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BLOOD GROUPING AND TRANSFUSION THERAPY Dr.JAISANKAR.P.
PG in General Medicine.
Madurai Medical College. |
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More than 100 blood groups composed of more than 500 antigens.
Introduced by Landsteiner in 1900
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ABO SYSTEM First and the most important system.
Groups - A, B, AB and O.
A and B antigens are found on the RBC membrane either as Glycosphingolipis or as Glycoprotiens.
They are also found on other blood cells, all body fluids except CSF and on intestinal epithelium, urothelium & vascular endothelium. |
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Genes for A & B - on Chr 9.
Co- Dominant inheritance.
H substance - the immediate precursor to which A and B antigens are added.
H + N Acetyl Galactosamine ? A antigen.
H + Galactose ? B antigen
Lack of H substance ? Bombay Phenotype (Oh) |
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WHY ABO MATCHING ? All individuals produce antibodies against the ABO antigen that they lack.
Group A ? Anti B antibodies.
Group B ? Anti A antibodies.
Group AB ? No Anti A/Anti B antibodies.
(universal recipients)
Group O ? No antigens. Both antibodies +
(universal donors) |
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Group Oh (Bombay) ? Anti H antibodies
so, compatible only with another Oh.
A and B antigens are secreted by the RBCs into the plasma. Non secretors are susceptible to infections with,
- Candida albicans,
- Neisseria meningitidis,
- Pneumococcus,
- H. influenza.
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RHESUS SYSTEM 2nd most important.
Involves 45 antigens. D, E, e, C, c are common.
various combinations DcE, Dce etc resuls in various phenotypes.
D antigen present in 85% ? Rh +ve
absent in 15 % ? Rh -ve
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D antigen is a potent Alloantigen.
Exposure of Rh -ve individuals to even small quantities of Rh +ve cells ? Anti D alloantibody ? severe HTR and HDN.
Rh null phenotype occurs when red cells do not express Rh antigens.
Anti D antibodies are IgG ? cross placenta ?HDN |
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Clinical significance
1. prophylactic Rh immune globulin is to be administered to Rh(D)-negative mothers during pregnancy and at delivery if the infant is Rh(D) positive
2. Rh discordance can lead to severe transfusion reactions. |
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LEWIS SYSTEM Carbohydrate antigen.
Chr 19.
Groups Lea, Leb
MCC of incompatibility during pre transfusion screening.
IgM antibodies ? do not cross placenta.
Lewis antigens are not integral part of RBC membrane. They are synthesized in plasma and adsorbed onto the membrane. |
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Clinical significance
1. Transfused red cells always absorb Lewis antigens from the plasma of the transfusion recipient; hence, within several days of the transfusion, the phenotype of the circulating transfused red cells is the same as the patient's red cell phenotype
2. The cell envelop of H. pylori expresses Le x and Le y
This finding may be helpful in treating H. pylori infection in future.
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KELL SYSTEM Protein antigens.
Chr 7.
Principal antigens are K and k.
98% of the population are K-k+ |
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Clinical significance
1. Kell antigens are the second most immunogenic after Rh.
2. absence of Kell antigens
- acanthocytosis
- shortened RBC survival McLeod -
- muscular dystrophies phenotype.
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DUFFY SYSTEM Protein antigens.
Chr 1
six antigens, Fy a, Fy b, Fy3, Fy4, Fy5 and Fy6,
Fya and Fyb are Co dominant.
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Clinical significance
1. Both Fya and Fyb serves as receptors for Plasmodium vivax.
2. Antibodies to both are IgG. can cross placenta. Anti Fya has caused HDN. |
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I SYSTEM I and i are Oligosaccharide antigens that differ only in branching.
Clinical significance
some patients with cold agglutinin disease due to IMN, mycoplasma or lymphomas can produce anti I antibodies that can destroy RBCs.
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P SYSTEM Carbohydrate antigens.
Chr 22.
Single antigen P1.
Anti-P1 is usually IgM.
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Clinical significance
1. in some patients suffering from syphilis and viral infections, Paroxysmal Cold Hemoglobinuria occurs due to production of anti P1 antibodies that binds to RBCs in the cold and fixes compliment in warm temperature.
Donath Landsteiner Antibodies.
2. P antigens also serves as receptor for
- Parvo virus B19
- E coli. |
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MNS SYSTEM Protein antigens.
Chr 4.
Major antigens are M, N, S and s. They are attached to the RBC membrane via Glycophorin A and B.
