immunhematological disorders. principles of blood transfusion
TRANSCRIPT
Anaemias. Blood groups and transfusion FOKDr. Istenes Ildikó
April 1th 2020
• DD of anaemia: See: Lecture of Anaemias part I. (February)
• Hemolytic anaemias:
• Autoimmun hemolytic anaemias (AIHA)- see: Seminar immunhematological disorders (case presentations, practical recommendations) and lecture
• DD of thrombopenia
• THIS LECTURE:
• Heparin induce thrombocytopenia
I. Impaired production
2. Impaired DNA synthesis
3. Impaired Hgb synthesis 4. Decreased erythropoetin 5. Decreased hemopoesis (due
to lack of space)
6. Multifactorial
Aplastic anaemia Myelodysplastic sy Megaloblastid anaemia due to decreased vitamin B12 or folic acid Iron deficiency anaemia Renal anaemia, Bone metastasis of tumors, malignant hematological diseases Anaemia of chronic diseases (tumor, infection, rheumatic diseases)
II. Increased distruction
2. Eytraerythrocyter causes
Extracorpuscular haemolytic anaemias -iso-/autoantibodies -drugs -infections -physical/chemical noxa -metabolic disorders - mechanic
bleedings Anaemia due to bleeding
IV. Impaired distribution
Hypersplenic syndrome
• Not a disease, it is a SYMPTOM
• It is not enough to normalize hemoglobin levels, the cause of anaemia has to be found.
Hemoglobin, hematocrit or RBC count falls below normal level
Hgb <13,5 g/dl (male) Htk <40% (male)
<12 g/dl (female) <37% (female)
we meet the patient first, not the disease
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Differential diagnose of anaemias based on mean cell volume (MCV) and mean cell hemoglobin (MCH)
Hypochrom microcytic anaemia
Normochrom normocytic anaemia
Hyperchrom macrocytic anaemia
MCH↑+MCV↑
MCH35pg/l
Reticulocyte↑: Haemolytic anaemia Anaemia due to bleeding
Reticulocyte↓: Aplasticanaemia Renal anaemia
Iron↓, ferritin↑, ret ↓: anaemia due to inflammation, infection, tumor
Etiology? : decreased RBC, Hb, MCH, (MCV), reticulocyte, ferritin
Ferritin should be evaluated with CRP! Reticulocyte: reflects bone marrow function:
Hyporegenerative: low, hyperregenerative: high
Iron deficiency ACD
Serum transferrin elevated low
Serum iron binding capacity
Bone marrow iron storage
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-membrane defect inherited: Spherocytosis, elliptocytosis acquired: paroxysmal nocturnal hemoglobinuria
-enzyme defect Glucose- 6-phosphate dehydgrogenase defect Piruvate kinase defect
-hemoglobinopathy Qualitiative problem: sickle cell anaemia Quantitative problem: Thalassaemia (alfa, beta)
Extra- Erythrocyter causes =Extra- Corpuscular Haemolytic anaemia
-alloantibodies hemolytic transfusion reaction Morbus hemolyticus neonatorum
-autoantibodies Autoimmune hemolytic anaemia - cold-warm - Idiopathic- secondary
-drugs Immune-mediated: Penicillin, kinidin, metildopa non immun-mediated= oxidative stress: salazopyrin
-infections Malaria, clostr. Perfringens sepsis
-mechanic: RBC fragmentation syndrome
Cardiac origin: artificial valve, graft Microangiopathic: TTP, HUS, DIC, HELLP, vasculitis Arteriovenosus malformations
-physical- chemical effects
(See lecture.
Haemolytic anaemias
The life of RBCs shortens to couple of weeks/days (normal: 120 days)
Clinical course:
acute: Fever, shivering, collapse, icterus, headache, abdominal pain, backpain, hemoglobinuriaa
eg: hemolytic transfusion reactions, See later
eg: hemoglobinopathies, AIHA
Laboratory parameter reason
Hb↓, Ht ↓ Anaemia
Indirect bilirubin ↑ (icterus), urobilinogenuria
Hem destruction is increased → non-conjugated, albumin-bound (indirect) bilirubin is elevated
Haptoglobin ↓ Hgb coming out of intravascularly destroyed RBC binds to haptoglobin
Hemoglobinuria (brownish urine)
In case of massive intravascular hemolysis, when the tubular reabsorption capacity of the kidney is overrun
Reddish serum Free haptoglobin in the serum in case of intravascular hemolysis
Retikulocyte number↑ In case of intact bone marrow function: erythropoesis is increased, ratio of premature RBC forms is increased
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The severity and type of red cell alteration determine the cell's site of
destruction. In most cases (eg, oxidant attack, metabolic insult,
hemoglobinopathy) this leads to an alteration of the RBC membrane.
Sites of RBC Destruction
INTRAVASCULAR HEMOLYSIS
• If the damage is severe enough, immediate lysis occurs in the circulation (intravascular hemolysis)
For example:
• Heat damage (thermal burns)
• Complement induced hemolysis (PNH)
• Bacterial phospholipas toxins (clostridial sepsis
• Microangiopathy
• EXTRAVASCULAR HEMOLYSIS
• If the damage is less severe, the cell is destroyed within the monocyte-macrophage system in the spleen, liver, bone marrow, lymph nodes.
For example: • Corpuscular hemolytic anaemias
• AIHA
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Normally: Extravascular RBC destruction extravascularly in the RES (reticuloendothelial system) of the spleen
In case of hemolysis: in the liver, bone marrow as well, and if their capacity is fulfilled
Intravascular hemolysis: RBCs are destroyed within the blood vessel
↓ free hgb binds to haptoglobin
↓ free haptoglobin↓ (measurable value)
↓ free hgb will be present in the plasma, which
transforms to haematin, which is transferred to RES by haemopexin → finally haemopexin level↓
↓ Free hgb is filtrated and reabsorbed in the kidney
If reabsorption capacity is overrun ↓
hemoglobinuria (red urine)
• Auto- antibody
• Antibodies against RBC:
- IgM- complete antibody: it can agglutinate (big enough to cover the distance between 2
RBC-s), Cold antibody (optimum temperature is below 22C)
- IgG -incomplete antibody: it can’t agglutinate, just cover the cell warm antibody (optimum temperature is at 37C)
24nm
•Coombs test= antiglobulin test
- Shows antibodies that cover RBCs
-Patient erythrocytes that are covered with IgG will agglutinate with Coombs
serum
- shows free antibodies in the serum
- Patient serum containing IgG is mixed with Target RBCs (that contains target
antigen of the investigated IgG)→ the IgG covers target RBCs →Coombs
serum is added→aggultination
•Coombs’ serum: serum that contains antihuman globulin: antibodies against IgG and
complement (retreived from a rabbit or other animal previously immunized with purified human
globulin)
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- morbus hemolyticus neonatorum…
50%-primary (idiopathic)
50% secondary (disease: NHL, Hodgkin, drug, virus)
Warm AIHA: caused by incomplete IgG autoantibodies (90% adults, 75% children)
-IgG binds at body temperature to RBCs, that are destroyed in the liver and in the spleen → erythropoesis compensates for a while, then→ symptoms
Cold AIHA: caused by complete IgM autoantibodies
- Cold temperature causes acrocyanosis, hemolysis
- Antibodies activate complements (DAT test: complement coverage)
- acut: usually preceeded by infection
- chronic: idiopathic or secondary (B cell lymphoma) Search for a
primary cause!!!
Zs.D, female, b. 1940.
