August 2, 2013
PH 156 – Blood Banking and Serology (Part 1)
Elysse, Janel, Angel, Jester
Prof. Teresita de Guzman OUTLINE I. Definition of Terms II. History III. Rules of Donation IV. Apheresis/Blood Components V. Blood Compatibility Testing: Blood Typing and Crossmatching VI. Blood Processing, Preservation, and Storage VII. Transfusion Reaction/Risks VIII. Immunohematology ** She didn’t strictly follow the outline kasi may part 2 pa raw
DEFINITION OF TERMS Blood banking o also known as transfusion medicine o The process of collecting (donation), testing, processing, and storing blood for later use (transfusion) o A cornerstone of emergency and surgical medicine o Dependent on the clinical lab for ensuring the safe use of blood and its components HISTORY 1667 – Jean-Baptiste Denis (France) o Direct human blood transfusion o Using human blood to treat disease and trauma 40 years later – William Harvey o discovered the circulatory system 1900s – Richard Lewisohn o Discovered that when sodium citrate is added to freshly drawn blood, it will not clot/coagulate 1937 o First true blood bank was opened by Chicago’s Cook County Hospital 1947 - American Association of Blood Banks (AABB) o Organized to support and encourage continued blood research o Promote exchange of information o Develop standards of practice for blood banks. 1948 – American National Red Cross o Operating a full scale blood program to collect and distribute blood to patients in need 1953 o Plastic blood bag was introduced by Fenwal Co. o Blood bags were approved by FDA in 1963 Before, blood bottles were used but they were prone to breakage Blood bag use in the Philippines started in the 1970s to 1980s Dr. Charles Drew o Pioneer in plasma preservation and a major contributor to the advancement of blood banking in the US o Helped supply thousands of units of plasma for WW2 victims BLOOD DONATION RULES Whole blood is collected from healthy donors who are required to meet strict criteria:
o o o
Medical history Physical Health Possible contact with transfusion-transmissible infectious diseases including: History of sexual behaviour Drug use Travel to areas with endemic diseases (e.g. Malaria in Palawan) A photo ID is required for all donors Potential donor must: o Be in good health and feeling well on the day of donation o Be on no prescribed medication that would cause the donor problems when donating or those that would affect the recipient o Have a haemoglobin level which meets the established USFDA standard o Wait 56 days before giving another donation of whole blood Donors must meet these criteria to ensure their safety and also the security of the recipients Rules of eligibility have been established by the USFDA, but some banks may have different criteria Donors must be: o 17 years old although some states permit younger people to donate if they have parental consent o In good health o Weigh at least 110 pounds if <110 lbs, must adjust the amount of blood and anticoagulant in bag o Pass a physical examination and health history exam prior to donation Physical exam includes: Blood pressure measurement Pulse rate Body temperature Test for anemia (Hb determination) To protect the health of both donor and recipient, potential exposure to transfusion-transmissible disease is asked: o Viruses: HIV, Hepa B & C, Human T-Lymphotropic Virus (HTLV) I & II o Parasites: Malaria, Babesiosis, Chaga’s Disease Certain people are not permitted to donate: o Anyone who has ever used illegal IV drugs o Men who have had sex with men since 1977 o Hemophiliacs o Anyone with a positive HIV test o Men and women who have ever taken money, drugs, or other payments for sex since 1977 th o Anyone who has had hepatitis since 11 birthday o Anyone who has had babesiosis or Chaga’s disease o Anyone who has taken Tegison for psoriasis o Anyone with Creutzfeldt-Jakob Disease (CJD) or who has an immediate family member with CJD o Anyone who has spent time in the UK between 19801996 that adds up to 3 months or more
1
4
o
Anyone who, from 1980 to present, spent time in Europe that adds up to 5 years or more o Anyone who received blood transfusion in the UK between 1980 and present o Some travel or health problems may require a temporary deferral or may be ineligible to donate like individuals on human growth hormone (HGH) or bovine insulin from the UK must be deferred indefinitely All donors are required to complete a health questionnaire and blood safety form during a confidential interview by a donor center healthcare worker each time they come in to donate blood Frequently Asked Questions (FAQs) Why the year 1977? » Because HIV was discovered in 1982 and people who were exposed in the last 5 years (incubation period) were included Why the year 1980? » There was an outbreak of Bovine Spongiform Encephalitis (BSE) & other prion diseases that year Why on the 11th birthday? » May be because nearing puberty so baka maging sexually active na Difference between Hemophilia A and B? » A - deficit in Factor 8 » B – deficit in Factor 9 Why are individuals taking HGH and Bovine Insulin not allowed to donate? » Higher risk of carrying CJD if you have received pituitary derived HGH injects [Redcross, 2013] » Bovine insulin – Possible transmission of variant CJD from cattle to humans [Redcross, 2013]
o
3.
