LABORATORY INVESTIGATION OF
TRANSFUSION REACTION CASES
HS221/5B
Lecturer name: madam evana kamarudin
Date of submission: 2...
LEARNING OUTCOMES
At the end of this lesson, student will be
able to
- Define transfusion reaction
- Describe
initial
meas...
INTRODUCTION
Transfusion reaction
- Reaction of the body to a transfusion of
blood that is not compatible with its own
blo...
ROLE OF CURRENT DAY LABORATORY
 Return

all transfused packs to Blood Bank full
or empty
 Return giving set and attached...
WHAT HAPPEN WHEN TRANSFUSION REACTION
GONE WRONG?!!

Retrieved from : http://www.youtube.com/watch?v=qwu8aqzhgq0
INITIAL MEASURE BEFORE THE INVESTIGATION
TEST.
Stop the transfusion

An intravenous line with normal saline should be main...
SAMPLE CRITERIA
SAMPLE REJECTION

MINIMUM SAMPLE REQUIREMENT
•
•
•
•
•

Verify the patient’s identity using at
least two u...
The role of lab for hemolytic
transfusion reaction(HTR)
Acute HTR

Delayed HTR
Immediate
procedures

•
•
•

Check for cler...
TRANSFUSION REACTION LABORATORY
INVESTIGATION


After the initial measure , the 3 basic preliminary
test

Clerical
check
...
CLERICAL CHECK
To identify any possibilities of ABO incompatibility.
 Compare the component bag, label, paperwork with
pa...
VISUAL CHECK
What’s checked:
 Plasma or serum post-reaction & compare with pretransfusion
 This step is done to examine ...
Some causes of false-positive visible plasma
hemoglobin:
 Poor phlebotomy technique (traumatic stick, drawing
through IV ...
SEROLOGY CHECK
On post-transfusion sample redo the ABO
test and perform the direct antiglobulin test
(DAT)
 The
sample po...
TRANSFUSION REACTION
LAB INVESTIGATION
PRELIMINARY
LABORATORY

CLERICAL

VISUAL
CHECK

SEROLOGY

IF ANY OF THESE THREE TES...
1.






REDO ABO & RHESUS GROUPING

ABO and Rhesus grouping are the most important serological test
performed on pre-t...


Below are the table summarize the results for forward and reverse
grouping for 4 major ABO blood group.

ABO
group

A
B...
2) ANTIBODY SCREENING (IAT)






The aim of antibody screening is to determine presence of the
unexpected antibody oth...
Antibody screening involve three phases to allow for antibodyantigen agglutination:
1) Immediate spin (Room
Temperature)
•...
LIMITATION OF ANTIBODY SCREENING TEST
This test cannot detect all antibodies of potential clinical
significance
 Antibody...
3) REPEAT COMPATIBILITY
TESTING







The compatibility testing or cross-match procedure is done again for
confirmati...
THE CROSS-MATCH HAS MANY LIMITATIONS.
A COMPATIBLE CROSS-MATCH DURING
PRETRANSFUSION WILL NOT:
Guarantee normal survival o...
ADDITIONAL TEST NEEDED
FOR DETERMINATION OF:
1.
2.
3.
4.
5.
6.
7.
8.
9.

TRALI
TACO
Acute hemolytic transfusion reaction
A...
TRALI & TACO CASES

Retrieved from : http://www.youtube.com/watch?v=_oQVMcGUwIE
1.

TRANSFUSION RELATED ACUTE LUNG INJURY
(TRALI)

Defnition:


Adverse reaction to transfusion that is characterize by h...
LAB INVESTIGATION
Chest X-ray
 Chest X-ray showed massive
pulmonary congestion with diffuse
infiltrates for TRALI patient...
2. TRANSFUSION ASSOCIATED CIRCULATORY
OVERLOAD (TACO)
Definition:
 Adverse reaction to transfusion that is
characterize b...
3. ACUTE HEMOLYTIC TRANSFUSION
REACTION
Definiton:
 immunologic destruction of transfused
red cells, due to incompatibili...
4. ALLERGIC TRANSFUSION REACTIONS
(ANAPHYLACTIC)
Definition:
•
Anaphylaxis is a life-threatening allergic reaction that ca...
LAB INVESTIGATION
Serum IgA


