Transfusion Medicine

L. Bonstein PhD

E. J. Dann MD

Reference:Harrison’s principle of internal Medicine 16th edition chapter 99 pages 662-667

• In 1901 Karl Landsteiner discovered the ABO blood groups.

• In 1914 the effect of sodium citrate was described.

• In 1915 the first successful transfusion of preserved blood took place.

• In 1920 the first blood banks were created in Paris and SAN PETERSBURG

• In 1932 the !st blood bank was established in Chicago

• Combat conditions blood bank was 1st used during the Spanish civil war

LANCET

April 1 1939 236:773-775

• In 1940 the "Rhesus" system was discovered by Levine, together with Landsteiner and Wiener.

• In the Second World War about 50,000 transfusions of preserved blood were given on the German side and millions on the Allied side.

• After the Second World War: improvement in the stabilizing solutions.

• Today: separation of blood into various blood components.

Close Circuit Donation System

Preservation solutions

ADSOL 100ml

More Adenine

Mannitol

CPDA 60ml

Citrate

Phosphate

Dextrose

Adenine

Whole Blood (historical option)

מכיל את כל מרכיבי הדם•יינתן במקרים של איבוד דם רב•ניתן לפי סוג ולאחר הצלבה• ימים35נשמר במקרר עד ••450ml 35-45%הפלזמה במוצר זה בעלת ערך •

אונקוטי בלבד ולא מכילה א הפסיק ”פקטורי קרישה –מד

.לספק מוצר זה לאחרונה

PACKED תהליך הפרשת הפלזמה ממנת הדם ויצירת CELL

Packed Red Blood Cells (PC)

One unit of packed RBC will raise Pt hemoglobin 1

gr/100mlUnit volume 250-350 ml Hct of

70%-60%Indication: acute bleeding

Anemia with Hb of less then7gr% or ischemic Pt with less

then 12 gr%Storage period 35 or 42 days at

1-60cType and cross

Platelets Concentrates

• A unit of platelets contain 5x1010 increase count of platelets by 10000/ul (20-30ml)

• Adult dose is 6 units • Platelet count should be kept above 5-

10 x103 /ul or 50 x103 /ul in acute bleeding • Platelets concentrate are kept at 220c

and are kept for 5 days • Refractoriness is caused by HLA allo

immunization or non immune sepsis hyper splenism

• Matching of blood type is not mandatory

Relative contra indications for platelets

Fresh frozenפלסמה קפואהplasma FFP

• Frozen within 6h from collections

• Indications for use in coagulation factors deficiency (Massive bleeding Hepatic failure DIC Disseminated intravascular coagulation)

• Volume of 200 –250 cc kept at -20°c for a year period

• Given according to type but not crossed

Cryopercipitate

• Plasma is frozen at –80 0c, thawed at 40c and then separated from plasma and kept at –200c for up to 1 year

• Contain factor viii and fibrinogen• Use at DIC low fibrinogen and for

hemophilia A and von Willebrand’s disease

• Cryo supernatant (cryo poor plasma) is used for apharesis in TTP patients

Left: Freezer filled with

FFP and Cryo.Upper Right:

Refrigerator with bagsof RBCs.Lower Right :

Platelet Storage.

Left: Freezer filled with FFP and Cryo.Upper Right:

Refrigerator with bags of RBCs.Lower Right :

Platelet Storage.

A over view of Machupichu and waina pichu

Transfusion Transmitted Diseases

Select safe donors

Serial testing

Viral-inactive procedures

Control unnecessary use of blood products

Transfusion 43:787 Lee DH Mehta MD

Classification of Tx Reactions•Acute R with Fever

–IHA (ABO incompatible) less commonFNHTR common

–Bacterial Contamination less common

•Acute R without Fever–Urticarial TR common

–Circulation Overload less common–Anaphylaxis less common

–TRALI less common

Delayed R with FeverDHA common

TA-GVHD less common

Delayed R without FeverPost-transfusion Purpura

Iron Overload

Work out Transfusion Reactions

Cross Match

Direct Antiglobulin Test

Antibody Screen

Blood Culture

Acute Reaction with Fever

Febrile Non hemolytic TR

Bacterial Contamination

IHA (ABO incompatible)

Febrile Non hemolytic TRs

• Most frequently reported reactions, 1-1.5%• Increase in temperature 10C or 2 0F with no

other explanation• Signs/Symptoms: Fever & chills (no rigors),

Headache, Flushing , Rapid pulse, Nausea, vomiting , Shortness of breath

• Lab findings: Nothing

Febrile Nonhemolytic TRs

Cytokines released by donor WBC

Cytokines released after transfusion (donor anti-HLA antibodies)

