Dr. Ahmad Hassaneen

1. Blood transfusion Dr. Ahmad Hassaneen

2. Important Notes

3. Comparison of ABO and RhD systems

4. In ABO system, there are 4main types of blood groups- A, B, AB, and O. Identification of these groups is based on presence or absence of A and/or B antigens on red cells. According to Landsteiner’s law, anti-A and/or anti-B antibodies are always present in plasma of individuals who lack corresponding antigen(s) on their red cells. There are two major subgroups of A: A1 (80%) and A2 (20%). Thus ABO system comprises of six groups. A1: Having anti-B A2: Having anti-B , and in 1-8% cases anti-A1 B: Having anti-A A1B: nil ( No antibodies) A2B: Having anti-A1in 22-35% cases O: Having anti-A and anti-B.

5. Usually, anti-A1 antibodies are weak and are of little clinical significance in routine practice. • N.B. : A2B can be wrongly grouped as B

6. Secretors and non-secretors Secretors are persons who secrete A, B, and H antigens into body fluids (such as plasma, saliva, sweat, tears, semen, milk, etc.). This ability is dependent on presence of a dominant secretor gene (Se). About 80% of individuals are secretors (genotype Seseor SeSe) and the remaining are non-secretors (genotype sese). Both secretors and non-secretors express ABO antigens on red cells. • Antigens secreted by different ABO blood groups are: • Group A: A, H • Group B: B, H • Group AB: A, B, H • Group O: H

7. RH SYSTEM ●According to Fisher and Race, three closely linked genes are inherited together on one chromosome (haplotype) from each parent. Allelic forms of these genes are C and c, D and d, and E and e with eight possible haplotypes- CDe, cde, cDE, cDe, cdE, Cde, CDE, and CdE. ● It has been found that the RH locus is located on chromosome 1 and consists of two closely linked genes- RHD and RHCE. The allelesof RHCE are CE, Ce, ce, and cE. ●The presence of D in either homozygous (D/D) or heterozygous (D/d) state makes that individual Rh positive, while Rh negative persons are homozygous for d (d/d). ● d gene is an amorph→ No d Ag or Anti-d Ab

8. Blood Components

9. ●In the past , whole blood was the only preparation that could be given to replace red cells , platelets , coagulation factors , …. ● Now , whole blood can be separated into different components by centrifugation due to differences in specific gravities of these components. ● This is facilitated by introduction of double and triple bags having closed integral tubing. ● After their separation, various components can be transferred from one bag to another in a closed circuit thus maintaining the sterility. ● Blood should be processed for component separation within 6 hours of collection.

10. Whole blood: • It remains a commonly employed blood product at some places because of lack of facility for component separation. • Total volume of one unit is about 400 ml (350 ml blood+50 ml of anticoagulant-preservative solution) • Commonly used anticoagulant is citrate phosphate dextrose adenine (CPDA) • It consists of the cellular elements and plasma. • Stored in blood bank refrigerator at 2-6 °C • Shelf life is 35 days (for CPDA ). • Hematocriteof whole blood is about 40 %

11. ●Before ordering whole blood transfusion , the following should be noted: ▪ Transfusion of one unit raises the hemoglobin by 1 g/dl or the hematocrite by 3 % (detectable 24 hours after transfusion) ▪ If stored for 48 hours does not contain functionally effective plateletsand labile coagulation factors (V and VIII). ▪ There is risk of volume overload in patients with impaired cardiovascular function. ● Currently , the only indications are : 1-Acute massive blood loss 2-Exchange transfusion of newborn 3-Non-availability of packed red cells.

12. Blood components: ●Red cells: Packed red cells Leucocyte-poor red cells Frozen red cells Irradiated red cells. ●Platelets: Platelets concentrate ●Granulocytes Granulocytes concentrate ●Plasma Fresh frozen plasma Cryoprecipitate

13. ●Red cells components: Packed red cells Prepared by removal of most of the plasma from one unit of whole blood. Method: Whole blood is either allowed to sediment overnight in a refrigerator at 2 °C to 6 °C OR is spun in a refrigerated centrifuge → supernatant fluid (PLASMA)is separated from red cells in a closed system by transferring it to the attached empty satellite bag. Red cells and a small amount of plasma are left behind in the primary blood bag. The main indication: Replacement of red cells in case of anemia.