Double immunodiffusion assay
may be used as a screening test to
identify individuals with a...
BACTERIAL CONTAMINATION
Definition:
 A small number of bacteria enter the blood
during collection or processing.
 During...
LABORATORY
INVESTIGATION
1. Examination of the pack


Examine: discolouration, smell and gram stain



May rapidly confi...
DELAYED HEMOLYTIC
TRANSFUSION REACTION
Definition:
A type of transfusion reaction that can occur 1 to 4 weeks after the tr...
LABORATORY INVESTIGATION
Component

Delayed HTR result

Normal value

Lactate dehydrogenase (LDH)

Elevated

-

Bilirubin
...
TRANSFUSION ASSOCIATED GRAFT VERSUS
HOST DISEASE (GVHD)
Definition:


A serious complication due to the engulfment and pr...
LABORATORY INVESTIGATION
Human Leucocyte Antigen (HLA)
typing

Skin biopsy



Acute GVHD of the skin is characterized by...
POST-TRANSFUSION PURPURA
LABORATORY INVESTIGATION


Definition:
 Adverse reaction to blood or platelet
transfusion that ...
TRANSFUSION-INDUCED
HEMOSIDEROSIS
Definition:


Iron overload in the liver, heart, pancreas, and endocrine glands in the ...
LABORATORY INVESTIGATION
1. Serum iron/ ferritin
 This is a blood test that may be done on a regular basis for high risk
...
WE HAD EXPLAINED ABOUT ALL
GENERAL LAB INVESTIGATION WHEN
THERE IS PRESENCE OF TRANSFUSION
REACTION..SO NOW,,LETS TEST YOU...
Example of case
study :
Transfusion relate
acute lung injury
(TRALI)
CASE STUDY


A 25 year old female suffered a broken femur in a car accident,
underwent surgery the next day and received ...
LAB DIAGNOSIS RESULTS
A differential diagnosis of pulmonary/fat embolism,
aspiration pneumonitis, pulmonary edema, fluid o...
TRALI DIAGNOSIS AND MANAGEMENT
DISCUSSION
There are two distinct mechanisms have been suggested to
have caused TRALI which are:1)

2)

An antibody-mediat...










TRALI is caused most often when anti-HLA class I and antineutrophil antibodies from blood products are pass...


Early diagnosis of TRALI is important in the supportive
treatment measures of these reactions and should be
suspected w...
TREATMENT


Treatment of TRALI is largely supportive, and
oxygen supplementation is needed in almost all
cases. Intubatio...
OVERALL SUMMARY REGARDING TRANSFUSION
REACTION LAB INVESTIGATION,,

Retrieved from: http://www.youtube.com/watch?v=frYwXcL...
REFERENCES
http://www.transfusionmedicine.ca/arti

cles/iga-deficiency
http://www.patient.co.uk/doctor/bloodtransfusion-...
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LABORATORY INVESTIGATION OF TRANSFUSION REACTION CASES

