|Year : 2012 | Volume
| Issue : 1 | Page : 59-129
|TRANSCON 2011 - 36th Annual National Conference of Indian Society of Blood Transfusion and Immunohematology (ISBTI)
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|Date of Web Publication||16-Apr-2012|
|How to cite this article:|
. TRANSCON 2011 - 36th Annual National Conference of Indian Society of Blood Transfusion and Immunohematology (ISBTI). Asian J Transfus Sci 2012;6:59-129
|How to cite this URL:|
. TRANSCON 2011 - 36th Annual National Conference of Indian Society of Blood Transfusion and Immunohematology (ISBTI). Asian J Transfus Sci [serial online] 2012 [cited 2013 Dec 10];6:59-129. Available from: http://www.ajts.org/text.asp?2012/6/1/59/95062
30 th Oct - 1 st Nov 2011, Panchkula, Haryana
| Free Papers|| |
To study usefulness of platelet cross matching for single donor platelets in the management of platelet refractoriness in hematological patients
Elhence P, Chaudhary RK, Nityanand S and Katharia R
Department of Transfusion Medicine, SGPGI, Lucknow, India
Background: Platelet transfusion support is mainstay of management in patients with hematological oncology and aplastic anemia. Repeated platelet transfusions lead to immune platelet refractoriness. The approach of identification of HLA, platelet-specific antigen antibodies and then issuing antigen-negative platelets is tedious, as thousands of typed donors are required. Transfusion of platelet cross match compatible to platelet can be used as an alternative.
Aims: To study the usefulness of platelet cross match in patients requiring Single donor platelets (SDPs).
Material and Methods: A total of 58 SDP transfusion episodes in patients with hematological oncology and aplastic anemia were evaluated for outcome of transfusion by corrected platelet count increment (CCI) at 24 hr, post transfusion. CCI ¡Ý 4500 plt X m 2 /ul was considered an adequate response. Demographic and other clinical data was collected. Modified antigen capture Elisa (MACE I and II, GTI diagnostics) was used for platelet cross matching, using pre transfusion patient sera sample and platelets from respective SDP transfused.
Result: Of the 58 SDP transfusion episodes, inadequate response was observed in 15 (25.8%). Platelet cross match was positive in 10 out 15 (66.6%) SDP transfusion episodes with inadequate response and in 2 out of 43 (4.65%) SDP transfusion episodes with adequate response. The Sensitivity, specificity, positive predictive value and negative predictive value of platelet cross match for assessment of clinical transfusion outcome was 66.6%, 95.3%, 83.3% and 89.9% respectively.
Conclusion: Selecting platelet cross match compatible donors for immune refractory patients can improve the transfusion outcome.
To Assess Prevalence and Risk Factors Responsible for Platelet Transfusion Refractoriness in Multitransfused Hemato-oncological Patients at Tertiary Care Centre in North India
Vijay Kumawat, R R Sharma, Pankaj Malhotra 1,
Departments of Transfusion Medicine, 1 Medicine, PGIMER, Chandigarh, India.
Background: This study was designed to determine the prevalence and assess the risk factors responsible for platelet transfusion refractoriness in hemato-oncological patients and aimed to formulate guidelines for management of refractory patients.
Materials and Methods: The study included 30 patients, who were regularly being supported by the transfusion medicine department of large tertiary care hospital of North India. 20 of these patients were clinically diagnosed as aplastic anemia (AA) and the rest 18 were of acute myeloid leukemia (AML). A prospective 3 month follow up was planned to monitor response of platelet transfusion therapy, based on their post transfusion corrected count increment (CCI) at 1 h and 24 h. Based on the observations, patients were categorized into refractory and non refractory groups. Response to apheresis platelet (AP-PC) as well as random donor platelet (RDP) support was monitored. Common non immunological causes such as fever, sepsis, bleeding, DIC, chemotherapy, splenomegaly, ABO mismatch and ATG therapy was monitored. Amongst the immunological causes, presence of anti HLA class I antibodies and platelet glycoprotein antibodies in patient's serum were monitored.
Results: During study period, 17 (56.66%) patients did not show desired platelet count increment. Transfusion requirements of refractory group for both red cell and platelet product were significantly higher (P < 0.05) in comparison to non refractory group. Among immunological causes anti HLA class I antibodies (P < 0.013), anti HPA-5b antibodies (P < 0.033) were significantly associated with refractoriness. Among non immunological causes bleeding (P < 0.019), fever (P < 0.08), infection (P < 0.07) were found to be associated with refractoriness.
Conclusion: Platelet refractoriness should be suspected in multitransfused patients not showing expected increment in platelet counts and discussion with clinical colleagues so as to frame further guidelines for individual patient's treatment should be carried out at the earliest, in order to ensure proper management of these kinds of patients.
Transfusion Therapy for Patient's with Auto Immune Hemolytic Anemia: Least Incompatible versus Partial Phenotype matched Blood Transfusion
Rajesh Sawant, Sahjid Mukhida, Jyoti Bhatt,
Chandni Karia, Bhanu Radadiya, Maitrik Dave.
Rajkot Voluntary Blood Bank and Research Centre, Pitroda House, Rajkot, Gujarat, India
Background: Transfusion support may be urgently required for patients with Auto Immune Hemolytic Anemia (AIHA), who present with fulminant hemolysis. The presence of RBC auto-antibodies can make it difficult to detect co-existing alloantibodies, which can cause severe hemolytic transfusion reaction. Clinicians are extremely concerned about the transfusion of least incompatible blood. Provision of clinically safe transfusion support within a short time remains a challenge in these cases.
Aim: To compare and evaluate the safety and efficacy of least incompatible versus partially antigen matched blood transfusion in patients' with AIHA.
Material and Methods: Between March 2009 and July 2011, 30 patients were identified serologically as cases of AIHA. Only 1 amongst the above had serology consistent with cold AIHA. In 15 out of 30 cases, the treating clinician denied for transfusing least incompatible blood. 8 patients (27%) were transfused with least incompatible blood transfusion and 7 patients (23%) received limited phenotype matched i.e. ABO, D, C, E, c, e and K matched blood transfusion.(i.e. donor RBC's matched with the patient's phenotype). All cellular blood components issued to the above 15 patients were leucocyte reduced. Both the patient groups were compared for serological findings (panel studies), Direct antiglobulin test (DAT), number of transfusions received, interval between two transfusions, increase in patient's hemoglobin per unit of red blood cells transfused and any immediately or delayed adverse transfusion reaction. On receiving the patient's samples for subsequent transfusion requirement, panel studies and DAT was performed and appearance of any new alloantibodies was monitored.
Results: All 15 patients had established serologic diagnosis of warm AIHA, and DAT was found to be negative in 2 (14%) cases. In the least incompatible group, a mean of 8 units were transfused per patient, while in the partial phenotype matched patient group, a mean of 3 RBC units were transfused per patient. The post transfusion increase in hemoglobin was 0.9 gm/dl in the least incompatible group compared to an increase of 1.7 gm/dl in the partial phenotype matched group. The mean interval between two transfusions was 9 days in the least incompatible transfusion group and 23 days in the partial phenotype matched group. Delayed hemolytic transfusion reaction was reported in 2 cases- both receiving least incompatible transfusions. A new allo-antibody (Anti-M) appeared in one patient, who had received a least incompatible transfusion.
Conclusion: The provision of partial phenotype matched blood for transfusion support in AIHA cases was clinically more beneficial than the transfusion of least incompatible RBC units. We now have started maintaining a record of phenotypically matched donors for patients with AIHA and Thalassaemia, who have previously determined phenotypes. This practice has enhanced transfusion safety in urgent situations.
Morphological and Functional changes in random donor platelets stored for seven days in additive solution
Tulika Chandra 1 , Ashish Gupta 1,2 , Ashutosh Kumar 2
1 Department of Transfusion Medicine and Blood Bank, 2 Department of Pathology, Chhatrapati Shahuji Maharaj Medical University (Earlier King Georg's Medical University), Lucknow, Uttar Pradesh, India.
Background: In India, platelets are currently stored in plasma for 5 day at 22 °C. The biochemical, structural and functional changes that occur during platelet storage under blood bank conditions are collectively known as platelet storage lesion. Optimized synthetic media might help attenuate the platelet storage lesion, thereby facilitating extended storage.
Objective: Our objective was to assess platelet morphology and function in random donor platelet stored for 7 days in platelet additive solution.
Materials and Methods: The random donor platelet was prepared by PRP method. Platelet concentrates from 50 blood donor were stored in 100 % plasma (n=24) and 20% / 80% composol (n=24) additive solution. The RDP were placed in incubator and agitator at 22°C.
Results: Out of total 50 samples, 48 samples were analyzed and 2 were discarded due to the bacterial contamination. On comparing the mean values of platelet count and MPV in both groups, no significant difference was observed on day 7 of storage period. A significant difference in PDW was observed on day 7 (p < 0.001) in plasma. The mean values of LDH and pH showed no significant difference on day 7 in both the groups. A significant difference was observed in the levels of glucose on day 7 (p < 0.001) in plasma. In platelet aggregation, also, a significant decrease was seen in plasma (p < 0.001) on day 7 at 22 °C
Conclusion: The platelet morphology and function was better maintained in composol additive solution on day 7.
The importance of evaluation of grey zone in transfusion transmitted infection testing by ELISA: SGPGI experience
Katharia R, Chaudhary R, Elhence P, Verma A, Agarwal P, Sonkar A.
Department of Transfusion Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
Background: Hepatitis B, Hepatitis C and human immunodeficiency virus are the most important agents responsible for morbidity related to transfusion-transmitted infections (TTI). Despite the advances in techniques for detection of TTIs, India is still far from achieving zero risk blood supply. Calculation of grey zone of donor samples tested by ELISA is a routine done in out department as per the departmental SOP.
Material and Methods: Blood donation record was reviewed from May 2005 to July 2011, retrospectively. A total of 125026 donors were screened for HBV, HCV and HIV on fully automated ELISA system. Grey zone was calculated by multiplying the OD of the cut off with 0.9. All donor samples falling under the grey zone were retested in duplicate.
Results: Out of the total 1,25,026 donors were tested, 317 donor samples were in grey zone for HBV, 150 donor samples for HCV and 97 donor samples for HIV. 55 (17.3%) out of 317 HBV grey zone donor samples, 30 (20%) out of 150 HCV grey zone samples and 19 (19.5%) out of 97 HIV grey zone donor samples were reactive on repeat testing. Grey zone evaluation was able to prevent 102 probable transfusion transmitted viral infections.
Conclusion: As there is no guideline for inclusion of grey zone samples in TTI testing as per existing standards, absence of grey zone evaluation on ELISA screening, a substantial number reactive donor samples would have been missed. This would have resulted in transfusion related adverse consequences in the recipient. The donor samples that were repeat reactive after grey zone were not confirmed by confirmatory assay. Although, grey zone evaluation results in increased discarding of blood units, but blood safety remains the priority.
ID-NAT vs. ELISA
Kaur Daljit, Doda Veena, Singh Reena, Bharti Rashmi Rani, Kirtania Tapan, Kumar Virender
Dr. Ram Manohar Lohia Hospital, New Delhi, India.
Background: Aim of blood transfusion services is to provide safe blood to patients. With advances in technology, greater emphasis can be placed on testing blood to improve safety in developing countries.Implementation of nucleic acid testing in blood bank setting is a big challenge for a developing nation like ours. The balance between blood safety and cost effectiveness remains a major concern in this scenario.Looking into the increasing trend for HIV, HBV and HCV markers, we evaluated whole blood donor testing by ID-NAT for simultaneous detection of all the three markers and compared with serological tests for the same.
Aim: To compare ELISA with ID-NAT testing for detection of HIV, HBV and HCV among blood donors at Dr Ram Manohar Lohia hospital.
Materials and Methods: A retrospective study was conducted at blood bank in our hospital during the period of July 2010 to June 2011. In addition to the routine mandatory testing,, which include screening for anti-HIV1/2, HBsAg and anti- HCV, all donor samples were subjected to INDIVIDUAL NUCLEIC ACID TESTING (ID-NAT) for the same markers. NAT was done by Transcription Mediated Amplification (TMA) technology using multiplex and discriminatory testing by Procleix Ultrio Assay (Chiron Corp., Emeryville, CA) for simultaneous detection of HIV-1, HBV and HCV.
Results: A total of 11,098 samples were tested both by ELISA and NAT, Out of which, 257 (2.31%) were seroreactive and 215 (1.94%) were NAT reactive. There were 87 seroreactive samples, which were NAT nonreactive. NAT yield was 25 (NAT reactive but serononreactive cases), which included 1 HIV, 1HCV and 23 HBV NAT reactive cases. The NAT coinfection yield cases (seroreactive for 1 but NAT reactive for 2 markers) were 23 including 8 HIV, 5 HCV and 10 HBV cases. We observed 4 NAT coyield cases (NAT reactive for 2 markers, but Serononreactive) comprised of 1 HIV-HBV and 3 HBV-HCV cases. One coinfection was observed by ELISA that was HBV /HCV.
Conclusion: This is the pioneer study from a Government tertiary care centre of the region. Although, Antigen or Antibody based screening tests has high sensitivity, antigen-antibody seronegative transmission of viral infections can still occur due to window period. The NAT yield rate for each HIV and HCV was 0.09 per 1000 donors, while for HBV, it was 2 per 1000 donors at our centre.ID-NAT is expected to contribute significantly to scientific knowledge on the detection and dynamics of HIV, HBV and HCV infections. Thus, NAT together with serology can bring blood safety towards close to zero risk blood supply by providing an additional layer of safety.
Assessment of maternal red cell antibodies implicated in hemolytic disease of the new born
Singh L, Basu S, Huria A, Chawla D
Departments of Transfusion Medicine, Obstetrics and Gynecology and Pediatrics
Background: Hemolytic disease of the fetus and newborn (HDFN) results from shortened life span of the infant's red cells, due to their immune destruction by trans-placental passage of maternal antibodies. These maternal antibodies could be anti A or anti B; or immune antibodies to any of the blood group antigens, commonly the Rh (D) antigen.
Aims: To determine the frequency of maternal ABO antibodies and red cell alloantibodies implicated in haemolytic disease of the fetus and newborn, and to correlate the antibody specificity with the newborn outcome.
Materials and Methods: This was a prospective study conducted over a period of 18 months. All pregnant women, both Rh(D) positive and negative, with 35 completed weeks of gestation were enrolled and assessed for the presence of antibodies by the indirect antiglobulin test (IAT). All newborns of mothers with IAT positive results and newborns with significant jaundice (requiring phototherapy) were tested for the direct anti-globulin test (DAT). Antibody identification was done as and when necessary, using standard procedures.
Results: Anti D was the most common antibody detected. Among the 2,500 mothers screened, the frequency of alloimmunization was 0.68% (excluding ABO HDN). Rh D alloimmunisation was seen in 8 (0.36%) cases and non-D alloimmunisation seen in 7 (0.32%) cases. The non-D antibodies included one case each of anti K, anti E, anti E + anti c, and anti S. There were 3 cases of antibodies to the Lewis antigen. The frequency of ABO HDN was found to be 0.2% (6 cases), of which 1 was in Rh (D) negative mother. Maternal alloimmunization and/or ABO HDN occurred in 11 Rh (D) positive mothers. The need for phototherapy and exchange transfusion was found to be statistically more in HDN due to ABO and Rh D incompatibility as compared to the non D category.
Conclusion: Hemolytic disease of the newborn was detected both in Rh (D) positive and negative mothers. Anti D was the most commonly detected antibody. Phototherapy and/or exchange transfusion was more often required in ABO HDN and Rh(D) HDN as compared to non Rh(D) HDN group.
Clinical Profile and outcome of 64 Rh D alloimmunised pregnancies in a Tertiary Care Centre in Kerala
Department of Transfusion Medicine, Medical College, Trivandrum, India.
Introduction: Development of anti D immunoglobulin, better facilities for early detection and treatment and better neonatal care has brought down the frequency and magnitude of HDFN. But these advantages are limited to places with good access to health care, making it prudent to have studies from areas with less access to health care. Evaluation of diagnostic tools available in each facility is also important so as to replace the less sensitive tests with better tests in a cost effective way.
