V and VIII
- Acute sequestration – Hb <5.0 g/dL or decrease
of 20% from baseline Notes
- Acute chest syndrome – Target Hb =10 g/dL,  Anticoagulant used is 63 mL (450 mL of blood)
HbS fraction <30%  During storage, the changes in the plasma when
- Stroke prophylaxis – Target HbS fraction <30% refrigerated 1-6°C
- General anaesthesia – Target Hb =10.0 g/dL, - NH4 – increased upon prolonged storage
HbS fraction <60% - K+ - increased upon prolonged storage
- pH – decreased upon prolonged storage
Platelet Transfusion Guidelines - Na+ - decreased upon prolonged storage
 Thrombocytopenia due to decreased production  Granulocyte must be at 20-24°C
- Stable patient – platelet count <10,000/µL  If blood bag has lesions, especially packed RBCs, the
- Fever – platelet count <20,000/µL expiration will be 24 hours if refrigerates, and 4 hours
- Bleeding, invasive procedure or surgery – if in room temperature
platelet count <40,000-50,000/µL  For platelets, expiration will be in 4 hours during open
- Retinal or CNS bleeding – platelet count system and cryoprecipitation
<100,000/µL
 Microvascular bleeding due to platelet dysfunction Transfusion Conditions

Plasma Transfusion Guidelines Transfusion Conditions

 Coagulation factor deficiency, factor concentrate  Autologous
unavailable  Emergency
 Dilutional coagulopathy  Massive transfusion
 Hemorrhage in liver disease  Neonatal transfusion
 Disseminated intravascular coagulation (DIC)
 Coumadin reversal Autologous
 Thrombotic thrombocytopenic purpura (TTP)  Predeposit
- Patient donates blood several days before surgery
Equipment - Takes ferrous sulfate or erythropoietin to
 Blood filters replenish
- Necessary for transfusion of any blood component - Blood is transfused back to the patient during
- Prevent embolism from blood clots and cellular surgery
debris - Done in rare cases (e.g., rare blood type)
- Clot filter screen (170µm)  Intraoperative hemodilution
- Leukocyte depletion filters - Withdrawal of blood from the patient right before
 Blood warmers surgery
- Not compulsory - Infusion of blood expanders (NSS)
- Used to prevent hypothermia and when patient - Blood withdrawn is returned to the patient during
has clinically significant cold agglutinins or after surgery

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 Salvage  The desirable rate of administration depends on the
- Collection, washing and filtering of shed blood patient’s
during or after surgery - Blood volume
- Intraoperative or postoperative - Cardiac status
- Hemodynamic state
Emergency  Blood should be infused slowly during the first 10-15
 Type specific blood should always be used for minutes (2 mL/min)
transfusion Type of Transfusion
Signs
 O, Rh negative red cells Reaction
 AB (regardless of Rh type) plasma Acute hemolytic Fever and low back pain
Urticarial Pruritus
Massive Transfusion Volume overload Signs of congestive heart
 >10 units failure
 Patient’s platelets and clotting factors tend to be Febrile non-hemolytic Fever
diluted Delayed hemolytic Jaundice and decreasing
 Transfuse platelets and plasma if hematocrit within 7-10
- Prothrombin time >16 seconds days post-transfusion
- Partial thromboplastin time >60 seconds  If no signs of transfusion reaction is seen within the
- Fibrinogen <100 mg/dL first 15 minutes, blood should then be transfused as
- Platelet count <50,000/µL quickly as tolerated (at most, 4 hours)
 Blood typing  Monitor vital signs

Transfusion Reactions

Transfusion Reactions
 Hemolytic transfusion reactions (HTR)
- Immediate
- Delayed
 Non-hemolytic transfusion reactions (NHTRs)
- Immediate – febrile, allergic, anaphylaxis or
anaphylactoid, TRALI, TACO, bacterial
contamination and physical damage to red cells
- Delayed – alloimmunization, post-transfusion
purpura, TAGVHD, iron overload and
immunosuppression

- Positive will float Hemolytic Transfusion Reactions (HTR)

- Negative will sink  Intermediate intravascular hemolysis
- Gradient/smudge indicates massive transfusion - RBC destruction releases hemoglobin, stromata,
and intracellular enzymes
Neonatal Transfusion - Pathology
 Blood products less than 7 days old are preferred  Hemoglobinemia  hemoglobinuria 
(potassium increases upon prolonged storage, which kidney and liver pathology
might harm the baby) - Signs and symptoms
 Hemoglobin S negative blood for hypoxic and acidotic  Fever with or withour chills
newborns  Oliguria to anuria
 Irradiated blood  Coagulopathy
- Intrauterine transfusion  Death due to hypotension
- Exchange transfusion - Treatment
- Transfusion of premature neonate  Diuretic agents – mannitol, ethacrynic acid
and furosemide
Blood Administration  Vasoactive agents – dopamine
 Properly identify patient  IV fluids
 IV transfusion device should be ready before blood is  Immediate extravascular hemolysis
issued from the blood bank - Mild and not life-threatening
 Always use clot filters. Blood warmers are optional - Signs and symptoms
 Use only isotonic saline or 5% albumin in diluting  Fever, chills, jaundice, anemia and decreased
blood components haptoglobin