  1. 1. LABORATORY INVESTIGATION OF TRANSFUSION REACTION CASES HS221/5B Lecturer name: madam evana kamarudin Date of submission: 25th october 2013
  2. 2. LEARNING OUTCOMES At the end of this lesson, student will be able to - Define transfusion reaction - Describe initial measures after transfusion reaction occur - List the preliminary test of transfusion reaction investigation and its reasons - Understand additional test for the investigation
  3. 3. INTRODUCTION Transfusion reaction - Reaction of the body to a transfusion of blood that is not compatible with its own blood - An adverse reaction can range from fever and hives, to renal failure, shock and death
  4. 4. ROLE OF CURRENT DAY LABORATORY  Return all transfused packs to Blood Bank full or empty  Return giving set and attached solutions  Return post transfusion blood samples  (opposite arm)  Return transfusion sheet with full details of  suspected reaction
  5. 5. WHAT HAPPEN WHEN TRANSFUSION REACTION GONE WRONG?!! Retrieved from : http://www.youtube.com/watch?v=qwu8aqzhgq0
  6. 6. INITIAL MEASURE BEFORE THE INVESTIGATION TEST. Stop the transfusion An intravenous line with normal saline should be maintained The patient should then be assessed and supported as necessary while the patient’s physician and the transfusion service are notified A responsible physician will need to evaluate the patient and determine appropriate clinical care The unit and all tubing should be returned to the blood bank, along with postinfusion blood and urine samples as clinically indicated The reaction should be documented in the patient’s chart
  7. 7. SAMPLE CRITERIA SAMPLE REJECTION MINIMUM SAMPLE REQUIREMENT • • • • • Verify the patient’s identity using at least two unique identifiers. Date and time of sample collection Ensure all sections in the form are completed in a legible and detailed manner. Complete all information in the “Specimen Collection” section. Ensure both the Nursing and Facility of Blood bank clerical checks have been completed and this is documented on the form. This will prevent delays in testing. • • • • • • Specimen receives unlabeled/improperly labelled or overlabelled with more than one name. Key identifier information is missing, incorrect or discrepant on the sample and/ or requisition Specimens not received in the laboratory within 8 hours of collection Unacceptable tube received Specimens which are hemolyzed. Hemolyzed specimen may contain enough soluble material to interfere with typing reaction, detection of clinically significant antibodies or compatibility testing by acting to neutralize antibodies. Insufficient of sample. Generally, a minimum of 6 mL of whole blood yielding at least 3 mL of serum required to provide adequate specimen volume for antibody and compatibility testing.
  8. 8. The role of lab for hemolytic transfusion reaction(HTR) Acute HTR Delayed HTR Immediate procedures • • • Check for clerical errors Check for visual hemolysis Test the post-transfusion sample: Redo ABO grouping and perform direct antiglobulin test (DAT) • • • compare the positive post-transfusion DAT to pre-transfusion DAT Post antibody screen to identify antibody, elution of DAT (+) cells Re-do pre antibody screening.
  9. 9. TRANSFUSION REACTION LABORATORY INVESTIGATION  After the initial measure , the 3 basic preliminary test Clerical check Visual check Serology check Purpose : to determine the likelihood the occurrence of hemolytic transfusion reaction.  If there is evidence of hemolysis or if the clinical situation suggests something severe and unusual, the additional test such as TRALI and TACO must be performed. 
  10. 10. CLERICAL CHECK To identify any possibilities of ABO incompatibility.  Compare the component bag, label, paperwork with patient sample and look for errors.  If an error is found, the physician must be notified.  Most common errors:  Misidentification of patient when pre-transfusion sample drawn.  Mix up of samples in the lab.  Not enough incubation time. 
  11. 11. VISUAL CHECK What’s checked:  Plasma or serum post-reaction & compare with pretransfusion  This step is done to examine the presence of hemolysis  The destruction of red cells and releasing the free hemoglobin will resulting a pink to red supernatant  The pink or red colored serum indicate intravascular hemolysis  Thus the ABO testing must be repeated on the post-transfusion specimen  An urine examination of a post-reaction helps in diagnosis of an acute hemolysis.  The free hemoglobin in the urine indicates the intravascular 
