A woman had an anaphylactic reaction during a blood transfusion minutes after it started, with symptoms of flushing, chest tightness and difficulty breathing. Epinephrine was administered with good effect. The most likely cause was the woman being IgA-deficient and having antibodies against IgA in the donor blood. A woman developed a fever and jaundice after a blood transfusion during surgery. Her hemoglobin had dropped unexpectedly. The most likely cause was recipient antibodies against donor red blood cell antigens not detected on the pre-transfusion testing, causing a delayed hemolytic reaction. A man receiving a blood transfusion developed a fever within 15 minutes. Tests found no evidence of hemolysis.

1. Immunohematology Antonio Rivas PA-C 2008

2. A 28-year-old woman receiving her first blood transfusion begins to complain of flushing, tightness in her chest, and difficulty breathing within minutes of the start of the infusion. Her blood pressure drops rapidly and the transfusion is immediately discontinued. Epinephrine is administered with good effect. Specimens sent to the lab show no evidence of hemolysis. What is the most likely cause of such a reaction?

3. A. An ABO incompatibility B. Recipient antibodies against donor red cell antigens not detected on cross match C. Recipient antibodies against donor white cell or platelet antigens D. Recipient antibodies against donor IgA E. Donor antibodies against recipient white blood cells

4. Answer D. Recipient antibodies against donor IgA Anaphylactic reactions may occur in rare patients who are IgA-deficient and have developed anti-IgA antibodies. Reactions occur in response to IgA, which is normally present in donor blood. Symptoms develop rapidly (seconds to minutes after starting the transfusion) and may include bronchospasm, nausea, vomiting, flushing, urticaria, and hypotension. Immediate treatment including epinephrine and possible intubation is required. Subsequent transfusions must consist of red cells, which are washed to remove IgA and plasma from IgA-deficient donors.

5. A 47-year-old woman presents to your office after developing a low-grade fever and mild jaundice over the past several days. Her recent history is significant for a total abdominal hysterectomy performed 12 days ago, at which time she received 2 units of packed red blood cells without incident. Although there is no evidence of bleeding at present, her hemoglobin level is only 10.2 g/dl. You believe this may be a delayed transfusion reaction. What would be the most likely cause of such a reaction? A. An ABO incompatibility B. Recipient antibodies against donor red cell antigens not detected on cross match C. Recipient antibodies against donor white cell or platelet antigens D. Recipient antibodies against donor IgA E. Donor antibodies against recipient white blood cells

6. Answer Recipient antibodies against donor red cell antigens not detected on cross match

7. Delayed hemolytic reactions occur in patients previously sensitized (through transfusion or pregnancy) to red blood cell antigens other than ABO. Levels of these antibodies are not detectable by routine laboratory tests but quickly rise when the patient is challenged with donor cells displaying the appropriate antigen (an anamnestic response). These reactions are extra vascular in nature (hemolysis occurs mainly in the spleen). Clinical symptoms appear days to weeks after the transfusion, and may include fever and mild jaundice, along with an unexpected fall in hemoglobin. While rarely life threatening, these reactions are important to recognize because of the potential for more severe reactions with subsequent transfusions.

8. Immunohematology Study of the human blood groups Evaluation of blood donors Collection and processing of donor blood Testing for blood group antigens Matching patient with compatible blood before transfusion Antiglobulin tests IAT / DAT

9. Terminology Antibody : serum protein that is induced by, and reacts specifically with a foreign substance (Ag) Antigen : foreign substance that induces an immune response by causing production of antibodies and or sensitized lymphocytes that react specifically with that substance

10. Terminology Primary Ab response: immune response occurring after the first exposure to the Ag First Ab detected is IgM, 3-4 days after exposure Peaks and drops in a few weeks IgG detectable after 1-2 weeks, peaks within weeks and return to normal within few months

11. Terminology IgM increases reflects recent exposure Changes in IgG titters within 2-3 weeks also means recent exposure Seroconversion: when an antibody becomes detectable in serum/plasma of a patient who was previously tested as negative for the same Ab