Aim: 1. To find out the frequency of Rh D alloimmunization in antenatal cases and frequency of HDFN in their off springs 2. Correlate the antenatal anti Rh D titre and cord blood values with severity of HDFN
Materials and Methods: Longitudinal crosssectional study done in Department of Transfusion Medicine, on 64 antenatal cases, positive for anti Rh D antibodies by ICT and followed up with serial titres and ultrasound. Peak titre levels were correlated with severity of disease and cord blood values. Data was analyzed in SPSS ver.17 and correlations done by Pearson correlation.
Results: Out of 2,496 Rh D negative women tested with ICT, 78 (3.12%) were positive. Failure to administer RhIg lead to alloimmunization in 42(65.6%) cases. Frequency of HDFN was 57/ 64 cases. 54 RhD positive newborns were DCT positive (93.1%) and 4 were negative (6.9%). Male: female ratio 1.46:1.50. 9% cases were unaffected or mild and 10% were severe. Majority (50%) received no treatment and phototherapy was the major modality of treatment. Maternal titres correlated with severity of disease, cord Hb (negative correlation r=-.310, p=.016) and cord bilirubin (r=.591, p.000). Cord Hb had a negative correlation (p.04) and cord bilirubin (p.004) had positive correlation with intensity of treatment. DCT grade did not correlate with treatment (p=.39). Overall survival rate of affected newborns was 92.18%. Out of 6 hydropic babies, 4 died in utero.
Conclusion: Frequency of Rh D alloimmunization is higher in the institution compared to global standards, but survival rate in newborns is >90%. Hydropic babies have a higher death rate. Serological tests correlates acceptably with the disease. Better strategies to prevent Rh D alloimmunization and introduction of interventions like IUT are warranted.
Comparison of fetomaternal hemorrhage using Kleihauer Betke and microcolumn gel technique in Rh D negative mothers
Kshitija Mittal, Neelam Marwaha, Praveen Kumar,
S.C. Saha, Beenu Thakral
Department of Transfusion Medicine, PGIMER, Chandigarh, India.
Aim: To assess the efficacy of microcolumn gel technology in detection and quantification of fetomaternal hemorrhage (FMH) in comparison to the Kleihauer-Betke test (KBT) in non isoimmunized Rh D negative mothers
Materials and Methods: 80 Rh D negative, Indirect Coombs' test negative mothers, who delivered live babies from January 2008 to March 2009, were included. Peripheral venous blood samples were collected in plain and EDTA vials within 1 h of delivery, before administration of RhIg. FMH was determined by KBT (Sigma Aldrich Chemie GmbH, Steinheim, Germany) and microcolumn gel technology (FMH kit, Diamed AG, Switzerland) and the results compared. FMH was recorded as < 4 ml, by KBT, no fetal cells were seen after examining 25 fields using 10 x objective. This critical value of 4 ml of RBCs was chosen because even a low dose of 100 μg RhIg can adequately neutralize upto 5 ml of FMH. If fetal cells were seen, slides were examined further to quantify FMH. By using gel technique, FMH was reported as <0.1%, 0.1%, 0.2% and ≥0.4%.
Results: No case had FMH > 15 ml by KBT, so no additional anti D dose required as this is covered by standard dose of 300 μg being administered in India. 62 patients (77.5%) had FMH<4 ml by KBT. FMH was ≤ 0.2% (approximates 4 ml) by gel technology in all these cases. The mean volume of FMH in rest 18 (22.5%) cases by KBT was 8.33±1.69 ml. 15 (83.3%) out of these 18 cases had FMH ≥0.4% (approximates 8 ml) by gel technology. The 3 cases (16.7%) which differed from KBT had FMH of 0.2% by gel technique, where maximum FMH was 6.38 ml by KBT and hence did not require any additional dose of RhIg. No correlation was seen between FMH and maternal parity and number of abortions. FMH was significantly increased in Caesarean section (mean FMH 9.48±0.84 ml, range 7.9-10.37 ml) and antepartum hemorrhage (mean FMH 9.46±0.90 ml, range 7.9-10.37 ml).
Conclusion: Gel technique is an effective screening test. Technologies like KBT / flow cytometry are better options for detecting large volume of FMH. Antepartum hemorrhage and Caesarean section are risk factors for FMH but in none of the case FMH was more than 15 ml. The dose of 300 μg is sufficient immunoprophylaxis.
Autologous Platelet Derived Growth Factors as a treatment modality in early Osteoarthritis Knee - A Prospective Randomized Control Trial
Ashish Jain, Sandeep Patel 1 , Sameer Aggarwal 1 , Neelam Marwaha, M. S. Dhillon 1
Department of Transfusion Medicine and 1 Orthopedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Background: Osteoarthritis (OA) of the knee is one of the main causes of musculoskeletal disability. Current available management options provide symptomatic relief but in general, do not address the disease process itself. Autologous platelet-rich fibrin, prepared from platelet-rich plasma (PRP) is a biological delivery system of a complex mixture of bioactive proteins essential to natural repair. Released proteins such as insulin-like growth factor (IGF-I), platelet-derived growth factor (PDGF) and transforming growth factor-1 (TGF-1) could favor cartilage stabilization by regulating metabolic activities of resident chondrocytes and subchondral bone.
Aims: The study was designed to evaluate the efficacy of intra-articular injection of platelet rich plasma as a treatment option for early osteoarthritis of knee joint. We also evaluated the safety profile of PRP injection in knee joint osteoarthritis.
Materials and Methods: A total number of 75 patients with bilateral early OA of knee were selected on the basis of pre-defined inclusion and exclusion criteria after informed consent. The subjects were randomly divided into 3 groups, which constituted 27 patients in group A (54 knees), 25 patients in group B (50 knees) and 23 patients in group C (46 knees). For each therapeutic procedure about 100 ml of venous blood was drawn under aseptic precautions from the antecubital vein and collected in a blood bag with Citrate Phosphate Dextrose and Adenine (CPD-A1) as anticoagulant - preservative solution. The blood was separated into platelet rich plasma (PRP) and residual RBCs with the buffy coat through centrifugation. The PRP was then extracted through a pipette and transferred to a test tube. A leucocyte filter was then used to prepare the final PRP, which was dispensed in a syringe in a quantity of 8 ml for a knee along with 2 ml calcium chloride (CaCl 2 ). The 'Group A' received single injection of 10 ml of PRP, 'Group B' received two injections of 10 ml of PRP 2-3 weeks apart and 'Group C' received 10 ml of normal saline (controls). The patients in the 3 groups were blinded in the study and did not know what they were receiving. Follow up evaluation was done on 3 week, 3 months and 6 months by an independent observer (blinded) for clinical assessment and adverse effects.
Results: All the 3 groups were homogenous in respect to age, sex, height, weight, BMI and Ahlback's grading, and could be compared for effect of treatment without any confounding factors. The baseline WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) score for each parameter were also similar in all 3 groups. The results of major parameters are shown in [Table 1].
At each follow up, the percentage benefit from base line was greater in Groups A and B than Group C (p < 0.001) in terms of decrease in pain, improvement in physical functions, decrease in stiffness and improvement in WOMAC score. The minor difference in percentage benefit between Groups A and B was not statistically significant for the above parameters. 6 patients (22.2%) in Group A and 11 patients (44%) in Group B had complications. This was significant in comparison to Group C, which had no complications. In Group B, 5 patients (20%) had complications during the second procedure. There was no significant difference between Groups A and B. The mean duration to benefit was 17.63 days in Group A and 16.54 days in Group B. Males had an earlier response compared to females in both groups, but was significant in Group B.
Conclusion: The results of our study support the hypothesis of the effectiveness of PRP injection over placebo for relieving pain, stiffness and improving knee functions in osteoarthritis of the knee. Improvement of symptoms was noted by 2 to 3 weeks and persisted till the end of third follow up (6 months), however with a slight worsening of symptoms compared to second follow up.
Case Report of a Panagglutination due to alloantibodies
Annapurna Ramesh, Deepak Bhandari, Ankit Mathur TTK Rotary
Regional Transfusion Centre, Bangalore, India
Background: Red cell serology is a complex area though appears as simple technology. Panagglutinating sera are rare (0.089%) occurrence. Panagglutination is a patient sera agglutinates with all red blood cells (RBCs) tested in first approach. Also agglutinates all RBCs screening and identification of panel cells. A Panagglutinating serum is challenging dilemmas of the antibody identification and to manage the patient transfusion wise, even in advanced countries. In this situation, systematic workup is necessary to reduce the risk of error and optimize the sample use as many tests need to be done and repetitions of few tests are necessary. Panagglutinating sera to high frequency antigen e.g. Cartwright, Colton, Diego, Vel, Scianna etc is (0.002%), and due to auto antibody is (0.087%)
Case Report: We investigated serum of a female patient 31years of age for Panagglutination, posted for Spinal cord neurosurgery. We received her sample on 14 April 2011 for grouping and two units PRBC reservation. She gave H/O G3, P1, A2, without previous H/O blood transfusions, H/ O treated tuberculosis 2 years ago.
We sent the sample for Ab identification to TTK Regional Centre and found 2 + agglutination in all 11 Ab identification panel red cells; auto control was negative for agglutination (Bioview), DCT Negative, tube technique did not pick up the alloantibody.
Clinical Management: Informed all details to clinicians. Blood was neither reserved nor utilized. Post operative period was uneventful. Oral haemetenics prescribed.
- DCT Negative, auto control negative, Hb-11.6gm %, normal blood smear ruled out auto antibody and alloantibody was causing Panagglutination.
- Alloantibody to high-frequency antigen (HFA) - Ab corresponding to HFA usually best reacts by IAT, uniform grading seen in panel cells and IAT tests with red cells.
- Multiple antibodies to recognizing antigens (other than HFA) - differential Grading seen is due to variable intensity and distribution of multiple antigens in panel cells.
- Clinically insignificant High-titer, low-avidity (HTLA) antibodies usually agglutinate with W+ to 1+ grading in IAT.
- Uniform 2+ agglutination in IAT suggested alloantibody to a HFA.
- Chances of HTLA antibodies cannot be ruled out and further investigations such as extended cell panel testing, genotyping and in vitro test for predicting the outcome of transfusing incompatible blood are desirable.
Conclusion: In this case, panagglutination was due to HFA alloantibodies (? HTLA) acquired as a result of pregnancy. Patients lacking high-frequency antigen with HFA alloantibodies are rare. Due to rarity of blood donors lacking corresponding HFA, it is most difficult to arrange HFA negative blood. Also in vitro pre-transfusion tests for predicting the outcome of transfusing incompatible blood are invaluable in these rare cases.
The Effect of Repeated Freezing and Thawing on Vitamin K- Dependent Coagulation Factors and Fibrinogen Levels in Fresh Frozen Plasma
Pathak Amardeep, Col Philip J, Col Sarkar R S, Surg Cdr Mallhi R S
Department of Transfusion Medicine, AFMC, Pune - 411 040, Maharashtra, India.
Background: Component therapy has had a profound impact on the practice of transfusion-medicine. Fresh Frozen Plasma (FFP) is considered adequate for transfusion immediately after thawing or for 24 h if kept at 1- 6°C, and is currently used most often to replace deficient clotting factors. This study examines the levels of Vitamin K dependent factors (Factor II, VII, IX and X) as well as fibrinogen upon twice freezing and thawing of FFP. If factor levels in refrozen FFP are within normal limits, then this component can possibly be transfused, thus avoiding wastage of FFP.
Aim: To study the fate of Vitamin K- dependent Coagulation factors (FII, FVII, FIX, FX) and Fibrinogen activity levels in repeatedly (twice) frozen and thawed FFP.th
Materials and Methods: 200 FFP units comprising 50 of each major blood group (A, B, AB, O) was thawed at 37°C, immediately after taking out from the deep freezer (-18°C) within 24 h of preparation i.e. day zero. FFP samples (representative samples) was taken in aliquots for assessment of various coagulation factors (1 st Sampling). The FFP bags was kept for 24 h at 4°C after the sampling. At the end of 24 h, repeat samples were taken in aliquots from the above FFP bag (2 Sampling). After the repeat sampling the bags were re-stored at less than -18°C. 1 week later, the above procedure was repeated again. Coagulation factor activity and fibrinogen levels were measured by the coagulation analyzer.
Results: The mean levels of prothrombin, F VII, F IX, FX and fibrinogen of each blood group (A, B, AB and O) were calculated for each of the 4 points of time and found not statistically different (p >0.05). Therefore, the rest of the analysis was done for all the 200 FFP units as 1 group. The mean ± SD levels of each coagulation factor at each time point demonstrated that all levels were within normal limits of all factors measured. There was no significant decay in the level of activity of any Vitamin-K dependent factors.
Conclusion: The levels of F II, F VII, F IX, F X and fibrinogen remain stable and adequate for transfusion in twice-thawed-and-refrozen FFP. This component can be safely used for transfusion as a source of vitamin K dependent clotting factors and fibrinogen.
Dynamic Intelligent Blood Donor Network
Rajeev Joshi, Uday Thatte, Sanjay Bedi
HITECH Medical Informational Services Pvt. Ltd., MM IMSR, Mullana, Ambala, India.
Background: Scarcity of blood is a major problem all over the country. This is largely due to inefficient management of supply and demand of blood. In addition, there are several issues regarding donor availability, donor screening and blood quality. Various solutions, which attempted to resolve this medico-social problem, have failed for various reasons.
Aims: Our goal is to help the needy patients in getting donors of required blood group as quickly as possible with the use of state of the art information and communication technology.
Material and Methods: In our service, we are linking all the blood banks to central database of blood donors. This database is updated through mobile phone using our innovative technology, â€útemplate based SMS to update web enabled databaseâ€. The Intelligent Blood Donor Network is designed to meet following criteria:
- Highly automated with lowest possible degree of human intervention Instant response
- Highly accessible as SMS is selected as the mode of communication. 80% people use mobile phone as against 10% using net.
- Non-intrusive to donors
Easy to operate for donors as well as blood banks
- Message processing programs employ logic to avoid sending search requests to female donors during 8pm-8am (for logistical reasons).
- Once a donation event is recorded, the same donor is not contacted for next 4 months.
- Location of blood requirement is identified and donors in the vicinity are contacted first / based on preferred blood bank
- Blood donors are allowed to specify their preferred blood banks and requests from other blood banks are not sent to them.
- Availability of donors (e.g. 5pm-9pm) is recorded in the system and requests are sent only during this time period.
- Reason and/or duration of non-availability are recorded and accordingly message is not sent.
- Request initiation for blood donors as well as blood banks is kept simple with only the service keyword. E.g. Donor sends only AROGYA BLDDNR and Blood banks send only AROGYA BLDREQ. Remaining information is collected by the system by sending a template and asking the requester to fill in data and forward the same message back.
- No one is required to use internet (blood banks may do so if desired)
Intelligent matching and screening of donors
- The system is built upon Bulk SMS service for receiving and sending SMS. These services are very low-cost e.g. we can send 1,00,000 messages of 160 characters for Rs. 6,000.
- Blood banks do not require any skilled personnel such as data entry operators or administrators. Hence they have no additional costs.
- The system is designed to match blood groups ABO and Rh.
- Donors with permanent disqualification criteria are completely eliminated.
- Donors with temporary disqualification criteria are removed temporarily.
- Donors' criteria of availability are taken care of.
Results: It is easy to be used by common man, and with novel logistics developed by us, our service has a promise of solving most of the problems faced by blood bank supply chain.
Conclusion: The service has been launched in Pune on 14 Jun 2011, the World Blood Donor Day, and is already showing its impact.
Classification of anemia in rejected blood donors
Nehal A. Patel, Hemanti Buch, Abhay G. Jhaveri
Surat Raktadan Kendra and Research Center, Gujarat, India.
Background: The requirement for safe blood is increasing with time and so is the need of voluntary, healthy donors. Among the donor deferral reasons, anemia is the commonest cause. People are unaware of the condition and its consequences. It is necessary to educate and motivate them to consult a health care provider for proper diagnosis and treatment of anemia
Aims: To study types of anemia in donors rejected due to low Hb values.