  12. 12. Some causes of false-positive visible plasma hemoglobin:  Poor phlebotomy technique (traumatic stick, drawing through IV line)  Non-immune hemolysis (infusion with 0.45 NS, faulty blood warmers)  Autoimmune hemolysis  G6PD deficiency and hemoglobinopathies Some causes of false-negative visible plasma hemoglobin:  Delay in drawing sample (with functioning kidneys, hemoglobin may be cleared in several hours)  Sample collected from IV line (dilution of blood)
  13. 13. SEROLOGY CHECK On post-transfusion sample redo the ABO test and perform the direct antiglobulin test (DAT)  The sample post-transfusion must be preserved in a EDTA preservative (lavender top tube)  If the DAT is positive on the posttransfusion sample, then one should be performed on the pre-transfusion sample.  If the result for pre-transfusion DAT is negative but the result for post-transfusion is positive, it indicates the presence of 
  14. 14. TRANSFUSION REACTION LAB INVESTIGATION PRELIMINARY LABORATORY CLERICAL VISUAL CHECK SEROLOGY IF ANY OF THESE THREE TEST ABOVE HAVE POSITIVE AND SUSPICIOUS RESULTS, REDO TEST DONE BEFORE BLOOD TRANSFUSION WHICH ARE: 1. ABO & RHESUS GROUPING (PRE & POST SAMPLE). 2. ANTIBODY SCREENING (PRE & POST SAMPLE). 3. REPEAT CROSSMATCH (PRE & POST SAMPLE).
  15. 15. 1.    REDO ABO & RHESUS GROUPING ABO and Rhesus grouping are the most important serological test performed on pre-transfusion. A full ABO and Rhesus group comprises a forward and reverse group which must be done at the same time crucial for result’s confirmation. Below are table of differences between forward and reverse grouping: FORWARD GROUPING DIFFERENCES REVERSE GROUPING Blood (RBC) USE WHAT Serum/ Plasma Antigen A, Antigen B. DETECT WHAT Anti-A, Anti-b Known Anti-A, Anti-B, AntiAB. REAGENT USED Known A Cells, B Cells, O Cells. More Accurate (Method Of Choice) RELIABILITY Accurate, But Need To Confirm With Forward Grouping. Yes NEONATE (UNDER MONTHS AGE) No ( ABO Antibodies Is Not Detectable)
  16. 16.  Below are the table summarize the results for forward and reverse grouping for 4 major ABO blood group. ABO group A B AB O    ABO antisera ABO cells (Reverse) Rh D (Forward) antisera Anti-A Anti-B Anti- A cells B cells O Anti-D AB cells + 0 + 0 + 0 0 + + + 0 0 + + + 0 0 0 0 0 0 + + + The principle of ABO grouping is based on a specific agglutination reaction between antigens on RBCs and antibodies in the typing serum. + sign indicate agglutination. 0 sign indicate no agglutination.
  17. 17. 2) ANTIBODY SCREENING (IAT)    The aim of antibody screening is to determine presence of the unexpected antibody other than anti-A and anti-B. PRINCIPLE  Antibody screening test involve testing patient’s serum against screening cells which are commercially prepared group O red cells suspension.  The cells are selected so that the following antigens are present on at least one of the cell sample;  D, C, E, c, e, M N, S, s, P, Lea, Leb, K, k, Fya, Fyb, and Jkb. These are possible reasons why unexpected antibody present in post reaction sample: a) b) c) Clerical or technical error. Passive transfer of antibody from a recently transfused component. Amnestic response : Appearance of alloantibodies can occurs within hours of exposure (Delayed Hemolytic Transfusion Reaction).
  18. 18. Antibody screening involve three phases to allow for antibodyantigen agglutination: 1) Immediate spin (Room Temperature) • 3 tubes is used using recipient serum plus saline suspension screening cell I, screening cell II, and the recipient’s own cells for auto control. • Centrifuge these three tubes and observe for agglutination. • This phase detects IgM antibodies which usually considered “nuisance” antibodies. 2) 37°C incubation • This phase required to detect the presence of IgG which is warm-acting antibodies. • Enhancement media is added such as Low Ionic Strength Solution (LISS) or albumin. • LISS will speeds up antigen-antibody reaction but unfortunately enhances “nuisance” antibodies, so it is add after immediate spin step. • Albumin will lower zeta potential so that cells can agglutinate without Coombs step and may detect Rh antibodies. 3) Coombs phase Antihuman Globulin (AHG) • This step is important to detect IgG antibodies, which are considered clinically significant and capable of causing HFDN and HTR. • Wash the cells for 3-4 times after 37C incubation • Remove saline and add AHG • Mix and centrifuge • Read the agglutination • If the result is negative, add Coombs Control Cells to confirm negative reactions.