Recipient macrophages release cytokines

More common with random platelets

Use pre-storage leukoreduced blood components

Y Y Y IL1

IL6

TNF IL8

Cytokines in FNTR

IL 1IL 1: : Causes fever by production of PG ECauses fever by production of PG E22

TNFTNF

IL6IL6

IL1IL1

Central mediators of inflammationCentral mediators of inflammation

Febrile Reaction: ThresholdsFebrile Reaction: Thresholds

5 x105 x1088 WBC per unit will cause FNTR WBC per unit will cause FNTR

5 x 105 x 1066 WBC per unit will cause HLA sensitization WBC per unit will cause HLA sensitization

5 x105 x1088 WBC per unit will cause FNTR WBC per unit will cause FNTR

5 x 105 x 1066 WBC per unit will cause HLA sensitization WBC per unit will cause HLA sensitization

דם מסונןדם מסונן

הסינון ע"י פילטר מסוג •Leukostop

להורדת כמות התאים •הלבנים במרכיב (כדוריות או

X5 106טסיות)לערך נמוך מלמניעת תגובות כתוצאה

מיצירת נוגדנים כנגד תאים לבנים במטופלים שמקבלים

מרכיבי דם במהלך תקופה ארוכה

CMVלמניעת הדבקה ב-•

FNTRFNTR

• Most common in :Most common in :

- Women (2:1)- Women (2:1) - Multiply transfused patients- Multiply transfused patients

• Rare in childrenRare in children

• Most common in :Most common in :

- Women (2:1)- Women (2:1) - Multiply transfused patients- Multiply transfused patients

• Rare in childrenRare in children

Bacterial Contamination (Septic TR)At the time of phlebotomy, components preparation, during storage, thawing in water-baths.

Yersinia enterocolitica, Citrobacter freundii, E. coli, PseudomonasGrow in low temp, Produce endotoxinDark brown colorIncidence 1:3000 mainly in platelets concentrations

Bacterial Contamination (Septic TR)

symptoms

Rapid high fever with flushing and dryness of skin

Rigors

Abdominal cramping

Nausea & vomiting

Shock

Bacterial Contamination (Septic TR)Laboratory findings:

Discolored product

Hemoglobinemia and hemoglobinuria

DAT negative

Gram stain is unreliable

Bacterial culture is positive Rx:

Immediate iv antibiotics (broad-spectrum)

Therapy for shock (fluid support, dopamine, steroids)

Immediate Hemolytic TR (ABO)

Clerical errors

Disastrous, often fatal

Intravascular (ABO) extravascular (others)

ABO incompatibility

Red Blood Cell Lysis as seen by Red Blood Cell Lysis as seen by transmissiontransmission

Electron Microscope. Electron Microscope.

(From Rossi E. “Principles of (From Rossi E. “Principles of Transfusion Medicine” 2Transfusion Medicine” 2ndnd Edition) Edition)

Intravascular Hemolysis

Immediate Hemolytic TR (ABO)

Signs & Symptoms

Fever and chills

Pain in the back or at infusion site

Hypotension/Shock

DIC/Bleeding (important in anesthetized patients)

Immediate Hemolytic TR (ABO)Lab findingsPink or red serumDAT positive (unless all donor cells are destroyed)Elevated bilirubinHemoglobinemia/hemoglobinuriaLab finding of DIC (PT, aPTT, DD)RBC abnormalities (schistocytes/spherocytes)

Rx:Support volume ,Maintain urine output

Treat DIC

Acute TR without Fever

Urticarial TR

Circulation Overload

Anaphylaxis

TRALI

Urticarial TR•Second most frequently reported

reaction•Localized rash and edema

•Mechanism–Hypersensitivity to plasma

proteins/mast cells release histamine

•Prevention and treatment–Benadryl 25-50mg

–“Washed” blood components

Urticarial TR• Second most frequently

reported reaction• Mechanism

– Hypersensitivity to– plasma proteins

• Prevention– “Washed” blood

components

Anaphylactic TR

•Classic story: IgA deficient Pt got IgA-containing products

•IgA deficient 1/700, Anaphylactic TRs 1/20,000.

•Anaphylactic shock within the first few drops of transfusion

Anaphylactic TR

•Mechanism–Hypersensitivity to plasma proteins

•Prevention–No plasma transfusion–Washed RBC, Platelets

•Treatment–Epinephrine 1:1000, subcut; 1:10,000 iv

inf

Transfusion-Related Acute Lung Injury - TRALI

•Rare, may occasionally be febrile

•Mechanism–Donor’s anti-WBC/HLA antibodies

–WBC micro-aggregates in pulmonary microcirculation

•Clinically identical to ARDS, but resolves in 12-24 hours

FEBRILE NON HEMOLYTIC TRANSFUSION REACTION

Klein HG ASH 1998

YY

YY

YYYY

YY

Clumps of WBC form and get trapped in the Clumps of WBC form and get trapped in the pulmonary microcirculation.pulmonary microcirculation.Clumps of WBC form and get trapped in the Clumps of WBC form and get trapped in the pulmonary microcirculation.pulmonary microcirculation.