Clinical significance
anti S and anti s are IgG antibodies. Can lead to severe HDN similar to RH. |
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OTHER MAJOR GROUPS Lutheran
Kidd
Diego
Scianna
Dombrock
Colton
Landsteiner Wiener Chido Rogers
Cromer
Knops
Gerbich
Yt
Kx
Xg |
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BLOOD TRANSFUSION |
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Donor selection Good health and feeling well.
Age 17 - 60 yrs.
Weight at least 45 kg.
Hb at least 12.5 g/dl.
Temp not more than 99.5 oF
BP - 110/60 to 160/90 mm Hg.
No h/o high risk behaviour eg: IV drug abuse
Informed consent. |
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Blood donation Draws 450 - 500 ml of blood into a PVC bag containing citrate based anticoagulant.
Tests done on collected blood
- ABO grouping and Rh typing
- Red cell antibody screen
- Tests for HIV 1 & 2, HBsAg, anti HBc, Anti HCV, anti HTLV I & II , and VDRL.
These tests are performed on pools of 16 to 24 donor specimens. |
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Blood Typing Forward typing
detects the ABO and Rh groups.
Reverse typing
detects iso-agglutinins in sera that correlate with the ABO and Rh type. |
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Blood Screening Identifies antibodies directed against other antigens.
Done by mixing donor’s sera with type ‘O ‘ RBCs which contains the major antigens of most blood groups and is of a known extended phenotype. |
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Blood Cross matching Done when there is high probability that the recipient will require multiple PRBC transfusions.
Serological cross matching
Donor’s RBCs + Recipient’s plasma
if Agglutination ? Incompatible
Electronic Cross matching |
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Whole blood Indicated for acute, massive blood loss
Contain approximately 450-500 mL donated blood + 70 mL of a citrate-based anticoagulant-preservative solution
Stored at 4oC with citrate-phosphate-dextrose-adenine (CPDA-1) solution has a 35-day shelf life and a hematocrit of approximately 35 percent. |
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Upon storing,
- platelets disintegrate.
- coagulation factors disintegrate.
- Red cell 2,3 DPG levels come down.
- spheroechinocytosis
- ? ATP
- Lactic acidosis |
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Glycerolized Red Blood Cells stored frozen at -65°C or lower for up to 10 years
Glycerol is removed by washing before transfusion
This approach is indicated for prolonged storage of rare red cells for patients with antibodies to red cells with rare red cell antigen phenotypes |
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Leukocyte-Reduced Red Blood Cells Indicated for
- patients with a history of multiple febrile non hemolytic transfusion reactions,
- for patients who are frequent transfusion candidates,
- for prevention of cytomegalovirus infection in immuno compromised
Adsorption filters enable the removal of 99.9 percent of donor leukocytes
Cell washing
Centrifugation techniques |
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Washed Red Blood Cells They are indicated only for patients who have had severe allergic reactions associated with transfusion or those with immunoglobulin deficiency
Washing of red cells may be used to remove excess potassium from older units.
prepared by centrifugation with saline to remove almost all plasma and cytokines.
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Irradiated Whole Blood/RBCs To reduce the possibility of transfusion-related graft-versus-host disease.
RBCs are exposed to a standard dose of ionizing (gamma) radiation to render viable lymphocytes incapable inducing reaction.
In premature newborns and highly immuno- compromised patients |
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Mild functional impairment manifested by significant leakage of potassium and accumulation of plasma hemoglobin has been demonstrated subsequent to gamma irradiation
Watch for conduction disturbances / arrhythmias
Shelf life 28 days |
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Attempting to achieve normal BP in the setting of active bleeding through extensive fluid therapy is associated with disruption of haemostatic mechanisms, dilution of clotting factors, increased blood loss and decreased survival.
If in emergency ? O - ve blood can be transfused while waiting for the cross matched blood. |
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EXCHANGE TRANSFUSION Indications
- In neonates when hyperbilirubinemia does not respond to photo therapy
- DIC
Irradiated fresh red cells ( < I wk old ) are used.
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PLATELET TRANSFUSION |
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HARVESTING PLATELETS 450 - 500 ml whole blood @ room temp with in 8 hrs
slow centrifugation
PRBC
PRP
fast centrifugation
FFP
RDP
(in 50 - 60 ml plasma) |
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One unit Random Donor Platelet contain 5.5 × 1010 platelets
Platelets can alternatively harvested from the Buffy coat. Such PC contain fewer WBCs as contaminants. |
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Platelet Apheresis The technique of selectively extracting platelets from the donor and returning the remaining components back to his circulation.
