Dr.JAISANKAR.P.

PG in General Medicine. Madurai Medical College.

BLOOD GROUPING AND TRANSFUSION THERAPY

BLOOD GROUPS

More than 100 blood groups composed of more than 500 antigens. Introduced by Landsteiner in 1900

ABO SYSTEM

First and the most important system. Groups - A, B, AB and O. A and B antigens are found on the RBC membrane either as Glycosphingolipis or as Glycoprotiens. They are also found on other blood cells, all body fluids except CSF and on intestinal epithelium, urothelium & vascular endothelium.

Genes for A & B - on Chr 9. Co- Dominant inheritance. H substance - the immediate precursor to which A and B antigens are added. H + N Acetyl Galactosamine A antigen. H + Galactose B antigen Lack of H substance Bombay Phenotype (Oh)

WHY ABO MATCHING ?

All individuals produce antibodies against the ABO antigen that they lack. Group A Anti B antibodies. Group B Anti A antibodies. Group AB No Anti A/Anti B antibodies. (universal recipients) Group O No antigens. Both antibodies + (universal donors)

Group Oh (Bombay) Anti H antibodies so, compatible only with another Oh. A and B antigens are secreted by the RBCs into the plasma. Non secretors are susceptible to infections with, - Candida albicans, - Neisseria meningitidis, - Pneumococcus, - H. influenza.

RHESUS SYSTEM
2nd most important. Involves 45 antigens. D, E, e, C, c are common. various combinations DcE, Dce etc resuls in various phenotypes. D antigen present in 85% Rh +ve absent in 15 % Rh -ve

D antigen is a potent Alloantigen. Exposure of Rh -ve individuals to even small quantities of Rh +ve cells Anti D alloantibody severe HTR and HDN. Rh null phenotype occurs when red cells do not express Rh antigens. Anti D antibodies are IgG cross placenta HDN

Clinical significance 1. prophylactic Rh immune globulin is to be administered to Rh(D)-negative mothers during pregnancy and at delivery if the infant is Rh(D) positive 2. Rh discordance can lead to severe transfusion reactions.

LEWIS SYSTEM

Carbohydrate antigen. Chr 19. Groups Lea, Leb MCC of incompatibility during pre transfusion screening. IgM antibodies do not cross placenta. Lewis antigens are not integral part of RBC membrane. They are synthesized in plasma and adsorbed onto the membrane.

Clinical significance 1. Transfused red cells always absorb Lewis antigens from the plasma of the transfusion recipient; hence, within several days of the transfusion, the phenotype of the circulating transfused red cells is the same as the patient's red cell phenotype 2. The cell envelop of H. pylori expresses Le x and Le y This finding may be helpful in treating H. pylori infection in future.

KELL SYSTEM

Protein antigens. Chr 7. Principal antigens are K and k. 98% of the population are K-k+

Clinical significance 1. Kell antigens are the second most immunogenic after Rh. 2. absence of Kell antigens - acanthocytosis - shortened RBC survival McLeod - muscular dystrophies phenotype.

DUFFY SYSTEM

Protein antigens. Chr 1 six antigens, Fy a, Fy b, Fy3, Fy4, Fy5 and Fy6, Fya and Fyb are Co dominant.

Clinical significance 1. Both Fya and Fyb serves as receptors for Plasmodium vivax. 2. Antibodies to both are IgG. can cross placenta. Anti Fya has caused HDN.

I SYSTEM

I and i are Oligosaccharide antigens that differ only in branching. Clinical significance some patients with cold agglutinin disease due to IMN, mycoplasma or lymphomas can produce anti I antibodies that can destroy RBCs.

P SYSTEM

Carbohydrate antigens. Chr 22. Single antigen P1. Anti-P1 is usually IgM.

Clinical significance 1. in some patients suffering from syphilis and viral infections, Paroxysmal Cold Hemoglobinuria occurs due to production of anti P1 antibodies that binds to RBCs in the cold and fixes compliment in warm temperature. Donath Landsteiner Antibodies. 2. P antigens also serves as receptor for - Parvo virus B19 - E coli.

MNS SYSTEM

Protein antigens. Chr 4. Major antigens are M, N, S and s. They are attached to the RBC membrane via Glycophorin A and B. Clinical significance anti S and anti s are IgG antibodies. Can lead to severe HDN similar to RH.

