Principles of BLOOD TRANSFUSION

RONALD A. HUKOM

DIVISI HEMATOLOGI & ONKOLOGI MEDIK, DEPARTEMEN ILMU PENYAKIT DALAM,

FAKULTAS KEDOKTERAN UNIVERSITAS INDONESIA / RUMAH SAKIT KANKER DHARMAIS - Jakarta

History

• 1818 – the first human-to-human transfusion takes place….unfortunately patient dies

• 1901 – Karl Landsteiner discovers blood groups

• 1907 – checking for incompatibilities (crossmatching) is performed and leads to less transfusion reactions (N=128)

• 1916 – a citrate-glucose solution is developed to prolong the life of stored blood (weeks)

History

• 1917 – the first blood depot is formed with Group O blood for casualties in World War I

• 1922-1937 – more blood donor and transfusion services are established and the term “blood bank” is coined

• 1939-1940 – Rh system discovered

• World War II begins….

History

• 1940 – Plasma of Britain campaign begins after a shortage of plasma in WWII; plasma separation methods are first used

• 1941 – the American Red Cross organizes a civilian blood donor service for WWII

+

History

• 1960’s – Factor VIII concentrate developed for hemophiliacs

• 1971 – Blood banking becomes regulated by the FDA

• 1980’s – dozens of blood recipients develop what is now called AIDS

• 1980’s to present – more sensitive tests have been developed to screen donors (hepatitis and HIV)

Blood Donation

• Parts of the donation process:– Donor screening

• Physical exam and medical history

– Blood collection• Phlebotomy, adverse reactions, blood labeling

– Special donors• Directed donation, autologous donation,

hemapheresis, and therapeutic phlebotomy

Blood Donation

• Most blood donations are allogeneic

• Allogeneic donations are used for the general population

• Donors are not paid for donations; nor are they required to donate

• Donor centers must keep a record on each donor for at least 10 years

ABO Blood Groups

• Based on 2 Antigens (agglutinogens)

• 4 blood types: A, B, AB, O

• Blood antigens are genetically coded located on the surface of RBC membrane

• Antigen found on RBC corresponds to blood type.

Blood Groups

• TYPE ANTIGEN PRESENT

– A A– B B– AB AB– O Neither A nor B

Blood Groups

• Antibodies are called agglutinins they develop after birth in the plasma

• You will have the antibody for the antigen that is NOT present.

• If you have A blood you have the A antigen on your RBC, and you will develop the B antibody

Antibody

• TYPE ANTIGEN ANTIBODY

• A A anti B

• B B anti A

• AB AB neither

• O neither anti A antiB

BLOOD TYPE PERCENTAGE

O 45%

A 40%

B 11%

AB 4%

• A reaction outside the body between antigens and antibodies result in agglutination which means the blood cells clump together.

• A reaction within the body between antigens and antibodies results in hemolysis which means the red cells burst

Rh Factors

• 1946 Landsteiner, Levine and Weiner did research on the rhesus monkey and developed the Rh factor

• Three genes code for the antigen on red cells- C, D, E

• Blood Types based on Rh

• Rh positive means the Rh antigen is present on the RBC (+)

• Rh negative means the Rh antigen is not present on the RBC (-)

• Rh negative people that receive Rh positive blood, will trigger the immune system to develop Rh antibodies, that will remain in the blood

Erythroblastosis Fetalis

• Hemolytic Disease of the Newborn

• A Rh negative mom may be exposed to an Rh antigen from the blood of a Rh positive baby during pregnancy or birth.

• If Rh + cell enters Rh- mom, the mother’s immune system will respond and produce antibodies against the Rh positive blood antigen

• In pregnancies thereafter Rh antibody may cross the placenta, and cause RBC hemolysis in fetus. The baby will be anemic and very ill.

• This can be avoided by giving a Rh- mom antibodies, in the form of a RhoGam shot within 72 hours after delivery of every Rh+ child

Donor Screening

• Registration

• AABB Standards require that the donor be linked to the donor records (photo ID)

• Required information:– Name (first, last, MI)

– Date and time of donation

– Address

– Telephone

– Gender

– Age (date of birth) – allogeneic donors must be at least 17 years of age

Drugs• Aspirin, piroxicam, Plavix®: if taken within 3 days

(some say 48 hours), you cannot donate platelets by apheresis; however, whole blood donations are acceptable. Remember: aspirin effects platelet function (inhibits cyclooxygenase); Plavix blocks ADP receptors on platelets

• Chemotherapy: wait 4 weeks from last dose

• Human Growth hormone: permanent deferral

• Heparin or Coumadin: wait at least 5 days after discontinuing therapy (or until clotting is regulated)

Have you donated blood in the last 8 weeks?