Material and Methods: Present study was carried out at Surat Raktadan Kendra and Research Centre (SRKRC). A study was planned in which blood samples of blood donors rejected due to low Hb were collected in tapping room of SRKRC as well as from the different blood donation camps organized in different parts of Surat city.
On the basis of red cell indices values, it was decided to carry out further investigations. The rejected donors, whose MCV values was č78fl, were screened for iron deficiency anemia and ß thalassemia trait. The tests used for detection of iron deficiency anemia were serum iron, total iron binding capacity (TIBC) and serum ferritin. Hemoglobin electrophoresis was performed on cellulose acetate at alkaline pH, for detection of ß thalassemia trait. If HbA 2 value was more than 3.5%, the sample was further confirmed by using high performance liquid chromatography (HPLC).
Results: The present study detected various types of anemia in donors rejected due to low Hb. 108 samples were collected from donors, whose Hb was ≥ 12.5 gm% and found fit to donate, as controls. During study 470 donors were rejected, out of which 149 (31.7%) were found to have anemia. Out of these 149 donors (all males) 30 donors had iron deficiency anemia, 8 donors were having ß thalassemia trait, 3 donors were suffering from both iron deficiency anemia and ß thalassemia trait and 1 donor was having sickle cell trait. No significant difference was found between vegetarians and non-vegetarians. Maximum rejected donors were between 41 to 50 years of age group, then respectively in 18 to 30 years and 31 to 40 years of age. As number of donation increase the iron stores of the body decrease. Iron deficiency anemia commonly occurs in regular blood donors who donate blood multiple times.
- Anemia (both iron deficiency and others) are more common in middle age group i.e. between 41 to 50 years of age.
- Out of total rejected donors, the donors having iron deficiency anemia was 26.1%, ß thalassemia trait was 5.3%.
- Serum ferritin and TIBC measurement are more reliable markers for detection of iron deficiency anemia than serum iron.
Voluntary Platelet Donor Registry: Need of the Hour
Marathe A.N, Hirve A. S, Ojha S, Poojary M, Tirlotkar A
Department of Transfusion Medicine, Tata Memorial Centre, Advanced Centre for Treatment, Research and Education in Cancer, Navi Mumbai, Maharashtra, India.
Background: Patients treated for Hematological malignancies and Bone marrow transplant at our Oncology Centre, are highly dependent on Single Donor Platelet (SDP) transfusions. Currently, it is the prime responsibility of patient's relative to arrange for donors. Since, patients from distant places are referred to our National Oncology centre for their treatment; it is difficult for the relatives to arrange committed donors for plateletpheresis. Thus it is necessary to have a dedicated voluntary platelet donor pool to supplement the requirements.
Material and Methods: Requirements for SDPs over a period of 5 Years (15 Aug 2005 to 15 Aug 2011) were evaluated. Since October 2009, idea of voluntary Blood and Platelet donor club was nurtured and implemented. Information Brochures regarding plateletpheresis was distributed. Special educational and motivational drives for platelet donations were conducted targeting the youngsters at professional institutes and offices. Regular in-house voluntary blood donors were explained about platelet donation procedures and converted into platelet donors.
- Measures taken to build a committed Voluntary Platelet Donor Registry
- To evaluate the effectiveness of the strategies implemented.
Results: Total SDPs collected was 1,496, out of which 75.33% was donated by Replacement donors. Platelets processed in initial 3 years was 76 per annum on an average whereas from 2009 onwards was 304 per annum. The requirements for SDPs increased fourfold with increase in number of patients treated over last 2 years. Therefore, 600 potential donors were targeted at 6 special Platelet donation drives as well as in 11 Blood donation camps. 201(33.7%) donors were motivated and registered for plateletpheresis. In-house voluntary donors, who were convinced for platelet donation, were 348. A total of 549 voluntary platelet donors have been registered in our set up. The voluntary donations in emergencies and especially over weekends account for 22.93% of total aphaeresis procedures.
Conclusion: Voluntary platelet donors play a crucial role for supporting patients having genuine difficulty in arranging donors. Voluntary platelet donation drives have definitely increased database for registry. Further efforts and strategies need to be implemented to create awareness regarding voluntary platelet donations.
Evaluation of donor's deferral causes in whole blood and platelet donors in oncology set up
Chawan K. M, Ojha S., Marathe A. N, Arunkumar N, Rajadhyaksha S.B
Department of Transfusion Medicine, Advanced Centre for Treatment, Research and Education in Cancer, Tata Memorial Centre, Kharghar, Navi Mumbai, Maharashtra, India.
Background: Donor deferral is one of the major impediment in maintaining blood and blood component inventory. Platelet being one of the major component required in oncology patient, maintaining inventory of platelets (single donor platelet and random donor platelet) become a major challenge.
Material and Methods: A retrospective study of the main causes of deferral of whole blood and platelet donors was performed. Manual records of all, whole blood and platelet donors from 15 August 2005 to 30 July 2011 was studied, which included 10,122 blood donors and 2,970 platelet donors. They were categorized according to type of donation, sex, temporary or permanent deferral and cause of deferral. National guidelines were followed for the above categorization.
- To find out the incidence and causes for deferral in whole blood and platelet donors.
- To categorize and analyze the cause of deferral in whole blood and platelet donors.
Results: 1,865 (18.4%) of whole blood donors were deferred out of 10,122 donors, who came for donation. Deferral rate for voluntary donors (17.8%) was significantly less (p= 0.0005) compared to replacement donors (21.5 %). Similarly, deferral for female donors (50.4%) was significantly higher (p=0.0001) compared to male donors (10.3%).The most common cause for deferral in whole blood donors was low hemoglobin (52.3%), followed by malaria (9.4%), uncontrolled blood pressure (6.2%) and, infection (6.1%). Temporary causes for deferral (97.5%) was more than permanent causes (2.5%). Deferral due to pathological causes (90.2%) was more than physiological causes(9.8%). In case of platelets donors total deferred were 287(9.6%) out of 2970. In contrast to whole blood donors, deferral rate was significantly lower (p =0.0001) in replacement donors (7.1%) compared to voluntary donors (15.7%). Deferral rate for female donors (44.7%) was significantly higher (p=0.0001) compared to male donors (6.9%). The most common cause for deferral in platelet donors was low hemoglobin (27.5%) followed by poor venous access (12.5%) medication (11.4%), malaria (9.7%) and, underweight (8.0%). Temporary causes for deferral (93.7%) were more than permanent causes (6.2 %).More deferral was due to pathological causes (70%) than physiological causes (30%).th Conclusion: Due to high deferral rate, it is very difficult to recruit eligible donors, especially in platelet donation and also to maintain proper blood inventory. It has negative impact on donor recruitment and retention. Hence, there is need to develop proper strategies to minimize unnecessary donor deferral in both, whole blood and platelet donation.
Quality in Blood Donation Drives: A Study of Noncompliance
Rajat Kumar Agarwal, Kumari Ankita, Lalith Parmar, Rakesh Dhanya
Sankalp India Foundation, Bangalore, India.
Background: Sankalp organizes regular blood donation drives with the blood banks, which conform to the 'Blood Bank Policy' of the organization, which identifies the parameters related to quality to be followed. This paper aims at studying the non-compliance to the aforesaid policy on identified parameters related to quality and safety issues of a blood donation drive. The study was conducted from 1 January 2009 to 31 December 2010. A total of 70 blood donation drives with 132 instances of blood bank participation.
Aims: Aim of this study was to identify the areas of non-conformance to the parameters related to donor's safety by the blood banks.
Material and Methods: Every participating blood bank agreed to follow a minimum basic quality standard in blood donation drives by signing the policy identifying the same. The following quality parameters were identified: HB%, gloves, refreshment, certificates, timing, rest, less technicians, pillows, beds and sheets, missing something else, testing, resting beds, hygiene issues and others. Over 2 years, blood donation drives was organized where a volunteer from the organization monitored the process followed by the blood bank and identified non-compliance. The non-compliance was systematically logged in a web based application. Systematic communication followed each camp, in order to allow the blood banks to identify and fix the areas of non-compliance.
Results: Out of the 132 blood donation drives, 84 were found to be non-compliant on 1 parameter or more. The parameters on which highest non-compliance was observed are:
The Government Hospital based blood banks were non-compliant by 59%, the voluntary organisations by 64% and the private hospital based blood banks by 86%.
- Came late by more than 30 minutes (25%)
- Did not wear gloves (20%)
- Did not give adequate rest to donors (11%)
- Skipped HB test (10%)
- Others (10%)
Conclusion: The study revealed high degree of non-compliance in voluntary blood donation drives. Though the blood banks chosen for the blood donation drives are those, which are known for better quality and standards and regular feedback was given to initiate corrective steps, 64% non-compliance was observed. This calls for the need to re-look at the standard operation procedures that the blood banks follow in blood donation drives and the need to ensure proper compliance to the same. High degree of non-compliance on parameters including those, which directly relate to the selection and well being of the donor, indicate that immediate steps need to be taken to ensure compliance to procedures, safety and retention of voluntary blood donors in blood donation drives.
Young Donors with High BMI Predisposed to Donation Related Adverse Events
Fortis Escorts Heart Institute, New Delhi, India.
Background: Blood donation is extremely safe and well tolerated by most of the donors. But still continuous monitoring and evaluation of donor reactions as part of the hemovigilance surveillance is important to ensure donor safety. Some donors may experience side effects from donating blood, which is of variable severity and may occur during or at the end of collection. The adverse reactions that occur in donors can be divided into local reactions and systemic reactions.
Aims: To identify the predisposing factors, which could be of significance in identifying the underlying factors of donor related adverse reactions. In addition to age, sex, voluntary / replacement, volume of blood drawn etc. parameters - our study included body mass index (BMI) of the donors as one of the predisposing factors of donor reactions.
Material and Methods: The data was studied from September 2010 to August 2011 i.e. over a period of 12 months. The total no. of donors was 12,610 of which 11989 were male, while 621 were female donors. The details of age, sex, height, weight, time of last meal, whether voluntary / replacement was taken from donor screening forms. Body mass index (BMI) was calculated for all the donors who suffered from reactions.
Results: Donor reaction occurred in 58 donors i.e. 0.45% of our donor population of which 41/58 (70.6%) were voluntary donors and 17/58 (29.3%) were replacement donors.
Body Mass Index (BMI):
48 donors between 18-35 years of age
- 10 donors between 36-50 years of age
- No donors above 50 years showed reactions
Site of Reaction:
- 45 donors had BMI >23 - Overweight and Obese
- 2 donors had BMI <19 - Underweight
- 11 donors had BMI between 19-23 - Normal
- 42 (72.4%) reactions occurred in phlebotomy room
- 13 (22.4%) reactions occurred in refreshment room
- 3 (5.17%) reactions occurred beyond blood bank area
- 45 (77.5%) were first time donors and 13 (22.4%) were repeat donors
- 3 donors had previous history of donor reaction
Conclusion: Pre-disposing factors to donor reactions can be associated with
53 (91.37%) were male donors and 5 (8.62%) female donors.
- Reaction rate of female donor 0.80% and for males 0.44% of the donation.
- 10 donors experienced difficulty during donation.
- Time elapsed from last meal and sleep pattern did not show any significance in donor reactions.
- No correlation between volumes of blood withdrawn to donor reaction.
Our study showed a definite correlation between the high BMI and the donation related adverse reaction, while only a few studies (which have studied BMI) have indicated that donor reactions may occur in donor with low BMI.
- Young donors <35 years
- Voluntary donors
- Female donors
- High Body Mass Index >23
- First time donors
- Difficult phlebotomy
- Psychological factors - fear, apprehension
Are repeat blood donors based from a closed social community group safer?
Jignasa Gami, Kirit Bhatt, Sajid Mukhida, Rajesh Sawant
Rajkot Voluntary Blood Bank and Research Centre, Rajkot, Gujarat, India.
Background: In Saurashtra region of Gujarat, most of the collected blood originates from voluntary, community based blood donors. Recruiting and retaining voluntary blood donors requires considerable planning and costs. There are many social groups who are associated with our blood centre, since more than a decade for voluntary blood donation. One of these was selected as a model for this study.
Aim: To study and compare the safety and quality parameters related to voluntary blood donation in general outdoor voluntary blood donation camps with reference to those organized by a social community group.
Method and Materials: To assess the impact on safety and quality parameters related to voluntary blood donation, the demographic details, findings of medical history, high-risk behavior, physical examination, deferral rates, repeat blood donation frequency, TTI test results, and adverse reactions in blood donors were analyzed. Various quality parameters related to the voluntary blood donation camp organization was also analyzed. The results obtained in the 2 groups was analyzed and compared statistically.
Results: In a period of 10 years, the social community based group conducted 22 voluntary blood donation camps with an average collection of 182 blood units per camp. Average blood collection per camp in general at our blood centre is 73 units. 82% of blood donors at the social community group were between 18-45 years of age.
The repeat blood donation rate was 26.39% for male donors and 13.59% in female donors at the social community based group, whereas in the general blood donation camps repeat donation rates were 8.79% in male donors and 3.41 % in female donors.
The regulation of blood donors from rare blood groups could be effectively implement in the focused group and proportionately more number of blood units could be utilized for component separation. The donor reactions rate (1.24 % v/s 2.92 %) and deferral rates of blood donors (14.85 % v/s 21.4 %) was significantly lower than the general voluntary blood donation camps.
Conclusion: Voluntary blood donation activity by focused social groups in a co-ordinated manner makes the gift of life safer in various aspects. Retaining donors and maintaining optimal quality at voluntary blood donation camps is very effective by this approach.
This role model group has set an example for various other voluntary blood donor groups in our region to contribute effectively towards ensuring repeat, regular voluntary blood donation and consequently enhancing blood safety in the region.
| Poster|| |
Category 1- Immunohematology
Red cell antibody screen - is it necessary?
Krishnamoorthy R, Panicker V.K, Febe R. S
Department of Transfusion Medicine, Sri Ramachandra University, Porur, Chennai, India.
Background: Compatibility testing between the blood donor and the recipient's sample includes crossmatching in saline and coombs phase. Unexpected red cell antibody screen done on the recipient's serum and in particular on samples from multiply transfused patients and multiparous women, will enhance blood safety. Aim of the study: to estimate the incidence of unexpected red cell antibodies in transfusion recipients.
Materials and Methods: This study was conducted at Sri Ramachandra Blood Bank, Department of Transfusion Medicine, Sri Ramachandra Medical College and Research Institute, Sri Ramachandra University, Porur, Chennai during the period of June 2010 to May 2011. All recipient samples were subjected to an unexpected red cell antibody screen by the gel technique. A commercially obtained 3 cell panel was used for screening and a11 cell panel was used for identification. Low ionic strength saline (LISS) was used as an enhancer.
Results: Out of 8,341 samples screened, 21 samples (0.25%) showed antibody screen positivity. These antibodies were reactive at 37°C and hence clinically significant. Multiparous women accounted for most cases of antibody screen positivity. Anti-D was the most common alloantibody identified.
Conclusion: Unexpected red cell antibody screen and identification performed on recipient samples will help in choosing donor red cells that are negative for the antigen, against which the identified antibody is directed. This process will ensure a safe blood transfusion and will increase the donor red cell survival in the recipient. This, in turn will benefit the recipient by way of necessitating less frequent transfusions.
Red Blood cell alloimmunization in transfusion dependent patients'
population - A study from tertiary care hospital in Eastern India
Suvro Sankha Datta, Somnath Mukherjee,
Prasun Bhattacharya, Biplabendu Talukder
Department of Immunohematology and Blood Transfusion, Medical College Hospital, Kolkata, India.
Background: Red blood cell (RBC) alloimmunization is due to difference in antigenic expressions on red cell membrane between donor and recipients. There is no significant data available from eastern region of India about RBC alloimmunization in transfusion dependent patients' population, as pre-transfusion antibody screening is not done routinely.
