Transfusion Pathology

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Transfusion Pathology

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Transfusion Pathology

  1. 1. Transfusion pathology Kristine Krafts, M.D. September 24, 2007
  2. 2. Transfusion Pathology Outline <ul><li>Blood groups </li></ul><ul><ul><li>Introduction </li></ul></ul><ul><ul><li>ABO system </li></ul></ul><ul><ul><li>Rh system </li></ul></ul><ul><ul><li>Other systems </li></ul></ul><ul><li>Blood transfusion </li></ul><ul><ul><li>Blood products </li></ul></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><li>Testing </li></ul></ul><ul><ul><li>Dangers </li></ul></ul>
  3. 3. intro Rh ABO products other groups indications testing dangers
  4. 4. Transfusion Pathology Outline <ul><li>Blood groups </li></ul><ul><ul><li>Introduction </li></ul></ul>
  5. 5. <ul><li>Q. What determines a blood group? </li></ul>intro Rh ABO products other groups indications testing dangers
  6. 6. <ul><li>Q. What determines a blood group? </li></ul><ul><li>A. The antigens on the red cell surface. </li></ul>intro Rh ABO products other groups indications testing dangers
  7. 7. <ul><li>Antigens are inherited (Mendelian pattern) </li></ul><ul><li>Real function unknown </li></ul><ul><li>Damn important during transfusion </li></ul><ul><li>Lots of antigens exist (grouped into systems) </li></ul><ul><li>Most important systems: ABO and Rh </li></ul>Red Cell Antigens intro Rh ABO products other groups indications testing dangers
  8. 8. Transfusion Pathology Outline <ul><li>Blood groups </li></ul><ul><ul><li>Introduction </li></ul></ul><ul><ul><li>ABO system </li></ul></ul>intro Rh ABO products other groups indications testing dangers
  9. 9. What are the antigens? <ul><li>A and B </li></ul><ul><li>Some people have A antigen (“type A”) </li></ul><ul><li>Some people have B antigen (“type B”) </li></ul><ul><li>Some people have both A and B (“type AB”) </li></ul><ul><li>Some people have neither A nor B (“type O”) </li></ul>intro Rh ABO products other groups indications testing dangers
  10. 10. Type A intro Rh ABO products other groups indications testing dangers What are the antigens? Type B Type AB Type O
  11. 11. How do you make the antigens? <ul><li>Start with a protein precursor </li></ul><ul><li>Add fucose to make H antigen </li></ul><ul><li>Add N-acetylgalactosamine to H Ag to make A Ag </li></ul><ul><li>Add galactose to H Ag to make B Ag </li></ul>intro Rh ABO products other groups indications testing dangers
  12. 12. H antigen A antigen B antigen intro Rh ABO products other groups indications testing dangers
  13. 13. What are the genes? <ul><li>H gene </li></ul><ul><ul><li>everyone * has this one </li></ul></ul><ul><ul><li>codes for an enzyme that makes H Ag. </li></ul></ul><ul><li>A, B, and O genes </li></ul><ul><ul><li>everyone has two genes. </li></ul></ul><ul><ul><li>six possible genotypes: AA, BB, AB, AO, BO, OO </li></ul></ul><ul><ul><li>A and B code for enzymes that make A and B antigens. </li></ul></ul><ul><ul><li>O has no gene product * . </li></ul></ul>* almost! intro Rh ABO products other groups indications testing dangers
  14. 14. O None OO AB A and B AB B BO BB AO AA Genotype B A A Blood type Antigens intro Rh ABO products other groups indications testing dangers
  15. 15. How common is each blood type? 42% O 6% AB 12% B 40% A Percent of population Blood type intro Rh ABO products other groups indications testing dangers
  16. 16. So What? <ul><li>We have antibodies to the antigens we don’t have! </li></ul><ul><li>Anti-A antibodies lyse type A red cells. </li></ul><ul><li>Anti-B antibodies lyse type B red cells. </li></ul><ul><li>This is very important during blood transfusion. </li></ul>intro Rh ABO products other groups indications testing dangers
  17. 17. Type A intro Rh ABO products other groups indications testing dangers So what? Type B Type AB Type O
  18. 18. anti-A anti-B none anti-A anti-B Antibodies O None OO AB A and B AB B BO BB AO AA Genotype B A A Blood type Antigens intro Rh ABO products other groups indications testing dangers
  19. 19. Compatible blood types * type O = universal d O nor! O O AB B A Recipient blood type AB, A, B, or O B or O A or O * Donor blood type intro Rh ABO products other groups indications testing dangers
  20. 20. O AB A B
  21. 21. Transfusion Pathology Outline <ul><li>Blood groups </li></ul><ul><ul><li>Introduction </li></ul></ul><ul><ul><li>ABO system </li></ul></ul><ul><ul><li>Rh system </li></ul></ul>intro Rh ABO products other groups indications testing dangers
  22. 22. What are the antigens? <ul><li>Most important antigen: D! </li></ul><ul><li>“ Rh” because discovered using Rhesus monkeys. </li></ul><ul><li>“ Rh factor” refers to the D antigen. </li></ul><ul><li>Two alleles: D and d. </li></ul><ul><li>People with the D allele make D antigen and are Rh+. </li></ul>intro Rh ABO products other groups indications testing dangers