  19. 19. LIMITATION OF ANTIBODY SCREENING TEST This test cannot detect all antibodies of potential clinical significance  Antibody may be reactive with low incidence antigen absent on screen cells  If antibody is exhibiting “dosage” it may be missed. Duffy (Fy), Kidd (Jk) and Rh antibodies may only be detected with homozygous cells. It will influence decision to use 2 or 3 cell screen  If antibody screening is positive, additional tests to specifically identify antibody using the antibody identification panel and red cell antigen typing must be performed.
  20. 20. 3) REPEAT COMPATIBILITY TESTING     The compatibility testing or cross-match procedure is done again for confirmation to determine whether blood donor is compatible with recipient blood. This test involve 3 phases which are Immediate spin, 37°C, and AHG. The 2 main function of the repeating cross-match test are:  It is the final check of ABO compatibility between donor and patient.  It may detect the presence of an Ab in the patient’s serum that was not detected in the Ab screening because the corresponding Ag was lacking from the screening cell. There are two types of crossmatch : Major cross-match • The major cross-match involves testing the patient’s serum with donor cells. • To determine whether the patient has an antibody which may cause HTR or decreased cell survival of donor cells. Minor Cross-match • This test involves testing the patient’s cells with donor plasma. • To determine whether there is an antibody in the donor’s plasma directed against an antigen on the patient’s cells.
  21. 21. THE CROSS-MATCH HAS MANY LIMITATIONS. A COMPATIBLE CROSS-MATCH DURING PRETRANSFUSION WILL NOT: Guarantee normal survival of transfused RBCs  Prevent immunization of the recipient  Detect all unexpected RBC antibodies in the recipient serum  Prevent delayed hemolysis due to an amnestic antibody response to antigens against which the patient has previous but undetectable immunization  Detect all ABO grouping errors either in donor or recipient  Detect most group D grouping errors in the donor or recipient 
  22. 22. ADDITIONAL TEST NEEDED FOR DETERMINATION OF: 1. 2. 3. 4. 5. 6. 7. 8. 9. TRALI TACO Acute hemolytic transfusion reaction Allergic transfusion reaction(Anaphylactic) Bacterial contamination Delayed hemolytic transfusion reaction Transfusion associated GVHD Post- transfusion purpura Transfusion-induced hemosiderosis
  23. 23. TRALI & TACO CASES Retrieved from : http://www.youtube.com/watch?v=_oQVMcGUwIE
  24. 24. 1. TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI) Defnition:  Adverse reaction to transfusion that is characterize by hypotension and pulmonary edema. Cause:  Occur when human leucocyte antigen (HLA) or human neutrophil antigen (HNA) antibodies found in the donor’s plasma are directed against the recipient’s leucocyte antigen.  It is likely to occur to those who were transfused with a large volume of plasma such as fresh frozen plasma (FFP). Symptoms:  Acute onset of fever, chills, dyspnoea, tachypnoea, tachycardia, hypotension, hypoxaemia and noncardiogenic bilateral pulmonary oedema leading to respiratory failure during or within 6 hours of transfusion.  TACO is frequently confused with TRALI as a key feature of both is pulmonary oedema and it is possible for these complications to occur concurrently.  The main constant feature in TRALI is hypotension.
  25. 25. LAB INVESTIGATION Chest X-ray  Chest X-ray showed massive pulmonary congestion with diffuse infiltrates for TRALI patient.  A is the normal chest x- ray image while C is the subsequent radiographic imaging of the chest showed massive pulmonary congestion with diffuse fluffy infiltrates Human leukocyte antigens (HLA) and human neutrophil alloantigen (HNA) antibody detection • HNA-3a, the former 5b, HLA class I and HLA class II antibody indicate severe and fatal cases • For HLA antibody screening, antibody binding tests (EIA, immunofluorescence) are preferred- 20% of blood components contain HLA alloantibodies • HNA antibodies are usually detected by immunofluorescence. However, HNA-3a antibodies which are known to cause severe TRALI reactions are often better detected by agglutination
