Overview

• Classification
• Signs and
symptoms
• Work-up
• Therapy and
prevention
• Immediate (24hrs)
• Delayed
– Immunologic – Immunologic
• IHTR & EHTR • HTR
• FNHTR • TA-GVHD
• Allergic or urticarial • Post transfusion
• Anaphylactic purpura
• TRALI – Non-immunologic
– Non-immunologic • Hemosiderosis
• Bacterial contam • Disease
• TACO transmision
• Physical or chemical
hemolysis
• INTRAVASCULAR • EXTRAVASCULAR
HTR HTR
– Complement – Liver and spleen
cascade – Bilirubin into the
– Hemoglobin into plasma
plasma – Antibodies fail to
– Proportional to activate
amount of blood complement or
transfused activate via C3
stage
– Kell, Kidd, Duffy BGS
• FNHTR
– Increase in – Usually in multiple
temperature of 1°C or pregnancies or
more that is associated previous
with a transfusion and
transfusions
cannot be explained by
any other condition
– Due to recipient
alloantibodies to
lymphocytes &
granulocytes or
platelets
LEUKOREDUCTION/LEUKODEPLETION

•Definition Of Terms:

•Any production, method, or process

that decrease the count of White
Blood Cells (Leukocytes) in a blood
component.
• Red Cells, Platelets, Plasma, Whole Blood
TRANSFUSION REACTIONS

Total Transfusion
Population (80%)
Transfusion
Reactions (19.24%)
Excluding Transfusion reaction like TA-GVHD
which rarely occurs.

Alloimmunization CMV infection Others

51.98% 36.38% 9.04%

Non-hemolytic Febrile Transfusion

Reaction (NHFTR) 2.60 %

91% of Transfusion Reaction is associated

to WBC
WALKER : A.J.C.P. 88(3):374-
378,1987.
TRANSFUSION REACTIONS

• WBC Associated Transfusion Reactions:

• Non-hemolytic Febrile Transfusion Reactions (NHFTR)

• HLA Alloimunizations (RBC and Platelets)

• CMV Infection
TRANSFUSION REACTIONS

• Non-hemolytic Febrile Transfusion Reactions:

• Febrile Reactions are caused by the patient’s antibodies that

are directed against the antigens present on transfused
lymphocytes or granulocytes
• Chills and rigors occur and patient’s temperature rises to > 1
degree

• HLA Alloimunizations (RBC and Platelets):

• Platelets contain HLA, A and B antigens. Prior exposure to non-

self HLA antigens (WBC contaminated) can result in formation of
antibodies that would destroy platelet on the 2nd or later
transfusion
• Platelet Refractoriness
• 80% Transfused Platelet Destruction
Transfusion Reactions
LEUKOREDUCTION/LEUKODEPLETION

“ at present, Leukoreduction is not

considered appropriate for the prevention
of Transfusion-associated Graft-
Versus Host Disease owing to the
availability of Irradiation as the preferred
and definitive method against this
serious adverse transfusion outcome. ”

* Guidance For Industry: Pre-Storage Leukocyte Reduction Of Whole Blood And Blood Components Intended For
Transfusion
USFDA Center For Biologics Evaluation And Research, January 2001
http://www.fda.gov/cber/guidelines.htm
LEUKOREDUCTION/LEUKODEPLETION

• Most Common Indications For

Leukoreduction:
• To prevent Non-hemolytic Febrile Transfusion
Reactions (NHFTR)
• To reduce the incidence of HLA Alloimunization
• For elimination of Cytomegalovirus (CMV) and other
Transfusion-Associated (TA) viral infections
• To prevent Transfusion Related Acute Lung Injury
(TRALI)

• To prevent reperfusion injury associated open-heart

surgery Clinical Benefits Of Leukodepleted Blood Products
Joseph Sweatney M.D. And Andrew Heaton M.D.

• To use among neonates and infants

LEUKOREDUCTION/LEUKODEPLETION

• Benefits Of Pre-Storage Leukoreduction

(USFDA):
• To reduce immunization to Leukocyte antigens that
may
complicate “patientcare” to pxs. undergoing
transplantation
or chronic transfusion therapy

• To reduce transmission of CMV to pxs. at increased risk

of
CMV disease

(e.g. recipients of chemotherapy, hematopoietic progenitor cell

replacement therapy,
CMV For
* Guidance seronegative to seronegative
Industry: Pre-Storage solid
Leukocyte Reduction Of organ grafts,
Whole Blood an low
And Blood birth-weight
Components Intended For
premature Transfusion
USFDA Center For Biologics Evaluation And Research, January 2001
infants) http://www.fda.gov/cber/guidelines.htm
LEUKOREDUCTION/LEUKODEPLETION

