unit 14 hemotherapy and organ transplantation
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Unit 14 Hemotherapy and Organ Transplantation. Terry Kotrla, MS, MT(ASCP)BB. Hemotherapy Introduction. Indications for transfusion must be defined. Transfuse appropriate product. Products most frequently used: Red blood cells Apheresis platelets Fresh frozen plasma Cryoprecipitate - PowerPoint PPT PresentationTRANSCRIPT
Terry Kotrla, MS, MT(ASCP)BB
Unit 14 Hemotherapy and Organ Transplantation
Hemotherapy IntroductionIndications for transfusion must be defined.Transfuse appropriate product.Products most frequently used:
Red blood cellsApheresis plateletsFresh frozen plasmaCryoprecipitate
Additional considerations:IrradiatedCMV negative
Red Blood CellsUsed to treat symptomatic anemia.Criteria for selection
ABO compatibleNegative for antigens that patient has
clinically significant, alloantibodies to.Infant – compatible with baby and mother
and lack antigens to which mother has clinically significant antibodies.
Red Blood CellsIndications for use:
Oncology patientsTrauma victimsCardiac, orthopedic and other selected
surgeries.End-stage renal diseasePremature infantsDiseases such as sickle cell, thalassemia,
aplastic anemia, etc.Additional considerations
Immunosuppressed give CMV negativeRisk of TA-GVHD give irradiated
Apheresis PlateletsUsed to treat thrombocytopeniaFunction includes
Maintenance of vascular integrityInitial arrest of bleeding by platelet plug
formation.Stabilization of hemostatic plug through
contribution to fibrin formation.Criteria for selection
ABO compatible if possibleIf ABO compatible not available limit exposure.D negative for D negative recipients, can give
RhIG
Apheresis PlateletsIndications for use:
Chemotherapy or radiation therapy patients.Post-hematopoietic progenitor cell transplant
recipientsPeri- or post-operative bleedingThrombocytopenic purpuraThrombocytopenia due to other causes
Additional considerationsImmunosuppressed give CMV negativeRisk of TA-GVHD give irradiated
Fresh Frozen PlasmaUsed to replace clotting factors including
labile factors V and VIII.Criteria for selection
MUST be ABO compatible.Crossmatching NOT necessary.
ABO selectionThink of ABO antibodies in PATIENT.AB universal donor.Group O universal recipient, WHY?
Fresh Frozen PlasmaPreparation
NEVER thaw until order to give is confirmed.Thaw at 37C for 30-45 minutes – several
methods available.Must use protective overwrap to protect
ports from contamination.Expiration
24 hoursAfter 24 hours can be relabeled “thawed
plasma” and used for 5 days if not needed for Factor V or VIII.
Fresh Frozen PlasmaIndications for use
Clotting factor concentrates not available.Massive transfusion.Patients on warfarin who are bleeding.PlasmapheresisSevere liver diseaseDICRare specific plasma protein deficiencies.
Two units frequently ordered.
CryoprecipitateWhat is it?
Insoluble precipitate which forms when FFP is thawed at 1-6C.
Contains concentrated levels of Factor VIII and fibrinogen.
Criteria for selectionDue to small volume ABO group does not
matter UNLESS patient is an infant or small child.
ABO compatibility considerations same as FFP.
CryoprecipitatePreparation
NEVER thaw until order to give is confirmed.Must be thawed at 37C.Protect ports.For adult patient pool 6-10 units for
therapeutic doseExpiration
Frozen 1 year.Thawed 6 hoursPooled 4 hours
CryoprecipitateIndications for use:
Massive transfusionDICFibrinogenemiaVonWillebrand’s disease
Massive Transfusion ProtocolMassively bleeding patients need EVERYTHING.Massive transfusion protocols have been studied
and are proven to reduce mortality rates.Numbers will vary according to institution but
standardizes the protocol to transfuse components.
Example for adult:6 units RBCs4 units FFP1 unit apheresis platelets
Continue until lab results are within normal limits.
TransplantationSolid organs
KidneyLiverLungsIntestinePancreasHeart
Living donor tissue and cell allograftsHematopoietic progenitor cells: bone marrow or
peripheral bloodCord blood
Tissue Allografts: bone, heart valves, tendons, etc.