OTHER MAJOR GROUPS

Lutheran Kidd Diego Scianna Dombrock Colton Landsteiner Wiener

Chido Rogers Cromer Knops Gerbich Yt Kx Xg

BLOOD TRANSFUSION

DONOR SELECTION

Good health and feeling well. Age 17 - 60 yrs. Weight at least 45 kg. Hb at least 12.5 g/dl. Temp not more than 99.5 oF BP - 110/60 to 160/90 mm Hg. No h/o high risk behaviour eg: IV drug abuse Informed consent.

BLOOD DONATION

Draws 450 - 500 ml of blood into a PVC bag containing citrate based anticoagulant. Tests done on collected blood - ABO grouping and Rh typing - Red cell antibody screen - Tests for HIV 1 & 2, HBsAg, anti HBc, Anti HCV, anti HTLV I & II , and VDRL. These tests are performed on pools of 16 to 24 donor specimens.

BLOOD TYPING

Forward typing detects the ABO and Rh groups. Reverse typing detects iso-agglutinins in sera that correlate with the ABO and Rh type.

BLOOD SCREENING

Identifies antibodies directed against other antigens. Done by mixing donors sera with type O RBCs which contains the major antigens of most blood groups and is of a known extended phenotype.

BLOOD CROSS MATCHING

Done when there is high probability that the recipient will require multiple PRBC transfusions. Serological cross matching Donors RBCs + Recipients plasma if Agglutination Incompatible

WHOLE BLOOD

PLATELET RICH PLASMA

PACKED RED BLOOD CELLS

RANDOM DONOR PLATELET

FRESH FROZEN PLASMA

WHOLE BLOOD

Indicated for acute, massive blood loss Contain approximately 450-500 mL donated blood + 70 mL of a citrate-based anticoagulantpreservative solution Stored at 4oC with citrate-phosphate-dextroseadenine (CPDA-1) solution has a 35-day shelf life and a hematocrit of approximately 35 percent.

Upon storing, - platelets disintegrate. - coagulation factors disintegrate. - Red cell 2,3 DPG levels come down. - spheroechinocytosis - ATP - Lactic acidosis

GLYCEROLIZED RED BLOOD CELLS

stored frozen at -65C or lower for up to 10 years Glycerol is removed by washing before transfusion This approach is indicated for prolonged storage of rare red cells for patients with antibodies to red cells with rare red cell antigen phenotypes

LEUKOCYTE-REDUCED RED BLOOD CELLS

Indicated for - patients with a history of multiple febrile non hemolytic transfusion reactions, - for patients who are frequent transfusion candidates, - for prevention of cytomegalovirus infection in immuno compromised Adsorption filters enable the removal of 99.9 percent of donor leukocytes Cell washing Centrifugation techniques

WASHED RED BLOOD CELLS

They are indicated only for patients who have had severe allergic reactions associated with transfusion or those with immunoglobulin deficiency Washing of red cells may be used to remove excess potassium from older units. prepared by centrifugation with saline to remove almost all plasma and cytokines.

IRRADIATED WHOLE BLOOD/RBCS

To reduce the possibility of transfusion-related graft-versus-host disease. RBCs are exposed to a standard dose of ionizing (gamma) radiation to render viable lymphocytes incapable inducing reaction. In premature newborns and highly immunocompromised patients

Mild functional impairment manifested by significant leakage of potassium and accumulation of plasma hemoglobin has been demonstrated subsequent to gamma irradiation Watch for conduction disturbances / arrhythmias Shelf life 28 days

Attempting to achieve normal BP in the setting of active bleeding through extensive fluid therapy is associated with disruption of haemostatic mechanisms, dilution of clotting factors, increased blood loss and decreased survival. If in emergency O - ve blood can be transfused while waiting for the cross matched blood.

EXCHANGE TRANSFUSION
Indications - In neonates when hyperbilirubinemia does not respond to photo therapy - DIC Irradiated fresh red cells ( < I wk old ) are used.

PLATELET TRANSFUSION

HARVESTING PLATELETS
450 - 500 ml whole blood @ room temp with in 8 hrs slow centrifugation PRBC

PRP
fast centrifugation

FFP

RDP
(in 50 - 60 ml plasma)

One unit Random Donor Platelet contain 5.5 1010 platelets Platelets can alternatively harvested from the Buffy coat. Such PC contain fewer WBCs as contaminants.