• The time interval between allogeneic whole blood donation is 8 weeks

• A donor must wait 48 hours after donating platelets / plasma, before donating whole blood

Physical Examination

• General Appearance (donations are now accepted from those 16 yrs old)

• Weight

• Temperature

• Pulse

• Blood Pressure

• Hemoglobin

• Skin Lesions

Physical Exam: General Appearance

• The donor should not show:– Intoxication– Drug-induced mental impairment– Signs of infection– Skin lesions on arms

(IV drug use)

• Should appear alert

Physical Exam: Weight

• Hypovolemia is a decrease in intravascular blood volume

• A minimum weight limit of 110 lbs. is used to avoid hypovolemia

• This means the maximum amount of blood that can be removed is 10.5 mL/kg of donor weight (donor unit including tubes for testing)

• Each bag can hold 450 or 500 mL of blood• Adjustments can be made if patient is small

Physical Exam: Hemoglobin

• Hemoglobin can quickly be obtained from a finger stick

• Hemoglobin should be high enough to support 405-550 mL of blood

• Hemoglobin should be ≥12.5 g/dL

• Hematocrit should be ≥38%

3 times rule 12.5 g/dL X 3 = 37.5% or 38%

Hemoglobin Testing

• Copper sulfate method or point-of-care instruments using a spectrophotometric method

• Copper sulfate method:– Solution of CuSO4 has a specific gravity of 1.054– The SG of blood correlates with the hemoglobin– A small blood sample is dropped in the solution to see

if it floats or sinks– Difficult to dispose of, so the test may eventually be

replaced

Informed consent

• Before donation, a donor must provide informed consent

• If for any reason a donor doesn’t think their blood is safe to donate, they may affix a barcoded sticker to the unit indicated it should not be used

• It is all kept confidential….

BLOOD COMPONENT

• RED BLOOD CELLS SUSPENSION (PACKED RED CELLS)

• THROMBOCYTE CONCENTRATE

• SUSPENSI GRANULOSIT (BUFFY-COAT)

• PLASMA AND DERIVATE (F.F.P., CRYOPRECIPITATE, FACTOR VIII/IX, ALBUMIN, etc.)

TRANSFUSION MEDICINE

• RATIONAL USE OF BLOOD COMPONENT

• DONOR (ALLO / AUTO-TRANSFUSI)

• GOALS, NO EXCESSIVE USE OF BLOOD COMPONENT

• SAFETY, TRANSFUSION SIDE EFFECT AND PREVENTION EFFORTS

RATIONAL BLOOD TRANSFUSION

• PREVENT DANGER

• EFFECTIVE (TUJUAN TERCAPAI)

• EFFICIENT (TIDAK ADA PEMBOROSAN / PENGHAMBURAN KOMPONEN DARAH)

IRRATIONAL BLOOD TRANSFUSION

• DARAH/KOMPONEN DARAH TIDAK TERPAKAI, PEMBOROSAN DARAH

• DANA DARI DONATUR, MASYARAKAT, PEMERINTAH TERBUANG

• KEBUTUHAN DARAH MENINGKAT• BIAYA DAN BAHAYA UNTUK PASIEN MENINGKAT• KEBUTUHAN DONOR MENINGKAT - DONOR

KOMERSIAL

• MALPRACTICE ?

RISK OF BLOOD TRANSFUSION

• IMMUNE REACTION

• NON-IMMUNE REACTION

• DISEASES (HBV, HCV, HIV, CMV, S.T.D., MALARIA)

• IMMUNOSUPPRESSION

RED BLOOD CELLS TRANSFUSION SIDE EFFECTS

• ALLOIMMUNIZATION OF LEUCOYTE AND/OR THROMBOCYTE = 1:10

• ALLOIMMUNIZATION OF ERYTHROCYTE = 1:100

• NON-HEMOLYTIC FEVER REACTION = 1:100• VIRAL HEPATITIS = 1:250• LATE TRANSFUSION REACTION = 1: 2500• ACUTE (HEMOLYTIC) TRANSFUSION

REACTION = 1:100,000• H.I.V. INFECTION < 1:250,000

(Jain, 1992)(Jain, 1992)

POST-TRANSFUSION G.V.H.D.

