MUST TO KNOW IN IMMUNOHEMATOLOGY (BLOOD BANKING) ISBT 001 ABO ISBT 002 MNS ISBT 003 P ISBT 004 Rh ISBT 005 Lutheran ISBT 006 Kell ISBT 007 Lewis ISBT 008 Duffy ISBT 009 Kidd ISBT 010 Diego ISBT 011 Cartwright Cartwrig ht ISBT 012 Xg ISBT 013 Scianna ISBT 014 Dombrock ISBT 015 Colton ISBT 016 Landsteiner-Weiner Landsteiner -Weiner ISBT 017 Chido/Rodgers Chido/Rodger s ISBT 018 H ISBT 019 Kx ISBT 020 Gerbich ISBT 021 Cromer ISBT 022 Knops ISBT 023 Indian Chromosome 1 Rh Duffy Scianna Cromer Knops Chromosome 2 Gerbich Chromosome 4 MNS Chromosome 6 Chido/Rodgers Chido/Rodger s Chromosome 7 Cartwright Colton Kell Chromosome 9 ABO Chromosome 11 Indian Chromosome 17 Diego Chromosome 18 Kidd Chromosome 19 H Lewis Landsteiner-Weiner Lutheran Chromosome 22 P Chromosome X Xg Kx Chromosome: Not known Dombrock Von Descatello (Decastello) AB Sturle (Sturli) Blood groups (Most common) O > A > B > AB (Least common)
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Cell typing
Uses of anti-AB Serum typing
Gel typing
Red cell Ag-Ab reactions
Universal donor Universal recipient Universal donor for RBCs Universal recipient for RBCs Universal donor for plasma Universal recipient for plasma RCS: Red cell suspension
Genotype Phenotype Homozygous Heterozygous Dominant Recessive Allele Silent/amorph Von Dungern Hirzfeld
Forward/direct typing Specimen: RBCs (Ag) Reagents: = Anti-A (blue: trypan blue) = Anti-B (yellow: acroflavin dye) = Anti-AB (colorless) Checks for the reaction of anti-A and anti-B Detects weak subgroup of A and B because it has higher titer of anti-A & anti-B Reverse/indirect typing Specimen: Serum (Ab) = 3-6 months (development) Reagents: = A1 cells = B cells Major Advantage: Standardization Medium: Dextran-acrylamide gel 0 = Unagglutinated Cells ---(media)---> Bottom of the μtube (microtube) 1+ = Agglutinated cells ---(media)---> May concentrate at the bottom of μtube 2+ = Agglutinated cells ---(media)---> Throughout the length of the μtube 3+ = Agglutinated cells ---(media)---> Concentrate near the top of the μtube 4+ = Agglutinated cells ---(media)---> Top of the media Mixed-field: = Agglutinated cells ---(media)---> Top = Unagglutinated cells ---(media)---> Bottom 0 = No agglutination/hemolysis W+ = Tiny agglutinates, turbid BG 1+ = Small agglutinates, turbid BG (25% agglutination) 2+ = Medium agglutinates, clear BG (50% agglutination) 3+ = Large agglutinate, clear BG (75% agglutination) 4+ = One solid agglutinate (100% agglutination) Group O Group AB Group O (No Ag) Group AB (No Ab) Group AB (No Ab) Group AB (No Ag) BB = 2-5% RCS Approximate = Tomato red Exact % RCS = [Vol. RBCs (mL) ÷ TV (mL)] x 100 One’s genetic makeup Expression of one’s genes In double dose In single dose Always expressed even in the heterozygous state Not expressed when (+) dominant gene To be expressed, it should be in the homozygous state One of two or more different genes that may occupy a specific locus on a chromosome Only indicates the absence of the Ag Subgroups of A = A1 (80%) and A 2 (20%) Page | 238
Dolichos biflorus Phenotype A1
Lectin source of anti-A1