• 1989. cold autoantibodies (no AIHA: Hb124, Ht 0,41, seBi, LDH norm)
• 2010. february: weakness- – AIHA: Hb 88 g/l, Ht 0,17, LDH681, Tbi 82, ret 48, haptoblobin: 0,08
– Serology: same as before (cold AIHA: anti-I, anti-E alloantitest, DC positive, comp coverage)
– IgM: 1366mg/dl, IgA, IgG suppressed
– crista ilei biopsy: Waldenström macroglobulinaemia with 30-40% bone marrow infiltration (CD20, CD19, CD38 positive, cytogenetics negative)
• Treatment: WM and AIHA – Immunetherapy (rituximab) and chemotherapy
• Outcome: – IgM decreased, hb/ht increased
– 2018. she is still feeling well, no hemolysis, no recidiva
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R.P, male, b. 1930
• 1933. Heine-medin- right lower limb hypotrophy- needs lots of pain killers
• Cholelithiasis, nephrolithiasis, diverticulosis coli
• 2009 sept: AIHA (warm)- steroid – effective, but slower response
• Bone marrow: CLL 50% infiltration- chemoterapy: Leukeran
• 2009. dec. renal tumor- FNAB: carcinoma renis- chemoembolisation
• 2012 nov AIHA- rituximab (100mg),-AIHA was thought of CLL activisation- chemotherapy: cyclophosphamid
• 2013, inguinal hernia operation, 2013 pneumonia-
• 2015 febr: anaemia, CLL: complete remission, no hemolysis
• Not AIHA: microcytic anaemia- probably due to renal tumor (urine test: hematuria ++)- transfusion, ferrlecit infusion
• AIHA had not reappeared since 2012, he died in 2016 (due to cc renis)
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• Chronic lymphoid leukaemia, comes to regular check-up
• Anaemia • AIHA? – common in CLL • Blood test: LDH, Tbi, haptoglobin norm • ??? • Ask the patient: blood in stool? • Answer: Yes: RDV: Weber positive • Gastro-colono:source of bleeding is not found • Capsule endoscopy: small intestine:
angiodysplasia
Message:
Reasons
• AIHA- look for underlying disease (and later as well)
• AIHA- treatment
– steroid (CAVE: side effects, hypertension, hyperglycaemia, it cannot be stopped immediately: Addison sy)
– other immunsuppressive drugs
– Rituximab: anti CD20
– Vital indication:
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• Thrombocytopenia (<150G/l)
• Fever
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Main reason for TMA • The endothel becomes thrombogenic due to
different reasons
– Erythrocyte fragmentation due to „rough” surface
– Organ dysfunction (ischaemia due to stenosis, block)
TTP:thrombotic thrombocytopenic purpura
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Etiology of TMA: I. Known molecular etiology Also called: primary TMA
1. Infectious
• Good prognosis, relaps is rare
– P-HUS: • neuraminidase producing bacteria: Streptococcus
pneumomniae, Clostridiums • Direct Coombs positive: neuraminidase cleaves sialic acid
from RBC/Platelet/endothel surface → T antigens become
vailable → the regular anti T antibodies cause agglutination
Besbas N et al. A classification of hemolytic uremic syndrome and thrombotic thrombocytopenic purpura and related
disorders. Kidney Int. Aug 2006;70(3):423-431.
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2. Complement regulation defect (a-HUS=atypical- hemolytic uremic syndrome)- bad prognosis
– due to genetical abnormalities
– due to acquired reasons
3. ADAMTS13 deficiency (TTP) – Genetic disorder of ADAMTS13
– Acquired deficiency (autoimmune, drug) (ADAMTS13: vonWF cleaving protease- if there is not enough: ultralarge multimers will cause a massive thrombocyte activation, aggregation on the endothel
vWF: thrombocyte adhesion- aggregation, carrier of FVIII)
(4. Defective cobalamin metabolism
5. Quinin induced) Besbas N et al. A classification of hemolytic uremic syndrome and thrombotic thrombocytopenic purpura
and related disorders. Kidney Int. Aug 2006;70(3):423-431.
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Frequent causes:
• Drugs: calcineurin inhibitors (transplantation!), ticlopidin, mTOR inhibitors, oral contraceptives,
• pregnancy, HELLP syndrome
Rare causes:
• HIV infection, Familial causes not included in part I, unclassified forms
Besbas N et al. A classification of hemolytic uremic syndrome and thrombotic thrombocytopenic purpura
and related disorders. Kidney Int. Aug 2006;70(3):423-431.
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platelet is above 150 on 2 consecutive
days, no fragmentocytes, no symptoms.
Acute shub:
– Sepis (PCT), endocarditis (TEE), SLE (anti-DNA, ANA), malignant disease, drug (calcineurin inhibitors), antiphospholipid antibodies
• For primary causes:
– Complement activity measurement
– ADAMTS13 activity measurement
ADAMTS13 measurement are necessary)
– Transfusion, hemodialysis
– Usually in case of D-HUS it is enough (PEX is not needed)
• PEX (plasma exchange)+ FFP – Acute, life saving treatment:
• Especially in TTP and a-HUS- where there is antibody to be removed
• Every day until remission
– FFP
• FFP by itself is enough in congenital ADAMTS13 deficiency of complement regulation problem (FFP contains complements and ADAMTS13)
• Immunesuppression: – Steroid, cyclophosphamide, rituximab
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Thrombocytopenia
– < 10G/l spontaneous life threatening bleeding
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Trombocyte defect coagulopathy
pressure)
membrane (oral,
Hemarthros Rare Frequent
Positive family history rare frequent
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Petechiae
venous pressure is incresed. Lower legs, ankle! Not on the
soles (there the vessels are protected by strong connective
tissue)
Ecchymosis
• A: dry purpura (skin only)
• B: wet purpura (bleeding on the mucous membranes)
Wet purpura is more dangerous, might predict life-
threatening bleeding
2. Real thrombocytopenia
Bone marrow: Megakariocyte number is low or absent
1.Hereditary
sy,
2.Acquired
II. Inreased damage
Bone marrow:
Primary immune thrombocytopenia (ITP)
Epidemiology: – Incidence: 2-3/100000 people/year
– Prevalence: kb. 10/100000 people/year
• No other underlying cause
• To our current knowledge both increased destruction and decreased production play a role in disease pathogenesis.
Provan D et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010 115: 168-186
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- antibodies against megakariocytes - relatively low TPO:
- TPO is bound to plt- there is less TPO available to stimulate plt prod
- TPO is lost when bound to apoptotic megakariocytes
Classic theory of ITP: Platelet-death and degradation in spleen due to anti thrombocyte antibodies Bone marrow: increased production, megakariocyte number increases
Formation of thrombocytes
Thrombopoetin (TPO): - interacts with hemopoetic stem cells and helps them differentiate into megakariocyte precursors
- helps these precursors to proliferate and differentiate into megakariocytes
-Increases peripheral thrombocyte count
– Majority is secondary, provoked by infection (morbilli, varicella), allergy, vaccination
• Adult ITP – Newly diagnosed (within 3 months)
– Persistant (3-12months)
– Chronic ITP (50-75%): (over 12 Months): 60% persistant remission, 35% requires continuous treatment, 1-5% fatal bleeding)
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Peripheral blood film
Blood group (Rh)
Direct Coombs test
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ITP treatment principles
• Treatment is based on the severity of thrombocytopenia AND the clinical signs!
• Normalisation of PLT is not a goal!
• Not to be treated:
• Plt transfusion?