  26. 26. 2. TRANSFUSION ASSOCIATED CIRCULATORY OVERLOAD (TACO) Definition:  Adverse reaction to transfusion that is characterize by hypertension and pulmonary edema. Cause:  This is usually due to rapid or massive transfusion of blood in patients with diminished cardiac reserve or chronic anaemia.  Patients over 60 years of age, infants and severely anaemic patients are particularly susceptible Symptom:  Dyspnoea, orthopnea, cyanosis, tachycardia, hypertension and pulmonary oedema (may develop within 1 to 2 hours of transfusion) Lab investigation: B-natriuretic peptide (BNP) test • It is a 32-amino-acid polypeptide secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. • BNP levels were measured by use of fluorescent immunoassay. • In TACO patient, BNP level shows raised. • Normal value for BNP 0-99 nanograms per liter
  27. 27. 3. ACUTE HEMOLYTIC TRANSFUSION REACTION Definiton:  immunologic destruction of transfused red cells, due to incompatibility of antigen on transfused cells with antibody in the recipient circulation.  Tends to present immediately or within 24 hours after transfusion Causes:  common cause is transfusion of ABO/Rh incompatible blood due to clerical errors, presence of red cell alloantibodies (nonABO) in the patient’s plasma which have not been previously identified. Symptom and clinical finding:  Fever, chills, chest pain or hypotension.  Transfused patients develop oliguria, haemoglobinuria and haemoglobinaemia. Lab investigation:  Diagnosis is confirmed by measuring urinary Hb, bilirubin, and haptoglobin.  Intravascular hemolysis produces free Hb in the plasma and urine; haptoglobin levels are very low. Hyperbilirubinemia may follow. N.R Blood Urine Hb Male: 13.8 to 17.2 gm/dL Female: 12.1 to 15.1 gm/dL negative Bilirubin 0.3 to 1.9 mg/dL - haptoglobin 41 - 165 mg/dL - Table 1 :Normal range
  28. 28. 4. ALLERGIC TRANSFUSION REACTIONS (ANAPHYLACTIC) Definition: • Anaphylaxis is a life-threatening allergic reaction that can occur after only a few milliliters of blood have been transfused Cause:  In the case of patients with IgA deficiency, the presence of IgA in the donor's plasma will trigger for anaphylaxis to occur. Because they lack IgA, their immune systems develops anti-IgA and sensitize to IgA. Symptom:  Commonly range from one lesion to widespread urticarial lesions but may be associated with mild upper respiratory symptoms, nausea, vomiting, abdominal cramps or diarrohea.
  29. 29. LAB INVESTIGATION Serum IgA  Double immunodiffusion assay may be used as a screening test to identify individuals with an IgA level below 2 to 4 mg/dL.  A more sensitive ELISA method with a sensitivity of 0.02 mg/dL is then necessary to determine which individuals are truly IgA deficient.  Truly deficient individuals, with levels below 0.05 mg/dL, may develop anti-IgA antibodies. Mast cell tryptase test • The tryptase test is a useful indicator of mast cell activation. It may be ordered to confirm a diagnosis of anaphylaxis • With anaphylaxis, tryptase levels typically peak about 1 to 2 hours after symptoms begin. • The reference range of serum tryptase is less than 11.4 µg/L
  30. 30. BACTERIAL CONTAMINATION Definition:  A small number of bacteria enter the blood during collection or processing.  During storage, bacteria may proliferate and if possible produce endotoxin which then will be transfused to another person.  It is rare but is more often reported with platelet concentrates (stored at 20-24 C) than with red cells (stored at 1−6 C).
  31. 31. LABORATORY INVESTIGATION 1. Examination of the pack  Examine: discolouration, smell and gram stain  May rapidly confirm the diagnosis. 2. Blood cultures  Blood cultures from different IV site- to detect any colonies formed on the streaked agar plate. 3. Product cultures (include a gram stain)  Gram positive bacteria : Staphylococcus epidermidis, Staphylococcus aureus, Bacillus cereus, Group B streptococci  Gram negative bacteria: E. coli, Pseudomonas species and other gram-negative organisms.
  32. 32. DELAYED HEMOLYTIC TRANSFUSION REACTION Definition: A type of transfusion reaction that can occur 1 to 4 weeks after the transfusion.  As a result of a secondary immune response with a drop in hemoglobin level.  Usually less severe than acute hemolytic transfusion reaction.  Symptoms:  Patients may present with unexplained fever and anaemia usually 2 to 14 days after transfusion of a red cell component.  The patient may also have jaundice, high bilirubin, high LDH, reticulocytosis, spherocytosis, positive antibody screen and a positive Direct Antiglobulin Test (DAT). Cause:  After transfusion, transplantation or pregnancy, a patient may make an antibody to a red cell antigen that they lack. If the patient is later exposed to a red cell transfusion which expresses this antigen a DHTR may occur.  DHTRs may also occur with transfusion transmitted malaria and babesiosis.