12. Terminology Secondary Ab response (anamnestic response): seen after reexposure to an Ag Immune cells remember the Ag response is fast IgM and IgG increase quickly within 2-3 days Higher levels that stay for months to years booster vaccination

13. Immunoglobulins

14. Immunohematology Earliest recorded Blood transfusion in 1628 Transfusing blood from animals to human Disastrous results Prohibition of transfusion in the late 1600s 1900 discovered ABO blood group Patient blood mixed with donor blood before transfusion to look for reactions Discover anticoagulants First Blood bank in US in 1937 in Chicago

15. Immunohematology 1940 US government established a nationwide blood collection program Continued improvement next three decades In 1980 transfusion medicine became a medical specialty 1984 the cause of AIDS was proven to be the HIV-transmissible by blood Changes in blood donor screening Development of more sensitive tests to detect HIV and other infectious agents

16. General health requirements for blood donors Age > 16 yo Weight 110 pounds Temperature < 99.5 F Blood pressure < 180/<100 mm Hg Hemoglobin >11 g/dl

17. Tests for infectious diseases performed on donated blood Antibody tests Anti-HBc Anti-HCV Anti-HIV 1 and 2 Anti HTLV I and II Syphilis test Antigen tests • HBsAg • HIV-1 • Hepatitis C virus • West Nile virus

18. Blood components Collected as whole blood(RBC/WBC/Plts suspended in Plasma) Separated into Red blood cells Platelets Plasma (FFP) Packed RBCs can be stored refrigerated up to 42 hrs Other components: factor VIII, IX concentrate

19. Pretransfusion testing ABO forward testing Rh testing ABO reverse testing Antibody screen Crossmatch

20. Procedures performed in the Blood Bank ABO grouping Rh typing Compatibility testing before transfusion Typing of donor blood Unusual blood group antibody testing

21. Blood group system Major blood group system is the ABO system Four major blood types A, B, AB, or O ABO grouping tests based on principle of agglutination 45 % of the population of the US is group O, 40% is group A, 11% is B and 4 % is AB Differs according to racial and ethnic group

22. Blood group antigens Presence or absence of group A or B antigens in RBCs, leukocytes and Plts. Inherited One allele from each parent A and B are codominant with respect to each other Group A person has A ag in blood cells Group B person has B ag in blood cells Group AB person has A and B antigen on blood cells Group O person has neither A or B antigens on blood cells

23. Testing Blood group Antigens Patients RBCs are combined with known antiserum (antibodies) commercially available, observing for agglutination If the Ag present on the cells correspond to the antibody in the reagent, Ab will bind to the Ag and cause clumping of the cells (agglutination) Forward grouping

24. Forward grouping

27. ABO antibodies (Ab) Naturally occurring IgM Ab is present if Ag is missing Not well developed in newborns Detected by reverse grouping

28. ABO antibodies (Ab) Reverse grouping Detects Abs present in patients serum, by reacting the serum/plasma with suspension of commercially available A or B cells suspension and looking for agglutination

31. Importance of ABO grouping Must be done before blood transfusion Patient should be transfused with blood of the same ABO group Severe blood transfusion reaction if not properly matched blood is transfused “ avoid giving the patient an Ag he does not already have” In emergency O packed RBcells given-universal donor

32. Tissue transplants Kidney, liver, cornea, skin, pancreas, BM, heart, lung, intestine and bone Autologous//autografts: from the same individual Homologous //allografts : from the same species ABO and Rh matched Histocompatibility testing

33. Exercise

34. Rh blood group Second most important blood group system(name from the Rhesus monkey) Composed of many Ags Most important D Ag-most antigenic Only test for D Ag Product of inherited genes Only present in RBCs

35. Rh blood group Antibodies to Rh system do not occur naturally RBCs that posses the D antigen are called: Rh –positive or D-positive Weak D antigen is possible needs xtra. Testing in order to detect RBCs are incubated with commercially available anti-D