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Colmplete response (CR) Platelet count ≥100 G/L, based on 2
measurements >7 days apart, no signs of bleeding
Therapeutic response (R) Platelet count ≥30 G/L and at least 2x increase to baseline, based on 2 measurements >7 days
apart, no signs of bleeding
No response (NR) Platelet count <30 G/L or less than 2x increase
to baseline, or bleeding, based on 2 measurements >1 days apart
Loss of complete response Platelet count <100 G/L or bleeding, based on
2 measurements >1 days apart
Loss of response Platelet count <30 G/L or bleeding, based on 2
measurements >1 days apart
Rodeghiero F et al.: Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009;113(11):2386-2393.
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– Killing antibody producing B cells (anti-CD20 monoclonal AB)
• Stopping thrombocyte destruction – Intravenous immunglobulin (IVIG)- „feeds” WBC-s attacking plts
– Anti-D
• Get rid of trigger mechanism: – Helicobacter pylori eradication, treat the underlying disease (eg.
Autoimmune)
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• Second line of treatment: – Splenectomy – TPO receptor mimetics – Vinca alcaloids – Azathioprin – Cyclosporin A – Cyclofoszfamid – Danazol – Dapson – Mycofenolat mofetil – Rituximab
• In case of ineffectiveness of the above – Combination of 1st and 2nd line options.
Provan D et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010 115: 168-186 Neunert C et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 117: 4190-4207.
Glucocorticoids : • Currently considered 1st
be required (even years) • Frequent side effects or
intolerance • Frequent relapse while on
treatment or at attempts on trapering
Agent Dosing Start of
Prednisolon 0,5-2 mg/ kg
2-4 weeks 4-14 7-28
ITP – treatment recommendations
Provan D et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010 115: 168-186 Neunert C et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 117: 4190-4207.
Intravenous immunoglobulin: • Efficient but transient effect • Cost, availability and
transient response limit durable administration
Anti-D products: • Similar mechanism of action • Off-label for the treatment of
ITP in Europe
• Second line of treatment: – Splenectomy – TPO receptor mimetics – Vinca alcaloids – Azathioprin – Cyclosporin A – Cyclofoszfamid – Danazol – Dapson – Mycofenolat mofetil – Rituximab
• In case of ineffectiveness of the above – Combination of 1st and 2nd line options.
Splenectomy: • Durable response after single
procedure • Requires adequate control of
platelet counts for the procedure
• CAVE: vaccinations have to be given!
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ITP – treatment recommendations
Provan D et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010 115: 168-186 Neunert C et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 117: 4190-4207.
Rituximab: • Durable response in 18-35% • Better result when
combined with dexamethasone
data • Seldom used except of vinca
alkaloids, azathioprin, cyclosporin A
• First line treatment: – Glucocorticoids – Intravenous immunoglobulin (IVIG) – Anti-D antibody
• Second line of treatment: – Splenectomy – TPO receptor mimetics – Vinca alcaloids – Azathioprin – Cyclosporin A – Cyclofoszfamid – Danazol – Dapson – Mycofenolat mofetil – Rituximab
• In case of ineffectiveness of the above – Combination of 1st and 2nd line options.
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• Second line of treatment: – Splenectomy – TPO receptor mimetics – Vinca alcaloids – Azathioprin – Cyclosporin A – Cyclofoszfamid – Danazol – Dapson – Mycofenolat mofetil – Rituximab
• In case of ineffectiveness of the above – Combination of 1st and 2nd line options.
ITP – treatment recommendations
Provan D et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010 115: 168-186 Neunert C et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 117: 4190-4207.
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Indications for TPO mimetics treatment based on EMA approval
TPO mimetics … • … are indicated for adult chronic immune (idiopathic)
thrombocytopenic purpura (ITP) splenectomised patients who are refractory to other treatments (e.g. corticosteroids, immunoglobulins).
• …may be considered as second line treatment for adult non- splenectomised patients where surgery is contraindicated.
• Eltrombopag is indicated for the treatment of adult thrombocytopenia in patients with chronic hepatitis C virus (HCV) infections, in whom thrombocytopenia is the main limiting factor for starting or continuing optimal interferon-based therapy.
Source: Package insert for Nplate and Revolade, May 2015.
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Eltrombopag Romiplostim
Pepti-body (antibody-peptide fusion protein)
Oral bioavailability Subcutaneous application
Daily intake Weekly application
Stable plasma levels
• In case of failure with one of the analogues the other compound may prove effective
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•Preventive supportation: •By critical platelet count (no bleeding)
Indication of platelet transfusion
Preventive supportation Plt count
Accompanying fever, sepsis, DIC, severe anaemia,
extreme leukocytosis, progressive thrombopenia
sternum punction, crista biopsy
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direct plt activation)
– within 4 days, resolves in 3 days despite heparin therapy
– No severe clinical consequence
• Type II – Immunological mechanism
• more than 50% or 30% falling below 100G/l
• Plt count usually: 50-80G/l
• Typically presents 4-14 days
– Sc./iv. heparin as well
– Risk: nem fractionated > LMWH, surgery patient>other
51.
• Platelet factor 4 (PF4) is releaed from activated thrombocytes
• Heparin forms a complex with PF4 (non fractionated heparin can circle around PF4 better, than LMWH)
• Consequences:
– The anticoagulant activity of heparin decreases
– IgG antibody is formed against heparin- PF4 complex, forming a Heparin-PF4- IgG complex
• These complexes will bind to thrombocytes (through Fc receptor) and endothel, causing platelet activation
Result: thrombocyte activation, thrombocytopenia and thrombosis
52.
Dg: 4T score 4T categories 2 points 1 point 0point
Thrombocyto penia (drop)
30% or nadir ≤ 10G/l
Surely between 5-10. days or ≤1 day (if heparin
exposition within 30 days)
5-10. days but uncertain; or After 10 days; or ≤ 1 day ( if heparin exposition 30-100 days
≤ 4 days, no previous exposition
Thrombosis or other consequence
New proven thrombosis, skin necrosis, acute systemic reaction to iv UFH
Progressive/recurrent thrombosis, Non necrotizing (erythemás) skin changes, suspicion of thrombosis
none
• 4-6 medium probability
• 6-8 high probability
• Do not overdiagnose!
– Those with risk higher than 1% (post operative surgery patients)
Adam Cuker. Clinical and Laboratory Diagnosis of Heparin-Induced Thrombocytopenia: An
Integrated Approach. Semin Thromb Hemost 2014;40:106–114
54.
Algorhythm
diagnose
4T ≥4 4T ≤3
Adam Cuker et al. Predictive value of the 4Ts scoring system for heparin-induced
thrombocytopenia: a systematic review and meta-analysis.Blood 2012 120: 4160-4167
55.
• Definition
• products
• Compatibility
Transfusion- definition
• The transfer of blood or blood components from one person (the donor) into the bloodstream of another person (the recipient).
What can be transfered?
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Antibody in serum
Anti B Anti A none Anti A and anti B
Inheritance • Follows the mendelian rule • A and B are cododominant • A and B dominates over 0 gene • The „O” gene is non-functional,
it does not produce a detectable antigene (no sugar transfer)
• It is the most important blood group system
• Blood group antigens are actually sugars attached to the red blood cell.
• Antigens are “built” onto the red cell.
• Individuals inherit a gene which codes for specific sugar(s) to be added to the red cell (tranferase)
• The type of sugar added determines the blood group.
Antibodies
•Individual’s will form immune antibodies to ABO blood group antigens they do not possess: Landsteiner’s rule
•Substances are present in nature which are so similar to blood group antigens which result in the constant
production of antibodies to blood group antigens they do not possess.