Possible Genotypes A1A1 A1A2 A1O A2 A2A2 A2O A1B A1B A2B A2B B BB BO O OO Gene Glycosyltransferase Immunodominant Sugar Ag Acceptor molecule H L-fucosyltransferase L-fucose H Precursor subs. A N-acetylgalactosaminyltransferase N-acetyl-D-galactosamine A H B D-galactosyltransferase D-galactose B H AB N-acetylgalactosaminyltransferase N-acetyl-D-galactosamine A H D-galactosyltransferase D-galactose B O ---Unchanged H Amount of H Ag (Greatest) O > A2 > B > A 2B > A1 > A1B (Least) Bombay individual Bhende (-) H gene hh or Hnull Lack H, A and B Ag’s Designated as Oh w/ anti-H, anti-A and anti-B Ab’s Mistyped as group O Parabombay Inherit weak H gene w/ detectable A and B Ag’s but no detectable H Ag Ah, Bh, ABh Anti-H Differentiates Group O from Oh individuals Ulex europaeus Lectin source of anti-H ABO Histoblood group = present on all tissues and organs of the body May be expressed in secretions depending on the secretor status (SeSe or Sese) Determination of Secretor Specimen: Saliva Status Principle: Hemagglutination-inhibition ABO antibodies Mixture of IgM, IgG and IgA (Henry) Anti-A Predominantly IgM Anti-B React at room temp Naturally occurring Anti-A,B (Group O) Predominantly IgG React at 37’C Immune Ab Immune Ab’s Production is stimulated by: 1. Pregnancy 2. Incompatible transfusion and transplant ABO HDN Mother: Group O Child: Group A or B Weak reacting/missing Ab’s Group I discrepancies Newborns Elderly patients Hypogammaglobulinemia/agammaglobulinemia Page | 239
Group II discrepancies
Group III discrepancies
Group IV
A3 Ax Aend Am Ay Ael B3 Bx Bm Bel Rh Nomenclatures
Immunogenicity of Rh Ag’s R or r 1 or ‘ 2 or ‘’ Z or y G Rh: 13, 14, 15, 16 Genetic weak D D Mosaic (Partial D)
C Trans f (ce) rhi (Ce) Hr0 Rh Ab’s
Weak reacting/missing Ag’s (Less frequent) Leukemia Acquired B phenomenon Subgroups of A Hodgkin’s disease BGSS (Remedy: Wash RBCs) Plasma abnormalities resulting to Rouleaux formation (Plasma factor) globulins: MM, WM, HL fibrinogen Dextran and PVP Wharton’s jelly (Remedy: Wash cord cells 6-8x (7x) Miscellaneous: Polyagglutination Anti-I (cold agglutinin) Cis “AB phenotype” Unexpected ABO isoagglutinins: = Anti-H: produced by A 1 and A1B (H Ag) = Anti-A1: produced by A2 and A2B (No A1 Ag) A Subgroups MF agglutination w/ anti-A & anti-A,B Weak MF agglutination w/ anti-A& anti-A,B MF agglutination w/ anti-A,B (-) Agglutination, (+) AH substance in secretions (-) Agglutination, AH substance in secretions (-) Agglutination, (+) H substance in secretions B Subgroups MF agglutination w/ anti-B & anti-A,B MF agglutination w/ anti-A,B (-) Agglutination, (+) BH substance in secretions (-) Agglutination, (+) H substance in secretions 1. Rosenfield = no genetic basis, indicates the presence or absence of Rh Ag’s 2. Fisher-Race (DCE) = inheritance of 3 genes (d= amorph/silent) 3. Wiener (Rh-hr) = inheritance of 1 gene (Ex. R 0), w/c codes for an agglutinogen (Ex. Rh0), w/c contains 3 blood factors (Ex. Rh 0hr’hr’’) (Most immunogenic) D > c > E > C > e (Least immunogenic) D or d Ce cE CE D+C+ red cell 4 different parts of the D mosaic D Ag’s expressed appear to be complete, but few in number If one or more parts of D Ag is missing weakened expression of D Ag May produce anti-D (Ab against missing fragment) 4 fragments D ---(trans)---> C (Ex. Dce/dCe) c ---(cis)---> e [Ex. Dce/DCE] C ---(cis)---> e [Ex. DCe/DcE] “Common” Rh phenotypes (R 1R1, R2R2, rr) IgG1 and IgG3 React at 37’C Immune Ab’s Page | 240
Rh HDN RhoGam or RhIg Full dose RhoGam (>12 weeks gestation) Minidose/Microdose RhoGam (<12 weeks gestation) # RhIg vials
As little as 1mL Rh(+) RBC Rh+ Perform test for Du (IAT) Rh2 conditions wherein an Rh- pt. can be transfused w/ Rh+ blood Anti-LW (Landsteiner-Weiner) Rhnull