“ LR has been reported to reduce NHFTR, HLA

Alloimunization and CMV transmission. And in addition, a
growing list of potential benefits of LR have been
suggested, but yet to be established.”
• Other Potential Benefits Of Leukoreduction
(USFDA):
• Transfusion-associated (TA) immunomodulation
• Bacterial overgrowth
• Viral Reactivation
• Reperfusion Injury following cardiopulmonary bypass
• RBC and Platelet Storage Lesions
• Theoretical risk of transmission of CJD and nvCJD
* Guidance For Industry: Pre-Storage Leukocyte Reduction Of Whole Blood And Blood Components Intended For
Transfusion
USFDA Center For Biologics Evaluation And Research, January 2001
http://www.fda.gov/cber/guidelines.htm
LR METHODS AND APPLICATIONS

“ USFDA therefore is issuing

recommendations for pre-storage leukocyte
reduction of Whole Blood and Blood
components for transfusion, including
recommendations for quality monitoring of
the leukocyte reduction process. Bedside
filtration remains available as a leukocyte
reduction method to physicians prescribing
transfusion therapy. However, it may fail to
adequately remove leukocytes due to
uncontrolled filtration times and
temperature. ”
* Guidance For Industry: Pre-Storage Leukocyte Reduction Of Whole Blood And Blood Components Intended For
Transfusion
USFDA Center For Biologics Evaluation And Research, January 2001
http://www.fda.gov/cber/guidelines.htm
LR METHODS AND APPLICATIONS (PRE-
STORAGE)
• Conventional Centrifugation

And Automated Component Separation:

• Separation of Plasma and Red cells
• Economical and Simple
• Buffy coat extraction from blood components to a satellite
bag
• Residual Leukocyte Count = “ Varies “
LR METHODS AND APPLICATIONS (PRE-
STORAGE)

• Spin – Cool Method For Red Cells:

• Method includes centrifugation, components cooling, and
filtration
• Spin: 1 – 6 oC @ inverted position to draw Buffy Coat
• Cool: Store @ 40 oC for 3 hours
• Use of Microaggregate Filters during transfusion
• Average Residual Leukocyte Count =

• Deglycerolization:
• For Red cells
• Advanced technology
• Available in big Blood Centers in developed countries
• High cost amounting to USD 250,000.00 $/Machine
• Washing components is a required procedure in deglycerolization
• Outdate is 24 hours
LR METHODS AND APPLICATIONS (PRE-
STORAGE)
• Filtration (Pre – Storage):
• Filters should be attached to Blood Bags using Sterile Tubing
Connecting Device for sterility and Closed system (USFDA
requirement)

• In line Filters are also recommended for Pre-Storage

Leukoreduction
• When performed according to cGMP, outdate is unchanged
• Optimum Leukoreduction of Blood components
• Average Residual Leukocyte Count = 2 x 105 (Imugard – III:
TERUMO)

• RBC recovery of 90% (Imugard – III: TERUMO)

+ + w/ or

In-line Filters
LR METHODS AND APPLICATIONS (PRE-
STORAGE)

•Filtration (Pre – Storage):

LR METHODS AND APPLICATIONS (POST-
STORAGE)

• Filtration By Aseptic Technique Only (Post –

Storage):
• Filter connection done without the use of a Sterile Tubing
Connecting Device (Laboratory or Bedside) is considered

Open system (USFDA requirement)

• Stored @ 1 – 6 oC
• Outdate is 24 hours
• Platelets outdate is 4 hours
• Average Residual Leukocyte Count = 2 x 105 (Imugard – III:
TERUMO)
• RBC recovery of 90% (Imugard – III: TERUMO)
• Available in Laboratory and Bedside Filters (Imugard – III:
TERUMO)
LR METHODS AND APPLICATIONS

“All blood components, including those

leukoreduced prior to storage should be
administered through a standard blood filter
designed to remove clots and/or
microaggregates that were formed during
blood storage. ”