•Critical for understanding compatibility between ABO blood groups. •Usually IgM type
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Rh blood group Name comes from Rhesus monkey:
The RBC-s of the Rhesus monkey was injected in rabbits and guineapigs → they
produced antibodies against these RBCs
→ these antibodies reacted 85% of human RBCs: these are called Rh positive, the
remainings are negative
chromosome) – Inherited in triplets: CDE, cde – Independent from ABO blood
group system – Dominant inheritance
- Usually immun-antibodies, irregular antibodies
- Can be autoantibodies (anti-e, anti-C)
Transfusion:
RhD matching is important and sometimes the
other (C, c, E, e) antigens have to match as well
Cause transfusion reaction
Warm antibodies: optimal temperature is 37C
Usually don’t bind complements
IgG crosses the placenta- causing morbus
hemolyticus neonatorum
D variant: gives weaker agglutination to anti D
than expected: reaction with standard anti D reagent
may be negative, but the more specific Coombs test
will be positive!!!
- it is considered positive,
negative individual
- it is considered negativ,
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+
-
fetal RBCs, causing: 1st pregnancy
-
+
Give the Rh negative mother human anti D globulin:
- it binds the fetal Rh positive RBCs that went into the mother’s blood
- the Rh positive fetal RBCs will not provoke immunisation in the mother
When?
Morbus hemolyticus neonatorum:
hydrops fetalis (heart works harder due to anaemia,
heart will be insufficient, causing oedema…)
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Thrombocyte antigens
- RBC antigens (A, B, Lewis, I, P) (Rh is not present but an Rh negative female can
only receive Rh negative thrombocyte due to RBC
contamination of the trombocyte pack)
- HLA 1 (human leukocyte antigen)
- HPA1a, 1b (human platelet antigen)
Clinical significance of anti-platelet
- Neonatal alloimmun thrombocytopenia
Clinical significance of anti-granulocyte
days
1g/dl in adult
up to 5 days, kept agitated
• Thr rise by 12-14000/ul
• Pooled (from more donors)
• Apheretic (from 1 donor)
well)
year
fibrinogen,
• Separated by freezing FFP, allowing it to thaw to 4-8ºC
• Re-frozen & stored at – 30ºC for up to 1 yr
• Enriched with FVIII, vWF and fibrinogen
• Indications: – Fibrinogen deficiency
• convenient, predictable, safe and widely practised form of transfusion support.
• It is not available to all patients, it requires – time to pre-donate – a starting hemoglobin >110 g/l which effectively excludes most emergency surgery.
• hospital admission and operative dates must be guaranteed, as donated blood has a limited storage life of 35 days.
• Required hb:
Same group: eg. „A” Rh+ gets „A” Rh+ RBC
Not the same group Eg. „A” Rh+ gets „0” Rh- RBC
Plasm has to be removed („washed”) to
Get rid of the antibodies in the blood product
Eg. Anti A and B in 0 RBC product)
chosen:
Other antigens are matched as well eg: recipient: „A” Rh+ with anti-C, anti-e antibodies will
receive blood that does not contain C or e antigen
• If the antibody screening of the recipient is positive (either allo or auto
antibody)
• Immunisation within 3 months
• Surgery performed in hypothermia;
• Transfusion of infants
• every situation where the possibility of immunisation is very high (eg.. MDS,
thalassaemia, sickle cell anaemia)
Not chosen:
Other antigens are not checked You go to the fridge and get an A+ blood to
an A+ patient,
- If the direct coombs test and the antibody
screening of the recipient is negative
-No anamnestic data for positive Coombs
test and antibody screening
(transfusion, pregnancy, vaccination,
Recipient does not have AB to donor RBC Emergency situation
This is usually the policy
How long is it valid?
Transfusion > 3 month: 72 hours
Transfusion within 3 month: 72 hours
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0 0 0, A, B, AB
A A, washed 0 A, AB
B B, washed 0 B, AB
AB AB, washed: B, A, 0 AB
RhD positive Rh pozitive, negative RhD does not have to be consideredRhD negative Rh negative
RhD variant Based on consultation: + or -
unknown 0 Rh Dnegative, maximum 2 units
AB
bearing potential can get
In Hungary FFPs are derived from male donors
(to avoid antibodies of previously pregnant
women)
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– Due to previous RBC Ag exposure
• recipient was previously sensitized to an Ag- antibody titers are low- when the recipient meets this Ag again- anamnestic response takes place
– Destruction of donor RBC with the antigen
– Usually mild, self limited
A: Hemolytic transfusion reactions
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• Symtoms
– Fever and chills: 80%
– Back or infusion site pain (heat sensation in the transfused vein)
– Hypotension/shock
– Hemoglobinuria
– Positive DAT (direct antiglobulin test= Direct Coombs test)
Due to incompatible blood transfusion: the recipient has a great amount of Ab-s
against donor RBC
→causing complement/coagulation activation, neuroendocrine
Transfusion reactions
– FNHTR: febrile non hemolytic transfusion reaction (citokins)
– Thrombocyte refracterity (HLA antibody)
– Immunmodulation (leukocytes)
Prevention:
- irradiation (blocks immun active WBCs- in case of TA GVHD
B/2: due to plasm contamination
– Urticaria (allergy to transmitted solubile
substances)
– Anafilaxia
– Passive transmission of ABO Antibodies (in case of compatible but not
identical transfusion)
antibodies)
Prevention:
A: Hemolytic transfusion reactions- due to incompatibility
B: Non hemolytic transfusion reactions
B/3. Transfusion associated circularory
Occurs 4-30 days after transfusion
Symptoms: fever, skin rash, liver dysfunction, diarrhoea
Bone marrow dysplasia
HLA
recipient
HLA
recipient
normal
Continuous attack on host tissues, causing GVHD
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TA-GVHD If Child1 gives blood to the mother (or the father)
Child 1’s „yellow” WBCs
will attack mother’s „blue”
cells.
foreign to her
attack child1’s yellow cells,
because she also has yellow
cells
– Immunologic:
– Non-immunologic:
• volume overload, hemolytic (physical or chemical destruction of RBC), air embolus, hypocalcaemia, hypothermia
• Delayed (>24 hours)
• STOP the transfusion
• keep line open with normal saline, using a new set,
• Check I.D of patient, bag and cross-match form
• Refer to handbook for further management
74
– Things to consider:
• Lung, heart, circulation, Hb, Htk, Hb-O2 affinity, metabolism affecting O2 uptake and release
75
• Transfusion
• Hb: 70 g/l (21 % Htk), usually makes transfusion necessary
depends on: age (> 65 years), concomitant diseases (heart, lung), activity of the patient
• Over 100 g/l Hb transfusion is usually not needed.
↓↓
2 units of RBC cc will get the patient out from hypoxia.
- speed of transfusion: 2-4 ml/kg/hour.
- 2 units a day is recommended
76
•Therapeutic support: •Bleeding due to thrombopenia or thrombopathy („wet purpura”, inner bleeding)
•Preventive support: •At critical platelet numbers (without bleeding)
Indication for platelet transfusion
Preventive support Plt count
Stable, afebrile patient < 5-10G/l
leukocytosis, deepening thrombopenia
Surgery, invasive diagnostics (except for sternal punction
and crista ilei biopsy)
polytraumatization
< 100G/l
77
- ABO identical or compatible product.
- Rh neg female of gestational age have to get Rh negative platelet
Preventive support is contraindicated usually in: – TTP, HUS, HIT (heparin induced thrombocytopenia)
Preventive support is ususally not indicated in: – ITP (except for splenectomy if plt 10 xG/l thr)
– PTP (post-transfusion purpura)
– Thrombocyte functional problem
– Thrombocyte transfusion refractory state
• But: it can be done in case of life threatening bleeding.
78
• STOP transfusion in case there is a reaction!
