Documente Academic
Documente Profesional
Documente Cultură
IMMUNOHEMATOLOGY
&
TRANSFUSION
MEDICINE
Mila
Amor
V.
Reyes,
MD,
FPSP
Anatomic
and
Clinical
Pathologist
IMMUNOHEMATOLOGY
• defines
the
immunologic
proper6es
and
reac6ons
of
all
blood
components
and
cons6tuents
+
-‐
-‐
+
A
-‐
+
+
-‐
B
+
+
-‐
-‐
AB
-‐
-‐
+
+
O
• infants
are
more
difficult
to
ABO
group
accurately
because
these
Ags
may
not
be
fully
expressed
on
the
RBCs
un6l
the
age
of
2
years
• they
do
not
have
the
appropriate
Abs,
produc6on
of
these
Abs
is
triggered
soon
aTer
birth
by
exposure
through
inges6on
or
inhala6on
of
an6genic
substances
in
nature
(e.g.,
bacterial
polysaccharides,
plant
pollens)
with
the
same
characteris6cs
as
the
A
and
B
Ags—"naturally
occurring
Abs“
• detectable
levels
of
ABO
agglu6nins
in
humans
usually
develop
by
about
3
to
6
months
of
age
• several
sets
of
genes
control
the
expression
of
the
ABO
blood
group
Ags:
– ABO
genes—expression
of
A
and
B
Ags
depends
on
the
presence
of
H
gene
(HH/Hh,
hh)
– H
gene—expression
of
H
Ag
depends
on
the
presence
of
Se
gene
in
the
secretory
glands
and
Z
gene
on
the
RBC
membrane
– Se
genes—SeSe/Sese
"secretors"
(80%
of
the
popula6on);
soluble
H,
A,
or
B
substances
may
be
detected
in
their
saliva
and
other
secretory
fluids
– sese—"nonsecretors"
(20%)
– Z
gene—allows
the
expression
of
H
gene
on
the
erythrocyte
membrane
(ZZ/Zz,
zz)
– "Bombay
phenotype“
(1)classic
(Oh)
phenotype—absence
of
H
gene
(hh),
inherited
ABO
genes
cannot
be
expressed
on
the
RBC
or
in
the
secre6ons,
an6-‐A,
-‐B,
-‐H
Abs
are
present
in
serum
(2)Hz
phenotype—rare,
absence
of
Z
gene
(zz),
may
express
A,
B,
or
H
substances
in
the
secre6ons,
depending
on
the
Se
and
ABO
genes
inherited
2. Rh
system
RhO
D
Rh1
rh’
C
Rh2
rh’’
E
Rh3
hr’
c
Rh4
hr”
E
Rh5
• Rh
typing
is
performed
to
established
the
presence
or
absence
of
the
D
Ag—most
immunogenic
Ag
(exposure
to
this
Ag
in
Rh(-‐)
persons
is
highly
likely
to
result
in
forma6on
of
an
alloAb)
+ Rh posi6ve
-‐
Rh
nega6ve
• individuals
do
not
consistently
have
an6-‐D
Ab
when
they
lack
the
D
Ag
• an6-‐Rh
is
formed
only
following
exposure
to
Rh
Ag
during
pregnancy
and
transfusion
• an6-‐Rh
usually
IgG—crosses
the
placenta
• Rh(+)
can
receive
both
Rh(+)
and
Rh(-‐)
blood;
Rh(-‐)
must
receive
only
Rh(-‐)
blood
• in
urgent
situa6ons,
an
Rh(-‐)
may
receive
Rh(+)
blood,
if
Rh(-‐)
blood
is
unavailable;
however,
the
pa6ent
may
become
alloimmunized
to
the
D
Ag
and
risk
problems
with
pregnancy
or
transfusion
in
the
future
3. LW
System
(Landsteiner
and
Weiner)
Le
(a+b-‐)
+
-‐
Le
(a-‐b+)
-‐
+
Le
(a-‐b-‐)
-‐
-‐
Le
(a+b+)
+
+
5. I
and
i
System
I i
Lu
(a+b-‐)
+
-‐
Lu
(a+b+)
+
+
Lu
(a-‐b+)
-‐
+
Lu
(a-‐b-‐)
-‐
-‐
9. Kell
System
PHENOTYPES
OF
THE
KELL
SYSTEM
Phenotype
ReacHons
with
AnH-‐
K
k
Kpa
Kpb
Jsa
Jsb
K+k-‐
+
-‐
K+k+
+
+
K-‐k+
-‐
+
Kp
(a+b-‐)
+
-‐
Kp
(a+b+)
+
+
Kp
(a-‐b+)
-‐
+
Js
(a+b-‐)
+
-‐
Js
(a+b+)
+
+
Js
(a-‐b+)
-‐
+
Ko
-‐
-‐
-‐
-‐
-‐
-‐
• ordered
when
transfusion
may
be
required
at
some
6me
during
the
following
48
to
72
hours,
but
immediate
transfusion
is
not
an6cipated,
or
when
the
probability
of
transfusion
is
remote
• includes
ABO
and
Rh
(D)
typing,
and
Ab
screen
of
pa6ent's
blood
– If
Ab
screen
is
(-‐)—BB
stores
the
specimen
and
awaits
further
word
from
the
pa6ent's
physician
about
the
need
for
transfusion
– If
Ab
screen
is
(+)—BB
will
no6fy
the
physician,
and
if
the
possibility
of
transfusion
remains,
Ab
iden6fica6on
is
performed
TYPE
AND
CROSSMATCH
• ordered
when
transfusion
is
certain
or
likely
in
the
near
future,
or
if
any
possibility
of
transfusion
exists
in
a
pa6ent
with
an
RBC
Ab
• includes
ABO
and
Rh
typing,
Ab
screen
(and
iden6fica6on,
if
necessary)
• units
of
blood
are
tested
for