Aims and objectives: 1. To assess the incidence of RBC alloimmunization in transfusion dependent patients at a tertiary care hospital of Eastern India. 2. To standardize a protocol for selective antibody screening and extended antigen phenotyping in donors and transfusion dependent recipients.
Materials and Methods: Antibody screening test was performed in 20 patients, randomly selected from 154 transfusion dependent patients population prior to crossmatching by 3-cell panel (Diacell; Diamed GmbH) by polyspecific (anti-IgG+ C3d) coombs card (Diamed-ID). Antibody screen-positive samples were analysed for specific antibody detection by 11-cell panel (Diacell; Daiamed GmbH).
Results: The overall incidence of RBC alloimmunization in transfusion dependent patient was 13 out of 20. Out of 13 patients, whose antibodies were identified, 10 of them were against Rh and Kell system with anti-E(4) being commonest (30.76%) followed by anti-c(3),anti-C(1),anti-D(1) ,anti-K(1), others being anti-M(1), anti-Fyb(1) and anti-Le-b(1). Direct agglutination test (DAT) was positive in 13 out of 20 cases.
Conclusion: The majority of alloantibodies detected in this study were clinically significant. Thus antibody screening should be performed in transfusion dependent patients to reduce the risk of alloimmunization. Extended antigenic (Rh and Kell) phenotyping, both in donors and transfusion dependent patients would be helpful with an aim to make it a standardized protocol so that alloimmunization can be prevented in transfusion dependent patients.
Discrepancy on Rh D typing using Automated Column agglutination technology: Analysis and Interpretation of results
Sudha S Bhat, Shamee Shastry
Department of Immunohematology and Blood Transfusion, Kasturba Medical College, Manipal, Manipal University, India.
Background: Rh D typing, today is a challenge, due to several variables that can affect the outcome of the test including the D protein itself and the reagents and methods available to detect D antigen. Individuals who harbor partial D variant alleles have the potential to develop anti-D antibody, but common weak D types do not pose such risk. The challenge is in deciding as to what to report as final Rh type to the patient.
Objective: Evaluation of discrepant results of Rh D typing using automated column agglutination technology.
Materials and Methods: Routine Rh D typing of the patients was done using Automated Column agglutination Technology (by Auto-Vue: Ortho-Clinical Diagnostics, Inc) at our center. All the samples which gave weaker reactions, mixed field reactions were repeated using tube technology. The samples, which gave negative reaction on tube testing was subjected to AHG testing using IgG anti D. An in-house decision tree was derived to interpret the discrepant results.
Result: A total of 10,860 patient samples were tested for ABO and Rh D typing. 94% (10,217) of samples were Rh D positive and only 6% (743) were Rh D negatives on testing with column agglutination technique. 18 of 10,217 samples gave discrepant results, by showing positive reaction on automated technique and tested negative with traditional tube test using different reagents. The results was read as 1+ agglutination in 2 samples, 2+ in 2 samples, 3+ in 7 samples, 4+ in 1 sample and mixed field in 6 samples. In contrast to the reading of the equipment, visual reading of the results showed mixed field reaction in 16 samples and 1+ reaction in 2 samples. AutoVue had flagged results of 15 of 18 discrepant results (83%). All the 18 samples gave positive results on AHG testing using IgG anti D. Based on these results a decision tree was derived to approach and interpret the results of the samples, which gave weaker and mixed field reactions on column agglutination technique.
Conclusion: Variable positive reactivity with RBCs from individuals possessing weakened expression of Rh D is often seen while typing for the Rh grouping. We suggest the use of tube testing,which is the "gold standard", in addition to the automated column agglutination technology as confirmatory step for Rh D typing of the patient samples.
Study of Red Blood Cell, Alloimmunization in Multitransfused Thalassemic Children of Jammu Region
Ashu Dogra, Raman Kapoor
Government Medical College, Jammu, India.
Background: Thalassemia is a common hemoglobin disorder in Jammu and Kashmir, as it falls in thalassemic prone zone. Although, blood transfusions are life savers, they may be associated with some complications especially RBC alloimmunization. The purpose of this study was to investigate the prevalence of red cell alloantibodies and to determine types of these antibodies among multiple transfused thalassemic patients.
Aim: To study frequency of alloantibodies in multitransfused thalassemia children and to study most common alloantibodies involved.
Material and Methods: A total of 70 thalassemic patients registered at SMGS Blood Bank were included in study. Screening of antibodies was done and those samples which were found to be positive on screening were then subjected to antibody identification using a panel of recognized blood group antigens.
Results: In our study, frequency of alloimmunization was 8.5%. Alloantibodies detected was anti-E(50%), anti-K(33.34%), anti- D-(16.6%).
Conclusion: In present study, alloimmunization rate was 8.5% with 95% CI of 0.44-11.56, so it can be concluded that antibody screening should be carried out at regular intervals and those positive for screening should be given appropriately matched blood. The most common alloantibodies detected are anti-E (50%), anti-K(33.34%),anti-D(16.6%), so it can be concluded that in routine, apart from matching for ABO/Rh(D), blood should be matched for E antigen and K antigen. To minimize alloimmunization due to anti-D in Rh -ve individuals weak D testing by involving enhancing agent AHG and if possible partial D testing should be done in all Rh -ve donors.
Blood Group Discrepancies in Blood Donors in Regional Blood Transfusion Centre
Tanya Sharma, Bharat Singh
UCMS and Associated GTB Hospital, Delhi, India
Background: Regional Blood Transfusion Centre (RBTC), GTB Hospital, Delhi, India is providing safe and quality blood to one third of Delhi population. RBTC collects more than 33,000 Units of blood annually. Donor's blood grouping is being done by DiaMed-ID Card Micro Typing System using Gel Cards. Repeatedly, a discrepancy is observed in cell and serum grouping. Reporting of incorrect blood group can be life threatening for the patient.
Aim: All such blood group discrepancies reported was analyzed by performing additional tests and then reporting correct blood group of blood donors as well as patients.
Material and Methods: Retrospective data of blood donors with blood group discrepancies was recorded in Regional Blood Transfusion in centre (East) Delhi, during a period of 1 year from June 2010 to June 2011. In each case, DiaMed-ID Card Micro Typing System using Gel Cards was used for determination of the ABO/Rh blood groups combined with reverse grouping. A detailed serological workup of these cases was studied for recognition and resolution of the blood group discrepancy.
Results: Total number of donors during the study period was 32,654. Blood group discrepancies were found in 24 cases (0.07%).There was 8 cases with low avidity anti-B Antibodies, which were resolved by performing reverse grouping at 4°C. In 5 cases with weaker expression or subgroups of A, advanced serological testing with polyclonal and monoclonal cards and adsorption/elution studies was done. There was 3 cases with unexpected alloantibodies (Anti-N and Anti-M), which was resolved by performing reverse grouping after treatment with papain, DAT and screening and identification of antibodies. In 8 cases, discrepancy could not be resolved after incubation at 4°C, adsorption/elution study, DAT, antibody screening, use of polyclonal and monoclonal cards, and were referred to reference laboratory for confirmation by molecular analysis.
Conclusion: All discrepancies reported on ABO cell and serum grouping must be investigated for rare blood group antigen, so that correct blood group is reported on donor. A note of caution should be mentioned on the blood group card to prevent ABO incompatibility in case of transfusion.
Anti C and Anti D (Probable Anti G), a rare finding
Lutika N. Lyngdoh, Debdutta Bhattacharyya, Careen C. Marbaniang, Raphael V
Department of Blood Bank, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India.
Introduction: Antibodies to the antigens in the Rh system are well-known causes of HDN. The D antigen is a very potent immunogen and anti-D can cause severe HDN. Anti-C has also been shown to cause HDN, although generally less severe.
Case Report: A 27-year-old lady at 17 weeks of pregnancy of group "O", D -Negative; probable phenotype: rr (dce/dce), Gravida- 3 with 1 living issue and 1 history of abortion, was referred to our blood bank for investigation of presence of antibodies. She had received RhIG (Rh Immunoglobulin) post delivery and post abortion and had never received any blood transfusion.
Materials and Methods: Prenatal antibody screening and identification with ID Diacell and ID Diapanel (DiaMed) was done and anti-D and anti -C was found to be present. Antibody titration by tube technique (serial doubling dilution) was done for anti D using R 2 R 2 (DcE/DcE) cell and for anti C using r΄r (dCe/dce) cell. Adsorption studies using R 1 R 1 (DCe/DCe) cell for anti D and r΄r (dCe/dce) cell for anti C by PEG was performed. ABO grouping and Rh phenotyping by Gel card (DiaMed) of the patient, her husband and their living issue was done.
Results: 1. Prenatal antibody screening and identification showed presence of anti-D and anti-C (?AntiG). 2. Antibody titration gave the following result:
3. ABO and Rh Phenotyping:
- Anti-D Titer: 1:2000
- Anti C Titer: 1:8
4. Adsorption studies confirmed the presence of anti D and anti C antibodies in the patient.
Discussion: From the above results observed, presence of anti D and anti C (? anti-G) is confirmed. In this case, the patient must have got sensitized at the time of delivery of her first born child whose phenotyping shows R 1 r. Most cases of HDN are caused by anti D and less severe form of HDN has been shown to be caused by anti-C but the significance of anti-G remains controversial. At the time of last reporting, the patient had normal pregnancy with no abnormalities reported in the fetus. This made us believe that the fetus is probably Rh D-Negative. This belief was strengthened by the history of the patient's husband having a sibling, who is Rh D- Negative and the probable Rh phenotype of the patient's husband being R 1 r΄ (DCe/dCe) and not the commonly observed R 1 R 1 (DCe/DCe).
The G antigen was present on almost all D+ or C+ RBCs and absent from virtually all RBCs that are D- and C-. The apparent co-distribution of the G antigen with either the C or D antigen causes anti-G to appear serologically as anti-C plus anti-D activity. According to the publication "Distinguishing anti-G from anti C+D in prenatal serologic studies" in California blood bank society e-network forum (2003) if anti-C titre is more than anti-D the probability of anti-G being present is more. In our scenario, the anti-D titre is much more than anti-C, but the presence of anti-G still cannot be ruled out and more studies are required.
1. Immunohematology, Vol-22, Nov- 4: 2006, 166-170.
A case report of Delayed Hemolytic Transfusion Reaction due to formation of anti c and anti E
Debdutta Bhattacharyya, Lutika N. Lyngdoh, Samsad Ali Hassan, Raphael V
Department of Blood Bank, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya, India.
Introduction: Delayed Hemolytic Transfusion Reaction (DHTR) occurring due to alloimmunization is most often due to an anamnestic response in a patient previously sensitized by transfusion, pregnancy or transplant and in whom antibody is not detectable by standard pre-transfusion methods. DHTR usually causes unexpected or unexplained decreases in hemoglobin or hematocrit values following transfusion.
Case Report: An urgent request for packed red cells was made for a 25-year-old female patient of "A 1", Rh D positive blood group, diagnosed with Dilated Cardio Myopathy (DCMP) with severe anemia. Patient's hemoglobin was 4.0Gm%. The patient had received blood transfusions in another hospital before getting admitted into our hospital and had received transfusions on two different occasions in our hospital, the first, 6 months prior and the last, 1 month prior to the present request.
Materials and Methods: Antibody screening and identification with ID Diacell and ID Diapanel (DiaMed) was done and showed the possibility of presence of anti- C and anti- E. Rh phenotyping for the patient and multiple donors and PEG adsorption by rr (dce/dce) cells to remove anti- C and by R 2 R 2 (DcE/DcE) cells to remove anti- E was performed.
Results: 1. Antibody screening and identification (LISS and Enzyme) shows presence of anti-C and anti-E. 2. Auto control shows a positive result. 3. ABO and Rh Phenotyping. 4. Adsorption studies confirmed the presence of anti- C and anti- E antibodies in the patient.
Discussion: From the above results observed, presence of anti C and anti E is confirmed in the patient. The pre transfusion testing (antibody screening and cross matching) done for the first transfusion in our hospital done six month prior, showed the presence of anti-c and anti-E which could have been due to the sensitization caused by the transfusions in the outside hospital. The patient got re-admitted five months later and request for the second transfusion was made. Pre transfusion testing showed presence of no detectable alloantibodies and probably units of Packed Red Blood Cells of R 2 R 2 (DcE/DcE) or R 1 R 2 (DCe/DcE) phenotype inadvertently were transfused which caused the anamnestic response to re-produce the anti-c and anti-E antibodies. These antibodies caused the hemolysis of the donor cells thus causing DHTR. The presence of donor cells (R 2 R 2 /R 1 R 2 ) in the patient because of the last transfusion done one month prior showed the presence of dual cell population on Rh phenotyping and also gave a positive auto control result.
Conclusion: From the above case, it is learnt that though our standard protocol of pre-transfusion testing consists of antibody screening and identification and cross matching, it is always advisable to add Rh phenotyping to the protocol considering the immunogenicity of the Rh antigens.
1. Immunohematology, Vol-21, Nov- 3:2005, 94-96.
Phenotypic Frequency of Different Rh and Kell Antigen in Eastern India
Biplabendu Talukder, Sagar Chatterjee 1 , Somnath Mukherjee, Prasun Bhattacharya, C.R.Sadhu 1
Department of Immunohaematology and Blood Transfusion, Medical College Hospital, 88, College Street, Kolkata - 700 073, India.
Background: As we know there are more than 90% alloimmunization against Rh and Kell antigen globally in transfusion dependent patients. But there are very few laboratories in the country that are doing routine phenotyping of the donor and the recipient both for extended Rh and Kell phenotype. To make a strategy for giving safe blood to these patients, we have studied the relative frequency of Rh (D, C, c, E, e) and Kell antigen in our blood donor population in a tertiary care center in Eastern India.
Aims and Objective: To know the Extended Rh and Kell phenotype frequency in our donor population. To formulate our strategy of routine antigen phenotyping/antibody screening in our center, which caters services to 1,500 registered thalassemia patients.
Material and Methods: 118 voluntary blood donors of 'O' group are randomly selected from different districts of south of West Bengal for antigenic study of extended Rh and Kell phenotype. The antigen detection was performed by the standard blood grouping tube technique with monoclonal (IgM) reagent antisera (anti-K, C,c,E,e) of Diamed GMBH, marketed by Biorad laboratories, Gurgaon.
5% cell suspension of the donors' red cells in normal saline was added in the tubes containing the respective monoclonal anti sera in the ratio of 1:2. The above mentioned tubes were then incubated at room temperature for 5 min followed by centrifugation for 1 min at 1500rpm. All the results were recorded macroscopically and any negative results were confirmed by microscopic examination.
Results: Out of 118 'O' blood group donors, antigen phenotypic frequency was found in the following order. Most frequent Rh phenotype was observed DCe/DCe- (R 1 R 1 )48.3%, followed by Dce/Dce(R 1 R 0 )-30.5%, DCE/Dce(R Z R 0 )- 17.9%, DcE/DcE(R 2 R 2 )-0.8%, DcE/Dce(R 2 R 0 )-0.8%,DCE/DcE(R Z R 2 )-0.8% and dce/dce(rr)-0.8% respectively. Only 1 donor was found to be Kell (K) positive (0.8%).
Conclusion: The extended Rh and Kell antigen frequency data was obtained, though relatively small, but clinically significant from transfusion point of view. This is more important for thalassemic and chronic transfusion dependent patients, who are getting blood transfusion at regular interval. This extended Rh and Kell frequency would be very helpful in providing us information and detection of alloantibodies in the transfusion dependent patients.
Red Cell Alloimmunization in Transfusion Dependent Thalassaemia Patient's in Saurashtra Region of Gujarat, India
Chandni Karia, Jyoti Bhatt, Bhanu Radadia,
Maitrik Dave, Sahjid Mukhida, Rajesh Sawant
Rajkot Voluntary Blood Bank and Research Centre, Rajkot, Gujarat, India.
Background: Thalassaemia Major is a common hemoglobinopathy in Saurashtra region of Gujarat, India. However, very little is known about the frequency of red cell allo-immunization in this transfusion dependent Patient group.
Aim: To Study the Red cell allo-immunization in Transfusion dependent Thalassaemia Patients in our region.