T.R.A.L.I.T.R.A.L.I.T.R.A.L.I.T.R.A.L.I.

Delayed Hemolytic Anemia

The third most common TRs

Hemolysis occurs several days to weeks after transfusion

Usually extravascular hemolysis

Kidd (Jka), Duffy, Kell

Signs & Symptoms : Often none

Fever, Anemia, Mild jaundice

Hemolytic Transfusion ReactionsHemolytic Transfusion ReactionsHemolytic Transfusion ReactionsHemolytic Transfusion ReactionsExtravascular HemolysisExtravascular Hemolysis

RBC phagocytosis as seen by TEMRBC phagocytosis as seen by TEM(From Rossi E. “Principles of Transfusion Medicine” 2(From Rossi E. “Principles of Transfusion Medicine” 2ndnd Edition) Edition)RBC phagocytosis as seen by TEMRBC phagocytosis as seen by TEM(From Rossi E. “Principles of Transfusion Medicine” 2(From Rossi E. “Principles of Transfusion Medicine” 2ndnd Edition) Edition)

Delayed Hemolytic Anemia

Lab findings : DAT positiveAnemia ,

Positive antibody screen

Treatment: Usually not necessary

If severe treat like acute hemolysis

Transfusion Associated-GVHD

MechanismDonor,s cytotoxic lymphocytes attack recipient's stem cellsGetting blood from first-degree relativeUsually when “warm blood” is given and not irradiatedPatients at risk:

Marrow or stem cell transplant recipientsCongenital T-cell deficient Pts (DiGeorge,s)Neonatal/intrauterine transfusionsHodgkin,s disease

TA-GVHDBone marrow transplant patientsImmunocompromised patientsNeonatal patientsHodgkin’s

Develop 1-2 weeks after transfusion

Rash, diffuse mucositis, hepatitis

Pancytopenia, infection, bleeding

Hypoplastic/aplastic bone marrow failure

Fetal in 90% of cases, even with treatment

דם מוקרןדם מוקרן

ההקרנה מונעת פעילות •התאים הלבנים ע"י פגיעה

בחומר התורשתי שלהםלמניעת תגובת דחיה של •

המטופל ע"י הכדוריות ) GVHDהלבנות מהמנה (

במטופלים בעלי מערכת חיסון פגועה (למשל אחרי

טיפול כימותרפי)במקרים כאלה יינתנו •

כדוריות וטסיות מוקרנות

Infectious risks of Blood Transfusion

Viral I nf ection Estimated Risk Death/ 106 Units

Hepatitis A 1/ 106 0 Hepatitis B 1:30-250000 0-0.14 Hepatitis C 1:30-150000 0.5-17

HI V 1:2x105-106 0.5-5

HTLV I / I I 1: 250000 – 2x106 0 Parvovirus B19 1:10000 0

Bacterial inf ection

Red Cells 1:500000 0.1-0.25

Platelets 1:12000 21

NEJM, Feb 18, 525-533,1999

Copyright ©2003 American Society of Hematology. Copyright restrictions may apply.

Hillyer, C. D. et al. Hematology 2003;2003:575-589

Figure 1. New test implementation and declining risk of viral infections from transfusion

Post Transfusion Hepatitis

Jaundice and LFT abnormalities following blood transfusion

1968 Post Transfusion hepatitis HBV related

NANB - PTH

NANBNC” -PTH”

Hepatitis C

TransmissionInfected needles

Blood transfusion Surgical/ Endoscopic procedures

Prevention Questionnaire

anti-HCV - 1991HCV -RNA

HCV -Ag (experimental) ALT, anti-HBc - Surrogate Tests

HCV Markers During Early Infection

HCV RNA Day 12HCV antibody Day 70 58 Days

0 10 20 30 40 50 60 70 80 90 100 Days

HCV RNA

Anti-HCVHCV Ag

Hepatitis B transmission prevention

Questionnaire

HBsAg testing

Anti-HBc – some countries

HBV DNA - IND

HBV Markers During Early Infection

HBV DNA up to 23 days prior to HBsAg HBsAg Day 56; disappears day 120

HBV DNA

HBsAg

ALT

Anti- HBc

0 10 20 30 40 50 60 70 80 90 100 110 120 Days

חלון אנטיגני

וסרולוגי

בדיקה מולקולרית חיובית1:400000ב

TA - HIV

HIV Markers During Early Infection

HIV RNA Day 11HIV p24 Ag Day 16HIV antibody Day 22

11 Days

HIV RNA (plasma)