compa6bility
with
the
pa6ent's
serum—crossmatching
ANTI-‐HUMAN
GLOBULIN
TEST
(COOMBS'
TEST)
Recipient
Donor
A
A,O
B
B,O
AB
AB,
A,
B,
O
O
O
PRENATAL
SCREENING
• includes
ABO
and
Rh
typing,
and
Ab
screen
to
detect
fetuses
at
risk
for
HDN
• HDN—Ab
present
in
the
mother's
blood
(to
an
RBC
Ag
on
the
newborn's
RBC
inherited
from
the
father)
crosses
the
placenta
and
enters
the
blood
of
the
fetus,
binds
to
the
Ag
present
on
the
fetal
RBCs,
causing
premature
RBC
destruc6on—jaundice
• only
Abs
of
the
IgG
class
cross
the
placenta
and
enter
fetal
blood
• severity
of
the
disease
varies,
depending
on
the
reac6vity
of
the
Ab
and
Ag
involved,
and
Ab
6ter
– Rh
system—first
newborn
usually
not
affected,
most
common
because
D
Ag
is
so
immunogenic
– ABO
system
—first
newborn
usually
affected
– other
blood
group
system
s—IgG
Abs
of
the
Duffy,
Kidd,
and
Kell
• Treatment:
Exchange
Transfusion—removes
unbound
IgG
Ab,
excess
bilirubin,
Ab-‐coated
RBC
– blood
used
should
be
ABO-‐compa6ble
FWB
(<l
week)
and
close
to
body
temperature
– usually
mother's
serum
is
used
in
the
crossmatch:
if
the
baby
and
mother
are
not
of
the
same
ABO
blood
group,
“O”
blood
should
be
transfused
– if
the
mother's
serum
is
not
available,
the
baby's
serum
and
eluate
of
the
baby's
RBC
(if
DAT+)
can
be
used
for
crossmatching
EVALUATION
OF
Rh
IMMUNE
GLOBULIN
THERAPY
PACKED
RBC
(PRBC)
Volume=
250
mL
Same
as
WB
RBC
replacement
for
increased
Same
as
WB
Contains
RBCs,
small
amount
of
oxygen-‐carrying
capacity,
plasma,
an6coagulant,
liqle
or
no
symptoma6c
anemia,
and
platelet
ac6vity,
granulocyte
ac6vity,
preopera6vely
or
CFs
*RBC
with
addi6ve
Volume=
340
mL
I
-‐6°C
Can
be
used
like
WB
or
PRBC
solu6on
(adenine-‐ 42
days
saline)
PLATELETS
Volume=
50
-‐60
mL
20-‐24°C
Thrombocytopenia
Viral
transmission,
bacterial
*Maybe
from
a
single
Contains
platelets,
WBCs,
fresh
5
days
with
Thrombasthenia
contamina6on,
febrile
reac6ons,
donor
plasma,
an6coagulant
agita6on
volume
overload,
allergic
(plateletpheresis)
or
*1
unit
raises
the
platelet
count
response,
GVHD
pooled
from
several
by
10,000/uL
donors
FRESH
FROZEN
VOLUME=
250
mL
-‐18
to
-‐30°C
Replacement
of
CFs
in
mul6ple
Viral
transmission,
allergic
PLASMA
(FFP)
Contains
fresh
plasma,
all
CFs,
1
year
factor
deficiencies,
undefined
reac6ons,
volume
overload,
an6coagulant
factor
deficiencies,
TTP
hemolysis
*ATer
thawing
store
at
1-‐6°C
up
to
24
hours
CRYOPRECIPITATE
15
mL
-‐18
to
-‐30°C
Replacement
of
F
VIII,
XIII,
I,
vWF
Viral
transmission,
allergic
reac6ons
Contains
F
VIII,
XIII,
I,
fibronec6n,
I
year
deficiency
*Cold
insoluble
por6on
vWF
of
plasma
aTer
FFP
has
been
thawed
between
*ATer
thawing
store
…BLOOD
COMPONENTS
FOR
TRANSFUSION
CELLULAR
BLOOD
CONTENTS
STORAGE
USE
POSSIBLE
HAZARDS
PRODUCTS
CRYOSUPERNATE
200
mL
-‐18
to
-‐30°C
Replacement
of
CF
deficiencies
Viral
transmission,
allergic
reac6ons
*Residual
plasma
Contains
fresh
plasma,
all
CFs
I
year
except
FVIII
refrozen
aTer
removal
except
FVIIl,
an6coagulant
of
cryoprecipitate
*ATer
thawing
store
at
I-‐6°C
up
to
24
hours
GRANULOCYTE
250
mL
20-‐24°C
Severe
neutropenia
with
ac6ve
Febrile,
nonhemoly6c
reac6ons,
CONCENTRATE
Contains
fresh,
viable
granulocytes
24
hours
infec6on
and
no
response
to
viral
transmission,
pulmonary
and
other
leukocytes,
plasma,
an6bio6cs,
congenital
granulo-‐
reac6ons,
hemolysis,
*Collected
by
apheresis
an6coagulant
cyte
dysfunc6on
May
contain
platelets,
RBCs
Leukocyte-‐reduced
350
mL
1.Washed-‐RBC
*RBC
Preven6on
of
RBC
s
Contains
RBCs,
some
WBC
s
and
washed
with
1. febrile
transfusion
and
platelets
compa6ble
solu6on
allergic
reac6ons
due
to
to
reduce
WBCs
WBCs
or
plasma
proteins
1-‐6°C
2. forma6on
of
HLA
Abs
in
24
hours
mul6ply
transfused
pa6ents
2.