Materials and Methods: Retrospective analysis of data was done and a total of 160 Thalassaemia major patient data was found to be complete and available for analysis. Patient's clinical; immunohematological and biochemistry reports were reviewed. The age at which RBC allo /auto antibodies developed and the complete transfusion history was noted.
Results: 16 out of 160(10%) Thalassaemia Major Patients developed RBC allo-antibodies. The auto control and DAT was positive in 6 cases of which 4 (25%) Patients had an allo-antibody underlying the auto-antibody. Antibodies against the antigens in Rh system (25%) and Kell (18.75%) were the most common clinically significant allo-antibodies identified. Anti-K developed in 3 (18.75%) patients, Anti-E in 3 (18.75%) patients, Anti-D in 2 (12.5%) patients and Anti-Kpa in 3 (18.75%) patients. All allo-antibodies developed in between 1 year to 24 years of age, earliest allo-immunization to RBC transfusions was observed in a patient only after receiving 3 blood transfusions. Only 5% of Thalassamia patients were on leucodepleted blood component therapy.
Conclusion: The various contributory factors leading to allo-immunization in our Thalassaemia major patients need to be identified. Lack of completely matched blood (many centers still provide only blood compatible in saline phase of cross-matching) and non-leucodepleted blood components could be major contributory factors to transfusion complications in Thalassaemia major patients. Provision of pre storage leucodepleted blood and phenotyped matched RBC transfusion can prevent of delay alloimmunization in Thalassaemia Major Patients.
Antibodies against High Frequency Antigen Gerbich 2 (anti-Ge2): A Real Challenge in Cross Matching Lab
R. P. Singh
Red Cross Blood Bank Red Cross Building, 1 st Floor Near Kundaliya College, Suchak Road, Rajkot, Gujarat, India.
Introduction: Transfusion management of patients' alloimmunized against high-prevalence erythrocyte antigens is often problematic in emergency situations. Ge2 red cell antigen is one of extremely high frequency antigen within the general population. In 28,331 English, Danes, New Zealanders, Californians and 22,000 Japanese populations, none of them were found negative for Ge2 antigen. Only in Melanesians of Papua New Guinea population found significant number of Ge2 negative individuals (700 out of 3,110 population). Studies supported that harmless nature of Ge antibodies, but in few studies suggested that the antibodies to Gerbich antigen may be a rare cause of hemolytic disease of fetus and newborn.
Mterials and Method: A 27-years-old woman was admitted in gynecology and obstetrics department with the diagnosis of ovarian cyst with P 2+0 and requested 2 units of packed red cells on 26 June 2005. On blood grouping, she was O+ve and her hemoglobin was 11.2 gm/dl. In cross matching laboratory, her serum was found to be reactive with O+ packed cells units tested in indirect coombs testing (IAT) phase with polyspecific (IgG+C3d) Coombs GEL card (DiaMed AG, Switzerland) with 3+ agglutination, but no incompatibility in immediate spin and 37°C phase in tube technique . More than 90 O+ units were cross and none of them found compatible to the patient. On laboratory workup, her direct coombs test (DCT) and auto control were -ve and antibody screening (3 cells) and antibody identification by 11 cells panel (DiaMed AG, Switzerland) showed uniform reactivity with all 3 screening cells as well as 11 panel cells in indirect Coombs testing (IAT) phase with polyspecific (IgG+C3d) Coombs reagent with 3+ agglutination, but no reactivity in immediate spin and 37°C phase. A panel of Rare Antisera (Diamed AG, Switzerland) was used for the presence of alloantibodies. Her probable Rh genotype was R 2 R 2 with extended phenotype of Le (a-b+), P1+, M+, N+, S+, s- , K- k+, Fy (a+b-), Jk (a+b+), Ge ( 2-3- 4-). On identification panel anti-Ge2 antibodies were identified, which was reactive in IAT phase. The presence of common alloantibodies was excluded by using papain treated cells, however unable to exclude the presence of anti-s antibodies. We concluded that patient should receive Ge2 and s antigen negative blood. Because of rarity of Ge2 negative donors, patients siblings were call for screening, 6 siblings were tested and none of them found compatible to the patient. Patient's hemoglobin was 11.2 gm/dl and after consultation with director of gynecology and obstetric department, two units of autologous whole blood were collected on day 1 and 14 from surgery date. The patient was also prescribed oral Iron preparation to boost her hemoglobin. Surgery was done on day 30, calculated from the dated of first unit collected. 2 autologous whole blood units were issued and transfused to the patient perioperatively. The surgery was successful and we did not receive further request for this patient.
Discussion: Gerbich system began as a simple inherited blood group antigen and consists of 8 antigens, 3 of very high frequency, present in >90% of population (Ge 2, Ge 3, and Ge 4), while 5 are of low frequency, present in <1% of population (Wb, Ls a , An a , Dh a , and GEIS). The antibodies that Ge negative individuals produce may be immune or occur without red cell stimulation. Anti-Ge is usually IgG, but may have an IgM component. The clinical significance of the high frequency antibodies is variable, but various studies supported that to handle emergency situations with high frequency alloantibodies, we should try biological cross match to assess significance (i.e., harmful or harmless nature) of these antibodies.
Discussion: To manage such kind of problems with real emergencies, we should be think seriously for the implementation of rare donor registry program and cryopreservation of red cells of rare donors, which is still not been implemented in our center and secondly implement protocol for biological cross matching if high frequency antigen negative blood is not available.
Case Report of a Duffy (Fy a ) Negative patient with anti-Fy a antibody
Annapurna Ramesh 1 , Gangadhara D.S 2 , Mohd Ibrahim 3 , Ankit Mathur
Rotary blood bank (Regional Centre), Bangalore, BGS Global Hospital, Bangalore
Introduction: Duffy blood group was discovered in 1950 and named after the patient, Duffy (Fy a ) in whom alloantibody produced subsequent to previous transfusions resulted in hemolytic transfusion reaction. The frequency of the Duffy phenotypes varies among different population. Duffy negative phenotypes are more common among blacks. Antigens of the Duffy blood group are - Fy a , Fy b , Fy 3 , Fy 4 , Fy 5 and Fy 6 . Frequency of Duffy antigens among Asians are Fy a 89%, Fy b 18.5%, Fy 3 99.9%. Duffy alloantibody produce among duffy negative group population as a result of transfusion or pregnancy are mainly IgG type (IgM is rare).
Case Report: We received blood sample of a 51 years male patient on 8 April 2010 for grouping and crossmatching. He was diagnosed as Recurrent Brain Tumor (Rt falcian meningioma) with hypertension and DM and posted for tumor resection next day morning. His blood group was A 1 positive. However, we faced problem with crossmatching. Major crossmatching was incompatible (+3 agglutination) with 11 - A Rh D positive units, 2- O Rh D positive units, 2 - A Rh D negative units. His DAT negative and IAT found positive with 3 cell screening red cells. Cold antibody test was negative. Hence, we suspected alloantibody (warm type) in this case and informed the same to Anesthetist and Neurosurgeon. Earlier transfusion history of the patient revealed that he had undergone neurosurgeries before and also had received multiple blood transfusions. However, earlier transfusions were uneventful. Patient's blood sample also found incompatible with samples of his son and brother. We requested TTK Rotary blood bank (Regional Centre), Bangalore for Phenotyping and alloantibody identification. Patient's serum alloantibody identified as anti-Fy a and red cell phenotyping as Fy (a - b+).. Discussed the issue with chief anesthetist and planned for autologous transfusion considering good Hb of the patient. 2 units of compatible Duffy negative blood received from TTK Rotary blood bank (Regional Centre) also kept reserved. Patient was taken for surgery on 12 April 2010 and his Hb was 14.6 gms % at that time. Anesthetists collected 1000ml (3 units) of autologous blood with simultaneous isovolumic haemodilution following induction and intubation. High risk neurosurgery was performed on this patient. Autologous blood transfusion was uneventful and sufficient.
Discussion: Tertiary care hospitals in Indian set up (developing country) has to be concerned about transfusion safety in cases of patients with alloantibodies to minor blood groups and gather our resources to modify our transfusion practices in order to safeguard the patient and prevent haemolytic transfusion reactions.
Comparison of Dat Using Tube and Gel Technique in Hemato Oncology Patients
Raj Bharath R, Arumugam P
The Tamil Nadu Dr.M.G.R Medical University, Chennai
Background: Detection of immunoglobulin or complement bound to RBCs by using DAT is critical in the diagnosis of immune mediated hemolytic anemia. A positive DAT is often seen in conditions like auto immune hemolytic anemia, hemolytic disease of newborn, immune mediated hemolytic transfusion reactions and drug induced hemolytic anemia.
Aim and Objectives: The purpose of this study was to compare the test results of the DAT by tube and gel micro column techniques, on patients RBCs.
Materials and Methods: 2 ml of patient's blood sample was collected in EDTA vacutainers, Anti human globulin reagent (Polyspecific), Control IgG coated red cells and Diamed gel card (anti IgG and anti C3d).
- Wash 1 volume of 2-5 % red cell suspension 3 times.
- Add 2 volumes of AHG and mix properly.
- Centrifuge the tubes at 1000 rpm for 1 min.
- Read the tube over a light background. Record the grade of reaction
- Incubate the nonreactive tests at room temperature for 5 min, centrifuge, read and record the results.
The DAT is positive when agglutination is observed after immediate centrifugation or after centrifugation following room temperature incubation.
The DAT is negative, when there is no agglutination at the test phase but agglutination observed on adding IgG coated cells. If the IgG coated cells failed to agglutinate, then the test is invalid and has to be repeated
Patients 1% red cell suspension is added to the gel card microcolumn and centrifuged in a gel card centrifugal device.
The result is recorded and in case of a positive reaction, the strength of reaction is recorded.
Results: Among 113 samples tested for DAT, tube technique identified 15 positive cases and Gel technique identified 17 positive cases, which included 15 cases identified by the tube technique.
Discussion: The tube method requires a minimum about 300 to 500 cell bound IgG molecules per red cells to identify a positive DAT, while the gel requires 120 to 180 cell bound IgG per red cells for a positive DAT. This plays a vital role in the DAT positive samples, which have low levels of cell bound IgG. This was clearly demonstrated in our study in which the weakly positive DAT samples in the tube showed a clear high grade of agglutination in the gel. The reaction occurring in the tube has to be read quickly, otherwise there is a possibility of missing a positive reaction. The reading of reaction in tube is subjective. The gel is a simple technique and minimum errors occur while reading. The washing of red cells can be avoided and therefore loosely bound antibodies remain intact. Hence, the gel can be a good alternative technique to the tube in DAT.
Is it Necessary to Do Coombs Cross Match following Antibody Screening in Indian Scenario?
B. Latha, Arumugam P
Department of Transfusion Medicine, The Tamilnadu Dr.M.G.R Medical University, Chennai, India.
Background: Blood transfusion is the cornerstone of therapy for many serious and common diseases. The main objective is to demonstrate whether the type and screen procedure is a safe method of pretransfusion testing, when compared to the antiglobulin crossmatch, currently in use. Coombs crossmatch testing can assure ABO compatibility between donor and patient blood as well as detect most clinically significant antibodies. Only 0.3% to 2 % of the general population have unexpected antibodies and the incidence is higher in women, due to pregnancy. It has been well recognized that the patients with the negative antibody screening and absence of red cell alloimmunization do not require a complete 20 - 30 min crossmatch.
Aim: To find out whether Coombs crossmatch is necessary, following antibody screening in Indian Scenario.
Material and Method: The study was done in the Department of Transfusion Medicine, The Tamil Nadu Dr. M.G.R. Medical University Chennai. Antibody screening was done in 500 patients, who needed transfusion and the Coombs crossmatch was carried out. The results were compared. Antibody screening was done with commercial 3 Cell panel (ID Dia cell-I-II-III Asia) Gel card.
Results: Out of 500 samples, 5 were found incompatible by Coombs crossmatching, which includes 4 samples which were found positive by antibody screening. 1 sample which did not detect antibody in cell panel was found incompatible by coombs crossmatching.
Discussion: In Indian Scenario, antibody screening by using imported Asian cell panel may fail to detect antibodies against unrepresented antigens. Hence, it is absolutely necessary to do Coombs pretransfusion crossmatch till we develop indigenous cell panel representing our population.
Limitations of doing only forward grouping and immediate spin crossmatch in detecting ABO discrepancy and incompatibility in weak ABO subgroups -A case report
Ojha S, Nagaraju P, Marathe AN, Rajadhykasha SB, Vasantha K
Department of Transfusion Medicine, Tata Memorial Centre-Advanced Centre for Treatment, Research and Education in Cancer, India.
Background: Wrong ABO typing and ABO incompatibilities are the major cause of fatal transfusion reactions. There is a risk in doing only forward grouping and issuing blood on the basis of only immediate spin technique (IST) crossmatch. This may be important in case of weak ABO subgroups. We came across an interesting case to highlight this fact.
Aims: To highlight the importance of doing both forward and reverse grouping in blood donors to detect any discrepancy and prevent wrong blood typing. To discuss the approach for resolution of discrepancy in weak ABO subgroups. To highlight the necessity of doing Anti Human Globulin (AHG) crossmatch to avoid missing ABO incompatibility in such cases
Material and Methods: Forward and reverse blood grouping, IST and AHG crossmatch was done by conventional tube technique as described in AABB Technical Manual (15 th ed).For resolution of discrepancy adsorption-elution technique as well as hemagglutination inhibition technique for saliva secretor status was done as per methods given in AABB Technical Manual (15 th ed).For confirmation, retesting of blood group and AHG crossmatch was done using Gel card system as per manufacturer's instructions.
Results: A discrepancy was observed in forward and reverse grouping by conventional tube technique and Gel card system. By forward grouping donor, blood group was B Rh(D) positive and by reverse grouping, it was AB. The discrepancy was resolved by adsorption- elution technique, which showed the presence of weak A antigen. However, Hemagglutination Inhibition technique for saliva showed donor as non secretor for A, B and H substances. From interpretation of above result, donor blood group was found to be A weak b Rh(D) positive. Crossmatching with serum of B Rh(D) positive, patient gave compatible reaction with IST and 4+ reaction with AHG at 37°C. However, crossmatching with serum of AB Rh (D) positive patient gave compatible reaction with both techniques.
Discussion: The above case highlights that, both the forward (red cell) grouping and reverse (serum) grouping are important to detect any ABO discrepancy and prevent wrong blood typing. This kind of discrepancy is common in donors with weak ABO subgroups.Weak ABO subgroups can be detected on the basis of different serological techniques.The serologically determined weak ABO phenotypes require confirmation through genomic analysis. Secondly, blood of such donors should be crossmatched with AHG technique to prevent ABO incompatible transfusion, which may be missed by IST crossmatch. AHG crossmatch acts as a second check to detect such incompatibility missed in blood grouping to prevent any hemolytic transfusion reaction.
Distribution of ABO and Rhesus-D Blood groups
Narendra Kumar Gupta, S. Dadwal 1
Department of Pathology and Casualty 1 , ESIC Model Hospital and Occupational Disease Center, Indore, India.
Background: A blood group is a classification of blood based on the presence or absence of inherited antigenic substances on the surface of red blood cells. These antigens may be proteins, carbohydrates, glycoproteins or glycolipids, depending on blood group system. Blood groups are inherited and represent contribution from both parents. A total of 30 blood groups and over 600 different blood group antigens are now recognized. The most significant blood group system was discovered by Karl Landsteiner, ABO group in 1901 and in cooperation with Alexander S. Wiener the Rhesus group in 1937. ABO genes consist of multiple alleles, which are located on the long arm of chromosome 9. The Rh system is the second most significant blood group system in human blood transfusion with currently 50 antigens. The most significant Rh antigen is D antigen. Almost always, an individual has the same blood group for life, but very rarely an individual's blood group changes through addition, or suppression of an antigen in infection, malignancy or autoimmune disease. An example of this rare phenomenon is the case of Demi-Lee Brennan, an Australian citizen, whose blood group changes after liver implant. Another more common cause of blood group change is a bone marrow transplant. If a person receives bone marrow from someone who is different ABO group (e. g., a group A patient receives group O bone marrow), the patient blood group eventually convert to the donor's group.