Rhdeleted Lewis system Lewis Ag’s
Genotype ABH, lele, sese ABH, lele, SeSe/Sese ABH, LeLe/Lele, sese ABH, LeLe/Lele, SeSe/Sese Lewis Ab’s
MN Ag’s
Anti-M
(-) C’ binding = extravascular hemolysis (delayed HTR) Mother: Rh (-) Child: Rh (+), 2nd pregnancy Purified anti-D Administer w/in 72 hrs after 1 st delivery 300 μg anti-D Protect up to 30mL D+ WB or 15mL D+ RBCs 50 μg anti-D Protect up to 5mL of D+ WB or 2.5mL D+ RBCs Ex. Abortion Volume of FMH (mL) ÷ 30 Vol. FMH = % fetal cells x 50 --------------------------------------------x = (% Fetal cells x 50) ÷ 30 x ≈ __ + 1 = # RhIg vials Produces anti-D RBCs + anti-D = (+) agglutination If RBCs + anti-D = (-) agglutination = IAT is (+) agglutination = +D u (weak D) RBCs + anti-D + AHG reagent = (-) agglutination 1. No prior exposure to D Ag (males) or past childbearing age (females) 2. Administer RhoGam Originally identified as anti-Rh in early experiments involving rabbits immunized w/ Rhesus monkey blood Anti-LW agglutinates Rh+ and Rh- cells except Rhnull cells No Rh Ag Designated as ---/--Stomatocytes No C/c and E/e Ag Designated as D--/D-Le gene codes for the production of fucosyltransferase enzyme that catalyzes addition of fucose to the 4 th C of N-acetylglucosamine of type 1 precursor Lea ---(Se)---> Leb Produced by tissue cells Not well developed at birth = NB/cord cells = Le(a-b-) Decreased expression during pregnancy Substances (Secretion) Phenotype Le Ab’s a None ABH, Le(a-b-) Anti-Le & Anti-Leb ABH ABH, Le(a-b-) Anti-Lea & Anti-Leb Lea ABH, Le(a+b-) Anti-Leb ABH, Lea, Leb ABH, Le(a-b+) none a b Anti-Le & Anti-Le Naturally occurring IgM Activates the C’ Glycophorin A (MN-SGP) M = Ser-Ser-Threo-Threo-Gly N = Leu-Ser-Threo-Threo-Glu Well developed at birth Important in paternity testing IgM, pH-dependent (6.5), glucose-dependent Page | 241
Anti-N-like Ab SS Ag’s
Ss Ab’s
Phenotype P1 P2 p (p null) P1k P2k P1-like P1 substance Anti-P1
Anti-Tja Anti-P
Ii Blood Group
HEMPAS Anti-I
Anti-i
Anti-IT
K k Kpa Kpb Jsa Jsb Kell Ag’s
IgM Found in renal patients dialyzed w/ formaldehyde sterilized equipment Glycophorin B (Ss-SGP) S = Methionine (29 th) s = Threonine (29 th) IgG React at 37’C and AHG Severe HTR w/ hemoglobinuria and HDN Detectable Ag’s Possible Ab’s P1 and P None P Anti-P1 None Anti-P, P1, Pk (anti-Tja) Pk and P1 Anti-P Pk Anti-P, anti-P1 Plasma, pigeon and turtledove droppings, turtledove eggwhite Hydatid cyst fluid, Lumbricoides terrestris, Ascaris suum IgM Naturally occurring Strong anti-P1 = Hydatid disease (E. granulosus) Associated w/ fascioliasis, C. sinensis and O. viverrini infections Anti-P, P1, Pk Spontaneous abortions in early pregnancy IgG Naturally occurring Biphasic hemolysin (PCH) Test: Donath-Landsteiner I: Individuality Neonates = I I (Ag) = I-i+ Adults (18 mos.-adult) = I I = I+ii Ag in adults Interfere w/ reverse typing (Group IV) Benign anti-I = normal, IgM, naturally occurring, react at 4’C Pathologic anti-I = IgM, react at 30/32’C (CAS = PAP) Autoanti-I = M. pneumoniae, L. monocytogenes IgM React at 4’C EBV caused Diseases of RES: - Alcoholic cirrhosis - Myeloid leukemia - Reticuloses Transition: from i I Yanomama Indians Hodgkin’s lymphoma Kell Cellano Penney Rautenberg Sutter Matthews Immunogenicity: 2nd to D (D>K>c>E>C>e) Synthesized on precursor Kx Page | 242
MacLeod phenotype Anti-K Fy(a+b-) Fy(a-b-) Fya and Fyb Duffy gene Anti-Fya Anti-Fyb Jk a and Jk b Anti-Jk a Anti-Jk b