36. Rh antibodies Produced by a D negative person who has been sensitized or immunized to the D Ag Can occur during pregnancy or after blood transfusion Anti-D is an IgG

37. Hemolytic Disease of the newborn Abs from the mother enters the fetal circulation and destroys fetal red blood cells Caused primarily by maternal Anti-D recognizing D Ag in fetal RBCs D-negative mother becomes pregnant with a D-positive fetus During pregnancy or at birth (feto-maternal hemorrhage), mother becomes exposed to fetal RBCs and develops Anti-D

38. Hemolytic Disease of the newborn (HDN) Anti-D is a monomer can cross the placenta Usually affects subsequent pregnancies First pregnancy is not affected Prenatal screening for ABO/Rh and possible antibodies already present in their first trimester Father typing for Rh group

39. Hemolytic Disease of the newborn (HDN) Mild cases :mild anemia, jaundice, or breathing problems detected at birth Severe cases : heart failure, brain damage, stillbirth or miscarriage Prevention with Rh immune globulin (RhIG) given to the Rh negative mothers

40. RhIG (ROGHAM) Concentrated solution of anti-D from human plasma Given to D negative mothers at 28 Wks and 72hrs after delivery of a D-positive baby Also given after miscarriage, abortion or amniocentesis Repeated every pregnancy

41. Other immunological tests Antihuman globulin test (Coomb’s test) Uses a commercial antibody against human globulin (AHG) to detect globulin coated RBCs Also used for Hemolytic conditions

42. Hemolytic transfusion reactions Most severe with ABO mismatches Rapid intravascular hemolysis Free Hgb is released to the plasma Severity also related to the amount of RBCs given Acute or delayed

43. Hemolytic transfusion reactions Major HTR Fever Chills Backache Headaches Apprehension Dyspnea Hypotension Vascular collapse

44. Hemolytic transfusion reactions In very severe cases DIC Acute renal failure – from tubular necrosis Patient under general anesthesia will not voice symptoms, first findings may be oliguria, generalized bleeding Treatment : if suspected stop transfusion, draw sample of blood and look for Hemoglobenimia(pink plasma) Vigorously hydrate the patient Force diuresis with Manitol may help prevent renal damage

45. Other transfusion reactions Leukoagglutinin rx: to Ags in WBCs sensitized by previous pregnancy or transfusions Non hemolytic, Htc increases as expected Fever and chills within 12 hrs of transfusion Cough, dyspnea, and lung infiltrates may develop Treated with: Tylenol, Benadryl, and steroids Leukopoor filters are used to prevent

46. Other transfusion reactions Anaphylactic Reactions Urticaria or bronchospasm Due to plasma proteins most of the time IgA deficient patients , may have anti-IgA and develop reactions to the IgA dissolved in the plasma(transfusion)

47. Other transfusion reactions Contaminated blood With gram negative bacteria Rare Septicemia and shock from endotoxins If suspected, culture the blood unit and treat patient with antibiotics

48. Blood Products Whole Blood Packed cells Platelets concentrates Plateletaphoresis Granulocytes Fresh Frozen plasma Cryoprecitate Clotting factors concentrates

49. A 55-year-old man complains of chills, and is noted to have a rise in temperature from 98.9 to 101.7° F, within 15 minutes of starting a transfusion of packed red blood cells. The transfusion is stopped and antipyretics are administered, lowering his temperature. Specimens sent to the blood bank show no evidence of hemolysis, and there are no clerical discrepancies. What is the most likely cause of his reaction? A. An ABO incompatibility B. Recipient antibodies against donor red cell antigens not detected on cross match C. Recipient antibodies against donor white cell or platelet antigens D. Recipient antibodies against donor IgA E. Donor antibodies against recipient white blood cells

50. Answer C. Recipient antibodies against donor white cell or platelet antigens

65. The end