  23. 23. Rh - none dd Rh + Dd DD Genotype D Rh + D Blood type Antigens intro Rh ABO products other groups indications testing dangers
  24. 24. What are the antibodies? <ul><li>Antibodies in this system are acquired ! </li></ul><ul><li>To make anti-D you must: </li></ul><ul><ul><li>1. lack the D antigen on your red cells </li></ul></ul><ul><ul><li>2. get exposed to D + blood </li></ul></ul><ul><li>Donor and recipient are tested for the D antigen. </li></ul>intro Rh ABO products other groups indications testing dangers
  25. 25. Transfusion Pathology Outline <ul><li>Blood groups </li></ul><ul><ul><li>Introduction </li></ul></ul><ul><ul><li>ABO system </li></ul></ul><ul><ul><li>Rh system </li></ul></ul><ul><ul><li>Other systems </li></ul></ul>intro Rh ABO products other groups indications testing dangers
  26. 26. Don’t tell me there are more systems. <ul><li>There are a almost a sh*tload of other systems. * </li></ul><ul><li>These are not included in routine testing. </li></ul><ul><li>Antibodies to antigens in these systems are usually acquired (like anti-D), so unless a patient has been transfused or pregnant, you don’t need to worry too much. </li></ul>* Not quite: a sh*tload is defined as more than 42. intro Rh ABO products other groups indications testing dangers
  27. 28. Transfusion Pathology Outline <ul><li>Blood groups </li></ul><ul><ul><li>Introduction </li></ul></ul><ul><ul><li>ABO system </li></ul></ul><ul><ul><li>Rh system </li></ul></ul><ul><ul><li>Other systems </li></ul></ul><ul><li>Blood transfusion </li></ul><ul><ul><li>Blood products </li></ul></ul>intro Rh ABO products other groups indications testing dangers
  28. 29. What do you mean, products? <ul><li>In olden times, there was only whole blood. </li></ul><ul><li>Now, we separate blood into its components </li></ul><ul><li>Better for the patient </li></ul><ul><li>Conserves blood supply </li></ul>intro Rh ABO products other groups indications testing dangers
  29. 30. What are the products? <ul><li>Whole blood </li></ul><ul><li>Red cells </li></ul><ul><li>Platelets </li></ul><ul><li>Granulocytes </li></ul><ul><li>Cryoprecipitate </li></ul><ul><li>Fresh frozen plasma </li></ul>intro Rh ABO products other groups indications testing dangers
  30. 31. Whole Blood Red Cells Granulocytes Platelet-Rich Plasma BLOOD PRODUCTS
  31. 32. Whole Blood Red Cells Granulocytes Platelet-Rich Plasma BLOOD PRODUCTS
  32. 33. Whole Blood Red Cells Granulocytes Platelet-Rich Plasma BLOOD PRODUCTS
  33. 34. Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets BLOOD PRODUCTS Fresh Frozen Plasma
  34. 35. Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma VIII Cryoprecipitate BLOOD PRODUCTS IX Albumin IgG
  35. 36. Transfusion Pathology Outline <ul><li>Blood groups </li></ul><ul><ul><li>Introduction </li></ul></ul><ul><ul><li>ABO system </li></ul></ul><ul><ul><li>Rh system </li></ul></ul><ul><ul><li>Other systems </li></ul></ul><ul><li>Blood transfusion </li></ul><ul><ul><li>Blood products </li></ul></ul><ul><ul><li>Indications </li></ul></ul>intro Rh ABO products other groups indications testing dangers
  36. 37. Whole Blood Use: massive hemorrhage RBC WBC platelets plasma Contents: INDICATIONS
  37. 38. Whole Blood Red Cells Use: low hemoglobin RBC a few WBC a few platelets a little plasma Contents: INDICATIONS
  38. 39. Whole Blood Red Cells Granulocytes Use: sepsis in neutropenic patients neutrophils Contents: INDICATIONS
  39. 40. Whole Blood Red Cells Granulocytes Platelet-rich plasma INDICATIONS
  40. 41. Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Use: bleeding due to thrombocytopenia platelets Contents: INDICATIONS
  41. 42. Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma Use: bleeding due to multiple factor deficiencies (e.g., DIC) Plasma (including ALL coagulation factors) Contents: INDICATIONS
  42. 43. Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma Cryoprecipitate Uses: low fibrinogen, vW disease, hemophilia A fibrinogen von Willebrand factor VIII Contents: INDICATIONS
  43. 44. Whole Blood Red Cells Granulocytes Platelet-Rich Plasma Platelets Fresh Frozen Plasma Cryoprecipitate INDICATIONS A bunch of other stuff Use: rarely used
  44. 45. Transfusion Pathology Outline <ul><li>Blood groups </li></ul><ul><ul><li>Introduction </li></ul></ul><ul><ul><li>ABO system </li></ul></ul><ul><ul><li>Rh system </li></ul></ul><ul><ul><li>Other systems </li></ul></ul><ul><li>Blood transfusion </li></ul><ul><ul><li>Blood products </li></ul></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><li>Testing </li></ul></ul>intro Rh ABO products other groups indications testing dangers
  45. 47. patient red cells (type A) FORWARD TYPE anti-A antibodies AHG Forward typing is done using both anti-A and anti-B antibodies!