Lua and Lub Anti-Lua
Anti-Lub
Diego (Di) Defect in AE molecule
Cartwright (Yt) Xg
Scianna Dombrock
Colton (Co) Chido/Rodgers (Ch/Rg)
Gerbich (Ge) Cromer (Cr) Knops (Kn) Indian (In) Benneth-Goodspeed (Bg)
= On WBCs: remain unconverted. If (-) CGD = On RBCs: converted to Kell Ag’s. If ( -) MacLeod phenotype Acanthocytosis Muscular dystrophy IgG React at 37’C and AHG Chinese (90.8%) American blacks Resistant to P. vivax /P. knowlesi (malaria) Receptors for malaria 1st human gene to be assigned to specific chromosome (1) IgG React at AHG Enhanced by enzymes Notorious antibody = not easily detected Immune Ab’s (IgG) Common cause of delayed HTR Autoanti-Jk = Methyldopa (Aldomet) Development at age of 15 IgG, IgM, IgA Naturally occurring React at room temp IgG4, IgM, IgA Immune Ab React at 37’C Mongolian ancestry AE-1 = HCO3- <--> Cl“ASO” Acanthocytosis Hereditary Spherocytosis SEA Ovalocytosis Erythrocyte acetylcholinesterase = neurotransmission Sex-linked Females Short arm of X chromosome Sc1, Sc2, Sc3 Gregory (Gya) Holley (Hy) Joseph (Joa) CHIP, Aquaporin = water permeability HLA system (Bg) C4A (Rg) and C4B (Ch) = C’ component HTLA = exhibit reaction only at high dilution DAF (Cr) GPC and GPD Leach phenotype (GE: -2, -3, -4) = Elliptocytosis DAF CROM Ab’s = black individuals CR1 (C’ receptor 1) CD44 (immune adhesion) HLA Ag’s on RBCs (Class I MHC) Bga = HLA-A7 Page | 243
Bgb = HLA-A17 Bgc = HLA-B28 Public Ag High-incidence Ag’s Ena (99.9%) Private Ag Low-incidence Ag’s (<1%) HTLA Ab’s Anti-Ch Anti-Rg Anti-Kn Anti-Yk a Anti-Csa Anti-McC Anti-JMH Sources of Substances for Neutralization for Certain Antibodies Hydatid cyst fluid, pigeon droppings, turtledoves’ egg whites Anti-P1 Anti-Le Plasma/serum, secretor saliva Anti-Ch, Anti-Rg Plasma/serum a Anti-Sd Urine, guinea pig urine Anti-I Mother’s milk Anti-H Saliva Effect of Proteolytic Enzymes on Select Antigen-Antibody Reactions Enhanced P1 Rh I Kidd Lewis Destroyed MNS Duffy Chido Rodgers Cartwright Xg Donation Process At least 2 persons Bleeder Head (BB) Donor registration 1st step Interview & physical exam 2nd step Actual donor selection and 3rd step blood collection Collection <15 mins (7-10mins) >15 mins = (-) cryoprecipitate Donor bleeding 450 angle 10-200 angle (Venipuncture: 150 angle) Basic Qualifications of the Potential Blood Donor Good health Purplish blue lesions Kaposi’s sarcoma (HIV, HHV-8) Age 18-65 yrs old <18 yrs old = w/ parent’s consent >65 yrs old = w/ physician’s consent Body weight Max: 10.5mL/kg Ideal: 110 lbs (50kg) 450mL blood + 30mL blood (serologic tests) 63mL anticoagulant Page | 244
Donor
Vol. of blood to be drawn Vol. of anticoag. needed Vol. of anticoag. to be removed from blood bag 1:7
Temperature Pulse BP cuff BP (DOH) Min. H & H
CuSO4 method
Permanent
3 years 1 year (12 months)
9 months (DOH) 3 months (12 weeks) [DOH] 1 month (4 weeks)
2-3 weeks