14. • Volume of 1 unit of packed red cells is about 300 ml •Hematocriteof packed red cells is 55-75 % • Transfusion of one unit raises the hemoglobin by 1 g/dl or the hematocrite by 3 % (detectable 24 hours after transfusion) • Stored in blood bank refrigerator at 2-6 °C • Shelf life is 35 days (for CPDA )

16. Leucocyte-poor red cells • Most of white cells are removed. • Prepared by passing blood through special leucocyte-depletion filter at the time of transfusion. • Also can be prepared in the blood bank and then stored. • Indications: 1-To avoid febrile reactions in persons who need repeated transfusions or who have been sensitized to white cells antigens before. 2-To reduce the risk of transfusion of cytomegalovirus (CMV) if CMV-seronegative blood is not available.

17. Frozen red cells • Cells can be stored frozen for up to 10 years. Indications: • Donor red cells with rare blood groups can be stored frozen for transfusion to other recipients ORfor autologous transfusion.

18. Irradiated red cells • Red cells are irradiated by gamma rays to prevent graft-versus-host disease in susceptible individuals for example: 1-Immunodeficient patients 2-Patients receiving blood from first-degree relatives. (In this case, the donor's T- lymphocytes may not be rejected as the Human Leucocyte Antigen (HLA) type of the recipient has similarity with that of the donor) ▪ Gamma irradiation inhibits the replication of donor lymphocytes → they will not react against tissues of recipient.

19. ● Granulocyte concentrates • These are prepared either from a single donor unit by differential centrifugation or by leucapheresis. • Leucapheresis is preferred because it gives better granulocyte yield . • They are used in patients with severe neutropenia (< 500 neutrophils /ul) with bacterial or fungal infections who are not responding to antibiotic therapy. • Complications: 1-Transmission of cell-associated viruses like CMV . 2-Risk of causing GVHD (Graft versus host disease) , so it must be irradiated (Gamma rays) first.

20. Platelets There are 2 methods for obtaining platelets: 1-Differential centrifugation of a unit of whole blood (platelets concentrate) 2-Plateletpheresis

21. Platelet concentrate (Random donor platelets) - Prepared by differential centrifugation of one unit of whole blood within 6 hours of donation. • one unit of whole blood is centrifuged at low speed to obtain platelet-rich plasma (PRP). • PRP is then transferred to the attached satellite bag and spun at high speed to get platelet aggregates (at the bottom) + platelet-poor plasma (PPP) (at the top). • Most of PPP is returned back to the primary collection bag leaving the platelets with only 50-60 ml of PPP.

23. Platelets are stored at 20°C to 24 °C with continuous shaking (agitated) in a storage device called platelet agitator. • Maximum storage period is 3-5 days. - Transfusion of one unit will raise the platelets count by about 5000/ul - The usual adult dose is 4 – 6 units of platelet concentrate (from different donors) which are pooled into one bag before transfusion.

24. Plateletpheresis (single donor platelets) • A donor is connected to a blood cell separator machine in which whole blood is collected. • Platelets are separated and retained. • The remaining components are returned back to the donor. • By this method , a large number of platelets can be obtained from a single donor (equivalent to 6 units) Notes about platelets transfusion: • Most of adverse reactions associated with platelets are due to presence of contaminating leucocytes or plasma (e.g. febrile reactions , allergic reactions , …)

25. Transfusion of multiple platelet concentrates from random donors can induce alloimmunization to HLA antigens → causing resistance to further platelets transfusions. Those patients should receive HLA-compatible platelets from single donor by plateletpheresis. • Bacterial proliferation can occur in platelet concentrates as they are stored at room temperature , may cause septicemia in the recipient. • As platelet concentrates also contain a small amount of red cells it is better to be from the same or compatible ABO group and same Rh group.

26. Plateletpheresis

27. Preparations from human plasma: • Fresh frozen plasma (FFP) ▪Rapidly frozen plasma separated from fresh blood is stored at less than − 25° C. ▪ Volume of FFP is 200 to 250 ml ▪It contains all the coagulation factors. ▪Can be stored for 1 year if temperature maintained below -25 °C ▪When needed for transfusion , it is thawed between 30 and 37 °C and then stored at 2 to 6 °C and should be given within 2 hours of thawing because labile factors (V & VIII) are lost rapidly. ▪Used for: 1- Deficiency of multiple coagulation factors e.g. liver disease , DIC. 2- Inherited deficiency of a coagulation factor for which no specific concentrate is available.