79
[email protected]
April 1th 2020
• DD of anaemia: See: Lecture of Anaemias part I. (February)
• Hemolytic anaemias:
• Autoimmun hemolytic anaemias (AIHA)- see: Seminar immunhematological disorders (case presentations, practical recommendations) and lecture
• DD of thrombopenia
• THIS LECTURE:
• Heparin induce thrombocytopenia
I. Impaired production
2. Impaired DNA synthesis
3. Impaired Hgb synthesis 4. Decreased erythropoetin 5. Decreased hemopoesis (due
to lack of space)
6. Multifactorial
Aplastic anaemia Myelodysplastic sy Megaloblastid anaemia due to decreased vitamin B12 or folic acid Iron deficiency anaemia Renal anaemia, Bone metastasis of tumors, malignant hematological diseases Anaemia of chronic diseases (tumor, infection, rheumatic diseases)
II. Increased distruction
2. Eytraerythrocyter causes
Extracorpuscular haemolytic anaemias -iso-/autoantibodies -drugs -infections -physical/chemical noxa -metabolic disorders - mechanic
bleedings Anaemia due to bleeding
IV. Impaired distribution
Hypersplenic syndrome
• Not a disease, it is a SYMPTOM
• It is not enough to normalize hemoglobin levels, the cause of anaemia has to be found.
Hemoglobin, hematocrit or RBC count falls below normal level
Hgb <13,5 g/dl (male) Htk <40% (male)
<12 g/dl (female) <37% (female)
we meet the patient first, not the disease
4
Differential diagnose of anaemias based on mean cell volume (MCV) and mean cell hemoglobin (MCH)
Hypochrom microcytic anaemia
Normochrom normocytic anaemia
Hyperchrom macrocytic anaemia
MCH↑+MCV↑
MCH35pg/l
Reticulocyte↑: Haemolytic anaemia Anaemia due to bleeding
Reticulocyte↓: Aplasticanaemia Renal anaemia
Iron↓, ferritin↑, ret ↓: anaemia due to inflammation, infection, tumor
Etiology? : decreased RBC, Hb, MCH, (MCV), reticulocyte, ferritin
Ferritin should be evaluated with CRP! Reticulocyte: reflects bone marrow function:
Hyporegenerative: low, hyperregenerative: high
Iron deficiency ACD
Serum transferrin elevated low
Serum iron binding capacity
Bone marrow iron storage
6
-membrane defect inherited: Spherocytosis, elliptocytosis acquired: paroxysmal nocturnal hemoglobinuria
-enzyme defect Glucose- 6-phosphate dehydgrogenase defect Piruvate kinase defect
-hemoglobinopathy Qualitiative problem: sickle cell anaemia Quantitative problem: Thalassaemia (alfa, beta)
Extra- Erythrocyter causes =Extra- Corpuscular Haemolytic anaemia
-alloantibodies hemolytic transfusion reaction Morbus hemolyticus neonatorum
-autoantibodies Autoimmune hemolytic anaemia - cold-warm - Idiopathic- secondary
-drugs Immune-mediated: Penicillin, kinidin, metildopa non immun-mediated= oxidative stress: salazopyrin
-infections Malaria, clostr. Perfringens sepsis
-mechanic: RBC fragmentation syndrome
Cardiac origin: artificial valve, graft Microangiopathic: TTP, HUS, DIC, HELLP, vasculitis Arteriovenosus malformations
-physical- chemical effects
(See lecture.
Haemolytic anaemias
The life of RBCs shortens to couple of weeks/days (normal: 120 days)
Clinical course:
acute: Fever, shivering, collapse, icterus, headache, abdominal pain, backpain, hemoglobinuriaa
eg: hemolytic transfusion reactions, See later
eg: hemoglobinopathies, AIHA
Laboratory parameter reason
Hb↓, Ht ↓ Anaemia
Indirect bilirubin ↑ (icterus), urobilinogenuria
Hem destruction is increased → non-conjugated, albumin-bound (indirect) bilirubin is elevated
Haptoglobin ↓ Hgb coming out of intravascularly destroyed RBC binds to haptoglobin
Hemoglobinuria (brownish urine)
In case of massive intravascular hemolysis, when the tubular reabsorption capacity of the kidney is overrun
Reddish serum Free haptoglobin in the serum in case of intravascular hemolysis
Retikulocyte number↑ In case of intact bone marrow function: erythropoesis is increased, ratio of premature RBC forms is increased
10
The severity and type of red cell alteration determine the cell's site of
destruction. In most cases (eg, oxidant attack, metabolic insult,
hemoglobinopathy) this leads to an alteration of the RBC membrane.
Sites of RBC Destruction
INTRAVASCULAR HEMOLYSIS
• If the damage is severe enough, immediate lysis occurs in the circulation (intravascular hemolysis)
For example:
• Heat damage (thermal burns)
• Complement induced hemolysis (PNH)
• Bacterial phospholipas toxins (clostridial sepsis
• Microangiopathy
• EXTRAVASCULAR HEMOLYSIS
• If the damage is less severe, the cell is destroyed within the monocyte-macrophage system in the spleen, liver, bone marrow, lymph nodes.
For example: • Corpuscular hemolytic anaemias
• AIHA
11
Normally: Extravascular RBC destruction extravascularly in the RES (reticuloendothelial system) of the spleen
In case of hemolysis: in the liver, bone marrow as well, and if their capacity is fulfilled
Intravascular hemolysis: RBCs are destroyed within the blood vessel
↓ free hgb binds to haptoglobin
↓ free haptoglobin↓ (measurable value)
↓ free hgb will be present in the plasma, which
transforms to haematin, which is transferred to RES by haemopexin → finally haemopexin level↓
↓ Free hgb is filtrated and reabsorbed in the kidney
If reabsorption capacity is overrun ↓
hemoglobinuria (red urine)
• Auto- antibody
• Antibodies against RBC:
- IgM- complete antibody: it can agglutinate (big enough to cover the distance between 2
RBC-s), Cold antibody (optimum temperature is below 22C)
- IgG -incomplete antibody: it can’t agglutinate, just cover the cell warm antibody (optimum temperature is at 37C)
24nm
•Coombs test= antiglobulin test
- Shows antibodies that cover RBCs
-Patient erythrocytes that are covered with IgG will agglutinate with Coombs
serum
- shows free antibodies in the serum
- Patient serum containing IgG is mixed with Target RBCs (that contains target
antigen of the investigated IgG)→ the IgG covers target RBCs →Coombs
serum is added→aggultination
•Coombs’ serum: serum that contains antihuman globulin: antibodies against IgG and
complement (retreived from a rabbit or other animal previously immunized with purified human
globulin)
14
- morbus hemolyticus neonatorum…
50%-primary (idiopathic)
50% secondary (disease: NHL, Hodgkin, drug, virus)
Warm AIHA: caused by incomplete IgG autoantibodies (90% adults, 75% children)
-IgG binds at body temperature to RBCs, that are destroyed in the liver and in the spleen → erythropoesis compensates for a while, then→ symptoms
Cold AIHA: caused by complete IgM autoantibodies
- Cold temperature causes acrocyanosis, hemolysis
- Antibodies activate complements (DAT test: complement coverage)
- acut: usually preceeded by infection
- chronic: idiopathic or secondary (B cell lymphoma) Search for a
primary cause!!!
Zs.D, female, b. 1940.