TransplantationSolid Organ Compatibility testing
MUST be ABO compatible for solid organ transplants.
MUST be HLA compatibleProgenitor cells or bone marrow
ABO doesn’t matter.MUST be HLA compatible
Other tissues (bone, etc.) only stored, no compatibility testing necessary – bone and cornea most common.
Transfusion service roleAccurate ABO typing of donorSupply blood appropriate blood components.
Human Leukocyte Antigens (HLA)Complex array of genes and their
molecular products involved in immune regulation and cellular differentiation.
HLA antigens found on surface membranes of all NUCLEATED cells.
Second in importance to only ABO for solid organ transplant survival.
Human Leukocyte Antigens (HLA)HLA found on surface of nucleated cells which includes
WBC.Function of HLA is to help identify and in turn, fight
“foreign stuff”2 types of HLAsome for MHC I and MHC II (MHC genes
are on chromosome 6)Most important HLA are types A, B (MHC I) and DR (MHC
II)MHC I present antigens to cytotoxic T cells and MHC II
use antigen-presenting cells for helper T cellsFor this reason, it is important to have closely matched
HLA between donor and recipient to avoid rejection, i.e., to avoid donor cells being presented to recipient immune system by MHC for destruction.
Recipient QualificationsList of individuals waiting for organs far
exceeds supply.Most cases <60 yr oldDisqualified if:
Recent MIActive infectionMalignancySubstance abuseLimited life expectancy from unrelated
disease
Time Factors - FYIOnce harvested organs must be
transplanted quicklyKidney – 48 hoursPancreas – 24 hoursLiver – 12 hoursCorneas – 8 hoursHeart and lungs – 6 hours
Recipients closest to location of donor and who “match” are first ones offered organ.
United Network for Organ Sharing (UNOS) is clearing house http://www.unos.org/
Transfusion SupportLiver transplant require the most blood
components.Problem if patient has alloantibodiesUse antigen negative first 5-10 unitsSwitch to unscreened or partially matched
units.Use antigen negative last 5-10 units.Requires close communication between
physician and transfusion service.May use preop plasmapheresis to reduce
titer of clinically significant antibodies.
Transfusion SupportTransfusion support for other types of
transplants usually not a problem.Follow protocol at your institution.Products
IrradiatedCMV negative
Marrow TransplantationTypes
Autologous hematopoietic progenitor cells (HPC)(not really a transplant but a “rescue”).
Allogeneic hematopoietic progenitor cells.Bone marrow
Purpose is to reconstitute patient’s heamtopoietic system after destruction of the recipient’s.
ProcedureDestroy patient’s bone marrow totally.Infuse HLA matched HPC or bone marrow.Monitor for engraftment.
Marrow TransplantationIndications
Hematologic malignanciesSevere immunodeficiencyAplastic anemiaHemoglobinopathies
Malignant diseases are the most common indication.
Success rate depends onPatient’s disease and stage of diseaseDegree of prior treatmentAge and condition of patientDegree of HLA match between patient and
donor.
Transfusion Support for Marrow TransplantRefer to page 310 in textbook.Transfusion service staff must carefully
follow protocol and determine phase patient is in.Phase I compatible with recipient.Phase II compatible with recipient and donor.Phase III compatible with donor.
Marrow Transplantation – Transfusion Service ChallengesChallenges for transfusion service after successful
transplant with ABO marrow different than original.During transition mixed field results and ABO
discrepancies will occur, indicates successful engraftment.
Historical type will be one type, current sample will be another after successful engraftment.
History is CRUCIAL in these situations.Must have patient redrawn to verify no collection
error occurred.Must document from medical records when
transplant was performed.
ReferencesAABB Technical Manual 16th edition, 2008Basic & Applied Concepts of Immunohematology,
Blaney and Howard, 2009Massive Transfusion Protocols, 2009,
http://www.cinj.org/documents/MTP.pdf Massive Transfusion for Trauma is Appropriate, 2005,
http://www.itaccs.com/traumacare/archive/05_03_Summer_2005/appropriate.pdf
Transfusion Support in Solid-Organ Transplantation, 2001, http://www.itxm.org/tmu/tmu2001/tmu4-2001.htm
Role of Transfusion Services in Organ and Tissue Transplantation http://tinyurl.com/3ojbr9l
End of Unit 14