HIV p24 antigen

Anti-HIV

11 16 22

0 10 20 30 40 50 60 70 80 90 100 Days

HIV - prevention of transmission by blood

products

Blood donor educationBlood donor education

QuestionnaireQuestionnaire

Tests for HIVTests for HIVHIV -Ab, ElisaHIV -Ab, Elisap24Ag,p24Ag, Elisa Elisa

HIV - RNA HIV - RNA IND IND

Human T Lymphotrophic Virus I/II

RNA Virus - Present in T lymphocytes

Morbidity - ATL - Adult T Cell leukemia TSP - Tropical Spastic Paraparesis HAM - HTLV associated myelopathy

appears in 2-4% of carriers after >20 years

Human T Lymphotrophic Virus I/II

Transmission modes Endemic countries: Japan, Carribean, South America

Breast feeding, Sex , Blood transfusion

Other RegionsBlood Products, Infected needles

(HTLV II)

Transfusion Associated Viral Hepatitis, USA

Years of Transfusion

% Recipientsinfected

Cytomegalovirus = CMV

Most common virus transmitted by blood transfusion

Morbidity Infectious Mononucleosis Immunosupressed +

Retinitis, Gastritis, Nephritis, Rash Graft rejection, Pancytopenia, Etc.

Cytomegalovirus = CMV

Transmission by Lym in cellular products Risk groups Neonate <1500 Gr, Mother CMV neg

Transplanted Pt. CMV neg, Donor Pos Pregnant women CMV neg AIDS pts CMV neg

Prevention - CMV Ab neg bloodLeukoreduction

Mad cows and Blood BSE = Bovine Spongiform

Encephalitis 21.3.96 - Possible transmission to humans

10 cases nvCJD young short incubation period Brain changes similar to CJD

? Species barrier ?? Transmission by blood and

blood products

Parvovirus B19

DNA Virus Transmission during viremia Does not cause chronic infection

Morbidity Children Fifth Disease , Erythema Infectiousum Aplastic Crisis - Chronic Hemolytic anemias

- AIDS Prevention- No routine screening for donations

PCR 1:3300 units Positive

Malaria

> 250 millions acquired Malaria Chronic infection of Red Cells Morbidity - Parasite dependent USA - 3/ Cases year Transfusion realated Prevention of transmission by bloodPrevention of transmission by blood : :

No good test available for donor screeningResidents of endemic areas/Acquired Malaria Avoid donations 3 yearsTravel to endemic area

Avoid donations 1 year

Chagas’ Disease

Causative Agent Trypanosoma CruziTransmitted by MosquitosTransfusion Transmission significant inimmunosupressed

Endemic in central and south America Bolivia 62% population - exposed

MorbidityProlonged asymptomatic stageCardiomyopathy

Prevention No effective test for donor screening

Infectious markers tests in Israel

anti-HIV I/II HBsAg anti-HCV anti-HTLV I/II TPHA

ALT

NAT Reduction - Window NAT Reduction - Window PeriodPeriod

Virus Virus Infection to Infection to Infection to Infection to Reduction by Reduction by Ab detection NAT detection Ab detection NAT detection NAT testingNAT testing

HIVHIV 22 days 22 days 11 days 11 days 50%50%

HCVHCV 70 days 70 days 12 days 12 days 83%83%

HBVHBV 56 days 56 days 33-41 days 33-41 days 27-41% 27-41%

APHERESIS

APHERESIS

Therapeutic apheresis

TPE – therapeutic plasma exchange cholesterol reduction, immunoglobulins myasthenia gravis , TTP(

Leukodeplition, thrombodeplition

Photopheresis

פרזיס לתרומות

איסוף תאי אב•

•Single donor platelets

גרנולוציטים•

דם מלא מופרד•

Single Donor PlateletsSingle Donor Platelets

טסיות מתורם יחיד המופקות•X3 1011בתהליך של אפרזיס

יינתנו למטופלים שספירת הטסיות •שלהם לא עולה לאחר מתן תרכיז טסיות רגילאו חולים עם תופעות לואי קשות. אפשרות נוספת

•FILTERED POOL WITHIN 2 DAYS of STORAGE

פרזיס טיפולי

•TPE – therapeutic plasma exchange )TTP(כולסטרול, נוגדנים,

•Leukodeplition, thrombodeplition

•Photopheresis