o
Donation when a person donation his/her own blood for personal use o Since the blood is not to be used for anyone else, units positive for infectious agents and with irregular blood group antibodies are still acceptable o But units positive for hepatitis (HBsAg) and HIV are still not allowed into the blood bank
Three Ways to Make Use of Patient’s Own Blood aside from Predeposit 1. Hemodilution o Patient’s blood is collected prior to surgery and replaced with plasma o Any bleeding during surgery will lose fewer RBCs o The previously collected higher hematocrit blood will be given back after surgery 2. Cell Saver o Collection and reinfusion of blood lost during and immediately after surgery [United Blood Services] Blood from surgical field is recovered, mixed with saline and anticoagulant, centrifuged and washed Resulting RBCs are then reinfused into patient o Reduces the need for allogeneic blood transfusion[United Blood Services]
DIRECTED DONATION Occurs when a potential recipient of blood or its products specifically designate certain people as donors Additional Problems Confidentiality of the donor is difficult to maintain Donor may not want to answer the exclusionary question of the blood safety form and health questionnaire properly The procedure is not cost-effective There are contraindications such as: o An increased risk for transfusion-associated graft versus host diseases (TAGVHD) o Alloimmunization of potential recipients of transplants o Increased risk for hemolytic disease of the newborn (HDN) in mothers receiving blood from fathers There is a small but significant risk for TAGVHD in persons receiving blood from relatives o Due to similar genetic make up TAGVHD is fatal with no effective treatment Thus, all units of blood collected by directed donation typically undergoes gamma irradiation o To destroy any WBCs that could cause TAGVHD o Significantly adds to the cost of blood processing o Units must be discarded if not used within 24hrs
** AlloSy- same species but different individuals ** Xeno - different species
AUTOLOGOUS DONATION
Surgical field should not be contaminated with bacteria or malignant cells o Done during the war Wound Drainage o Blood is collected from cavities such as joint space into which bleeding has occurred o Then returned thru filter which removes big items like thrombi and tissue fragments but not the inflammatory chemical mediators or cytokines
PROTECTING THE BLOOD SUPPLY Certain tests must be performed in a blood bank lab on all donated blood ABO blood group and Rh status determinations as well as several screens to ensure the safety of the blood Screening is conducted for o Unexpected RBC antibodies that could cause reactions In the recipients such as those made as result of previous transfusion or pregnancy o Bacterial contamination in units of platelets important in Dengue cases o Current and past transmissible infections; each unit of donated blood is tested for Hepa B and C HIV 1 and 2 HTLV I and II Syphilis West Nile Virus BLOOD TYPES AND CROSS MATCHING Blood compatibility test must be done (except in life or death situations) Type includes a “front” type and a “back” type Note that there are more than 100 blood groups (kell, duffy, MN) but only the major ones are discussed
2
4
Front Type The “front” type determines which antigens (flags) in the ABO blood group system are on the patient’s RBC Using known sources of commercial anti-sera (“AbBy”) o Anti-A –blue o Anti-B – yellow
Table 1 – ABO Grouping (Front Type) Antigen on RBC Blood Type A only A B only B Both A and B AB Neither A nor B O* ** Not to say that Type O doesn’t have any surface antigen. It has H antigens! » Basic antigen on RBC surface » Dagdagan lang ng sugars kaya nagkakaroon ng types A, B, and AB ** There are more blood type A individuals than blood type B individuals Figure 1 – Different Sugar Combinations per Blood Type
1. 2.
1.
Back Type Or “reverse” grouping Detecting isohemagglutinins (naturally occurring antibodies) in the patient’s serum Using known reagent RBCs (namely A1 and B cells)
Table 2 – ABO Grouping (Back Type) Isohemagglutinins Anti A Anti B Both anti A and anti B Neither anti A nor anti B
Blood Type B A O AB
** Horror Autotoxicus – immunity is directed against foreign materials but not against the constituents of one’s own body ** During fetal development – genes are switched on or off depending on blood type » For example, baby is type A » Anti-A gene is switched off (not expressed) ** RBCs are also identified as Rh or D positive or negative
Screening for Alloantibodies A screen looks for unexpected RBC antibodies which may form following pregnancy or prior transfusion If screen is positive, the antibody is identified and 2 units
2.