Yields Single Donor Platelets (SDP)
- equal to six units of RD platelets
3 × 1011 platelets in 300 ml plasma
- contains fewer WBCs than RDP.
- shelf life of 5 days. |
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TRANSFUSION OF PLASMA AND COMMERCIAL PROTEIN CONCENTRATES |
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FRESH FROZEN PLASMA Prepared from citrated whole blood by centrifugation and freezing within 8 hrs of collection.
stored at -18°C or below for up to 1 year.
On storage - minimal loss of activity of the labile coagulation factors V and VIII. |
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Indications
- in patients who are bleeding or having an invasive procedure and who are deficient in multiple coagulation factors or in a single factor for which there is no specific factor concentrate available.
- for reversal of warfarin effect.
- for replacement of clotting factors during massive transfusion
- for plasmapheresis |
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Each unit of FFP ? 200 ml of plasma
Must be ABO compatible
A dose of 10 to 15 ml/kg would constitute approximately 25 to 30% replacement therapy for coagulation factors.
Factor VIII levels ? reduced to 1/3rd in 40 days
Factor V levels ? reduced to 1/3rd in 20 days
Other factors are relatively stable.
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CRYOPRECIPITATE Is an extract of FFP that is enriched in high-molecular-weight plasma proteins.
prepared by thawing 1 unit of FFP at 1° to 6°C.
The precipitated HMW protiens ( rich in Fibrinogen, Fa VII, vWF and Fa XIII ) is frozen with 15 ml of plasma.
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Each unit contains 80 - 120 units of Fa VIII and 150 mg of fibrinogen.
used in
- correction of hypofibrinogenemia in pts with
- DIC
- prolonged cardio pulmonary bypass.
- Hemophilia A.
- Fibrin Glue
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ALBUMIN Prepared from pooled plasma by Cold Ethanol (Cohn) Fractionation
95% pure.
Heat treated to eliminate the risk of transmission of viral hepatitis and HIV.
Available as 4%, 5% and 25%. |
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COAGULATION FACTOR CONCENTRATES FACTOR VIII - those derived from plasma can be used to treat both Hemophilia A and vWD.
Recombinant Fa VIII concentrates does not contain vWF.
PROTHROMBIN COMPLEX CONCENTRATES -
contains variable quantities of Vit K dependent clotting factors II, VII, IX, X. |
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ANTI THROMBIN III - In anti thrombin-deficient patients with thrombosis or in situations with a high risk of thrombosis. |
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INTRAVENOUS IMMUNE GLOBULINS Nonspecific IVIG preparations contain a broad spectrum of antibodies naturally present in the donor population
Available as 3 to 12% protein solutions or powders that have to be reconstituted.
Slow administration to reduve adverse reactions. |
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Indications
- prophylaxis of infections in patients with primary immunodeficiencies.
- prophylaxis of infection in patients with B-cell CLL.
- prevention of infections after BMT
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In treatment of
Kawasaki disease
ITP
Pediatric HIV co infections
Guillain - Barre syndrome,
Dermatomyositis,
Red cell aplasia due to parvovirus B19 infection
Adverse effects - renal failure and thrombotic events
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INTRAMUSCULAR IMMUNOGLOBULINS Prepared from pooled plasma by cold ethanol fractionation.
Available as 16.5% protein solutions, containing approximately 95% IgG and small amounts of IgA and IgM.
Specific IMIg
Rh immune globulin,
hepatitis B immune globulin,
Varicella zoster immune globulin. |
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Adverse Effects of Transfusion Immunologic
- Alloimmunization
- Hemolytic transfusion reactions
- Febrile transfusion reactions
- Transfusion-related acute lung injury
- Allergic transfusion reactions
- Post transfusion purpura
- Graft-versus-host disease |
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Non immunologic
- Volume overload
- Hypothermia
- Hyperkalemia
- Pulmonary micro embolization
- Transfusion hemosiderosis
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Infectious
Hepatitis: B, C
Human immunodeficiency virus -1/-2
HTLV -I/-II
Cytomegalovirus
Epstein-Barr virus
Bacterial contamination
Syphilis
Parasites: malaria, Babesia, trypanosomes |
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MANAGEMENT OF TRANSFUSION REACTIONS Discontinue the transfusion immediately
A post transfusion blood sample and the discontinued bag of blood should be sent to the blood bank for investigation.
Hydration with NS must be begun immediately to prevent renal failure
Mannitol or furosemide may be used to maintain urine output of min 100 ml/hr.
Anti Histamines and Cortico steroids.
Dopamine if hypotension develops.
Coagulopathy if develops may require specific management |
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