Compatibility Testing for Blood Transfusion

RIH Department of Anesthesiology

Whats new?

Why does it take so much time?

How much ONeg Blood Is OK?

What are our transfusion policies ?

Blood Bank Issues

ISBT = International Society of Blood Transfusion

Recognizes the Presence of Multiple Antigens on the Surfaces of Red Blood Cells that define Blood Group Systems

BLOOD GROUP SYSTEMS CONVENTIONAL NAME ISBT SYMBOL ISBT NUMBER ANTIGENS

*ABO MNSs

P *Rh Lutheran Kell Lewis Duffy Kidd Diego Cartwright

ABO MNS P1 RH LU KEL LE FY JK DI YT

001 002 003 004 005 006 007 008 009 010 011

4 37 1 47 18 21 3 6 3 2 2

BLOOD GROUP SYSTEMS CONVENTIONAL NAME ISBT SYMBOL ISBT NUMBER ANTIGENS

Xg Scianna Dombrock Colton

Landsteiner-Wiener

Chido/Rogers Hh Kx Gerbich Cromer Knops Indian Ok Raph JMH

XG0 SC DO CO LW CH/RG H XK GE CROMER KN IN OK RAPH JMH

012 013 014 015 016 017 018 019 020 021 022 023 024 025 026

1 3 5 3 3 9 1 1 7 10 5 2

----

Population Distribution of Major Blood Groups

O O A A B B AB AB

Rh pos Rh neg Rh pos Rh neg Rh pos Rh neg Rh pos Rh neg

38% 7% 34% 6% 9% 2% 3% 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 RBCs

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 newborns 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 RBCs

Intravascular hemolysis of donor RBCs

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 RBCs 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 CuSo4 solution CuSo4 solution has a SG of 1.053 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
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

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

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

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

Anti A

Anti B

Anti A

Anti B

Anti A

Anti B

Anti A

Anti B

AB

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
A B A

B
B A

A
B A

O
B

How do we know whether or not the host (or recipient) has antibodies to minor blood group antigens? Add commercial RBCs 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

If recipient antibodies have coated commercial RBC surfaces

Rabbit antiglobulin will bind to the Antibodies and the RBCs 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

Possibly significant minor blood groups

MNSs P *Rh Lutheran Kell Lewis Duffy Kidd Diego Cartwright

MNS P1 RH LU KEL LE FY JK DI YT

002 003 004 005 006 007 008 009 010 011

37 1 47 18 21 3 6 3 2 2

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

POSITIVE ANTIBODY SCREEN 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 centrifugation Testing

15 25

How much ONeg Blood Is OK?

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

What are our transfusion policies ?

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

Policies
Administration: Inspect bag Verify ABO Rh Match IDs If no access to name bracelet use Innovian to match IDs 2 licensed personnel & 2 signatures Normal saline only

Whats new?

Whats 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

Red blood cell compatibility table Recipient OO+ AA+ BB+ Donor

O- O+ A- A+ B- B+ AB- AB+

ABAB+

Plasma compatibility table

Recipient Donor

O A B A B

AB
A B O