Compatibility Testing for Blood Transfusion RIH Department of Anesthesiology

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

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

2011YT Cartwright 2010DI Diego 3009JK Kidd 6008FY Duffy 3007LE Lewis 21006KEL Kell 18005LU Lutheran 47004RH Rh 1003P1 P 37002MNS MNSs 4001ABO BLOOD GROUP SYSTEMS ANTIGENS ISBT NUMBER ISBT SYMBOL CONVENTIONAL NAME * *

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

Population Distribution of Major Blood Groups O Rh pos38% O Rh neg 7% A Rh pos34% A Rh neg 6% B Rh pos 9% B Rh neg 2% AB Rh pos 3% AB Rh neg 1%

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

Major Blood Groups ABO

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

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

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.

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

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)

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

Intravascular Clumping of Donor RBC’s

Intravascular hemolysis of donor RBC’s

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

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

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

But no intravascular clumping

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

Donor Questionnaire: Medical history Lifestyle Finger stick: Checking Hct

Donor Needs a Hct of 0.38 A drop of donor blood is placed into a test tube containing a CuSo 4 solution CuSo4 solution has a SG of RBC with Hct > 0.38 sink to the bottom of the test tube

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

DIFFERENT LEVELS OF COMPATIBILITY TESTING Landsteiner, 1899 Lifespan, 2008

COMPATIBILITY TESTING 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

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

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) ABO TYPING

Anti AAnti BAnti AAnti B Anti AAnti BAnti AAnti B AB OAB

ABO TYPING Back or reverse type with A and B cells Commercially available A and B cells are added to two tubes of plasma ABBAO ABABABAB

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 minutes Then add rabbit antiglobulin

If recipient antibodies have coated commercial RBC surfaces

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

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

2011YT Cartwright 2010DI Diego 3009JK Kidd 6008FY Duffy 3007LE Lewis 21006KEL Kell 18005LU Lutheran 47004RH Rh 1003P1 P 37002MNS MNSs * Possibly significant minor blood groups

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 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

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

Why does it take so much time?

Why does it take so long? Sample collection Specimen transport Specimen centrifugation15” Testing25” Sample collection Specimen transport Specimen centrifugation15” Testing25”

How much ONeg Blood Is OK?

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 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 How much ONeg?

What are our transfusion policies ?

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

PoliciesPolicies 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 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

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 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

Red blood cell compatibility table

Plasma compatibility table O B A AB ABAB BAO DonorRecipient