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 - Treatment o Limited fibrinolysis
 Monitoring of vital signs, coagulation status o Transient leukopenia
and renal output - Treatment
 Delayed HTR  Antipyretics
- 3-7 days post-transfusion  Leuko-reduced RBCs
- Causes  Allergic (Urticarial) NHTR
 Secondary immune response from previous - Immediate hypersensitivity (within minutes)
sensitization by transfusion, pregnancy or - Mild and not life-threatening
transplant - Pathology
 Primary alloimmunization  Protein  regain (IgE or IgG)  histamine
- Pathology release  vasodilation and permeability 
 Extravascular hemolysis (RES) swelling (pruritus)
- Signs and symptoms - Signs and symptoms
 Mild fever and moderate jaundice  Erythema, pruritus, hives, and fever
- Common antibodies - Rare complications
 Anti-Jka  Angioneurotic edema, laryngeal edema, and
 Anti-E bronchial asthma
 Anti-D - Treatment
 Anti-C  Anti-histamines and washed RBCs and
 Anti-K platelets
 Anti-Fya  Anaphylaxis/Anaphylactoid reaction
 Anti-M - Immediate hypersensitivity
- Uncommon antibodies - Non-IgE mediated
 Anti-A1 - IgA deficiency
 Anti-P1 - Any organ can be involved
- Treatment - Important features
 IV fluid therapy to support renal function  Absence of fever
 RBC transfusion for symptomatic anemia  Signs and symptoms appear just after a few
mL of plasma is transfused
Non-Hemolytic Transfusion Reactions (NHTRs) - Pathology
 Immediate NHTRs  Anti-IgA  histamines and leukotrienes
- Common - Treatment
 Febrile  Anti-histamines
 Allergic  Washed RBCs and platelets to avoid colloid
- Rare transfusion products
 Anaphylaxis or anaphylactoid reaction Anaphylaxis Anaphylactoid reaction
 Non-cardiogenic pulmonary edema IgA deficiency IgA levels normal but
 Febrile NHTR antibodies against the light
- 1°C rise in body temperature associated with chain of IgA are present
transfusion having no medical explanation other
than transfusion of components Less severe
- During or within 24 hours post-transfusion, with a  Non-cardiogenic pulmonary edema
minimum recorded temperature of 38°C - Transfusion-related acute lung injury (TRALI),
- During or within 8 hours post-transfusion pulmonary hypersensitivity reaction or allergic
- Pathology pulmonary edema
 Anti-leukocyte antibodies  complement - Clinically the same as acute respiratory distress
activation (C5a)  IL-1 release by WBCs  syndrome (ARDS)
prostaglandin synthesis by hypothalamus  - Pathology
fever  Anti-leukocyte antibodies  complement
- Signs and symptoms activation (C5a and C3a)  histamine and
 Mild serotonin release by basophils and platelets
o Fever with or without chills  leukocyte emboli in lung capillary bed 
o Pallor lung edema
o Hypotension - Signs and symptoms
 Severe  Chills, cough, fever, cyanosis, hypotension,
o Dyspnea and increasing respiratory distress
o Tachypnea - Possible complications
o Cough  Heart failure, volume overload, bacterial
o Cyanosis sepsis and myocardial infarction
o Hypertension - Treatment
o Tachycardia  Leukoreduced components
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 Transfusion-associated circulatory overload - Treatment
(TACO)  Corticosteroids
- Iatrogenic  Intravenous immunoglobulin
 Transfusion occurs too fast  Exchange transfusions
- At risk  Plasmapheresis
 Children and elderly, chronic anemia, cardiac  Transfusion-acquired graft vs. Host disease
disease, thalassemia major and sickle cell (TAGVHG)
disease - Symptoms appear 3-30 days post-transfusion
- Signs and symptoms - At risk
 Dyspnea, headache, coughing, restlessness,  Lymphopenia, congenital immunodeficiency
cyanosis, tachycardia, orthopnea, systolic syndromes, bone marrow suppression,
hypertension, chest discomfort and abnormal hematologic and oncologic disorders,
electrocardiograms intrauterine transfusion, blood components
- Complications from relatives and newborn exchange
 Congestive heart failure and pulmonary transfusion
edema - Pathology
- Treatment  Donor T-cells attack MHA molecules
 Oxygen therapy, IV diuretics, slower rate of - Signs and symptoms
transfusion (100 mL/hr)  Pancytopenia, fever, elevated liver enzymes,
 Washed or frozen RBCs watery diarrhea, erythroderma and
 Bacterial contamination reactions desquamation
- Endotoxin produced by psychrophiles such as E. - Treatment
coli, Y. enterocolitica and Pseudomonas sp.  Irradiation of blood components (25-35 gray)
- During or within 30 minutes post-transfusion  Iron overload
- Signs and symptoms - Hemosiderosis
 Dryness and flushing of skin, muscle pain, - Affected organs – heart, liver, and endocrine
shock, fever, vomiting, renal failure, glands
hypotension, abdominal cramps, DIC, shaking, - Signs and symptoms
bloody diarrhea, chills, and hemoglobinuria  Muscle weakness, fatigue, weight loss, mild
- Treatment jaundice, anemia, mild diabetes, and cardiac
 Antibiotics arrythmia
 Physically or chemically induced - Treatment
- RBC damage resulting in intravascular hemolysis  Non-chelating agent (deferoxamine)
 Citrate toxicity  Neocyte transfusion
 Hypothermia from cold fluid transfusions  Post-transfusion immunosuppression
- Signs and symptoms – non-specific - Mechanism not really understood
- Treatment – supportive - Immune suppression happens after transfusion