• 1989. cold autoantibodies (no AIHA: Hb124, Ht 0,41, seBi, LDH norm)
• 2010. february: weakness- – AIHA: Hb 88 g/l, Ht 0,17, LDH681, Tbi 82, ret 48, haptoblobin: 0,08
– Serology: same as before (cold AIHA: anti-I, anti-E alloantitest, DC positive, comp coverage)
– IgM: 1366mg/dl, IgA, IgG suppressed
– crista ilei biopsy: Waldenström macroglobulinaemia with 30-40% bone marrow infiltration (CD20, CD19, CD38 positive, cytogenetics negative)
• Treatment: WM and AIHA – Immunetherapy (rituximab) and chemotherapy
• Outcome: – IgM decreased, hb/ht increased
– 2018. she is still feeling well, no hemolysis, no recidiva
16
0
20
40
60
80
100
120
140
150
2 0
R.P, male, b. 1930
• 1933. Heine-medin- right lower limb hypotrophy- needs lots of pain killers
• Cholelithiasis, nephrolithiasis, diverticulosis coli
• 2009 sept: AIHA (warm)- steroid – effective, but slower response
• Bone marrow: CLL 50% infiltration- chemoterapy: Leukeran
• 2009. dec. renal tumor- FNAB: carcinoma renis- chemoembolisation
• 2012 nov AIHA- rituximab (100mg),-AIHA was thought of CLL activisation- chemotherapy: cyclophosphamid
• 2013, inguinal hernia operation, 2013 pneumonia-
• 2015 febr: anaemia, CLL: complete remission, no hemolysis
• Not AIHA: microcytic anaemia- probably due to renal tumor (urine test: hematuria ++)- transfusion, ferrlecit infusion
• AIHA had not reappeared since 2012, he died in 2016 (due to cc renis)
18
• Chronic lymphoid leukaemia, comes to regular check-up
• Anaemia • AIHA? – common in CLL • Blood test: LDH, Tbi, haptoglobin norm • ??? • Ask the patient: blood in stool? • Answer: Yes: RDV: Weber positive • Gastro-colono:source of bleeding is not found • Capsule endoscopy: small intestine:
angiodysplasia
Message:
Reasons
• AIHA- look for underlying disease (and later as well)
• AIHA- treatment
– steroid (CAVE: side effects, hypertension, hyperglycaemia, it cannot be stopped immediately: Addison sy)
– other immunsuppressive drugs
– Rituximab: anti CD20
– Vital indication:
20
• Thrombocytopenia (<150G/l)
• Fever
21
Main reason for TMA • The endothel becomes thrombogenic due to
different reasons
– Erythrocyte fragmentation due to „rough” surface
– Organ dysfunction (ischaemia due to stenosis, block)
TTP:thrombotic thrombocytopenic purpura
22
Etiology of TMA: I. Known molecular etiology Also called: primary TMA
1. Infectious
• Good prognosis, relaps is rare
– P-HUS: • neuraminidase producing bacteria: Streptococcus
pneumomniae, Clostridiums • Direct Coombs positive: neuraminidase cleaves sialic acid
from RBC/Platelet/endothel surface → T antigens become
vailable → the regular anti T antibodies cause agglutination
Besbas N et al. A classification of hemolytic uremic syndrome and thrombotic thrombocytopenic purpura and related
disorders. Kidney Int. Aug 2006;70(3):423-431.
23
2. Complement regulation defect (a-HUS=atypical- hemolytic uremic syndrome)- bad prognosis
– due to genetical abnormalities
– due to acquired reasons
3. ADAMTS13 deficiency (TTP) – Genetic disorder of ADAMTS13
– Acquired deficiency (autoimmune, drug) (ADAMTS13: vonWF cleaving protease- if there is not enough: ultralarge multimers will cause a massive thrombocyte activation, aggregation on the endothel
vWF: thrombocyte adhesion- aggregation, carrier of FVIII)
(4. Defective cobalamin metabolism
5. Quinin induced) Besbas N et al. A classification of hemolytic uremic syndrome and thrombotic thrombocytopenic purpura
and related disorders. Kidney Int. Aug 2006;70(3):423-431.
24
Frequent causes:
• Drugs: calcineurin inhibitors (transplantation!), ticlopidin, mTOR inhibitors, oral contraceptives,
• pregnancy, HELLP syndrome
Rare causes:
• HIV infection, Familial causes not included in part I, unclassified forms
Besbas N et al. A classification of hemolytic uremic syndrome and thrombotic thrombocytopenic purpura
and related disorders. Kidney Int. Aug 2006;70(3):423-431.
25
platelet is above 150 on 2 consecutive
days, no fragmentocytes, no symptoms.
Acute shub:
– Sepis (PCT), endocarditis (TEE), SLE (anti-DNA, ANA), malignant disease, drug (calcineurin inhibitors), antiphospholipid antibodies
• For primary causes:
– Complement activity measurement
– ADAMTS13 activity measurement
ADAMTS13 measurement are necessary)
– Transfusion, hemodialysis
– Usually in case of D-HUS it is enough (PEX is not needed)
• PEX (plasma exchange)+ FFP – Acute, life saving treatment:
• Especially in TTP and a-HUS- where there is antibody to be removed
• Every day until remission
– FFP
• FFP by itself is enough in congenital ADAMTS13 deficiency of complement regulation problem (FFP contains complements and ADAMTS13)
• Immunesuppression: – Steroid, cyclophosphamide, rituximab
28
Thrombocytopenia
– < 10G/l spontaneous life threatening bleeding
29
Trombocyte defect coagulopathy
pressure)
membrane (oral,
Hemarthros Rare Frequent
Positive family history rare frequent
30
Petechiae
venous pressure is incresed. Lower legs, ankle! Not on the
soles (there the vessels are protected by strong connective
tissue)
Ecchymosis
• A: dry purpura (skin only)
• B: wet purpura (bleeding on the mucous membranes)
Wet purpura is more dangerous, might predict life-
threatening bleeding
2. Real thrombocytopenia
Bone marrow: Megakariocyte number is low or absent
1.Hereditary
sy,
2.Acquired
II. Inreased damage
Bone marrow:
Primary immune thrombocytopenia (ITP)
Epidemiology: – Incidence: 2-3/100000 people/year
– Prevalence: kb. 10/100000 people/year
• No other underlying cause
• To our current knowledge both increased destruction and decreased production play a role in disease pathogenesis.
Provan D et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010 115: 168-186
37
- antibodies against megakariocytes - relatively low TPO:
- TPO is bound to plt- there is less TPO available to stimulate plt prod
- TPO is lost when bound to apoptotic megakariocytes
Classic theory of ITP: Platelet-death and degradation in spleen due to anti thrombocyte antibodies Bone marrow: increased production, megakariocyte number increases
Formation of thrombocytes
Thrombopoetin (TPO): - interacts with hemopoetic stem cells and helps them differentiate into megakariocyte precursors
- helps these precursors to proliferate and differentiate into megakariocytes
-Increases peripheral thrombocyte count
– Majority is secondary, provoked by infection (morbilli, varicella), allergy, vaccination
• Adult ITP – Newly diagnosed (within 3 months)
– Persistant (3-12months)
– Chronic ITP (50-75%): (over 12 Months): 60% persistant remission, 35% requires continuous treatment, 1-5% fatal bleeding)
39
Peripheral blood film
Blood group (Rh)
Direct Coombs test
40
ITP treatment principles
• Treatment is based on the severity of thrombocytopenia AND the clinical signs!
• Normalisation of PLT is not a goal!
• Not to be treated:
• Plt transfusion?
41
Colmplete response (CR) Platelet count ≥100 G/L, based on 2
measurements >7 days apart, no signs of bleeding
Therapeutic response (R) Platelet count ≥30 G/L and at least 2x increase to baseline, based on 2 measurements >7 days
apart, no signs of bleeding
No response (NR) Platelet count <30 G/L or less than 2x increase
to baseline, or bleeding, based on 2 measurements >1 days apart
Loss of complete response Platelet count <100 G/L or bleeding, based on
2 measurements >1 days apart
Loss of response Platelet count <30 G/L or bleeding, based on 2
measurements >1 days apart
Rodeghiero F et al.: Standardization of terminology, definitions and outcome criteria in immune thrombocytopenic purpura of adults and children: report from an international working group. Blood. 2009;113(11):2386-2393.