<110 lbs (<50kg): = Volume of blood to be drawn = Volume of anticoagulant A = (Donor weight ÷ Ideal weight) x 450mL B = (A ÷ 100) x 14 C = 63 – B Anticoagulant: Blood ratio (Blood bag) 63mL AC = 450mL blood 31.5mL AC = 200mL blood 37.5’C (99.5’F) 50-100 beats/min ( athletes = acceptable) 40-60 mmHg (if used as tourniquet) 90-160 mmHg 60-100 mmHg Allogeneic donation: Hgb: ≥12.5 g/dL Hct: ≥38% Autologous donation: Hgb: ≥11 g/dL Hct: ≥33% Hgb determination 30mL container = 25 tests, solution changed daily SG: CuSO4 = 1.053 1 cm = distance between blood and solution Acceptable drop of blood sink w/in 15 secs (Hgb: ≥12.5 g/dL) Donor Deferral Chagas’ disease Babesiosis Tegison (Tx: Psoriasis) = teratogenic Recipient of human (pituitary)-derived GH = risk of transmitting CJD [Recombinant GH = no deferral] Recipient of cornea/dura mater = risk of transmitting CJD Malaria refugee/immigrant Recipients of blood known to be possible sources of hepatitis Tattoo Rape Incarceration in jail (3 days/72 hrs) Blood transfusion Major operation including dental surgery Syphilis Gonorrhea Traveler malaria-endemic places Rabies vaccine Childbirth (AABB: 6 weeks) Recent blood donation (AABB: 8 weeks) = 450mL blood: 12 weeks = 200mL blood: 6-8 weeks Rubella vaccine Isotretinoin/Accutane (Tx: Acne) = teratogenic Proscar (Tx: Benign prostatic hyperplasia) = teratogenic After febrile episodes Page | 245
2 weeks
2 days (48 hrs) 12 hrs Cause: Arterial puncture Citrate
Dextrose/Glucose Citric acid Adenine Phosphate buffer Shelf-life: 21 days
Shelf-life: 35 days Shelf-life: 42 days
Additive solutions
Rejuvenation solutions
Heavy spin Light spin 6-8 hours processing Platelet concentrate
Blood Component Whole blood
Packed RBCs
Rubeola vaccine Polio vaccine Mumps vaccine After hemapheresis After alcohol intake Jet-like pulsating bleeding w/ bright red blood Binds Ca2+ Massive transfusion (8-10 units) Citrate toxicity Hypocalcemia Milk = Ca2+ Provides energy for red cells Prevents caramelization (pH) For improved survival of red cells ATP ACD (Apheresis) CPD CP2D CPDA-1 CPDA-2 (DOH) Additive solutions: -Adsol (AS-1) -Nutricel (AS-3) -Optisol (AS-5) SAGM: -Saline -Adenine -Glucose -Mannitol = RBC membrane stabilizing agent ATP & 2,3-DPG (Rejuvesol) PIGPA = Phosphate, Inosine, Glucose, Pyruvate, Adenine PIPA = Phosphate, Inosine, Pyruvate, Adenine 5000g for 5mins = pRBC, platelet concentrate 5000g for 7mins = cryo, cell-free plasma 2000g for 3mins = platelet-rich plasma To maximize the number of components derived from 1 unit of blood Light spin Heavy spin Centrifuge at 20-24’C [Other blood components: Ref. centrifuge (1-6’C)] Bacterial contamination Separate from WB w/in 6-8 hrs Indication
Storage
Transport
1. Blood vol. expansion & RBC mass 2. Massive transfusion & acute blood loss 1. RBC mass (Normovolemic patients)
1-6’C
1-10’C
1-6’C
1-10’C
Shelf-life 21d (ACD, CPD) 35d (CPDA-1) 42d (CPDA-2) 2d (Heparin Open system: 24h Closed system: 21d (ACD, CPD) 35d (CPDA-1)
Other Info 1 unit: Hgb by 1 to 1.5g/dL Hct by 3-5% ‡80% plasma removed ‡(Hct: 65-80% but not >80%) 1 unit: Hgb by 1 to 1.5g/dL Hct by 3-5%
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Blood Component Leukoreduced RBCs
Washed RBCs
Frozen RBCs
Deglycerolized RBCs Fresh frozen plasma
Indication
Storage
Transport
1. FNHTR (Leuko. Ab’s) = 1’C in temp. 2. Prevent CMV
1-6’C
1-10’C
1. Allergic (plasma w/ foreign protein) 2. FNHTR (Leuko. Ab’s) Anaphylactic: IgA w/ antiIga 1. Prolong storage of rare units 2. Prolong storage of autologous units
1-6’C
-65’C or -125’C
Shelf-life Same as WB
24h
Preparation: 1. Centrifugation 2. Filtration 3. Saline washing Also for polyagglutination
10 years
24h 1. Multiple coag. factor def. (liver disease) 2. Replace isolated factor def. when specific component is not available 3. Reverse effects of coumarin/warfarin
-18’C -65’C
1 year (-18’C) 7 years (-65’C)