  46. 48. patient serum (with anti-B Ab) AHG reagent red cells (type B) REVERSE TYPE Reverse typing is done using both type A and type B reagent cells!
  47. 49. patient serum AHG donor red cells CROSSMATCH
  48. 50. patient serum AHG reagent RBC number 1 patient serum AHG reagent RBC number 2 ANTIBODY SCREEN no agglutination (negative test) agglutination (positive test)
  49. 51. Transfusion Pathology Outline <ul><li>Blood groups </li></ul><ul><ul><li>Introduction </li></ul></ul><ul><ul><li>ABO system </li></ul></ul><ul><ul><li>Rh system </li></ul></ul><ul><ul><li>Other systems </li></ul></ul><ul><li>Blood transfusion </li></ul><ul><ul><li>Blood products </li></ul></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><li>Testing </li></ul></ul><ul><ul><li>Dangers </li></ul></ul>
  50. 52. What can go wrong? <ul><li>Transfusion reactions </li></ul><ul><ul><li>hemolytic </li></ul></ul><ul><ul><li>non-hemolytic </li></ul></ul><ul><li>Other complications </li></ul><ul><ul><li>circulatory overload </li></ul></ul><ul><ul><li>iron overload </li></ul></ul><ul><ul><li>infections </li></ul></ul>intro Rh ABO products other groups indications testing dangers
  51. 53. Acute Hemolytic Transfusion Reactions <ul><li>Happens when patient has ABO antibodies against the donor red cells. </li></ul><ul><li>Most common reason: clerical error ! </li></ul><ul><li>Symptoms: fever, chest pain, hypotension. </li></ul><ul><li>Hemoglobin in serum, urine. </li></ul><ul><li>Labs:  haptoglobin,  bilirubin, DAT positive. </li></ul><ul><li>Type and cross-match shows ABO mismatch. </li></ul>intro Rh ABO products other groups indications testing dangers
  52. 55. Delayed Hemolytic Transfusion Reactions <ul><li>Hemolysis occurs days after tranfusion. </li></ul><ul><li>Caused by antibodies to non-ABO antigens. </li></ul><ul><li>Hemolysis usually extravascular. </li></ul><ul><li>Presentation: falling Hgb after transfusion. </li></ul><ul><li>Usually not severe. </li></ul><ul><li>DAT +. Antibody screen identifies the antibody. </li></ul>intro Rh ABO products other groups indications testing dangers
  53. 56. Non-Hemolytic Transfusion Reactions <ul><li>Usually not as dangerous as hemolytic TRs. </li></ul><ul><li>Febrile TR: Fever. Treat with Tylenol. </li></ul><ul><li>Allergic TR: Hives. Treat with antihistamines. Rarely, may lead to anaphylaxis. </li></ul>intro Rh ABO products other groups indications testing dangers
  54. 57. Circulatory Overload <ul><li>Happens when too much blood is given too quickly </li></ul><ul><li>Symptoms: hypertension, congestive heart failure </li></ul><ul><li>Stop transfusion, give diuretics </li></ul>intro Rh ABO products other groups indications testing dangers
  55. 58. Iron Overload <ul><li>Too much iron can damage heart, liver </li></ul><ul><li>Patients with chronic anemias are at biggest risk </li></ul><ul><li>Give iron-chelating agents </li></ul>intro Rh ABO products other groups indications testing dangers
  56. 59. Infections <ul><li>Transfusion-related bacterial infection is rare but serious. </li></ul><ul><ul><li>Patients suddenly develop fever and shock. </li></ul></ul><ul><ul><li>Treatment: aggressive resuscitation and antibiotic therapy. </li></ul></ul><ul><li>Scary viruses (all donors tested for these): HIV, Hepatitis. </li></ul><ul><li>Other potential infections: EBV, malaria, Lyme disease. </li></ul>intro Rh ABO products other groups indications testing dangers
  57. 60. What’s the risk of getting an infection? One in 50,000 Hepatitis C One in a million Bacterial infection One in 100,000 HTLV One in 100,000 Hepatitis B One in 2 million HIV One in a million Other infections Risk Bug intro Rh ABO products other groups indications testing dangers
  58. 61. What’s the risk of other complications? One in 100 (severe: one in 20,000) Allergic reaction One in 4,000 (fatal: one in 4 million) Delayed hemolysis One in 3,000 Circulatory overload One in 200 Febrile reaction One in 20,000 (fatal: one in 600,000) Acute hemolysis Risk Complication intro Rh ABO products other groups indications testing dangers

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