42
– Killing antibody producing B cells (anti-CD20 monoclonal AB)
• Stopping thrombocyte destruction – Intravenous immunglobulin (IVIG)- „feeds” WBC-s attacking plts
– Anti-D
• Get rid of trigger mechanism: – Helicobacter pylori eradication, treat the underlying disease (eg.
Autoimmune)
43
• Second line of treatment: – Splenectomy – TPO receptor mimetics – Vinca alcaloids – Azathioprin – Cyclosporin A – Cyclofoszfamid – Danazol – Dapson – Mycofenolat mofetil – Rituximab
• In case of ineffectiveness of the above – Combination of 1st and 2nd line options.
Provan D et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010 115: 168-186 Neunert C et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 117: 4190-4207.
Glucocorticoids : • Currently considered 1st
be required (even years) • Frequent side effects or
intolerance • Frequent relapse while on
treatment or at attempts on trapering
Agent Dosing Start of
Prednisolon 0,5-2 mg/ kg
2-4 weeks 4-14 7-28
ITP – treatment recommendations
Provan D et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010 115: 168-186 Neunert C et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 117: 4190-4207.
Intravenous immunoglobulin: • Efficient but transient effect • Cost, availability and
transient response limit durable administration
Anti-D products: • Similar mechanism of action • Off-label for the treatment of
ITP in Europe
• Second line of treatment: – Splenectomy – TPO receptor mimetics – Vinca alcaloids – Azathioprin – Cyclosporin A – Cyclofoszfamid – Danazol – Dapson – Mycofenolat mofetil – Rituximab
• In case of ineffectiveness of the above – Combination of 1st and 2nd line options.
Splenectomy: • Durable response after single
procedure • Requires adequate control of
platelet counts for the procedure
• CAVE: vaccinations have to be given!
45
ITP – treatment recommendations
Provan D et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010 115: 168-186 Neunert C et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 117: 4190-4207.
Rituximab: • Durable response in 18-35% • Better result when
combined with dexamethasone
data • Seldom used except of vinca
alkaloids, azathioprin, cyclosporin A
• First line treatment: – Glucocorticoids – Intravenous immunoglobulin (IVIG) – Anti-D antibody
• Second line of treatment: – Splenectomy – TPO receptor mimetics – Vinca alcaloids – Azathioprin – Cyclosporin A – Cyclofoszfamid – Danazol – Dapson – Mycofenolat mofetil – Rituximab
• In case of ineffectiveness of the above – Combination of 1st and 2nd line options.
46
• Second line of treatment: – Splenectomy – TPO receptor mimetics – Vinca alcaloids – Azathioprin – Cyclosporin A – Cyclofoszfamid – Danazol – Dapson – Mycofenolat mofetil – Rituximab
• In case of ineffectiveness of the above – Combination of 1st and 2nd line options.
ITP – treatment recommendations
Provan D et al. International consensus report on the investigation and management of primary immune thrombocytopenia. Blood. 2010 115: 168-186 Neunert C et al. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 117: 4190-4207.
47
Indications for TPO mimetics treatment based on EMA approval
TPO mimetics … • … are indicated for adult chronic immune (idiopathic)
thrombocytopenic purpura (ITP) splenectomised patients who are refractory to other treatments (e.g. corticosteroids, immunoglobulins).
• …may be considered as second line treatment for adult non- splenectomised patients where surgery is contraindicated.
• Eltrombopag is indicated for the treatment of adult thrombocytopenia in patients with chronic hepatitis C virus (HCV) infections, in whom thrombocytopenia is the main limiting factor for starting or continuing optimal interferon-based therapy.
Source: Package insert for Nplate and Revolade, May 2015.
48
Eltrombopag Romiplostim
Pepti-body (antibody-peptide fusion protein)
Oral bioavailability Subcutaneous application
Daily intake Weekly application
Stable plasma levels
• In case of failure with one of the analogues the other compound may prove effective
49
•Preventive supportation: •By critical platelet count (no bleeding)
Indication of platelet transfusion
Preventive supportation Plt count
Accompanying fever, sepsis, DIC, severe anaemia,
extreme leukocytosis, progressive thrombopenia
sternum punction, crista biopsy
50
direct plt activation)
– within 4 days, resolves in 3 days despite heparin therapy
– No severe clinical consequence
• Type II – Immunological mechanism
• more than 50% or 30% falling below 100G/l
• Plt count usually: 50-80G/l
• Typically presents 4-14 days
– Sc./iv. heparin as well
– Risk: nem fractionated > LMWH, surgery patient>other
51.
• Platelet factor 4 (PF4) is releaed from activated thrombocytes
• Heparin forms a complex with PF4 (non fractionated heparin can circle around PF4 better, than LMWH)
• Consequences:
– The anticoagulant activity of heparin decreases
– IgG antibody is formed against heparin- PF4 complex, forming a Heparin-PF4- IgG complex
• These complexes will bind to thrombocytes (through Fc receptor) and endothel, causing platelet activation
Result: thrombocyte activation, thrombocytopenia and thrombosis
52.
Dg: 4T score 4T categories 2 points 1 point 0point
Thrombocyto penia (drop)
30% or nadir ≤ 10G/l
Surely between 5-10. days or ≤1 day (if heparin
exposition within 30 days)
5-10. days but uncertain; or After 10 days; or ≤ 1 day ( if heparin exposition 30-100 days
≤ 4 days, no previous exposition
Thrombosis or other consequence
New proven thrombosis, skin necrosis, acute systemic reaction to iv UFH
Progressive/recurrent thrombosis, Non necrotizing (erythemás) skin changes, suspicion of thrombosis
none
• 4-6 medium probability
• 6-8 high probability
• Do not overdiagnose!
– Those with risk higher than 1% (post operative surgery patients)
Adam Cuker. Clinical and Laboratory Diagnosis of Heparin-Induced Thrombocytopenia: An
Integrated Approach. Semin Thromb Hemost 2014;40:106–114
54.
Algorhythm
diagnose
4T ≥4 4T ≤3
Adam Cuker et al. Predictive value of the 4Ts scoring system for heparin-induced
thrombocytopenia: a systematic review and meta-analysis.Blood 2012 120: 4160-4167
55.
• Definition
• products
• Compatibility
Transfusion- definition
• The transfer of blood or blood components from one person (the donor) into the bloodstream of another person (the recipient).
What can be transfered?
58
Antibody in serum
Anti B Anti A none Anti A and anti B
Inheritance • Follows the mendelian rule • A and B are cododominant • A and B dominates over 0 gene • The „O” gene is non-functional,
it does not produce a detectable antigene (no sugar transfer)
• It is the most important blood group system
• Blood group antigens are actually sugars attached to the red blood cell.
• Antigens are “built” onto the red cell.
• Individuals inherit a gene which codes for specific sugar(s) to be added to the red cell (tranferase)
• The type of sugar added determines the blood group.
Antibodies
•Individual’s will form immune antibodies to ABO blood group antigens they do not possess: Landsteiner’s rule
•Substances are present in nature which are so similar to blood group antigens which result in the constant
production of antibodies to blood group antigens they do not possess.