28. Fresh frozen plasma (FFP)

29. Cryoprecipitate -Prepared by slowly thawing 1 unit of FFP at 4to 6 °C → formation of plasma + white precipitate. -After centrifugation , most of the supernatant plasma is removed leaving sediment of Cryoprecipitate suspended in 10-20 ml of plasma → frozen (− 25° C) for storage , can be kept for 1 year. - When required for transfusion , it is thawed between 30 °C and 37 °C and then stored in refrigerator at 2 to 6 °C and should be given within 6 hours of thawing. -It contains : F VIII , von Willebrand factor , fibrinogen , F XIII and fibronectin.

30. Factor VIII concentrate • Prepared by fractionation from large pools of donated plasma. • Supplied as freeze-dried powder in vials. • Stored in refrigerator at 2 to 6 °C. • Before use , it is reconstituted according to manufacturer’s directions and given I.V. • Now , it can be prepared by recombinant DNA technology without use of plasma and it is safer ; no risk of infection. • Uses: 1-Hemophilia A. 2-Severe von Willebrand disease.

35. Blood transfusion device

37. Important Notes

38. ►To reduce the risk of haemolysis in a case of non-identical but compatible ABO transfusion, packed red cells instead of whole blood should be transfused (i.e. most of the plasma which contains anti-A and/or anti-B should be removed). • ► This is especially important with group O donor blood, which can contain immune anti-A and anti-B antibodies that will cause serious haemolysis in a non-group O recipient. • ► For AB group recipients, if red cells of group AB are not available, group A donor blood is preferred over other alternatives since anti-B in group A is weaker than anti-A in group B.

41. Criteria for selection of blood donors

42. Criteria for selection of blood donors: ●Donor selection process consists of 4 parts: I- Predonationcounselling. II-Medical history III-Physical examination IV-Hemoglobin estimation

43. I-Predonationcounselling: This is an education programme including: 1-Giving information about health condition , self exclusion/self deferral , procedures involved in blood donation. 2-Donor’s questions are answered. 3-Reassurance is given in case of anxiety.

44. II-Medical history: Age: Lower and higher age limit for donation are 18 and 60 years respectively. This is because of : -Age of increased iron needs of adolescents (under 18) -Risk of cardiovascular and cerebrovascular disease in old age following removal of large quantity of blood. Donation interval: -Interval between 2 consecutive blood donations should be at least 3 months to avoid iron depletion. Pregnancy and lactation: Pregnant and lactating women (up to 1 year after labor) should not donate blood.

45. Infectious diseases: -HIV : - Blood should not be collected from donors who give history suggestive of HIV infection (unexplained fever , weight loss , enlarged lymph nodes , uncontrolled diarrhea) - Elimination of the “window period” which is early antibody-negative period in persons infected with HIV : Persons who have been exposed to the risk of HIV infection are excluded (e.g. homosexuals , intravenous drug abusers , or having contact with AIDS persons)

46. Hepatitis An individual with history of jaundice within 1 year should not be accepted. Malaria: -In endemic areas , a donor may be accepted after 3 months of asymptomatic period following malarial attack and after full treatment. -In non-endemic areas , a donor with any history of malaria is excluded.

47. Various illnesses: Exclusion of donors with : Diabetes mellitus , hypertension , heart disease , renal disease , liver disease , lung disease , cancer , epilepsy , bleeding disorders . Dentistry: 72 hours deferral period following tooth extraction or filling due to the possibility of bacteremia. Skin piercing: Exclusion of donors with history of : Tattooing or accidental needle stick during the last 12 months

48. Blood transfusion: A person should not be accepted as blood donor for 6 months after receiving blood transfusion. Vaccination: ♦ Donors who have received killed viral vaccines at any time are acceptable. ♦ Other types of immunization and respective deferral period are as follow: -Attenuated live virus vaccine for measles , mumps , yellow fever , poliomyelitis : 2 weeks -German measles(Rubella) : 4 weeks • Rabies : 1 year

49. ●III-Physical examination: • Weight: should be at least 45 kg • Blood pressure: Systolic: from 100 – 180 mmHg Diastolic: from 50 – 100 mmHg • Pulse: 50-100 /min , and should be regular • Body temperature: normal ● IV-Hemoglobin estimation Hemoglobin should be at least 12.5 g /dl

50. Complications (Adverse effects) of Blood transfusion