• DAPAT MEMBAHAYAKAN JIWA DALAM 3-4 MINGGU

• PERLU SELALU DIINGAT PADA KEADAAN APLASIA SESUDAH RADIASI / KEMOTERAPI DOSIS TINGGI, USIA > 65 TAHUN, PASIEN LEKEMIA DAN LIMFOMA

• PENCEGAHAN: RADIASI KOMPONEN DARAH

Irradiation of Blood Components

Irradiation of Blood Components

• Cellular blood components are irradiated to destroy viable T- lymphocytes which may cause Graft Versus Host Disease (GVHD).

• GVHD is a disease that results when immunocompetent, viable lymphocytes in donor blood engraft in an immunocompromised host, recognize the patient tissues as foreign and produce antibodies against patient tissues, primarily skin, liver and GI tract. The resulting disease has serious consequences including death.

• GVHD may be chronic or acute

‘‘LEUCOCYTE-POOR’ RED BLOOD CELLSLEUCOCYTE-POOR’ RED BLOOD CELLS

• PREVENTS NON-HEMOLYTIC FEVER AND ALLOIMMUNIZATION

• TECHNIQUE: RADIATION, WASHING, FILTRATION, CENTRIFUGING, SEDIMENTATION, FREEZING

FRESH FROZEN PLASMA (F.F.P.)

• PLASMA – CENTRIFUGE, IMMEDIATELY FROZEN ( - 80 C )

• VOLUME 1 UNIT = 180-240 ML

• INITIAL DOSE (ADULT, 70KG): 3 - 4 UNIT, EVERY 12-24 HOURS AS INDICATED

• IMPORTANT: ‘SHORT HALF LIFE’

FREH FROZEN PLASMA (F.F.P.)

• COAGULATION FACTOR DEFICIENCY

• MASSIVE BLOOD TRANSFUSION

• BLEEDING DUE TO WARFARIN

• SOMETIMES USED ALSO FOR D.I.C. AND THROMBOLYTIC OVER DOSAGE

CRYOPRECIPITATE

• RICH IN FACTOR VIII, FIBRINOGEN, PLUS FACTOR XIII, FACTOR VON WILLEBRAND

• INDICATION: HYPOFIBRINOGENEMIA, HEMOFILIA-A, AND VON WILLEBRAND DISEASE

• dose: 1-4 unit / 10 KG

Platelet Concentrate

RBCs PRP

Plasma

Platelet concentrate

Pooling Platelets• 6-10 units transferred into one bag• Expiration = 4 hours

PROPHYLACTIC THROMBOCYTE TRANSFUSION

• N.I.H. CONSENSUS CONFERENCE (1987) : THROMBOCYTE LESS THAN 10-20.000/MM3, HIGHER LEVEL FOR SYSTEMIC BLEEDING OR PATIENTS WITH HIGHER BLEEDING RISKS

Apheresis

• Apheresis involves the removal of whole blood, separating specific components, and returning the unused portion back to the donor– Plateletpheresis (no more than 2x per week)– Plasmapheresis (tested for protein and Ig; 2x wk)– Leukopheresis (uses components to stimulate

granulocytes; hydroxyethyl starch, steroids, G-CSF)– Double RBC pheresis (2 units every 16 weeks)

Apheresis Platelet Concentrate

• Used to decrease donor exposure, obtain HLA matched platelets for patients who are refractory to RD-PC or prevent platelet refractoriness from occurring.