Aim: It is well established that ABO and Rh genes and phenotypes vary widely between ethnic groups and both within and between geographical areas. Aim of this study to determine the distribution of ABO and Rh blood group in and around Indore.
Material and Methods: Blood groups were examined of the person who was referred to laboratory for blood group detection. Blood group detection was done for 4 years from 2007 to 2010. ABO and Rh blood grouping were done by using commercial available anti-sera A, B, and Rh. In case of doubt, the test was examined under microscope, and/or the result were confirmed by reverse grouping using known red blood cells of group A and B. For typing Rh we did only anti-D, which is most immunogenic. Hence, those tested positive with anti-sera D were considered positive and those tested negative with anti-sera D were considered negative.
Result: Results were analyzed and data compiled. Our study involving 17,080 persons both male and female show B group to be high, viz, 6,020 (32.25%) persons, followed by O group having 5,380 (31.50%) persons and A at 4,125 (24.15%) and AB at 1,555 (9.10%), being the lowest. Rh blood group frequency was 16,300 (95.43%) positive and 780 (4.57%) negative.
Discussion: Our study follows the Asiatic trend of Rh blood grouping, but trend differ slightly in ABO blood grouping. Our study show B > O > A > AB, whereas Asiatic trend is O > B > A > AB. It is expected that data generated in the study would assist in planning and improvement of blood transfusion service.
Hemolytic Disease of New Born due to Anti E in Rh (D) Positive Female - A case Report
Reeta Rai, M. Chandrashekhar
Max Super Speciality Hospital, Patparganj, Delhi, India.
Background: Hemolytic disease in a new born is an alloimmune condition in which life span of infant's red blood cells is reduced due to premature destruction by antibodies derived from mother by placental transfer. Antibodies in mother are produced due to previous transfusion or by the entry of fetal red cells expressing paternally inherited antigens in to maternal circulation. The most common antibody associated with HDN is anti D. Other antigen c, C and E are rarely involved. Kell, Kidd and Duffy are also implicated as a cause of HDN. We report one case of Hemolytic Disease of New born (HDN) due to maternal Anti E in a multigravida mother with two previous still births. Anti E alloimmunization is a less common cause of hemolytic disease of a new born.
Aim: To emphasize the routine antenatal antibody screening in both Rh Positive and Rh negative females.
Materials and Methods: A request was received in Blood bank to arrange blood for exchange transfusion for a 3 day old preterm (34 weeks) baby admitted with neonatal hyperbilirubinimia (18mg/dl) with sepsis. Mother had no history of Blood transfusion. Blood grouping of baby was done using neonatal ABO card and mother's blood group was done using ABO/Rh Reverse grouping gel card. Antibody screening of mother's sample using BioRad 3 cell panel and direct coombs test of baby was done using Newborn blood grouping card. Rh+Kell Phenotype of both mother and baby was done. Father's sample also taken and Rh+Kell phenotyping was done.
Result: Blood group of baby was 'O' Positive and mother's blood group was 'B' Positive. Antibody screening of mother's sample with 3 cell panel (BioRad) was Positive. Direct coombs test of baby sample was also positive using ABO/Rh for newborns card (BioRad). Coombs compatible one unit issued for exchange transfusion. Bilirubin level reduced after phototherapy and exchange transfusion. Result of Rh+kell phenotyping of baby and father was same. Mother was lacking E antigen. Antibody identification using 11 cell commercial panel (BioRad) confirmed presence of Anti E.
Discussion: Because Baby's cell carried E antigen on his red blood cells, Anti E from mother's serum has attached on the Red cells and is responsible for positive DAT and hyperbilirubinea. In our country, most of transfusion centres antenatal antibody screening is done only in Rh negative mother. The sera of both Rh (D) positive Rh (D) negative women should be screened for red cells antibodies on the first visit, since some IgG antibodies (Kell, Duffy, Kidd) that can cause HDN, may be found in Rh (D) positive woman. All pregnant females should also be screened for antibody at 34 - 36 weeks. Detection of antibodies at early stage that can cause hemolytic disease of newborn will help in appropriate intervention. Regular follow up of pregnancy is required and antigen negative and compatible unit can be arranged for intrauterine or exchange transfusion, if required.
Use of Salivary Hemagglutinins to resolve ABO Discrepancy
Department of Transfusion Medicine, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Four Bunglows,
Andheri West, Mumbai 53, India.
Background: Whenever a discrepancy exists between cell grouping and serum grouping, it must be resolved. We should never guess the patients ABO grouping as incorrect guess could be potentially fatal to the patient. The discrepancy may be due to weak or missing antigens, weak or missing antibodies, extra antigen or extra antibodies. Approximately, about 78% of all individuals possess the Se gene that governs the secretion of water soluble ABH antigens into all body fluids with the exception of cerebrospinal fluid. These secretary antigens can be demonstrated in saliva by inhibition methods.
Aims: The purpose of this study was to demonstrate the use of salivary hemagglutinins in resolving ABO discrepancy in a donor sample, as a case study.
Materials and methods: This study was carried out in the Immunohematology laboratory of KDA Hospital, Mumbai on the donor sample. The ABO grouping was carried out by column agglutination technology using Ortho AutoVue Innova system. The system did not reveal the blood grouping result due to discrepancy between cell grouping and serum grouping. To resolve the discrepancy, both cell and serum grouping was carried out by tube method. But tube method also failed to resolve the discrepancy. Further, the salivary hemagglutinin assay was performed. The saliva was collected from the donor and after inhibiting the salivary enzymes, the secretary antigen was detected in the saliva by inhibition method using prediluted Anti-A, Anti-B and Anti-H lectin as per the standard protocol. The obtained results were as follows.
Results: In Column Agglutination Technology, the cell grouping showed 'O' Positive and serum grouping showed 'B' group with agglutination reaction with A cells and no reaction with B and O cells. Hence, the system did not reveal the blood grouping. In tube method also, similar results were observed and it did not help in resolving the ABO discrepancy. In salivary hemagglutinin assay, agglutination was observed with Anti-A but no agglutination with Anti-B and Anti-H lectin indicated the presence of B and H secretary substance in the saliva. This showed that the donor group is B positive.
Discussion: This case study shows that if the person is a secretor, salivary hemagglutinin assay can be used as an additional method for resolving the discrepancy of ABO grouping.
Prevalence of ABO Blood groups at Mahavir Heart Institute Surat
Nidhi Mehta, Bhawna Swadas
Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Four Bunglows Andheri West, India.
Background: Blood provides an ideal opportunity for the study of human variation without cultural prejudice
Aims: ABO and Rhesus blood groups distribution in Surat city and to compare the results with previously published data.
Settings and Design: Department of Transfusion Medicine, Shri BDM Mahavir Heart Institute, Surat.
Methods and Material: All persons donating blood from March 2001 to June 2007 were included in the study. Statistical analysis used:
Results: 'B' was the most prevalent blood group i.e., 34.89%, while AB was the least prevalent group i.e., 8.68%. Majority 94.18% were Rhesus positive. Data showed that among the Rh +ve, 32.79% were B+ve, 30.26% O +ve, 22.95% A +ve and 8.18% AB +ve. Break up of the Rh -ve, 2.1% were B -ve, 2.06% were O-ve, 1.15% A -ve, and 0.51% AB -ve.
Conclusions: Blood group 'B' is the commonest blood group in our Surati community, followed by O, A and AB respectively. More than 94% of our population is Rhesus positive.
Incidence of Rh Phenotypes in 4500 Voluntary Blood Donors - a Population Based Study
Pramod Yadav, R S Sarkar, J Philip, R S Mallhi
Armed Forces Medical College, Pune, India.
Introduction: Antigens present on the red blood cells impart different characteristics to these red cells and blind mixing of blood can initiate an immune reaction. Only the blood samples, which share the same antigenic identity, do not initiate an immune response, and hence are termed as compatible. Several blood group systems, based upon different antigens, have been proposed so far. However, the ABO system put forward by Karl Landsteiner (1900) and the Rh system by Weiner et al (1940) are the most important ones. In combination with the Rhesus system, the ABO system has become the recognized system for determining blood group compatibility for safe transfusions. The Rh system currently is composed of 50 antigens and is the largest of all. The important antigens of Rh system are RhD(RH1), RhC(RH2), RhE(RH3), Rhc(RH4), Rhe(RH5). Appropriate antigen-positive red cells may stimulate antibody production in corresponding antigen negative individuals. The determination of Rh phenotypes can therefore be important during pregnancy, for previously transfused patients and for patients with known irregular antibodies. th
Aim and Objectives: To determine the incidence of Rh phenotypes in voluntary blood donors of central Maharashtra with a view to generate data for multipurpose future health utilities and prevention of alloimmunization. This study will also contribute to development of blood bank data for constitution of panel of blood donors, particularly, in cases of isoimmunization.
Material and Methods: The study was conducted on 4,500 healthy voluntary donors, who reported to the blood bank of Department of Blood Transfusion and Immunohaematology, Armed Forces Medical College and Command Hospital (SC), Pune. Determination of Rhesus factors (Rh) was done by the antigen antibody agglutination test by the test tube method. The confirmation, if required, was done by using gel cards.th
Results: The phenotypic frequencies of Rh blood groups in the studied population were D-93%, C-91%, E-37%, c-49% and e-99%. Thus 'e' was the most common and E was the least common of all the Rh types. Phenotypically, DCCee group was the most common phenotype and dccee was least common type.
Discussion: Till date, this is the largest study of ABO and Rh phenotypes in India. All the previous studies have mostly aimed at studying the phenotypic make up of the society without further utilizing the data generated. This study has gone further ahead and made a data base of the ABO and Rh phenotypes, to be used in future to prevent alloimmunization, and for compatibility matching in cases of rare and chronic diseases requiring frequent transfusions.
Weaker expression of blood group antigens: Case Reports
Ravi Dara, Vijay Kumawat, Ashish Jain, Neelam Marwaha and Ratti Ram Sharma
Department of Transfusion Medicine, PGIMER, Chandigarh, India.
Introduction: ABH is one of the most important blood group systems in humans, which play an important role in blood transfusion. Recognition and resolution of ABO discrepancies is essential for providing appropriate blood for transfusion. Weaker expression of these antigens can interfere with our routine blood grouping and crossmatching. Flow cytometry and molecular typing are great tools to resolve such discrepancies but are expensive and may not be available everywhere. This cases aims to create awareness regarding these discrepancies. We outline one of the serological approaches to such discrepancies in resource-poor settings.
Case 1: A 51-year-old female patient with hemoglobin of 2.6 gm/dl with total serum bilirubin of 6 mg/dl with a history of recent blood transfusion of B Rh D positive and suspected diagnosis of auto immune hemolytic anemia was admitted at the Internal Medicine department of PGIMER Chandigarh, India. 2 units packed red cells requisition was received by Department of Transfusion Medicine. On blood grouping, a discrepancy was observed between forward and reverse grouping. The patient typed AB Rh D Positive on forward grouping, whereas on reverse grouping the patient typed B. Strength of agglutination with monoclonal anti-A was 1+ and reaction with anti-A1 lectin was negative. Adsorption Elution (Heat elution) confirmed presence of A antigen on red cell surface. Patient was secretor for A, B, and H substances in saliva testing. In reverse grouping, Patient's serum was reacting with A1 cells and reaction with A2 cell was negative. That anti-A1 antibody was reacting both in saline phase at RT as well as 37°C and in AHG phase. Hence the blood group was confirmed as AwkB Rh D positive with anti A1 antibody reacting at 37°C. Patient was issued 2 units of compatible B Rh D positive units. Transfusion was uneventful and post transfusion hemoglobin increases to 5 gm/dl and TSB dropped back to normal level.
Case 2: A 27-year-old male, first time voluntary blood donor, donated blood at our centre and his blood group was reported as a grouping discrepancy by the technologist as forward grouping was O Rh D positive and on reverse grouping, it was B. On further work up, forward grouping showed a mix field reaction with monoclonal anti-B as well as with Anti-AB. Adsorption elution technique (Heat elution) confirmed the presence of B antigen on red cell surface. The donor was the secretor for B and H substances in saliva. Donor blood group was confirmed as weak sub group and donor was informed about rarity of his blood group and its significance.
Discussion: These cases represent a challenge that may be faced in routine testing. There is little awareness among clinicians regarding weak sub groups in the ABO blood group. In most cases, the weak subgroups are subtle and are not detected on routine serological testing. The cause of decreased expression of ABO antigens on the red cell is due to alteration in the genes directing the A- or B- glycosyltransferase enzymes, leading to decreased activity of the enzymes and, consequently, reduced amounts of ABO antigens. Recognition of weaker sub group is important from transfusion point of view. As a recipient, weaker subgroup patient should receive best next compatible blood as there is always risk of alloimmunization. Hence, our case presents the importance of weak subgroups and their relevance in Transfusion Medicine.
A Prospective Observational Study on Prevalence of Positive Direct Antiglobulin Test in Normal Healthy Blood Donors and its Association with Syphilis
Jyoti Sharma, Prashant Pandey, Aseem Kr. Tiwari, Surbhi Dixit, Vimarsh Raina
Department of Transfusion Medicine, Medanta - Medicity, Gurgaon, India.
Introduction: The direct antiglobulin test (DAT) is used to determine the cause of hemolytic anemia, a condition in which red blood cells (RBCs) are being destroyed more quickly than they can be replaced, is due to antibodies attached to RBCs. This may occur in autoimmune-related hemolytic anemia, which may be caused by a person producing antibodies against their own RBC antigens (autoantibodies). A positive direct antiglobulin test (DAT) is occasionally associated with a serologic test for syphilis. Positive DAT among blood donors ranges from 1:1000 to 1:36000. Objective of this study is to find out prevalence of positive DAT in healthy blood donors and to find out association of positive DAT with Syphilis in healthy blood donors.
Materials and Methods: This prospective study was carried out at the department of transfusion medicine medanta the medicity, a 1,600 bedded tertiary healthcare center in the national capital region of India, from August 2010 to July 2011 (12 months). For performing DAT and syphilis testing on pilot samples of blood donors, departmental standard operating procedures (SOP) were followed. EDTA samples were used for DAT. DAT was performed on AutoVue Innova (ortho clinical diagnostics, Johnson and Johnson,USA) a fully automated platform based on columan agglutination technique (CAT).Manufacturer's instructions were followed for DAT testing . Clotted samples were used for syphilis test. Syphilis testing was done using rapid device based on immunochromatographic method (SD Diagnostics, bio standard diagnostics pvt. Ltd.).
Results: DAT and syphilis was performed on a total of 16,739 donor samples. A total of 6 donors were positive for DAT and 69 were positive for syphilis. None of the syphilis positive donors had DAT positive results. Comprehensive results are shown in [Table 1].
Discussion: The prevalence of DAT positivity among the healthy blood donors was found to be 1:2790. None of the syphilis positive donors were DAT positive.
1. Stratton F, RawlinsonVI, Merry AH, Thomas EE. Positive direct antiglobulin tast in \normal individuals. Clin Lab Hematol 1983;5:17-21.
2. Mehta K, Taylo H, Holland B. Positive direct antiglobulin test in normal healthy blood donors. N J Med 1987;84:265-7.
3. Win N Islam SI, Peterkin MA, Walker ID. Positive direct antiglobulin test due to antiphospholipid antibodies in normal healthy blood donors. Vox sang 1997;72(3):182.
4. D.W Grost, V.I Rawlinson, A.H. Merry, F. Stratton.positive direct antiglobulin tes tin normal individuals. VOX SANGth 1980 Feb;38(2):99-105.
Antibody Screening - Can it alter practice of immunohaematology in? An analysis of crossmatch requests from 21190 patients at a blood bank of a tertiary referral centre in India
Molly Rajaiah, Amalraj, Chacko M P, SC Nair, Daniel D
Department of Transfusion Medicine and Immunohaematology, Christian Medical College and Hospital, Vellore, India.
