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Transfusion pathology Kristine Krafts, M.D. September 24, 2007
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Transfusion Pathology Outline • Blood groups • • • • Introduction ABO system Rh system Other systems • Blood transfusion Blood products Indications Testing Dangers
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intro ABO Rh other groups products indications testing dangers
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Transfusion Pathology Outline • Blood groups Introduction
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Q. What determines a blood group? intro ABO Rh other groups products indications testing dangers
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Q. What determines a blood group? A. The antigens on the red cell surface. intro ABO Rh other groups products indications testing dangers
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• • • • • Antigens are inherited (Mendelian pattern) Real function unknown Damn important during transfusion Lots of antigens exist (grouped into systems) Most important systems: ABO and Rh Red Cell Antigens intro ABO Rh other groups products indications testing dangers
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Transfusion Pathology Outline • Blood groups • • Introduction ABO system intro ABO Rh other groups products indications testing dangers
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What are the antigens? • • • • • A and B Some people have A antigen (“type A”) Some people have B antigen (“type B”) Some people have both A and B (“type AB”) Some people have neither A nor B (“type O”) intro ABO Rh other groups products indications testing dangers
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Type A What are the antigens? Type B intro ABO Rh other groups products indications testing dangers Type AB Type O
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How do you make the antigens? • • • • Start with a protein precursor Add fucose to make H antigen Add N-acetylgalactosamine to H Ag to make A Ag Add galactose to H Ag to make B Ag intro ABO Rh other groups products indications testing dangers
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H antigen intro ABO Rh other groups products indications testing dangers A antigen B antigen
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What are the genes? • H gene • • everyone* has this one codes for an enzyme that makes H Ag. • A, B, and O genes • • • • everyone has two genes. six possible genotypes: AA, BB, AB, AO, BO, OO A and B code for enzymes that make A and B antigens. O has no gene product*. * almost! intro ABO Rh other groups products indications testing dangers
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intro ABO Rh other groups products indications testing dangers
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How common is each blood type? intro ABO Rh other groups products indications testing dangers
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So What? • • • • We have antibodies to the antigens we don’t have! Anti-A antibodies lyse type A red cells. Anti-B antibodies lyse type B red cells. This is very important during blood transfusion. intro ABO Rh other groups products indications testing dangers
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Type A So what? Type B Type AB Type O intro ABO Rh other groups products indications testing dangers
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intro ABO Rh other groups products indications testing dangers
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O O AB B A Recipient blood type AB, A, B, or O B or O A or O* Donor blood type Compatible blood types * type O = universal dOnor! intro Rh ABO products other groups indications testing dangers
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O A B AB
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Transfusion Pathology Outline • Blood groups • • • Introduction ABO system Rh system intro ABO Rh other groups products indications testing dangers
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What are the antigens? • • • • • Most important antigen: D! “Rh” because discovered using Rhesus monkeys. “Rh factor” refers to the D antigen. Two alleles: D and d. People with the D allele make D antigen and are Rh+. intro ABO Rh other groups products indications testing dangers
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intro ABO Rh other groups products indications testing dangers
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What are the antibodies? • • • Antibodies in this system are acquired! To make anti-D you must: lack the D antigen on your red cells get exposed to D + blood Donor and recipient are tested for the D antigen. intro ABO Rh other groups products indications testing dangers
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Transfusion Pathology Outline • Blood groups • • • • Introduction ABO system Rh system Other systems intro ABO Rh other groups products indications testing dangers
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Don’t tell me there are more systems. • • • There are a almost a sh*tload of other systems.* These are not included in routine testing. Antibodies to antigens in these systems are usually acquired (like anti-D), so unless a patient has been transfused or pregnant, you don’t need to worry too much. * intro ABO Rh other groups products indications testing dangers Not quite: a sh*tload is defined as more than 42.