PLATELET APHERESIS

The technique of selectively extracting platelets from the donor and returning the remaining components back to his circulation. Yields Single Donor Platelets (SDP) - equal to six units of RD platelets 3 1011 platelets in 300 ml plasma - contains fewer WBCs than RDP. - shelf life of 5 days.

TRANSFUSION OF PLASMA AND COMMERCIAL PROTEIN CONCENTRATES

FRESH FROZEN PLASMA

Prepared from citrated whole blood by centrifugation and freezing within 8 hrs of collection. stored at -18C or below for up to 1 year. On storage - minimal loss of activity of the labile coagulation factors V and VIII.

Indications - in patients who are bleeding or having an invasive procedure and who are deficient in multiple coagulation factors or in a single factor for which there is no specific factor concentrate available. - for reversal of warfarin effect. - for replacement of clotting factors during massive transfusion - for plasmapheresis

Each unit of FFP 200 ml of plasma Must be ABO compatible A dose of 10 to 15 ml/kg would constitute approximately 25 to 30% replacement therapy for coagulation factors. Factor VIII levels reduced to 1/3rd in 40 days Factor V levels reduced to 1/3rd in 20 days Other factors are relatively stable.

CRYOPRECIPITATE

Is an extract of FFP that is enriched in high-molecularweight plasma proteins. prepared by thawing 1 unit of FFP at 1 to 6C. The precipitated HMW protiens ( rich in Fibrinogen, Fa VII, vWF and Fa XIII ) is frozen with 15 ml of plasma.

Each unit contains 80 - 120 units of Fa VIII and 150 mg of fibrinogen. used in - correction of hypofibrinogenemia in pts with - DIC - prolonged cardio pulmonary bypass. - Hemophilia A. - Fibrin Glue

ALBUMIN

Prepared from pooled plasma by Cold Ethanol (Cohn) Fractionation 95% pure. Heat treated to eliminate the risk of transmission of viral hepatitis and HIV. Available as 4%, 5% and 25%.

COAGULATION FACTOR CONCENTRATES

FACTOR VIII - those derived from plasma can be used to treat both Hemophilia A and vWD. Recombinant Fa VIII concentrates does not contain vWF. PROTHROMBIN COMPLEX CONCENTRATES contains variable quantities of Vit K dependent clotting factors II, VII, IX, X.

ANTI THROMBIN III - In anti thrombin-deficient patients with thrombosis or in situations with a high risk of thrombosis.

INTRAVENOUS IMMUNE GLOBULINS

Nonspecific IVIG preparations contain a broad spectrum of antibodies naturally present in the donor population Available as 3 to 12% protein solutions or powders that have to be reconstituted. Slow administration to reduve adverse reactions.

Indications - prophylaxis of infections in patients with primary immunodeficiencies. - prophylaxis of infection in patients with B-cell CLL. - prevention of infections after BMT

In treatment of Kawasaki disease ITP Pediatric HIV co infections Guillain - Barre syndrome, Dermatomyositis, Red cell aplasia due to parvovirus B19 infection

Adverse effects - renal failure and thrombotic events

INTRAMUSCULAR IMMUNOGLOBULINS

Prepared from pooled plasma by cold ethanol fractionation. Available as 16.5% protein solutions, containing approximately 95% IgG and small amounts of IgA and IgM. Specific IMIg Rh immune globulin, hepatitis B immune globulin, Varicella zoster immune globulin.

ADVERSE EFFECTS OF TRANSFUSION

Immunologic - Alloimmunization - Hemolytic transfusion reactions - Febrile transfusion reactions - Transfusion-related acute lung injury - Allergic transfusion reactions - Post transfusion purpura - Graft-versus-host disease

Non immunologic - Volume overload - Hypothermia - Hyperkalemia - Pulmonary micro embolization - Transfusion hemosiderosis

Infectious Hepatitis: B, C Human immunodeficiency virus -1/-2 HTLV -I/-II Cytomegalovirus Epstein-Barr virus Bacterial contamination Syphilis Parasites: malaria, Babesia, trypanosomes

MANAGEMENT OF TRANSFUSION REACTIONS

Discontinue the transfusion immediately A post transfusion blood sample and the discontinued bag of blood should be sent to the blood bank for investigation. Hydration with NS must be begun immediately to prevent renal failure Mannitol or furosemide may be used to maintain urine output of min 100 ml/hr. Anti Histamines and Cortico steroids. Dopamine if hypotension develops. Coagulopathy if develops may require specific management

REFERENCE

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