  33. 33. LABORATORY INVESTIGATION Component Delayed HTR result Normal value Lactate dehydrogenase (LDH) Elevated - Bilirubin Elevated 0.3 to 1.9 mg/dL Low 41 - 165 mg/dL Present in urine - D-dimer Elevated (may be) - Prothrombin test (PT), Elevated (may be) 12-14 s Partial thromboplastin time (PTT) Elevated (may be) 18-28 s Serum haptoglobin Free hemoglobin in urine * D-dimer, prothrombin test (PT), and partial thromboplastin time (PTT) may be elevated, particularly with disseminated intravascular coagulation (DIC).
  34. 34. TRANSFUSION ASSOCIATED GRAFT VERSUS HOST DISEASE (GVHD) Definition:  A serious complication due to the engulfment and proliferation of donor T-lymphocytes against patient.  Usually caused by transfusion of un-irradiated blood to an immunocompromised recipients. Symptoms:  Patients present with fever, rash and diarrhoea commencing 1-2 weeks post-transfusion. Causes:  Viable T lymphocytes in the transfused component engraft in the recipient and react against tissue antigens in the recipient.
  35. 35. LABORATORY INVESTIGATION Human Leucocyte Antigen (HLA) typing Skin biopsy   Acute GVHD of the skin is characterized by varying degrees of damage to the epidermal keratinocytes. Degrees of damage: Grade 1  White cells from a blood sample are a convenient source of “ tissue ” that the laboratory can use to determine individual’s HLA type.  Matching of stem cell donor to a recipient is determined by comparing their tissue types which can be present on nearly all tissues in the body.  Sample requirements: - 20-30ml of blood sample and white cells are isolated from whole blood .  Two methods used: 1. Serological testing: white cells are used. 2. DNA testing: where DNA extracted from white cells is used.  HLA typing reported as A 3,32, B 7,37, DR 1,15 which will compare the result of recipient and donor stem cell - Vacuolization of the basal keratinocytes is present. Grade 2 - Both basal keratinocyte vacuolization and dyskeratotic keratinocytes are present. Grade 3 - Focal clefting of the basal layer is formed. Grade 4 - The epidermis is totally separated from the underlying dermis. http://www.transfusionmedicine.ca/articles/iga-deficiency
  36. 36. POST-TRANSFUSION PURPURA LABORATORY INVESTIGATION  Definition:  Adverse reaction to blood or platelet transfusion that occurs when the body produces alloantibodies.  This antibody is directed against human platelet antigen system.  Symptoms:  Thrombocytopenia (platelet counts <10 x 109/L in 80% of cases),  typically 7 to 10 days after a blood transfusion.  Bleeding from mucous membranes and the gastrointestinal and urinary tracts is common.  Causes:  The immune specificity is against a platelet-specific antigen yet both autologous and allogeneic platelets are destroyed. Platelet antibodies screening  Method: Flow cytometry  Serum samples are tested against isolated group O donor platelets typed for following antigens: ( HPA-1a/b, -2a/b, -3a/b, -4a, 5a/b)  Antibody binding to donor platelets is detected using fluorescentlabeled polyclonal antibodies specific for human IgG and IgM  Positive result means plateletreactive antibodies detected
  37. 37. TRANSFUSION-INDUCED HEMOSIDEROSIS Definition:  Iron overload in the liver, heart, pancreas, and endocrine glands in the thalassemic patients  Hemosiderosis that occur due to blood transfusion may occur after transfusion of as few as 100 units of blood which each unit contain 250mg of iron. Symptoms:  Early symptoms are often vague such as muscle weakness, fatigue and weight loss. Later skin pigmentation, arthropathy, diabetes, cardiac failure and hepatic dysfunction can occur.  Evidence of iron overload with organ dysfunction, may occur after transfusion of 50 to 100 red cell units. Causes:  Each unit of red cells contains about 250 mg of iron and the average rate of iron excretion is only about 1 mg/day.  Hence in chronically transfused patients, the majority of iron can’t be excreted quickly enough and iron accumulates in the reticuloendothelial system, liver, heart, spleen and endocrine organs