Background: Antibody screening using the commercial 3 cell screen is standard practice in transfusion medicine. This has led to the practice of group and hold followed by an immediate spin crossmatch when blood is required. Whether this practice can be introduced into the Indian setting is a question that arises as the cells that we use are from predominantly Caucasian donors.
Aim: To compare antibody screen positivity and coombs crossmatch incompatibility in crossmatch requests received in blood bank over the period from January 2011 to July 2011 and to assess, if the need for a coombs crossmatch is predicted by the 3 cell screen results.
Materials and Methods: All requests received for a red cell crossmatch were collated, along with antibody screening results and crossmatch compatibility results. Antibody screening had been performed using the 3 cell screen panel from ortho clinical diagnostics from January 2011to May 2011, and the 3 cell screen from Diamed during the month of June 2011and July 2011. As per hospital policy, coombs crossmatch was performed on patients, who received more than 5 units of blood, all transplant patients, those receiving an exchange transfusion, all Rh negative patients, those with a clinical condition, where an antibody was considered likely. All other patients had a crossmatch processed with LISS and taken up to 37°C incubation. In the event of any incompatibility detected, the crossmatch was then taken up to the coombs phase. Crossmatch was performed using the tube platform.
Results: A total of 21,190 patients request were received and 38,196 crossmatches performed. Of these 6,135 were coombs crossmatches. Of these, 555 crossmatches showed coombs incompatibility, which was from 111 patients. Thus, Coombs incompatibility was detected in 0.52% of patients. Analysis of antibody screening results showed positivity in all these 111 patients.
Discussion: Antibody screening is a valuable and standardized tool to collect clinically significant antibodies. The concern that these cells come from a predominantly Caucasian population, and may not be completely suitable in the Indian setting, has been a common concern. However, our small study shows that antibody screening seems to be a good predictor for crossmatch incompatibility at the coombs phase. In this setting, it may be worth considering a group and hold policy for patients, who have negative antibody screen.
Discussion: In view of the 100% concordance between antibody screen positivity and coombs incompatibility, it may be possible to consider a group and hold policy for those patients, who have a clearly negative antibody screen.
Comparison of ABO grouping and Rh typing on the microplate and column agglutination platforms
Eliza Sherin Koshy, R. Molly, Mary P.C., Daniel D.
Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, India.
Background: Microplate and gel card techniques are contemporary methods of RBC typing and antibody screening used in laboratories. The benefits of using these platforms include standardization, and their amenability to automation and increased sensitivity, when compared to tube and slide technique. This report compares ABO grouping and Rh typing on micro-titre plate and column agglutination when performed on the Diamed Techno Twin station.
Aim: To compare the results of ABO grouping and Rh typing on the micro-titre platform and column agglutination platform on the Diamed Techno twin station.
Materials and Method: All samples received in the blood bank of Christian Medical College Hospital, Vellore, India from May 2011 to August 2011 were grouped and typed independently by both Gel and Microplate platforms on the Techno. Samples that showed inconsistent results between the two techniques were further analyzed using the manual tube technique.
Results: 3,000 samples were processed during the study period; 8 samples showed discordance between the microplate and gel card results. All the samples were non-reactive for Rh D on the microplate but showed reactivity ranging from 2+ to 3+ on the gel card. These samples were repeated in another lot on the microplate but continued to be non-reactive. Manual tube technique was then performed for these samples, which showed 2+ to 3+ in the saline phase. These samples were also tested using the D VI negative gel card and antisera, yet showed positive reaction, thus excluding partial D VI. There was no ABO grouping discrepancies among the 3,000 samples tested.
Discussion: The microplate and gel card showed consistent results with respect to ABO grouping. However, Rh grouping on the microplate was false negative in 0.267% of cases. These results were consistent and independent of the lot of the microplate suggesting that the cause may be related to a sample characteristic. The discordant samples have been stored for further analysis at the molecular level, which we hope will aid in resolving the discordance. Meanwhile, caution should be executed in the interpretation of results based on one technique alone.
An experience of RhD typing using DVI positive and DVI negative antisera among blood donors at a blood bank of a tertiary referral centre in India
P. Amalraj, Molly Rajaiah, Chacko M P, SC Nair, Daniel D
Department of Transfusion Medicine and Immunohaematology, Medical College and Hospital, Vellore, India.
Background: D VI is a category of partial D, which is attributed to loss or rearrangement of the RhD gene fragment encompassing exons 4, 5 and 6. D VI red cells frequently fail to react with polyclonal anti-D. However, detection of this variant is important in donors, as mistyping them as RhD negative could lead to sensitization or transfusion reactions in RhD negative recipients of their blood, as well as in patients, as they are capable of developing antibodies to the missing epitopes, if given RhD positive blood. Detection requires the use of two antisera - one that reacts with D VI while the other is negative for D VI but positive for other RhD subtypes.
Aim: To examine the prevalence of D VI in cohort of blood donors as defined by D VI positive and negative antisera.
Materials and Methods: All donors who donated blood in between April 2011 to August 2011 were typed, using D VI negative antisera coated microtiter plates and D VI positive gel cards on the Techno Twin station. Any sample that was negative on the microtiter plate and positive on the gel card was retested for DVI using D VI negative card or tube technique.
Results and Discussion: 13,237 donors were screened in the given time period. 667 (5%) were RhD negative. No D VI variants were identified in any of these samples .This contrasts with the prevalence of 1:5000 documented in the study by Kulkarni et al, in the Western Indian population.
Discussion: D VI did not show significant prevalence in our population. However, in view of the clinical significance of this variant, it remains important to use methods that categorize D VI donors as RhD positive and identify D VI recipients as negative to avoid sensitization.
Delayed hemolytic transfusion reaction by Anti Jka: Case report
Pandey HC, Chaudhary R, Katharia R
Department of Transfusion Medicine, Sanjay Gandhi Post Graduate institute of Medical Sciences, Lucknow, India.
Multiple transfusions to patients expose them to various complications of blood transfusion including alloimmunization against red cell antigens, especially in thalassemia. One complication of alloimmunization is delayed hemolytic transfusion reaction (DHTR). Kidd system is the most frequently encountered antibodies responsible for DHTR.
We report a case of 6-year-old male thalassemia patient, on hypertransfusion therapy. The patient was a known case of antibodies against Jk a and c antigen. The red cell units routinely issued were negative for Jk a and c antigen. Though the serum shows presence of only anti c not of anti Jk a . As per the departmental protocol the patient sample is screened for development of newer antibodies each time before transfusion.
Immunohematological workup showed the presence of anti Jk a and anti c in serum. Patient DAT and auto control also came out to be positive.
Elution of DAT positive cell was done to see the type of antibodies coating the red cells. The eluate prepared from the patient's cells was positive for the presence of anti Jk a . On investigating, the patient had taken transfusion outside, which probably was Jk a antigen positive. It resulted in anamnestic response. The patient was again transfused with Jk a and c antigen negative units.
Three weeks later this episode, immunohematological workup was repeated, DAT and auto control was negative. The antibody screening showed only the presence of anti c only. Laboratory investigations and immunohemaotogical workup suggests the occurrence of delayed hemolytic transfusion reaction in this case.
Evaluation of frequencies of clinically significant minor blood group antigens amongst voluntary blood donors
Singh D, Kaur R, Basu S
Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, India.
Background: Very little information is available regarding distribution of various clinically significant minor blood group antigens in our country. It is important to find out the frequency of various clinically significant blood group antigens other than ABO and RhD in voluntary blood donor population. Antibodies to these antigens are known to cause haemolytic transfusion reactions in blood recipients as well as haemolytic disease of fetus and newborn. It also helps to develop donor data base for minor blood group antigens in our blood bank.
Study Design and Methods: This is a prospective study, in which 500 healthy voluntary blood donors associated with the Department of Transfusion Medicine (Blood Bank), Government Medical College and Hospital, Sector 32 were studied for their clinically significant minor blood group antigens i.e. antigens of the Rh blood group system - RhC, Rhc, RhE, Rhe; Kell blood group system - K; Duffy blood system - Fy a and Fy b ; MNSs blood group system - M, N, S, s.
Results: Out of 500 healthy voluntary blood donors, 96.4% were RhD and 4.4% were K positive. Amongst Rh antigens, e was the most common (98.8%) followed by D (96.4%), C (87.4%), c (58.8%) and E (20.4%). All (100%) D Neg donors had both c and e antigens on their red cells. However, the C antigen was found to be more associated with presence of D antigen as compared to its absence (90.2% and 11.1%) respectively. In MNS blood group antigen, frequency was M (87.2%), N (55.6%), S (59.8%) and s (88%). Similarly for Duffy blood group system antigen frequencies were Fya (88.2%) and Fyb (58%).
Conclusions: Knowledge of red cell antigen frequencies in a population is helpful in terms of their ethnic distribution, in creating a donor data bank for preparation of indigenous cell panels, and providing antigen negative compatible blood to patients with multiple alloantibodies.
Rh Negative Blood Group Incidence in a Large Corporate Hospital of North India
Sangeeta Agarwal, Divya Pandey
Blood Bank / Fortis Escorts Heart Institute, New Delhi, India.
Background: Rhesus (Rh or Rh factor) blood group system is one of 30 human blood group systems. It has a very significant role in blood transfusion as well as a relevant cause of hemolytic disease of the newborn. Also in contrast to the ABO blood group, immunization against Rh can occur only through blood transfusion or placental exposure during pregnancy.
Aims: To study the frequency of Rh negative blood groups donated in our hospital blood bank as donor population reflects various parts of the country.
Material and Methods: The study included retrospective data, from January 2006-June 2011, of 69,158 healthy donors between 18-60 years. ABO and Rh blood grouping was done by forward and reverse testing by using commercially available Anti Sera A, B, AB and Rh(D). For Rh grouping Anti-D was used and for Rh negative Du testing was done with D 1 (IgG) and D 2 (IgG + IgM).
Results: Of the total 69,158 donors, 64,405 (93.11%) donors were Rh D positive and 4,763 (6.88%) were Rh negative. Out of 4,763 Rh D negative donors, 1,070 (1.547%) were A Negative, 1,727 (2.49%) B Negative, 1,479 (2.14%) O Negative, 485 (0.70%) AB Negative and 1 each (0.00014%) of A 2 Negative and A 2 B Negative.
Discussion: As compared to various published data of the incidence of Rh D negative blood group of 5- 6%, our data showed higher incidence rate of 6.88%. Also our data reflected the rarity of A 2 Negative and A 2 B Negative groups with only 1 out of 69,158 donations. The incidence of various Rh negative was B > O > A > AB, which relates to most of the published data.
Prevalence of phenotypes and genes of ABO and Rhesus (Rh) blood groups in and around Amritsar district, Punjab - A four year study (June 2007-June 2011)
Harjot Kaur, Mridu Manjari, Sonam Sharmath
Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India.
Background: The ABO blood groups and Rhesus (Rh) D blood group antigens are the most frequently studied genetic markers in the large number of population world wide. Blood groups have been the subject of research because of the importance of blood transfusion and the disastrous consequences of transferring blood of the wrong type. Despite the long list of several other blood groups discovered so far, the ABO blood groups, being the major blood groups hold a respectable position in view of safety of blood and blood products transfusion till date. The knowledge of the distribution of ABO and Rh blood groups is essential for effective management of blood banks inventory, be it a facility of smaller local transfusion service or a regional or a national transfusion service.
Aim: To calculate the prevalence of phenotypes and genes of ABO and Rhesus (Rh) blood groups in and around Amritsar district, Punjab, as no study till now has been reported.
Material and Methods: Records of blood grouping of blood donors, blood recipients, patients attending antenatal care as well as individuals who were presented for routine medical examinations in between June 2007 to June 2011, were examined. The study involved 14,725 subjects, both male and females of all age groups. ABO-Rh blood grouping was carried out in our blood bank by standard tile techniques with appropriate positive and negative controls using 1 drop of whole blood mixed with 1 drop of anti-sera (Diamed /Tulip) and rocked gently. In case of doubt, the test was examined under a microscope, or the results were confirmed by reverse grouping using known group A and B red cells (Dacie and Lewis). Data on the frequency of ABO and Rh-D blood groups was reported in simple percentages.
Results: In our study, B blood group was the most frequent (38.064%). The frequency of bloodgroup O was 34.309% and for A and AB bloodgroups, the frequency was 18.014% and 9.611% respectively. In Rhesus blood grouping system the frequency of Rhesus (D) positive was 91.27% and Rhesus (D) negative was 8.73%.
Discussion: With these number of subjects /samples , we established that among the various ABO-Rh -D blood groups in and around Amritsar district , gene frequencies with respect to ABO and Rhesus (D) was B > O > A > AB. It is expected that the data generated in this study would assist in the planning and establishment of a functional blood service that would meet the ever increasing demand for safe blood and blood products.
The impact of Type and Screen policy on Blood Transfusion services
Gethziyal, Rema Menon
Department of Transfusion Medicine, Apollo Hospitals, Chennai, India.
Background: In the recent past, pre-transfusion compatibility tests have gone through several changes. There was a growing consensus that compatibility testing could be simplified without affecting the safety of the blood. In 1984, AABB recommended that Full Cross Match (FXM) test could be replaced by an abbreviated crossmatch in patients who were negative for cross-reacting antibodies and declared that the minor crossmatch was unnecessary. These recommendations led to the development of Type and Screen policy for pre-transfusion tests.
Aim: The purpose of this study was to compare Type and Screen tests and Type and Full Cross Match tests and to evaluate the impact of the select tests on the efficacy of transfusion services.
Materials and Methods: The study was carried out at Apollo Hospitals, Chennai, India. The samples for the purpose of the study included all donor and recipient samples. Prior to the introduction of type and screen method, all donors and recipients samples were manually typed and the results were documented. The manual method also included compatibility testing by full cross match that was carried out using AHG cassettes in Column agglutination technology. The second phase of the study included observations on automated systems that performed all immunohematological assays like blood grouping, antibody screening and cross matching. The third phase of the study involved the introduction of type and screen, in which the ABO, Rh grouping and antibody screening using 3 cell panels (Ortho AutoVue Innova system) was performed simultaneously. Donor and recipient samples that were antibody screening negative was subjected to immediate spin cross match followed by issue of compatible blood, when required. The impact of type and screen test policy in transfusion services, in terms of safety to the recipients, turnaround time, productivity and efficiency when compared to the typing and cross-match test policy was evaluated.
Results: An improved turnaround time, increased productivity and efficiency was reflected in the type and screen method. Improved turnaround time resulted in availability of time as an abundant resource for laboratory staff. It also reflected in improved time management and work flow amongst the laboratory personnel, thus enhancing their productivity.
Discussion: The type and screen policy has proven to be a safe and efficient method of blood testing. It will also help in reducing the errors of compatibility testing thereby enhancing transfusion safety.
Incidence of red cell allo and auto antibodies in multiply transfused Thalassemia major patients
Shukla JS, Chaudhary R.
Department of Transfusion Medicine, SGPGIMS, Lucknow, India.
Thalassemia patients are subjected to all hazards associated with repeated blood transfusions including red cell alloimmunization and autoimmunization.
Aim: We studied the frequency of alloimmunization and auto antibody formation among the multi transfused Thalassemia patients coming for regular transfusion at our centre.
Material and Methods: A total of 264 thalassemia patients receiving regular transfusion were analyzed for the formation of auto and allo antibodies. Direct antiglobulin test was performed on all patients to detect auto antibody while antibody screening (using 3-cell panel) and antibody identification (11 cell panel) were carried to detect the presence of alloantibody. All patients received ABO and Rh (D) matched transfusion.
Results: Of these 264 patients, irregular red cell antibodies were found in 25 (9.4%) patients of whom 4 (1.5%) patients had auto antibodies. Out of 25 patients with allo antibodies, 3 patients had more than one antibody. The antibodies identified were, Anti E:8, Anti K:6, Anti Jka:3, Anti c:4, Anti C: 2, Anti D:2, Anti S:1, Anti Fya:1 and Anti N:1.
Discussion: Since the rate of alloimmunization is relatively high in our thalassemia patients, extended phenotype cross match may be implemented to decrease this complication of transfusion.