• Prepared by hemapheresis.• One pheresed unit is equivalent to 5-6 RD-PC.• Store at 20-24 C (RT) with agitation for 5 days.• D negative patients should be transfused with D

negative platelets due to the presence of a small number of RBCs

Apheresis Platelet Concentrate

• One bag (unit) from one donor

• One unit is a therapeutic dose

• Volume approximately 250 ccs

THROMBAPHERESIS

• ADVANTAGE: PREVENTS AUTO-ANTIBODY IN MULTIPLE RANDOM DONOR TRANSFUSION

• BEST FOR PATIENTS WITH AGGRESSIVE CHEMOTHERAPY (e.g. ACUTE LEUKEMIA), BONE MARROW TRANSPLANTATION / P.B.S.C.-T

Blood Typing

• Blood typing is when blood samples are tested with known antiseras that contain known antibodies

Cross Matching

• Cross matching is where typing the donor’s RBC’s are mixed with the recipients serum to check for compatibility before a blood transfusion

#Crossmatching (50 min)

1) Confirms ABO and Rh typing

2) Detects antibodies to the other blood group systems

3) Detects antibodies in low titers or those that do not agglutinate easily

Blood blank practices

Blood blank practices

# Antibody screen : Indirect Coombs test

(45 mins)

the subject serum + red cells

( antigenic composition) ----- red cell agglutination

# Type&screen

# Emergency transfusion

T&S -determines ABO and Rh status and the presence of most commonly encountered antibodies – risk of adverse rxn is 1:1000

-takes about 5 mins

T&C -determines ABO and Rh status as well as adverse rxn to even low incidence antigens – risk of rxn is 1:10,000

-takes about 45 mins

Type and screen vs Type and crossmatch

Type and screen vs Type and crossmatch

T&S:Type O red cells are mixed with pt serum Antibody screen

T&C Type O red cells are mixed with pt serum Antibody screen

Donor red cells are then mixed with the pt’s serum to determine possible incompatibility

:

Immunomodulatory effects of transfusion

• Wound infection: circumstantial evidence (? leukocyte filters for immunocompromised)

• Beneficial effects on renal graft survival (now < NB with CyA)– 97: 9% graft survival advantage after 5 years

• Nonspecific overload of RES lymphocytes, APCs– Modification T helper/suppressor ratio– Allogeneic lymphocytes may circulate for years after

transfusion

INFECTIOUS COMPLICATIONSINFECTIOUS COMPLICATIONS

I. Viral (Hepatitis 88% of per unit viral risk)

Hepatitis B • Risk 1/ 200,000 due to HBsAg, antiHBc

screening (7-17 % of PTH) • Per unit risk 1/63-66,000• 0.002% residual HBV remains in ‘negative’

donors (window 2-16 weeks)• Anti-HBc testing retained as surrogate marker for

HIV

NANB and Hepatitis C

• Risk now 1/ 103,000 (NEJM 96) with 2nd/ 1/ 125,000 with 3rd generation HCV Ab/ HVC RNA tests

• Window 4 weeks

• 70 % patients become chronic carriers, 10-20

% develop cirrhosis

HIV

• Current risk 1/ 450- 660,000 (95) • With current screening (Abs to HIV

I, II and p24 Ag), window 6-8 weeks (third generation ELISA tests in Europe)

sero -ve window to < 16 days

HTLV I, II

• Only in cellular components (not FFP, cryo)• Risk 1/ 641,000 (window period unknown)• Screening for antibody I may not pick up II

CJD (and variant CJD)

CMV

• Cellular components only• Problem in immunocompromised, although 80

% adults have serum Ab• WBC filtration decreases risk of transmission• CMV -ve blood:

– CMV -ve pregnant patients, LBW neonates, CMV -ve transplant recipient,

– CMV-ve/ HIV +ve

II. Bacterial• Contamination unlikely in products stored for > 72

hours at 1-6 0 C • gram –ve, gram +ve bacteria most frequent – Yersinia enterocolitica

Produced endotoxin Platelets stored at room temperature for 5 days, with

infection rate of 0.25%

III. Protozoal• Trypanosoma cruzi (Chaga’s disease) • Malaria• Toxoplasmosis• Leishmaniasis

Serological Testingfor Infectious markers

• HIV – Ag

• Anti – HIV

• HBsAg

• Anti – HCV

• Test for syphilis

TRANSFUSION REACTIONSTRANSFUSION REACTIONS

• is any unfavorable transfusion-related event occurring in a patient during or after transfusion of blood components

TRANSFUSION REACTIONSTRANSFUSION REACTIONS

@RBC’s !• Nonhemolytic 1-5 % transfusions Causes -Physical or chemical destruction of

blood: freezing, heating, hemolytic drug -solution added to blood -Bacterial contamination

: fever, chills, urticaria– Slow transfusion, diphenhydramine , antipyretic for fever

• Hemolytic– Immediate: ABO incompatibility (1/ 12-33,000) with fatality (1/

500-800,000)