Cryoprecipitate
1. Fibrinogen def. 2. Hemophilia A 3. vWD 4. Factor XIII def.
-18’C or colder
1 year
Granulocyte concentrate
1. Granulocyte dysfunction (CGD) 2. Myeloid hypoplasia 1. Thrombocytopenia
20-24’C w/o agitation 20-24’C w/ agitation 1-6’C
24h
Platelet concentrate
Other Info
‡Contains plasma,
all coag. factors and complement ‡FFP: Thaw at 37’C ‡Thawed plasma: store at 1-6’C ‡Administer w/in 24hrs once thawed ‡Contains: -150mg fibrinogen -80 U AHF -vWF -Factor XIII ‡Cryoppt.: Thaw at 37’C ‡Thawed cryoppt (<15mL; not groupspec.): store at RT’ ‡Administer w/in 6 hrs Contains 1 x 1010 granulocytes
5d (20-24’C w/ agitation) 2d (1-6’C)
1 unit will platelet count by 5,000- 10,000/μL Usually RBCs and platelets are irradiated
Irradiated blood component
1. Prevent GVHD
Factor VIII concentrate Factor IX concentrate
1. For hemophilia A
1-6’C
28 days from irradiation or orig. exp. date whichever comes first Varies
1. For hemophilia B
1-6’C
Varies
NSA
1. Hypovolemic shock
2-10’C
5 years
Stored in lyophilized form ‡A.k.a. prothrombin complex ‡Contains factors II, VII, IX and X 96% Albumin 4% Globulin
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Blood Component PPF
Indication
Storage
1. Hypovolemic shock
Transport
2-10’C
SDP
High glycerol (Slow freezing) Low glycerol (Fast freezing) Agglomeration
Cryoprotective agent Deglycerolization High glycerol (DG) Low glycerol (DG) Agglomeration (DG) Cryoprecipitate Leukapheresis
Shelf-life 5 years 5 years
Methods of Freezing RBCs Concentration Frozen at 40% w/v glycerol -80’C
Stored at -65’C
20% w/v glycerol
-120’C
-196’C
Other Info 80-85% Albumin 10-15% Globulin SDP: Single donor plasma
Equipment Mechanical freezer Liquid nitrogen
Glycerol -80’C -65’C Mechanical Glucose freezer Fructose EDTA Prevents rupture of RBCs during freezing Ex. Glycerol Removal of glycerol Hypertonic solution followed by an isotonic solution 12% NaCl -----> 1.6% NaCl -----> 0.9% NaCl 45% NaCl in 15% mannitol 50% Glucose + 5% Fructose -----> 0.9% NaCl After thawing = administer w/in 6 hours After pooling = administer w/in 4 hours HES (Hydroxyethylstarch) = Separation bet. WBCs and RBCs Donor: administered w/ corticosteroids 12-24 hrs before donation = # of circulating granulocytes
Plateletpheresis
Usually takes 1-2 hours Donor: = Platelet count: ≥150 x 109/L = Aspirin-free: 3 days Single donor platelets (SDP) A.k.a. super packed platelets From plateletpheresis For patients who are refractory or unresponsive to RDP Limit patient exposure to multiple donors RDP: Random Donor Platelets SDP: Single Donor Platelets Preparation From WB: Light spin Heavy spin Plateletpheresis 10 Amount 5.5 x 10 platelets 3.0 x 1011 platelets Vol. of plasma 50-75mL 300mL ≥ 6.0 (New: 6.2) ≥6.0 (New: 6.2) pH Storage 20-24’C w/ agitation 20-24’C w/ agitation Shelf-life 5 days 5 days At risk of TA-GVHD Recipient of BM transplant Patients w/ hematologic or oncologic disease Patients w/ congenital immunodeficiency Recipient of blood from 1 st degree relative (direct) Irradiation Radiation source: 25-35 Gy (Gy: Gray | 1Gy = 100 rads) a. Cesium (Ce) b. Cobalt (Co) Infusion IV fluids: a. NSS = the only fluid allowed to start an IV line prior to transfusion Page | 248
b. D5W (5% dextrose in H 2O) = Not allowed to start (hypotonic hemolysis) c. Ringer’s lactate =not allowed to start (contains Ca 2+ promote coagulation) 37’C Blood warmers Temp. >42’C = hemolyzed 1. Clot screen filter (170μm) = to remove gross clots Filters 2. Leukocyte depletion filter Speed of infusion 15gtts = 1mL 60gtts = 1min 1min = 4mL 1hr = 240mL Rate = 240mL/hr 1 unit must be completed w/in 4hrs of blood transfusion Polyagglutination (Hubener-Thomsen-Fridenrich Phenomenon) Hidden Ag’s Cryptantigens Covered w/ NANA (N-acetylneuraminic acid) or sialic acid When NANA is destroyed (by neuraminidase) Ag’s are exposed Exposed Ag’s Agglutination = React w/ tetrasaccharide of Thomas & Winzler (T receptor) Acquired Microbially-Associated Polyagglutination T C. perfringens V. cholerae S. pneumoniae All produce neuraminidase Th E. coli Proteus sp. Produce weaker neuraminidase Tx Bacterial and viral Unknown mechanism “CABS” Tk C. albicans A. niger B. fragilis S. marcescens All produce endo/exogalactosidase Altered precursor substances (Altered: ABH, Le, I, P) Acquired B phenomenon Bacteria: Deacetylase enzyme N-acetylgalactosamine --(Deacetylase)--> N-acetyl + galactosamine Galactosamine = Group B Remedy: Add acetic anhydride VA Vienna, Virginia Microbial fucosidase = fucose = H Acquired Non-Microbially Associated Polyagglutination Tn (-) β-3-D-galactosyltransferase enzyme needed for the normal structure of T receptor (Tetrasaccharide of Thomas and Winzler) Inherited Polyagglutination Sda Cad Adult i Ag = H Ag, Sialic acid HEMPAS/CDA II HbM – Hyde Park Others NOR = Norfolk, Virginia