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Transfusion Pathology Outline • Blood groups • • • • Introduction ABO system Rh system Other systems • Blood transfusion Blood products intro ABO Rh other groups products indications testing dangers
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What do you mean, products? • • • • In olden times, there was only whole blood. Now, we separate blood into its components Better for the patient Conserves blood supply intro ABO Rh other groups products indications testing dangers
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What are the products? • • • Whole blood Red cells Platelets • • • Granulocytes Cryoprecipitate Fresh frozen plasma intro ABO Rh other groups products indications testing dangers
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Whole Blood Red Cells Granulocytes Platelet-Rich Plasma BLOOD PRODUCTS
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Whole Blood Red Cells Granulocytes Platelet-Rich Plasma BLOOD PRODUCTS
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Whole Blood Red Cells Granulocytes Platelet-Rich Plasma BLOOD PRODUCTS
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Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets BLOOD PRODUCTS Fresh Frozen Plasma
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Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma VIII Cryoprecipitate BLOOD PRODUCTS IX Albumin IgG
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Transfusion Pathology Outline • Blood groups • • • • Introduction ABO system Rh system Other systems • Blood transfusion Blood products Indications intro Rh ABO products other groups indications testing dangers
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Use: massive hemorrhage Whole Blood RBC WBC platelets plasma Contents: INDICATIONS
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Whole Blood Use: low hemoglobin Red Cells RBC a few WBC a few platelets a little plasma Contents: INDICATIONS
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Whole Blood Red Cells Granulocytes Contents: neutrophils Use: sepsis in neutropenic patients INDICATIONS
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Whole Blood Red Cells Granulocytes Platelet-rich plasma INDICATIONS
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Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Contents: platelets Use: bleeding due to thrombocytopenia INDICATIONS
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Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Use: bleeding due to multiple factor deficiencies (e.g., DIC) Fresh Frozen Plasma Plasma Contents: (including ALL coagulation factors) INDICATIONS
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Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma Uses: low fibrinogen, vW disease, hemophilia A Cryoprecipitate fibrinogen von Willebrand factor VIII Contents: INDICATIONS
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Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma Cryopr ecipitate INDICATIONS A bunch of other stuff Use: rarely used
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Transfusion Pathology Outline • Blood groups • • • • Introduction ABO system Rh system Other systems • Blood transfusion Blood products Indications Testing intro Rh ABO products other groups indications testing dangers
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patient red cells (type A) Forward typing is done using both anti-A and anti-B antibodies! FORWARD TYPE anti-A antibodies AHG
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patient serum (with anti-B Ab) AHG reagent red cells (type B) REVERSE TYPE Reverse typing is done using both type A and type B reagent cells!
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patient serum AHG donor red cells CROSSMATCH
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patient serum AHG reagent RBC number 1 patient serum AHG reagent RBC number 2 ANTIBODY SCREEN no agglutination (negative test) agglutination (positive test)
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Transfusion Pathology Outline • Blood groups • • • • Introduction ABO system Rh system Other systems • Blood transfusion Blood products Indications Testing Dangers
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What can go wrong? • intro ABO Rh other groups products indications testing dangers Transfusion reactions • • hemolytic non-hemolytic • Other complications • • • circulatory overload iron overload infections
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Acute Hemolytic Transfusion Reactions • • • • • • Happens when patient has ABO antibodies against the donor red cells. Most common reason: clerical error! Symptoms: fever, chest pain, hypotension. Hemoglobin in serum, urine. Labs:  haptoglobin,  bilirubin, DAT positive. Type and cross-match shows ABO mismatch. intro ABO Rh other groups products indications testing dangers
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Delayed Hemolytic Transfusion Reactions • • • • • • Hemolysis occurs days after tranfusion. Caused by antibodies to non-ABO antigens. Hemolysis usually extravascular. Presentation: falling Hgb after transfusion. Usually not severe. DAT +. Antibody screen identifies the antibody. intro ABO Rh other groups products indications testing dangers
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Non-Hemolytic Transfusion Reactions • • • Usually not as dangerous as hemolytic TRs. Febrile TR: Fever. Treat with Tylenol. Allergic TR: Hives. Treat with antihistamines. Rarely, may lead to anaphylaxis. intro ABO Rh other groups products indications testing dangers
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Circulatory Overload • • • Happens when too much blood is given too quickly Symptoms: hypertension, congestive heart failure Stop transfusion, give diuretics intro ABO Rh other groups products indications testing dangers
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Iron Overload • • • Too much iron can damage heart, liver Patients with chronic anemias are at biggest risk Give iron-chelating agents intro ABO Rh other groups products indications testing dangers
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Infections • Transfusion-related bacterial infection is rare but serious. Patients suddenly develop fever and shock. Treatment: aggressive resuscitation and antibiotic therapy. • • Scary viruses (all donors tested for these): HIV, Hepatitis. Other potential infections: EBV, malaria, Lyme disease. intro ABO Rh other groups products indications testing dangers
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What’s the risk of getting an infection? intro ABO Rh other groups products indications testing dangers
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What’s the risk of other complications? intro ABO Rh other groups products indications testing dangers