Compatibility Testing for Blood Transfusion

1. Compatibility Testing for Blood Transfusion RIH Department of Anesthesiology

2. What’s new? How much ONeg Blood Is OK? What are our transfusion policies ? Why does it take so much time? Blood Bank Issues

3. ISBT = International Society of Blood Transfusion Recognizes the Presence of Multiple Antigens on the Surfaces of Red Blood Cells that define Blood Group Systems

4. ABO ABO 001 4    MNSs MNS 002 37    P P1 003 1    Rh RH 004 47    Lutheran LU 005 18    Kell KEL 006 21    Lewis LE 007 3    Duffy FY 008 6    Kidd JK 009 3    Diego DI 010 2    Cartwright YT 011 2 BLOOD GROUP SYSTEMS CONVENTIONAL NAME    ISBT SYMBOL    ISBT NUMBER  ANTIGENS  * *

5. CONVENTIONAL NAME    ISBT SYMBOL    ISBT NUMBER    ANTIGENS     Xg XG0 012 1    Scianna SC 013 3    Dombrock DO 014 5    Colton CO 015 3 Landsteiner-Wiener LW 016 3    Chido/Rogers CH/RG 017 9    Hh H 018 1    Kx XK 019 1    Gerbich GE 020 7    Cromer CROMER 021 10    Knops KN 022 5    Indian IN 023 2    Ok OK 024 - -    Raph RAPH 025 - -    JMH JMH 026 - - BLOOD GROUP SYSTEMS

6. Population Distribution of Major Blood Groups O Rh pos 38% O Rh neg 7% A Rh pos 34% A Rh neg 6% B Rh pos 9% B Rh neg 2% AB Rh pos 3% AB Rh neg 1%

7. Why do we care? Compatibility testing is done to avoid a hemolytic transfusion reaction If the Host or Recipient recognizes the donor RBC surface antigens as foreign, the host will mount an immune response to the donor RBC’s

8. Major Blood Groups ABO

9. ABO blood group antigens present on red blood cells and IgM antibodies present in the serum

10. Why do we have Anti-A or Anti-B Antibodies??? They are not present in the newborn They develop in the first years of life Exposure to plant, bacterial, viral antigens provokes this response

11. Why do we have Anti-A or Anti-B Antibodies??? Viruses transmitted from the respiratory tracts of humans to other humans drag along various antigens including ABO blood group antigens. Prime the newborn’s immune system. Reduces transmissibility of viruses within a population.

12. Major Blood Groups Rhesus 47 Antigens make up the Rhesus Blood Group The most significant is the D antigen

13. There is no naturally occurring Anti D Production of Anti D in the RH negative recipient requires previous exposure to the D antigen (in utero or by transfusion)

14. If red cells are administered to an ABO- or D-incompatible recipient, the recipient will mount an antibody response to the foreign RBC surface antigens IgM is polyvalent and fixes complement

15. Intravascular Clumping of Donor RBC’s

16. Intravascular hemolysis of donor RBC’s

17. Clumps and extruded RBC stroma result in organ dysfunction and possible death Incidence 1:38,000 – 1:70,000 Mortality 1:30

18. Other Blood Groups No naturally occurring antibodies Immune response requires previous exposure Weaker titers of univalent antibodies

19. Donor RBC’s coated with host antibodies Stiffer RBC membrane Susceptible to attack by splenic macrophages

20. But no intravascular clumping

21. Bits of Donor RBC membrane lost traversing splenic sinusoids (extravascular hemolysis) Spherocytes Decreased RBC survival Delayed anemia Priming for worse reaction

22. Donor Questionnaire: Medical history Lifestyle Finger stick: Checking Hct

23. Donor Needs a Hct of 0.38 A drop of donor blood is placed into a test tube containing a CuSo4 solution CuSo4 solution has a SG of 1.053 RBC with Hct > 0.38 sink to the bottom of the test tube