Filtered-‐RBC
3. anaphylac6c
reac6ons
in
IgA
*leukocyte-‐ deficiency
reduc6on
4. risk
of
CMV
and
other
WBC
filters
associated
viral
infec6ons
20-‐24°C
6
hours
3.
Frozen
deglyce-‐ Same
as
washed
and
filtered
rolized
RBCs
RBC,
also
useful
for
rare
blood,
-‐65°C
or
colder
autotransfusion
10
years
*1-‐6'C
24
hours
aTer
wash
4.
Irradiated
RBC
*y-‐
irradiated
blood
Preven6on
of
TAGVHD,
in
with
viable
WBCs
congenital
T-‐cell
immunodefi-‐
ciencies,
BMT
recipients,
fetuses
ALTERNATIVES
TO
BLOOD
TRANSFUSION
• Surgical
Blood
Conserva6on
Methods
– improved
surgical
hemostasis
– reduced
diagnos6c
blood
loss
– autologous
transfusion
• Pharmacological
Interven6ons
– s6mulate
blood
replacement—r-‐hEPO
,
thrombopoie6n,
GM-‐CSF,
G-‐CSF,
M-‐CSF,
IL-‐1,
IL-‐2,
IL-‐3,
IL-‐6,
IL-‐11
– serve
as
blood
subs6tute
or
oxygen
carrier
• perflourocarbons
• Hb
solu6ons
and
encapsulated
Hb
– reduced
blood
loss
• DDAVP
or
desmopressin
acetate—increases
plasma
level
of
F
VIII
and
vWF
• topical
agents
e.g.,
fibrin
glue,
fibrin
gel
• agents
that
preserve
platelet
func6on
e.g.,
dipyridamole,
prostacyclin,
heparin
• an6fibrinoly6c
agents
e.g.,
€-‐aminocaproic
acid,
tranexamic
acid,
apro6nin
Key
Points:
1. Most
blood
bank
tests
are
performed
to
find
compa6ble
blood
for
transfusion
and
involve
tes6ng
for
RBC
Ags
and
Abs.
2. Proper
labeling
of
the
blood
specimen
for
blood
bank
tes6ng
is
of
paramount
importance
in
ensuring
a
safe
transfusion,
as
is
proper
iden6fica6on
of
the
recipient
at
the
6me
of
transfusion.
3. The
presence
of
an
Ab
to
an
RBC
Ag
in
a
pa6ent's
serum
complicates
the
procurement
of
compa6ble
blood
for
transfusion.
Addi6onal
6me
must
be
allowed
prior
to
the
an6cipated
transfusion.
4. The
ABO
blood
group
is
the
most
important
RBC
Ag
system
clinically.
Mul6ple
tests
in
the
pretransfusion
work-‐up
are
performed
to
ensure
the
ABO
compa6bility
of
blood
components,
because
transfusion
of
ABO
incompa6ble
units
may
be
life-‐threatening.
5. The
D
Ag
in
the
Rh
blood
group
is
one
of
the
most
immunogenic
RBC
Ags
in
humans.
Therefore,
units
of
blood
compa6ble
with
the
recipient's
Rh
(D)
type
are
issued
whenever
possible.
6. The
direct
Coombs'
test
detects
IgG
Ab
and/or
C3
complement
fragments
on
the
surface
of
RBCs.
The
indirect
Coombs'
test
detects
RBC
Ab
in
the
pa6ent's
serum.
7.
During
pregnancy,
maternal
IgG
Ab
to
RBC
Ags
can
cross
the
placenta
into
the
fetal
circula6on
and
cause
hemolysis
of
fetal
RBCs
bearing
the
Ag
(HDN).
Prenatal
screening
is
performed
by
the
blood
bank
to
iden6fy
fetuses
at
risk
for
this
disease.