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Arachis hypogaea Salvia sclarea Salvia horminum Glycine soja
Predeposit AD
Intraoperative AD Immediate preoperative hemodilution Postoperative salvage
FNHTR
Allergic Anaphylactic
Anaphylactoid
TRALI (NCPE)
Hemolytic TA-GVHD PTP
DHTR TACO
Tn + + +
Cad + +
T + +
Tk + -
Autologous Donation Before anticipated transfusion Requirements: *No age limit *No strict weight requirement ( vol. by 4mL/1 pound below 110) *Hgb ≥ 11g/dL *Hct ≥ 33% *Frequency: every ≥ 3days Collect blood during surgical procedure reinfused immediately Collect blood replace patient volume w/ colloid/crystalloid reinfuse during surgical procedure Drainage tube Postoperative bleeding salvaged (saved) clean and reinfused Immediate Immune Transfusion Reactions 1’C in temperature Cause: anti-leukocyte Ab’s (leukoagglutinins) Prevention: Leukopoor RBCs Cause: Donor plasma w/ foreign proteins Prevention: Washed RBCs Afebrile (no fever) Signs and symptoms occur only after the infusion of only few mL of blood IgA deficiency w/ anti-IgA antibody Prevention: Washed RBCs | IgA-deficient donor (rare) Afebrile Normal IgA w/ anti-IgA to donor IgA Prevention: Washed RBCs | IgA-deficient donor (rare) Cause: Anti-leukocyte Ab’s (leukoagglutinins) Signs and symptoms resemble respiratory distress Prevention: Leukopoor RBCs Bleeding, hypotension, hemoglobinuria, anuria Delayed Immune Transfusion Reactions Cause: T lymphocyte proliferation Prevention: Irradiated RBCs Onset of thrombocytopenia Cause: anti-platelet Ab’s (HPA-1a negative platelets) Prevention: Therapy a. Administration of corticosteroid b. Exchange transfusion c. IV immunoglobulins 7 days Immediate Nonimmune Transfusion Reactions Administration of blood w/o equivalent blood loss Iatrogenic: physician-caused At risk: a. Young children b. Elderly patients Page | 250
Bacterial contamination
c. Patients w/ cardiac disease Prevention: Therapy a. Therapeutic phlebotomy b. IV diuretics c. O2 therapy Cause: Endotoxin production by psychrophilic/cryophilic bacteria Y. enterocolitica (most common) E. coli P. aeruginosa Factors: a. During phlebotomy b. During preparation/processing c. During thawing Prevention: a. Sterile technique b. Visual inspection of unit Blood unit = Brown, purple, hemolysis, clot Plasma = Murky (dark brown) purple, red Causes: - Small bore needle - Warming blood above 50’C - Freezing blood w/o cryoprotective agent - Citrate toxicity Delayed Nonimmune Transfusion Reactions Patients w/ normovolemic anemia Transfusion-dependend patients: - Aplastic anemia - Congenital hemolytic anemia Prevention: a. Iron-chelating agent = Deferroxamine b. Neocytes = young RBCs, has longer lifespan HBV, HCV, HDV, CMV, EBV, HTLV-I and II, HIV, T. pallidum, Plasmodium spp., B. microti, T. cruzi, T. gondii Hemolytic Disease of the Newborn Anemia ( immature RBCs, enlarged spleen & liver = extramedullary hematopoiesis) Hydrops fetalis = cardiac insufficiency, edema Unconjugated bilirubin Brain Kernicterus 1. Intrauterine transfusion - In utero - Corrects anemia - X-match: Mother’s serum 2. Exchange transfusion - Neonatal period - Removes bilirubin & Ab-coated RBCs - X-match: Mother’s serum (preferred) or infant’s serum Cross-Matching 2 hours Can be shortened to 30 mins Type/screen + immediate spin DC/PS = no agglutination/hemolysis Patient blood type is determined on 2 occasions → →
PCITR
Iron Overload (Hemosiderosis)
Disease transmission
In utero
Neonatal period Treatment
Full X-match Abbreviated X-match Electronic X-match
Page | 251
Emergency situation (+) Major X-match Ratio of serum to cells Saline for washing Incubation period Enhancement media
Anti-A1 Anti-H Anti-M
Anti-N
Anti-B Annually Quarterly (Every 3 months)
Monthly Daily Daily when in use
Every 4 hours Apheresis/Hemapheresis Intermittent-flow centrifugation (IFC)
Continuous-flow centrifugation (CFC)