  38. 38. LABORATORY INVESTIGATION 1. Serum iron/ ferritin  This is a blood test that may be done on a regular basis for high risk individuals.  Serum ferritin levels increase as the amount of non-transferrin bound iron (NTBI) increases in the blood.  Blood ferritin levels that are greater than 1,000 mcg/L indicate iron overload.  Healthy men usually have a serum ferritin of 12-300 mcg/L and healthy women 12-150mcg/L. 2. Liver biopsy  Liver biopsy to check iron concentration.  While this test may give slightly more accurate results than serum ferritin levels, it requires a fairly invasive procedure that can lead to complications, such as infection and bleeding.  If the biopsy shows greater than 7 mg iron per gram of liver, the patient is considered iron overloaded.
  39. 39. WE HAD EXPLAINED ABOUT ALL GENERAL LAB INVESTIGATION WHEN THERE IS PRESENCE OF TRANSFUSION REACTION..SO NOW,,LETS TEST YOUR UNDERSTANDING BY EXPLORING THIS EXAMPLE OF CASE STUDY BELOW TOGETHER!!
  40. 40. Example of case study : Transfusion relate acute lung injury (TRALI)
  41. 41. CASE STUDY  A 25 year old female suffered a broken femur in a car accident, underwent surgery the next day and received 2 units of packed red blood cells.  Patient was extubated after adequate spontaneous ventilation was established. Approximately 3 hours after transfusion and 15 minutes after extubation, -patient’s respiratory rate increased from 12 to 32breaths/minute. -temperature rose from 36.7 to 38.7 C. -blood pressure dropped from 120/70 to 101/74. -Blood oxygen saturation (Spo2) dropped from 100% to 90%. -chest x-ray showed severe pulmonary edema. -Patient’s arterial blood gas (ABG) showed hypoxemia With PaO2 of 60 mmHG. -Patient’s oxygen saturation was not maintained above 90% with O2 supplementation and patient was reintubated.       
  42. 42. LAB DIAGNOSIS RESULTS A differential diagnosis of pulmonary/fat embolism, aspiration pneumonitis, pulmonary edema, fluid overload, ARDS and TRALI were suspected.  Chest X-ray showed massive pulmonary congestion with diffuse infiltrates. Urine sample showed hemolysis.  ETT suction showed blood stained secretions.  Supportive measures were taken in the ICU and patient showed improvement clinically.  By Post-operative day two, chest x-ray became clear and patient was weaned and extubated.  Laboratory studies at the blood transfusion service confirmed the diagnosis of TRALI at a later date. 
  43. 43. TRALI DIAGNOSIS AND MANAGEMENT
  44. 44. DISCUSSION There are two distinct mechanisms have been suggested to have caused TRALI which are:1) 2) An antibody-mediated reaction between recipient granulocytes and anti-granulocyte antibodies from donors who were sensitized during pregnancy. An antibody-mediated reaction between recipient granulocytes and anti-granulocyte antibodies from donors who were sensitized during previous transfusion.
  45. 45.      TRALI is caused most often when anti-HLA class I and antineutrophil antibodies from blood products are passively transfused to a recipient. Less frequent is the recipient antibody reacting to the white blood cells in the transfused blood product. The subsequent antibody-antigen reaction in the recipient activates complement, and C5a produced during complement activation promotes neutrophil aggregation, margination, and sequestration in pulmonary microvasculature. The entry of neutrophils into the lung damages and increases permeability of the pulmonary microvasculature, leading to pulmonary edema. This reaction is likely to occur in multiparous women. Another theory suggest accumulation of lipid product resulting from cell degradation. This pro-inflammatory molecules accumulate during storage of cellular blood products.
  46. 46.  Early diagnosis of TRALI is important in the supportive treatment measures of these reactions and should be suspected with symptoms that may include:Dypsnea  Hypoxemia  hypotension  fever along with physical findings of bilateral pulmonary edema, even many hours after the actual transfusions.   Suspicion of TRALI should be reported to the blood transfusion service so appropriate action can be taken to prevent future morbidity and mortality in other patients
  47. 47. TREATMENT  Treatment of TRALI is largely supportive, and oxygen supplementation is needed in almost all cases. Intubations and mechanical ventilation might be necessary for severe hypoxemia. Prevention  
  48. 48. OVERALL SUMMARY REGARDING TRANSFUSION REACTION LAB INVESTIGATION,, Retrieved from: http://www.youtube.com/watch?v=frYwXcLv5yc
  49. 49. REFERENCES http://www.transfusionmedicine.ca/arti cles/iga-deficiency http://www.patient.co.uk/doctor/bloodtransfusion-reactions http://labtestsonline.org/understanding /analytes/tryptase/tab/test http://www.transfusion.com.au/advers e_transfusion_reactions/

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