Delayed NHTRs Transfusion Reaction Investigation

 Alloimmmunization
- Patient gets sensitized with antigens from blood Reasons for Investigation
components  Diagnosis
- Signs and symptoms  Therapy
 Slight fever, decreasing hemoglobin and  Transfusion management
hematocrit, bleeding  Prevention of future transfusion reactions
- Treatment
 Leukoreduced RBCs Relevant Information
 Matching of patient and donor  Diagnosis
 Post-transfusion purpura  Medical history of pregnancies, transplants, and
- Usually involves platelet concentrates and previous transfusions
multoparous women  Current medications
- Pathology  Clinical S/S of the reaction
 Anti-platelet antibodies (HPA-1a or anti-PLA1),
HLA-A2 and lymphocytotoxic antibodies  Tests
extravascular platelet destruction  Clerical checks – who made the mistake?
- Common feature – thrombocytopenia in 7-14  Visual inspection
days  DAT
- Signs and symptoms
 ABO and Rh typing
 Purpura
 Compatibility test
 Bleeding
 Platelet count <10,000/mm3  Antibody screen and identification

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 Urine test (hemoglobinuria) Therapeutic Cytapheresis
 Bilirubin test  Platelets
 Hemoglobin and hematocrit - 1,000,000/µL
- Polycythemia vera
Apheresis  Leukocytes
- 100,000/µL
Apheresis - Leukemia of the myeloid lineage
 Types  Lymphocytes
- Continuous flow centrifugation (CFC) – two - Conditions with a cellular immune mechanism
veins used; uninterrupted such as rheumatoid arthritis, systemic lupus
- Intermittent flow centrifugation (IFC) – one erythematosus, kidney transplant rejection and
vein used autoimmune and alloimmune diseases
 Purpose  Red cells
- Therapeutic - Complications of sickle cell disease, such as
- Blood donation priaprism, acute chest syndrome and impending
stroke
- Parasites – malaria and babesiosis

Therapeutic Plasmapheresis (Plasma Exchange)

 Factors removed by plasmapheresis
- Immune complexes (e.g., systemic lupus
erythematosus)
- Autoantibodies or alloantibodies (e.g., factor
VIII inhibitors)
- Antibodies causing hyperviscosity (e.g.,
Waldenstrom;s macroglobulinemia)
- Inflammatory mediators (e.g., fibrinogen and
complement)
- Antibody blocking the normal function of the
immune system
- Protein-bound toxins (e.g., barbiturate
poisoning)
- Lipoproteins
- Platelet-aggregating factors (e.g., possible role
in TTP)

Donation Apheresis
 Plateletpheresis
- Contains a minimum of 3x1011 granulocytes
 Leukapheresis
- Granulocyte concentrate
- Must contain a minimum of 1.0x1010 granulocytes

Donation Erythrocytapheresis
 Contains RBCs equivalent to two units at once
 More stringent donor requirements
- Females – 5’5’’, 150 lbs., and hematocrit =40%
- Males – 5’1’’, 130 pounds., and hematocrit =40%

Donation Plasmapheresis
 Used to collect immune plasma from donors with
increased concentrations of certain plasma
immunoglobulins for treatment of patients who are
immunosuppressed and have been exposed to
varicella, herpes, or other diseases