Patient blood type is unknown Group O (Rh-) pRBCs (-) Alloantibody control (+) Autoantibody, autocontrol Routine = 40:1 Det. weak Ab’s = 133:1 pH 7.2-7.4 30-120 mins (majority: 30 mins) 1. Albumin 2. PEG 3. LISS (Incubation pd: 5-15 mins) Lectin Sources Dolichos biflorus Ulex europaeus Iberis amara Iberis umbellate Iberis semperivens Maclura aurantiaca Bauhinia variegate Bauhinia purpura Bauhinia bonatiana Bauhinia candicans Vicia graminea Bandeirae simplicifolia Quality Control Mercury thermometers Speed timer (centrifuge) Cell washers (speed, timer) Blood warmers Alarm Activation (refrigeration and freezers) Temperature (refrigerated centrifuge) Refrigerators and freezers (continuous monitors) Platelet incubators (enclosed, monitored chambers) Transfusion service: - Heating blocks - Water baths Donor facility: - Donor unit agitators - Scales - Balances - Hemoglobinometer - Microhematocrit centrifuges Platelet incubators (ambient temperature storage) Other Topics Whole blood is withdrawn, a desired component separated, and the remainder of the tube returned to the donor 1 venipuncture Blood is withdrawn and reinfused through the same needle Once the desired component is separated, the remaining components are reinfused to the donor 2 venipunctures Withdraw, process and return the blood to the individual simultaneously Page | 252
Antibody screen Donor & recipient samples Compatibility testing
DHTRs Virus inactivation in plasma products Y. enterocolitica Density Requirements for blood products to be transfused to infants Allogeneic donor blood from outside sources w/in 30 mins Procedure when HTR occurs Specimens for investigation of HTR
LISS ZZAP True chimerism
Artificial chimerism
AB cis genotype Acquired A antigen
Collect new specimen every 3 days in a series of transfusion Keep for 7 days after transfusion (at 1-6’C) Series of tests that ensure safety of transfusion to recipient and donor 1. Review of BB records 2. ABO and Rh 3. Ab screen 4. Cross matching a. Major X-match = DC/PS b. Minor X-match = PC/DS Occur 3 to 7 days after transfusion Heating in a liquid state w/ LMW stabilizers Heating in lyophilized state UV irradiation Bacterial contamination of blood Separates neocytes from mature RBCs 1. (-) HbS 2. <7 days 3. γ-irradiated 4. (-) CMV Repeat ABO and Rh typing Time limit when a unit of blood is removed from 2-8’C and returned back to the refrigerator 1. Stop transfusion 2. Keep IV line open 3. Notify the physician and BB 1. Patient pre-transfusion blood sample 2. Patient post-transfusion blood sample = PT/PTT/DAT = Pink: Hgb 0.2 g/L or 20 mg/dL = Red: Hgb >1 g/L or 100 mg/dL 3. Patient post-transfusion urine = Bilirubin/Urobilinogen 4. Blood bag = GS/CS Glycine/glucose + saline 5-15 mins incubation Cysteine-activated papain Mixture of DTT and papain Presence of 2 cell population Ex. Twins Mixed-field agglutination After: -BM transplantation -Blood transfusion -Exchange transfusion -Fetomaternal hemorrhage Group IV discrepancy Inheritance of 3 ABO genes (AB/O) 1. Tn activation 2. P. mirabilis Page | 253
Acquired B antigen
HAT medium Hybridoma cells Polyspecific AHG reagent Monospecific AHG reagent Type 1 precursor substance
Type 2 precursor substance
Agglutination in Gel technology Affinity column technology (Gamma ReACT) Wash RBCs # cryobags # units to test Enzyme technique
Elution
Adsorption Biphasic hemolysin Perfluorocarbons
“EPIC” 1. E. coli O86 2. P. vulgaris 3. Intestinal obstruction 4. Carcinoma of the colon and rectum Hypoxanthine, Aminopterin, Thymidine medium Culture for hybridoma cells Plasma cells (mouse) + myeloma cells + PEG Anti-IgG and anti-C3d Prepared by conventional technique (rabbits) Anti-IgG or anti-C3d Prepared by monoclonal Ab production (mice) β 1 3 ABH substance in secretions (glycoproteins) HAB, Se, Le genes β 14 ABH on RBC (glycoproteins) HAB genes Incompatible Affinity adherence of IgG-sensitized RBCs to immunologically active matrix 2-3x to remove unbound globulins [Desired level of Factor VIII x volume of plasma (mL)] ÷ 80 # units required ÷ frequency of donors (-) for relevant Ag 1. Papain = papaya 2. Bromelin = pineapple 3. Ficin = figs 4. Trypsin = pig’s stomach Breaking of bonds between Ag and Ab by: a. Physical: heating, shaking b. Chemical: ether, acid Removal of Ab in serum using appropriate RBC Cold = attaches to RBCs Warm = RBC lysis O2 carrying capacity RBC substitute
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