Transfusion Medicine Kristine Krafts, M.D.

1. Transfusion Medicine Kristine Krafts, M.D.

3. Transfusion Medicine Outline • Blood groups • Introduction • ABO system • Rh system • Other systems • Blood transfusion • Blood products • Testing • Dangers

4. Transfusion Medicine Outline • Blood groups • Introduction

5. Q. What determines a blood group?

6. Q. What determines a blood group? A. The antigens on the red cell surface.

7. Red Cell Antigens • 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

8. Transfusion Medicine Outline • Blood groups • Introduction • ABO system

9. 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”)

10. Type A Type B Type AB Type O

11. 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

12. H antigen A antigen B antigen

13. What are the genes? H gene • Everyone* has this one • Codes for an enzyme that makes H antigen 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

15. How common is each blood type?

16. 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.

17. Type A Type B Type AB Type O

19. Compatible blood types *type O = universal dOnor!

20. A B O AB

21. Transfusion Medicine Outline • Blood groups • Introduction • ABO system • Rh system

22. 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+.

24. What are the antibodies? • Antibodies in this system are acquired! • To make anti-D you must: 1. lack the D antigen on your red cells 2. get exposed to D + blood • Donor and recipient are tested for the D antigen.

25. Transfusion Medicine Outline • Blood groups • Introduction • ABO system • Rh system • Other systems

26. 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. *Not quite: a sh*tload is defined as more than 42.

28. Transfusion Medicine Outline • Blood groups • Introduction • ABO system • Rh system • Other systems • Blood transfusion • Blood products

29. 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

30. What are the products? • Whole blood • Red cells • Platelets • Granulocytes • Cryoprecipitate • Fresh frozen plasma

31. Apheresis donation

32. BLOOD PRODUCTS Whole Blood Red Cells Granulocytes Platelet-Rich Plasma

33. BLOOD PRODUCTS Whole Blood Use: massive hemorrhage RBC WBC platelets plasma Contents:

34. BLOOD PRODUCTS Whole Blood Red Cells Use: low hemoglobin RBC a few WBC a few platelets a little plasma Contents:

35. BLOOD PRODUCTS Whole Blood Granulocytes Use: sepsis in neutropenic patients Red Cells Contents: neutrophils

36. BLOOD PRODUCTS Whole Blood Red Cells Granulocytes Platelet-rich plasma

37. BLOOD PRODUCTS Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Use: bleeding due to thrombocytopenia Contents: platelets

38. BLOOD PRODUCTS Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma Use: bleeding due to multiple factor deficiencies (e.g., DIC) Plasma (including all coagulation factors) Contents:

39. BLOOD PRODUCTS Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma Cryoprecipitate Use: low fibrinogen, vW disease, hemophilia A, XIII deficiency fibrinogen von Willebrand factor VIII XIII Contents:

40. BLOOD PRODUCTS Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma Cryoprecipitate VIII Use: hemophilia A

41. BLOOD PRODUCTS Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma Cryoprecipitate VIII IX Use: hemophilia B

42. BLOOD PRODUCTS Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma Cryoprecipitate VIII IX Albumin Use: hypovolemia with hypoproteinemia

43. BLOOD PRODUCTS Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma Cryoprecipitate VIII IX Albumin IvIG Use: disease prophylaxis, autoimmune disease, immune deficiency states

44. Transfusion Medicine Outline • Blood groups • Introduction • ABO system • Rh system • Other systems • Blood transfusion • Blood products • Testing

45. FORWARD TYPE anti-A antibodies AHG patient red cells (type A) Forward typing is done using both anti-A and anti-B antibodies!

46. REVERSE TYPE reagent red cells (type B) AHG patient serum (with anti-B Ab) Reverse typing is done using both type A and type B reagent cells!

47. CROSSMATCH donor RBC AHG patient serum

48. Transfusion Medicine Outline • Blood groups • Introduction • ABO system • Rh system • Other systems • Blood transfusion • Blood products • Testing • Dangers

49. What can go wrong? • Transfusion reactions • hemolytic • non-hemolytic • Other complications • infections • circulatory overload • iron overload

50. Acute Hemolytic Transfusion Reactions • Happen 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.