* Guidance For Industry: Pre-Storage Leukocyte Reduction Of Whole Blood And Blood Components Intended For
Transfusion
USFDA Center For Biologics Evaluation And Research, January 2001
http://www.fda.gov/cber/guidelines.htm
LR METHODS AND APPLICATIONS
Leukoreduction
Universal Leukoreduction Emergency/Sporadic LR
• Leukoreduction is mandatory
to all blood component
• Blood bank mandates that only
LR Blood components shall be
released from the BB
• HBTC may mandate strict “LR
transfusion only” to all pxs
• Mostly, BB shall be the one
responsible for leukoreducing
the blood components, in
cases
wherein laboratory LR is not
possible, bedside LR may be
considered
• Leukoreduction is on a PRN
basis
only
• Blood bank & HBTC recommends
the use of LR blood components
among patients to be transfused
• Blood bank may help in
facilitating
the process of Leukoreduction,
but
mostly, bedside would be the
most
appropriate method for this case
• Nurses and some Med Techs
aid
the clinician (MD) or
LR METHODS AND APPLICATIONS

Leukoreduction
Practical Leukoreduction Optimum Leukoreduction
• Leukoreduction @ a lower LR • Leukoreduction </= USFDA or
rate AABB Standards
• Blood bank may mandates that • Leukoreduction is at its
only LR Blood components shall optimum
be rate to address the need or
released from the BB re –
quirement of tx regimen of a
• HBTC may mandate strict “LR
transfusion only” to all pxs
disease specific px
• Mostly, BB shall be the one Chronically Transfused Pxs.,
responsible for leukoreducing immunocompromised pxs,
the blood components, in cases onco pxs, geriatrics, pediatrics

• Optimum LR may not be • Only Polyurethane filters can

necessary to all pxs deliver an optimum
Leukoreduction rate
• ALLERGIC • ANAPHYLACTIC
– Recipient antibody – Can be life
to donor plasma threatening
proteins – Even with few ml
– Mediated by – Reaction between
histamine release patient’s potent
from mast cells class specific anti-
IgA Ab’s & IgA
• When IgA deficient
recipients are
previously exposed
to IgA
• TRALI
– Donor plasma – Ag-Ab rxn gets
containing trapped in
leukoagglutinins pulmonary
directed against circulation
recipient leukocytes • Pulmonary edema
– HLA system specific • Complement
activation
– Donor is usually • Sequestration &
multiparous degranulation of
PMN’s
• BACTERIAL
CONTAM – Contamination
– Sepsis during collection,
thawing or storage
– Usually from
platelets – Common agents:
• Yersinia enterolitica
– Transient
• S. Epidermidis
bacteremia in
• S. Aureus
asymptomatic
• B. subtilis
donors
 S. epidermidis, 30.2%
S. aureus, 10.5%
E. coli, 9.3%
B. cerus, 9.3%
S. cholerae-suis, 8.1%
E. cloacae, 5.8%
B-hem. Strep, 5.8%
E. aerogenes, 2.3%
10 others, 1.3% each

Compilation of data from Clin Micro Rev

1994; 7:290-302; Transfusion 2001;41:1493-
99; www.shot.demon.co.uk/toc
n = 86
• CIRCULATORY
OVERLOAD – Can lead to:
– Rapid infusion of large • CHF
volumes of blood • Pulmonary edema
products
• Very young, elderly,
cardiac patients,
chronic anemia
– Rapid infusion of even
small volumes
• Pre-existing
cardiopulmonary
disease
• PHYS / CHEM’L
HEMOLYSIS (Prior to
transfusion) – Thermal trauma
– Mechanical damage • Freezing blood
without
• infusion through small
cryoprotectant or
bore
warming above 45°C
• open heart surgery
bypass machines – Osmotic or
chemical change
• Hypotonic or
hypertonic solutions
or drugs
• TA-GVHD
– Immunocompromised • Receipients of donor
patients transfused with units from a blood
immunocompetent relative
lymphocytes • Newborns receiving
exchange
• Recipients of bone
marrow or peripheral transfusions
stem cell transplants • Patients with certain
• Transfusion recipients hematologic and
with inherited oncologic
immunodeficiency disorders
syndromes
• Fetuses receiving
intrauterine transfusions
• DELAYED HTR
– Anamnestic response – Mild (14 days)
– Previous transfusion or – Due to gradual
pregnancy destruction of
– Ab’s no longer antibody coated
detectable RBC by
macrophages and
RES
– Implicated BGS:
• Kell
• Duffy
• Kidd
• Rh
• POST TRANS • HEMOSIDEROSIS
PURPURA – Iron overload
– HPA antigens – Chronically
transfused (>100
units)
– Each unit of RBC =
200 mg Fe
• DISEASE
TRANSMISSION – HIV
– Hepatitis B, C and D – Treponema
– Cytomegalovirus pallidum
– Epstein-barr – Plasmodium
– HTLV I & II – Babesia microti
– Trypanosoma

Note: please review

chapter 19 of
Harmening