Majority are group O patients receiving type A, B or AB blood

Complement activation, RBC lysis, free Hb (+ direct Coombs Ab test)

Acute Hemolytic Transfusion Reaction

Ab (in recipient serum) + Ag (on RBC donor)

-Neuroendocrine responses

-Complement Activation

-Coagulation Activation

- Cytokines Effects

Acute hemolytic transfusion reaction

Pathophysiology

Acute Hemolytic Transfusion Reactions

Acute onset within minutes or 1-2 hours

after transfuse incompatible blood

Most common cause is ABO-incompatible

transfusion

Signs and Symptoms of AHTR

• Chills , fever• Facial flushing• Hypotension• Renal failure• DIC• Chest pain• Dyspnea• Generalized bleeding

• Hemoglobinemia• Hemoglobinuria• Shock• Nausea• Vomitting• Back pain• Pain along infusion

vein

@WBC’s!@WBC’s!• Europe: All products leukodepleted• USA: Initial FDA recommendation now reversed pending

objective data (NOT length of stay for expense)

• Febrile reactions– Recipient Ab reacts with donor Ag,

stimulates pyrogens (1-2 % transfusions) – 20 - 30% of platelet transfusions– Slow transfusion, antipyretic, meperidine for

shivering

• TRALI (Transfusion related acute lung injury)

– Donor Ab reacts with recipient Ag (1/ 10,000) – noncardiogenic pulmonary edema– Supportive therapy

Transfusion-related Acute Lung Injury (TRALI)

Pathophysiology: Leukocyte Ab in donor react with pt. leukocytes

Activate complements

Adherence of granulocytes to pulmonary endothelium with release of proteolytic enz.&

toxic O2 metabolites

Endothelial damage

Interstitial edema and fluid in alveoli

Transfusion-related Acute Lung Injury (TRALI)

Acute and severe type of transfusion reaction

Symptoms and signs:• Fever• Hypotension• Tachypnea• Dyspnea• Diffuse pulmonary infiltration on X-rays• Clinical of noncardiogenic pumonary edema

Transfusion-related Acute Lung Injury (TRALI)

Therapy and Prevention:• Adequate respiratory and hemodynamic

supportive treatment• If TRALI is caused by pt. Ab use LPB• If TRALI is caused by donor Ab no special

blood components

• Transfusion-associated Graft-versus-Host Disease ( TA-GVHD)

– Rare: immunocompromised patients – Suggestion that more common with

designated donors– BMT, LBW neonates, Hodgkin's disease,

exchange Tx in neonates

Transfusion-associated Graft-versus-Host

Disease ( TA-GVHD) Pathophysiology

Infusion of Immunocompetent Cells

(Lymphocyte)

Patient at risk

proliferation of donor T lymphocytes

attack against patient tissue

Graft-versus-Host Reaction

Signs & Symptoms

Onset ~ 3 to 30 days after transfusion Clinical significant – pancytopenia Other effects include fever, liver enzyme,

copious watery diarrhea,

erythematous skin erythroderma

and desquamation

@Platelets!@Platelets!

Alloimmunization– 50 % of repeated platelet transfusions– Ab-dependent elimination of platelets with lack of response– Use single donor apheresis – Signs & Symptoms

• mild slight fever and Hb• severe platelet refractoriness with bleeding

Post-transfusion purpura– Recipient Ab leads to sudden destruction of platelets

1-2 weeks after transfusion (sudden onset)– Rare complication

METABOLIC COMPLICATIONS

Citrate toxicity• Citrate (3G/ unit WB) binds Ca2+ / Mg+

• Metabolized liver, mobilization bone stores• Hypocalcemia ONLY if > 1 unit/ 5 min or

hepatic dysfunction• Hypotension more likely due to cardiac

output/ perfusion than calcium (except neonates)

• Worse with hypothermia/ hepatic dysfunction

Hyperkalemia

• After 3 weeks, K+ is 25- 30 mmol/l • Only 8- 15 mmol per unit PRBC/ WB• Concern with > 1 unit/5 min @ infants

Acidosis

• Acid load after after 3 weeks 30-40 mmol/l (pH 6.6 - 6.9)

• Metabolic acidosis more likely due to decreased perfusion, hepatic impairment, hypothermia

• NaHCO3 or THAM if base deficit > 7-10 mEq/l

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