LACKING the corresponding antigen are cross-matched with the patient o If may nahanap na corresponding antigen, then automatically denied na ang transfusion kasi there will be a reaction o Note that 1 unit of blood = 1 pint = 473.18 mL The physician should be notified Antibody identification can be complicated and take more than a day to complete Cross Matching One part of pre-transfusion testing Major – PSDR o Donor’s RBC is cross matched with patient’s serum Minor – DSPR o Patient’s RBC is cross matched with donor’s serum o Minor because there are very few donor’s antibodies (that can destroy) with respect to recipient’s RBCs Hemolytic Disease of the Newborn (HDN) Also called Hemolytic Disease of the Fetus and Newborn (HDFN) or Erythroblastosis fetalis RH incompatibility with the mother Destruction of the RBC’s of the fetus and neonate by antibodies produced by the mother The mother can be stimulated to form the antibodies by previous pregnancy or transfusion IgG that was supposed to combat pathogens now attack the fetal RBC antigens that were inherited from the father Major: Rh- mother, Rh+ father, Rh+ fetus st o 1 Pregnancy: breakage of vessels (fetal RBC leaks into mother’s body) → recognized as foreign → production of antibodies o Subsequent pregnancy:Antibodies formed from previous pregnancy attacks fetal RBC Baby appears BLUE – cyanotic baby o RhoGAM or Rh-IG (Rh-immunoglobulins) antibodies against D antigens Minor (ABO incompatibility) o Mother is type O and the baby is A, B, or AB o Rh or (D), ABO antigens are most immunogenic
BLOOD GROUP SYSTEMS ** She skipped all the slides about this so all information found here were lifted from Harmening’s Modern Blood Banking and Transfusion Practices ** We included it na rin in case lang… pero medyo nice to know na rin siya
ABO System Only blood group system in which individuals have antibodies to antigens that are absent from their RBCs Occurs without any exposure to RBCs through transfusion or pregnancy (“naturally occurring”) Antibodies o believed to be acquired from exposure to bacteria, pollen particles, and other substances in nature Which are chemically similar to A and B antigens o Predominantly IgM
3
4
o
1. 2.
Produces strong direct agglutination reactions So if wrong group is transfused, rapid intravascular hemolysis can occur Can lead to death o Inheritance follows Mendelian genetics o A locus on each chromosome 9 is occupied by an A, B, or O gene. O gene is considered an amorph no detectable antigen is produced in response to the inheritance of this gene Considered an autosomal recessive trait inheritance of two O genes Antigens o The genes do not code for the production of antigens Produce specific glycosyltransferases that add sugars to basic precursor substances. o H antigen The precursor structure on which A and B antigens are made Not part of the ABO system, but can influence A and B antigen expression Found on chromosome 19 Must be inherited to form the ABO antigens on the RBCs Genes o H gene Encodes for transfer of L-fucose on precursor substance on RBC surface In O blood – no production of active transferase so H antigen is unmodified Bombay blood type – lacks H antigen on RBC surface and have anti-H in serum (hh genotype) o A gene Encodes for transfer of N-acetyl-Dgalactosamine (GalNac) sugar on H antigen o B gene Encodes for transfer of D-galactose (Gal) sugar to H antigen Rh System Refers to specific Rh or D antigen Second most important blood group system o Very immun0genic Rh positive o Possess D antigen Rh negative o Lacks D antigen Other Blood Systems Relatively insignificant International Society of Blood Transfusion (ISBT) Classification P Group o P1Pk (ISBT #003) o Globoside (028) o Related (209) MNS (002) System, Lutheran (005), Kell (006), Lewis (007) System, Duffy (008), Kidd (009) Diego (010), Yt (011), Xg (012), Scianna (013), Dombrock (014), Calton (015), Landsteiner-Wiener (016) Chido-Rodgers (017), Kx (019), Gerbich (020), Knops (022), Indian (023), Ok (024) Raph (025), John Milton Hagen (026), I (027) Antigen, Gill (029), RH-Associated Glycoprotein (030)
*** Extremely nice to know things :P
Figure 2 – Summary of ABO Antigens and Antibodies Present in Each Blood Type
Karagdagang Kaalaman Australia Antigen (Au Ag) » also known as Hepatitis B surface antigen (HBsAg) » 1967 : Dr. Baruch Samuel Blumberg discovered this antigen in an Australian Aboriginal with jaundice (along with Dr. Harvey Alter) » Discovery allowed for the development of a reliable blood screening test for hepatitis B » 1969: Dr. Blumberg also invented the HBV vaccine (along with Dr. Iriving Millman) Bombay Blood Type » First case - detected in Mumbai (called Bombay then) » Patient thought to be an O type but developed haemolytic transfusion reaction so they investigated » Bombay presents as O type in a routine ABO testing because we only use anti-A and anti-B sera Bombay has neither A nor B antigens so akala, O However, it is different from O-type in that it also does not have H antigens » Bombay blood type can DONATE TO ANY ABO BLOOD GROUP but it can only receive from fellow Bombay blood types
References: http://hospitals.unitedbloodservices.org/perioperative-bloodsalvage.html http://www.redcrossblood.org/donating-blood/eligibilityrequirements/eligibility-criteria-alphabetical-listing http://www.hepb.org/about/blumberg.htm http://www.thinkfoundation.org/kc_bombay_blood_groups.htm Harmening’s Modern Blood Banking and Transfusion Practices
#DoMimicry :P
4
4