•Critical for understanding compatibility between ABO blood groups. •Usually IgM type
59
Rh blood group Name comes from Rhesus monkey:
The RBC-s of the Rhesus monkey was injected in rabbits and guineapigs → they
produced antibodies against these RBCs
→ these antibodies reacted 85% of human RBCs: these are called Rh positive, the
remainings are negative
chromosome) – Inherited in triplets: CDE, cde – Independent from ABO blood
group system – Dominant inheritance
- Usually immun-antibodies, irregular antibodies
- Can be autoantibodies (anti-e, anti-C)
Transfusion:
RhD matching is important and sometimes the
other (C, c, E, e) antigens have to match as well
Cause transfusion reaction
Warm antibodies: optimal temperature is 37C
Usually don’t bind complements
IgG crosses the placenta- causing morbus
hemolyticus neonatorum
D variant: gives weaker agglutination to anti D
than expected: reaction with standard anti D reagent
may be negative, but the more specific Coombs test
will be positive!!!
- it is considered positive,
negative individual
- it is considered negativ,
60
+
-
fetal RBCs, causing: 1st pregnancy
-
+
Give the Rh negative mother human anti D globulin:
- it binds the fetal Rh positive RBCs that went into the mother’s blood
- the Rh positive fetal RBCs will not provoke immunisation in the mother
When?
Morbus hemolyticus neonatorum:
hydrops fetalis (heart works harder due to anaemia,
heart will be insufficient, causing oedema…)
61
Thrombocyte antigens
- RBC antigens (A, B, Lewis, I, P) (Rh is not present but an Rh negative female can
only receive Rh negative thrombocyte due to RBC
contamination of the trombocyte pack)
- HLA 1 (human leukocyte antigen)
- HPA1a, 1b (human platelet antigen)
Clinical significance of anti-platelet
- Neonatal alloimmun thrombocytopenia
Clinical significance of anti-granulocyte
days
1g/dl in adult
up to 5 days, kept agitated
• Thr rise by 12-14000/ul
• Pooled (from more donors)
• Apheretic (from 1 donor)
well)
year
fibrinogen,
• Separated by freezing FFP, allowing it to thaw to 4-8ºC
• Re-frozen & stored at – 30ºC for up to 1 yr
• Enriched with FVIII, vWF and fibrinogen
• Indications: – Fibrinogen deficiency
• convenient, predictable, safe and widely practised form of transfusion support.
• It is not available to all patients, it requires – time to pre-donate – a starting hemoglobin >110 g/l which effectively excludes most emergency surgery.
• hospital admission and operative dates must be guaranteed, as donated blood has a limited storage life of 35 days.
• Required hb:
Same group: eg. „A” Rh+ gets „A” Rh+ RBC
Not the same group Eg. „A” Rh+ gets „0” Rh- RBC
Plasm has to be removed („washed”) to
Get rid of the antibodies in the blood product
Eg. Anti A and B in 0 RBC product)
chosen:
Other antigens are matched as well eg: recipient: „A” Rh+ with anti-C, anti-e antibodies will
receive blood that does not contain C or e antigen
• If the antibody screening of the recipient is positive (either allo or auto
antibody)
• Immunisation within 3 months
• Surgery performed in hypothermia;
• Transfusion of infants
• every situation where the possibility of immunisation is very high (eg.. MDS,
thalassaemia, sickle cell anaemia)
Not chosen:
Other antigens are not checked You go to the fridge and get an A+ blood to
an A+ patient,
- If the direct coombs test and the antibody
screening of the recipient is negative
-No anamnestic data for positive Coombs
test and antibody screening
(transfusion, pregnancy, vaccination,
Recipient does not have AB to donor RBC Emergency situation
This is usually the policy
How long is it valid?
Transfusion > 3 month: 72 hours
Transfusion within 3 month: 72 hours
66
0 0 0, A, B, AB
A A, washed 0 A, AB
B B, washed 0 B, AB
AB AB, washed: B, A, 0 AB
RhD positive Rh pozitive, negative RhD does not have to be consideredRhD negative Rh negative
RhD variant Based on consultation: + or -
unknown 0 Rh Dnegative, maximum 2 units
AB
bearing potential can get
In Hungary FFPs are derived from male donors
(to avoid antibodies of previously pregnant
women)
67
– Due to previous RBC Ag exposure
• recipient was previously sensitized to an Ag- antibody titers are low- when the recipient meets this Ag again- anamnestic response takes place
– Destruction of donor RBC with the antigen
– Usually mild, self limited
A: Hemolytic transfusion reactions
68
• Symtoms
– Fever and chills: 80%
– Back or infusion site pain (heat sensation in the transfused vein)
– Hypotension/shock
– Hemoglobinuria
– Positive DAT (direct antiglobulin test= Direct Coombs test)
Due to incompatible blood transfusion: the recipient has a great amount of Ab-s
against donor RBC
→causing complement/coagulation activation, neuroendocrine
Transfusion reactions
– FNHTR: febrile non hemolytic transfusion reaction (citokins)
– Thrombocyte refracterity (HLA antibody)
– Immunmodulation (leukocytes)
Prevention:
- irradiation (blocks immun active WBCs- in case of TA GVHD
B/2: due to plasm contamination
– Urticaria (allergy to transmitted solubile
substances)
– Anafilaxia
– Passive transmission of ABO Antibodies (in case of compatible but not
identical transfusion)
antibodies)
Prevention:
A: Hemolytic transfusion reactions- due to incompatibility
B: Non hemolytic transfusion reactions
B/3. Transfusion associated circularory
Occurs 4-30 days after transfusion
Symptoms: fever, skin rash, liver dysfunction, diarrhoea
Bone marrow dysplasia
HLA
recipient
HLA
recipient
normal
Continuous attack on host tissues, causing GVHD
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TA-GVHD If Child1 gives blood to the mother (or the father)
Child 1’s „yellow” WBCs
will attack mother’s „blue”
cells.
foreign to her
attack child1’s yellow cells,
because she also has yellow
cells
– Immunologic:
– Non-immunologic:
• volume overload, hemolytic (physical or chemical destruction of RBC), air embolus, hypocalcaemia, hypothermia
• Delayed (>24 hours)
• STOP the transfusion
• keep line open with normal saline, using a new set,
• Check I.D of patient, bag and cross-match form
• Refer to handbook for further management
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– Things to consider:
• Lung, heart, circulation, Hb, Htk, Hb-O2 affinity, metabolism affecting O2 uptake and release
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• Transfusion
• Hb: 70 g/l (21 % Htk), usually makes transfusion necessary
depends on: age (> 65 years), concomitant diseases (heart, lung), activity of the patient
• Over 100 g/l Hb transfusion is usually not needed.
↓↓
2 units of RBC cc will get the patient out from hypoxia.
- speed of transfusion: 2-4 ml/kg/hour.
- 2 units a day is recommended
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•Therapeutic support: •Bleeding due to thrombopenia or thrombopathy („wet purpura”, inner bleeding)
•Preventive support: •At critical platelet numbers (without bleeding)
Indication for platelet transfusion
Preventive support Plt count
Stable, afebrile patient < 5-10G/l
leukocytosis, deepening thrombopenia
Surgery, invasive diagnostics (except for sternal punction
and crista ilei biopsy)
polytraumatization
< 100G/l
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- ABO identical or compatible product.
- Rh neg female of gestational age have to get Rh negative platelet
Preventive support is contraindicated usually in: – TTP, HUS, HIT (heparin induced thrombocytopenia)
Preventive support is ususally not indicated in: – ITP (except for splenectomy if plt 10 xG/l thr)
– PTP (post-transfusion purpura)
– Thrombocyte functional problem
– Thrombocyte transfusion refractory state
• But: it can be done in case of life threatening bleeding.
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• STOP transfusion in case there is a reaction!
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