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Apheresis Complications - Persons who received blood transfusions,
 Citrate toxicity underwent organ transplant or any surgical
 Vascular access complications (hematoma, sepsis, operation
phlebitis, neuropathy) - Tattoo, ear piercing, acupuncture or accidental
 Vasovagal reactions needle prick
 Hypovolemia - Persons who received HB Ig
 Allergic reactions - Persons who traveled to malaria-endemic areas
 Hemolysis - Persons who had any sexual contact with anyone
 Air ambolus who is at high risk of exposure to HIV
 Depletion of clotting factors - Female donors who had sex with bisexual males
 Circulatory and respiratory distress - Hepatitis A
 Transfusion-transmitted diseases - Peptic ulcer
 Lymphocyte loss
- Poliomyelitis
 Depletion of proteins and immuboglobulins
- Persons who received vaccine against rabies
Donor Recruitment and Screening  6 months
- Diphtheria
Blood Donation - Encephalitis
 Pre-donation - Major injuries
 Blood collection - Glandular fever
 Component preparation - Hydatid disease
 Pre-transfusion testing - Meningitis
- Osteomyelitis
Pre-donation - Nephritis
 IEC materials and registration - Acute pancreatitis
 Donor information - Peritonitis
- Name - Septicemia
- Address and phone number - Tetanus
- Gender - Toxoplasmosis
- Date of birth and age  2 months
- Date of donation - After whole blood donation
- Donor’s consent  6 months
- Additional identification
- Pregnancy
- Occupation
 4 weeks
- Time of last meal
- Accutane
- Race
- German measles vaccine
- Intended recipient, replacement credit, donor
- Varicella zoster virus
group
 2 weeks
 Self-deferral questionnaire
- Received vaccines for
- Yes or no questions only
 Smallpox
 Abbreviated physical exam
 Sabin polio
- General appearance
- Weight – 110 lbs (50 kg)  Rubeola
- Temperature – 37.5°C (99.5°F)  Mumps
- Pulse – 50-100 bpm  Yellow fever
- Blood pressure – Systolic ≤180 mmHg; Diastolic  Influenza
≤ 100 mmHg  48 hours
- Hematocrit – 38% - Apheresis
- Hemoglobin – 12.5 g/dL
- Skin lesions, arms check Blood Collection
- Review of permanent deferral file  For donors who weight ≥ 110 lbs (50 kg) – 450 mL +
- Deferral or denial 63 mL anticoagulant
 For donors who weight < 100 lbs (50 kg)
Deferrals 𝐷𝑜𝑛𝑜𝑟 ′ 𝑠 𝑤𝑒𝑖𝑔ℎ𝑡 𝑖𝑛 𝑙𝑏𝑠
𝐴𝑙𝑙𝑜𝑤𝑎𝑏𝑙𝑒 𝑎𝑚𝑜𝑢𝑛𝑡 = 𝑥 450 𝑚𝐿
 3 years 110 𝑙𝑏𝑠
- Persons who lived in a malaria-endemic area or 𝐴𝑙𝑙𝑜𝑤𝑎𝑏𝑙𝑒 𝑎𝑚𝑜𝑢𝑛𝑡
𝐴𝑛𝑡𝑖𝑐𝑜𝑎𝑔𝑢𝑙𝑎𝑛𝑡 = 𝑥 100 𝑚𝐿
have been treated for malaria 100 𝑙𝑏𝑠
 1 year  Needles – gauge 16-17
- Close contact with someone who has hepatitis

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 Preservative solutions
Volume per
Shelf-life
Preservative pH 100 mL
(in days)
blood
ACD 21 5.0 15
CPD 21 5.6 14
CPDA1 35 5.6 14
CP2D 21 5.6 14
 Additive solutions – SAGM
Commercial Abbreviation Shelf pH @ Added
name life 37°C to
Adsol AS-1 42 6.6 CPD
Nutricel AS-3 42 6.6 CP2D
Optisol AS-5 42 6.5 CPD

Component Preparation
 Important factors
- Centrifugation speed and duration
- Temperature

Pre-transfusion Testing
 Infectious disease detection
- Syphilis
- Hepatitis B
- Hepatitis C
- HIV
- HTLV-1 and 2
- CMV
- Malaria
 Antibody screening
- Screening cells
 Compatibility testing
- Sample collection
- ABO and Rh blood grouping
- Cross matching
 Major – Donor’s cells + Patient serum
 Minor – Donor’s serum + Patient cells
 Phases
o Saline phase
o Antibody potentiation phase – albumin,
LISS, or PEG
o Antiglobulin phase
o Addition of check cells

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