24. Donor Side sample (20cc) collected for testing: Blood group and Infection The bag is anticoagulated The unit is labeled with a lot# like any drug e.g. LH59321

25. DIFFERENT LEVELS OF COMPATIBILITY TESTING Landsteiner, 1899 Lifespan, 2008

26. COMPATIBILITY TESTING • The purpose of pre-transfusion compatibility testing is to PREVENT hemolytic transfusion reaction • Clerical and technical components • Samples must be labeled at the bedside • Two methods of ID required: • Name, SSN, MR#, DOB • The phlebotomist must sign the tube

27. COMPATIBILITY TESTING • Lab checks: • Identity • Record of previous specimen • Record of previous ABO-Rh type • History of abnormalities

28. COMPATIBILITY TESTING • Processing the specimen: • ABO Group determined (forward and reverse) • D typing determined • Antibody screen will be performed • ABO/Rh identical or compatible blood will be made available

29. ABO TYPING • Front or forward type using monoclonal anti-A and anti-B (commercial) • The sample is diluted to Hct 0.08, the commercial antibodies added & the test tube is centrifuged • The RBC’s are then examined for clumping (gross observation, gel suspension)

30. Anti A Anti B Anti A Anti B A B Anti A Anti B Anti A Anti B AB O

31. A A A A B B B B ABO TYPING Back or reverse type with A and B cells • Commercially available A and B cells are added to two tubes of plasma • AB B A O

32. How do we know whether or not the host (or recipient) has antibodies to minor blood group antigens? • Add commercial RBC’s with known important minor antigens on their surface to host (or recipient) plasma and centrifuge. Then incubate at body temperature for 15-30 minutes • Then add rabbit antiglobulin

33. If recipient antibodies have coated commercial RBC surfaces

34. Rabbit antiglobulin will bind to the Antibodies and the RBC’s will clump

35. ANTIBODY SCREENING • Detection of unexpected clinically significant antibodies against the minor blood group system antigens • Also called the indirect Coombs test or the indirect antiglobulin test • Positive in between 0 - 8% of samples depending on the population

36.    MNSs MNS 002 37    P P1 003 1    Rh RH 004 47    Lutheran LU 005 18    Kell KEL 006 21    Lewis LE 007 3    Duffy FY 008 6    Kidd JK 009 3    Diego DI 010 2    Cartwright YT 011 2 Possibly significant minor blood groups *

37. SCREENING TEST RESULTS • A negative antibody screen allows blood to be dispensed using an immediate spin X-match or an electronic X-match, either of which confirms ABO compatibility • A positive antibody screen requires a full antiglobulin phase X-match

38. POSITIVE ANTIBODY SCREEN • Can some or all of the antibodies be identified? • Identify red cells which lack these antigen(s)

39. Why does it take so much time?

40. Why does it take so long? • Sample collection • Specimen transport • Specimen centrifugation 15” • Testing 25”

41. How much ONeg Blood Is OK?

42. How much ONeg? • Past data from Vietnam war era • Minimal auto antibodies in universal donor blood • Per Dr. Sweeney > 80 units before anti-A and anti-B cause problems

43. What are our transfusion policies ?

44. Policies • Consent: Covered in surgical consent • Prescription: Needs to be ordered • Collection: Label blood at bedside • Name, MR #, other • Sign and date

45. Policies • Administration: • Inspect bag • Verify ABO Rh • Match ID’s • If no access to name bracelet use Innovian to match ID’s • 2 licensed personnel & 2 signatures • Normal saline only

46. What’s new?

47. What’s new? • 2007 Nature Biotechnology • USA, Denmark, France, Sweden • Convert blood types A, B, and AB • to O, using bacterial glycosidase • enzymes to cleave the antigens • from the RBC surface. • Need D negative cells

48. The End

50. Recipient Donor O- O+ A- A+ B- B+ AB- AB+ O- O+ A- A+ B- B+ AB- AB+ Red blood cell compatibility table