Alloimmunization in a patient of HbE Beta-Thalassemia Intermedia: A Case Report
Pritesh Rajani, Shweta Gupta, Rajesh Sonani, Jaymin Bhatt, Nidhi Bhatnagar, M. D. Gajjar
Department of IHBT, Civil Hospital, Asarwa, Ahmedabad, Gujrat, India.
Background: Hb E Beta-thalassemia occurs due to substitution of glutamic acid by lysine at position 26 of the β chain. After Hb S, it is the next prevalent abnormal Hb in the world, mainly in south-east Asian countries. Hb E is a slow moving Hb in the region of Hb A 2 on pH 8.6 starch glucose electrophoresis, Hb A 2 and E elute at the same time. However, Hb A 2 is not more than 9.5%, while Hb E is usually not less than 15%. Alloimmunization occurs in such cases, as they are transfusion dependent. Antibody identification and finding compatible unit then poses a challenging job.
Aim: To identify the alloantibodies and manage the patient of Hb E-β thalassemia intermedia.
Materials and Methods: A 23-year-old female patient with history of 7.5 months of amenorrhea was admitted in Civil Hospital, Ahmedabad on 2 August 2011 with complaint of pain in abdomen. Patient was admitted before 6 months with history of anemia where the investigations done on the patient showed a positive NESTROFT test. Patient was then diagnosed with Hb E-β thalassemia intermedia by High Performance Liquid Chromatography following which the patient was transfused 3 units of packed cells. On examination, patient was pale with hepatosplenomegaly. Blood investigations showed Hemoglobin of 6.6 gm/dL with reduced RBC count and platelet count for which patient was transfused 2 units of group compatible A Positive Packed Red Cells with no adverse reaction. On the 10 th post-partum day, Hb decreased to 3.1 gm/dL for which was to transfuse 4 units of PCV but on major cross-matching, no group compatible units were found. Serological Investigations: Fresh sample was obtained, which was not haemolysed with no auto-clumps:
Forward and Reverse (at Room Temperature) Grouping
Direct and Indirect Antiglobulin Test: Grade 3 Positive
Antibody screening with DiaMed 3 and 11 cell panels:
Results of 11 Cell Identification Panel:
Results: The above results showed the presence of Anti-K and Anti-M, which might have developed as a result of allo-immunization due to previous blood transfusions. The presence of Anti-M antibodies was further confirmed by using papain, which turned the previously positive result of cell 1 in 3 cell panel negative. M antigen and K Antigen negative blood was searched using commercial Anti-M and Anti-K sera, which was compatible on major cross-match.
Discussion: After development of significant antibodies, patients receiving multiple transfusions pose challenging task in management. When specific antibody is identified, as in this case, that particular antigen negative blood can be given.
ABO and Rh (D) group Distribution and gene frequency; the first multicentric study in India
IMA Blood Bank of Uttrakhand, Dehradun, India.
Background and Objectives: The study was undertaken with the objective of providing data on the ABO and Rh-D blood group distribution and gene frequency across India.
Materials and Methods: 10,000 healthy blood donors donating to blood banks, situated in five different geographical regions of the country(North, South, East, Centre), were included in the study. ABO and Rh (D) grouping was performed for all these samples. Data on the frequency of ABO and Rh-D blood groups were reported in simple numbers and percentages.
Results: The study showed that O is the commonest blood group (37.12%) in the country closely followed by B at 32.26%, followed by A at 22.88% while AB is the least prevalent group at 7.74%. 94.61% of the donor population was Rh positive and rest, were Rh negative. This distribution however shows regional variations. Using the maximum likelihood method, the frequencies of the I A , I B , and I O alleles were calculated and tested according to the Hardy Weinberg law of Equilibrium. The calculated gene frequencies are 0.1653 for I A (p), 0.2254 for I B (q) and 0.6093 for I O (r).As can be seen O(r) records the highest value in Indian population, followed by B (q) and A (p); O>B>A.
Discussion: The study provides information about the relative distribution of various alleles in the Indian population both on a pan India basis as well as region wise. This vital information promises help in planning for future health challenges, particularly regarding blood transfusion.
Anti M antibody in antenatal serological workup in mothers.
Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Ponducherry, India.
Background: Landsteiner and Levine's discovery of M and N antigen was the first blood group system found after ABO system. Anti M is relatively common antibody in adults. It reacts optimally at 4°C; it usually is non-reactive at 37°C. When Anti M develops in pregnancy, it may not affect the fetus. Rare instance of hemolytic disease of newborn (HDN) due to Anti M has been described.
Aims: We present two cases of Anti M antibody without direct evidence of Hemolytic Disease of Newborn
Materials and Methods: We report two antenatal mothers with presence of anti M antibody and their fetal outcome.
Result: Case 1 was a 30-year female. Blood typing and antibody screen was A1 neg and found to be positive for Anti-M during third trimester. Titer was consistently 1 in 2 dilutions till her delivery. Paternal grouping was not determined due to non-availability of the father. Baby was B positive and direct antiglobulin test (DAT) was negative for polyspecific DAT and monospecific DAT. Clinically patient had evidence of hemolysis with elevated bilirubin levels and peripheral smear suggesting of hemolysis. Case 2 was a 25 year female presenting with fetal distress. Baby Blood group was B positive and antibody screen was positive for Anti M. Emergency cesarean section was done. Term female baby was delivered with no evidence of hemolysis.
Discussion: Presence of immunoglobulin of M type is not uncommon. However they are not known to cause hemolytic disease of newborn. Moreover their critical titer has yet to be established for its implication in HDN, periodic follow up during antenatal period is needed.
Hemolytic disease of the newborn in a mother with the D--/D-- phenotype
Mohandoss M, S.P. Subbiah, Pratul Sinha, Sabari Priya E, Suresh S, Rajish Ramanath
Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.
Background: Anti-Hro is a rare alloantibody produced by individuals lacking C/c and E/e antigens of Rh blood group on their red cells. This rare blood group is designated as D--/-- and was first described by Race and Sanger in 1950. Hemolytic disease of Newborn (HDN) due to Anti-Hro antibody is severe and fatal.
Aims: We report a case of 5-day-old newborn presenting with HDN due to Anti-Hro antibody with D--/-- phenotype in mother.
Materials and Methods: A 5-day-old newborn was referred to our institute with kernicterus stage II. The Mother's antenatal status was G6P3L2A3. On pretransfusion testing, baby and mother's blood group was A1 positive. Direct antiglobulin test (DAT) on baby's sample was positive (4+). Baby's complete phenotype could not be determined for those minor blood groups that react in AHG phase. Mother's indirect antiglobulin test was pan-reactive (4+) with screening and identification panel. Mother's Rh phenotype was D+C-c-E-e- and her probable phenotype was D--/--. We suspected her alloantibody to be Anti-Hro, as it reacted with all screening cells except autologous cells. Two units of incompatible exchange transfusion were given, as we could not find a compatible unit. Transfusion event was uneventful. Baby expired due to sepsis related complications on day 12.
Result: D--/-- phenotype patient with Anti-Hro antibody should be managed carefully during pregnancy. Regular antenatal follow up and appropriate intrauterine transfusions is warranted for a better fetal outcome. In this case, exchange transfusion was attempted as last recourse. Confirmation of the specificity is not confirmed. However with the phenotype being known, it has a high probability of being against the Hro Ag.
Discussion: Compatibility in such a rare case for exchange transfusion is by using red cells of maternal origin. However, consent for using maternal blood was not available. As an alternative, incompatible O Rh neg blood was used. There was no acute hemolytic transfusion reaction. It is advisable to refer the patient at the very first instance during antenatal care to a higher tertiary care centre, where the patient can be looked after in a better way.
Red Cell Antibody Screening and Identification in a Standalone Blood Bank in Delhi
Lions Blood Bank, Cantt, New Delhi, India.
Background: Lions Blood bank is stand alone blood bank collecting only voluntary blood donations to the tune of approximately 35,000 donor units annually. Blood components are supplied to more than 400 hospitals and nursing homes. Clinically, significant antibodies cause accelerated destruction of red cells bearing the relevant antigen. We analyze the data to know the prevalence of unexpected antibodies in the patients requiring red cell transfusions.
Material and Method: Blood group for ABO and Rh D was done by tube test forward and reverse group. Antibody screening was done for all RBCs requests by CAT using three reagent red cells, procured from commercial source (Surgiscreen; OCD). If positive, 11 cell antibody identification panel was put and analyzed by crossing out. Patient's clinical diagnosis and history of previous transfusion and pregnancy was noted. DAT and auto-control was done, if required. Rules for interpreting, the results were that three antigen positive cells must react, three antigen negative red cells do not react, all clinically significant antibodies ruled out and patient must lack the antigen using specific antisera.
Results: Total 10,264 patients' requests were received between 1 January 2011 to 31 July 2011 and total 17,869 red cells were issued. Antibody screen was positive in 139 cases - 21 cases had auto-antibodies and 118 allo- antibodies. Out of 118 cases, 41 (35%) were male and 77 (65%) were female. Allo-antibodies could not be identified in 24 cases (20%) and identified in 94 cases (80%) out of which 77 (82%) had single allo-antibody and 17 (18%) had multiple allo-antibodies. Specificities of single all-antibodies included anti-D 25, anti-E 12, anti-Le a 15, anti-Le b 7, anti-M 6, anti-s 2 and 1 each for anti-c,-N,-S, -f, -H and-A1. Antigen negative AHG cross-match compatible units were issued in most of the cases. In 17 cases of multiple antibodies, the specificities of antibodies were suspected depending on the reaction pattern of screening and identification panels and phenotype of the patient. There were combinations of anti-c+ anti-E in 4 cases; anti-D + anti-C in 2 cases and others with various combinations of Rh, Duffy, Kell, Kidd and Lewis antibodies. They were difficult cases and in most of them, AHG cross-match compatible and pheno-typed matched donor units were issued.
Discussion: Pre-transfusion screening to detect clinically significant unexpected antibodies resulted in an antibody detection rate of 1.35 %. The allo-antibodies were 1.15 % and autoantibodies 0.20%. All the cases of autoantibodies were undiagnosed hitherto and diagnosis was established only because of pre-transfusion testing protocol. In most of the cases, transfusion was deferred. However in few cases, incompatible ABO group specific blood units were transfused without any immediate untoward reaction. Anti-D is still the most common allo-antibody followed by anti-E, -Le a , - Le b and-M. Kell, Duffy and Kidd antibodies were found only in combinations in cases of multiple antibodies. In view of these findings, it is highly recommended that pre-transfusion antibody screening to detect clinically significant antibody should be the standard protocol for a safe and effective blood transfusion.
Blood Donor Deferral in a Teriary Care Hospital in South India - An Analysis
Purnima S. Rao
Kasturba Medical College Hospital Blood Bank, Mangalore, India.
A blood donation programme is essentially a human operation that interacts with the community and relies totally on the support and goodwill of individual donors.
The purpose of donor screening and deferral programs is to minimize the possibility of transmitting infectious agents and to ensure the welfare of the donors and recipients. 1
In India generally, the people are replacement donors and not voluntary donors. This is basically due to lack of awareness and many misconceptions in the minds of the donors. 2, 3, 4
The goal of any blood donation system is to have a stable, safe, and adequate blood supply. Continual monitoring of the demographics of the blood donor population of any community is required to identify problems in, and direct efforts towards, reaching this goal.
Aims and Objectives: To find out the reasons for deferral.
Materials and Methods:
Study Design: A retrospective hospital-based study was conducted, from the donor records available in the hospital.
Study setting: The study was conducted in the blood bank of the KMC Hospitals, Mangalore, a super-specialty hospital.
Study subjects: On those who had come for blood donation to the hospital over a period of 6 months from July 2008 to December 2008. The data is presented in the form of tables and pie charts. The commonest reason for deferral was the donor being on medication in the past 72 hours(16%) followed by hypertension(12.75%), then came alcohol intake(12.24%) and anemia(12.24%). These causes agreed with other similar data-mining studies published from other regions of the country. 1,3,4
Conclusions: The retrospective hospital based study was conducted over a period of 6 months from July 2008 to December 2008. On the basis of results of the study conducted, it was found that out of a total of 6,509 people who came for blood donation, 10% were deferred due to various reasons. The commonest reason for deferral was that the patients were on medication for the past 72 h. The other common reasons for deferral were hypertension and alcohol intake during past 72 h.
D variants in apparently Rh D negative antenatal women
Swati Kulkarni, K. Vasantha, Kanjaksha Ghosh
National Institute of Immunohaematology, 13 th floor, NMS building, KEM hospital campus, Parel, Mumbai, India
Background: Rh is one of the most important and clinically significant blood group system. D antigen is the most immunogenic due to the ability of anti-D to cause transfusion reaction and Hemolytic disease of the newborn (HDN). The Rh blood group discrepancies may arise when an individual is a variant of D antigen. Partial D and weak Ds are the most commonly found D variants. Partial Ds lack one or more epitopes of D antigen, while weak D have all epitopes present but express a significantly reduced amount of D antigen/RBC and are usually identified by Indirect Antiglobulin Test (IAT). Partial D and weak D phenotypes give discrepant Rh grouping results, when different monoclonal anti-D reagents and techniques are used in laboratories. Partial D and weak D individuals may develop anti-D antibodies following immunization either through transfusion or pregnancy. D antigen discrepancies need to be resolved so that correct D antigen status can be assigned and appropriate (D positive or D negative) blood products can be administered. RhD discrepancies can also create confusion over the use of Rh immunoglobulin prophylaxis in D variant antenatal women.
Aim: The aim of this study is to identify partial D and weak D variants amongst Rh D negative antenatal women labeled as Rh D negative in their respective hospitals.
Material and Methods: A total of 600 antenatal women tested as RhD negative in their respective hospitals, were investigated for partial D and weak D by ALBAclone Advanced Partial RhD typing kit, which contains 12 epitope specific monoclonal anti-D reagents. The kit can identify and classify weak D type 1 and 2 and partial D variants (DII and DNU, DIII, DIV, DVa, DCS, DVI, DVII, DOL, DFR, DMH, DAR, DHK and DAU-4, DBT and RoHar). Rh phenotyping was determined using anti-C, c, D, E, and e antisera.
Results: Out of 600 RhD negative women tested, 21 (3.5%) were identified as D variants and 63 (10.5%) were found to be "C" antigen positive. One third (33.3%) of C positive apparently D negative women were identified as D variants. Out of these 21 D variant women, majority were either DFR or DOL partial D variant. Some rare Rh phenotypes like r'r, r''r and ryr was also detected.
Discussion: Advanced partial D typing kit was observed to be very useful for identification of D variants and confirmation of RhD status. To identify D variants amongst RhD negatives in our population, we should test them for "C" antigen and only "C" antigen positives can further be tested for D variants.
A Study on the Prevalence of Rh and Kell Antigen in Multitransfused Patients of Eastern India and Their Remedy
Rafique Uz Zaman
Apollo Gleneagles Hospital Ltd, Blood Bank, Kolkata, West Bengal, India.
Background: Blood Transfusion often becomes a challenging job to the multitransfused patient, whose Rh and Kell antigenic profile is not known before the first transfusion.
Aim: The aim of this study conducted on patients, who in due course of time would require multiple transfusion not only to study the prevalence of Rh antigen D,C,c,E,e and Kell antigens but also to give the same Rh and Kell Phenotype matched blood in every subsequent transfusion.
Material and Method: A total of 53 patients suffering from sickle cell disease, thalassemia, aplastic anemia, myelodysplastic syndrome and acquired chronic anemia, which were first diagnosed in Apollo Gleneagles Hospital, Kolkata, West Bengal were taken to study the prevalence of Rh and Kell antigens. All the 53 patients were registered in hospital from May 2010 to June 2011, did not have any previous H/o of blood transfusion and were subjected to extended Rh and Kell typing other than normal blood grouping. Kidd, Duffy Lutheran, MNS and other clinically significant antigen typing were not done as it would not be cost effective for the patient in the Indian scenario and on the other hand Rh/Kell antigen covers 90.1% of immunogenicity, which in subsequent days finally leads to incompatibility.
Result: Rh antigen study of C,c,E,e,D and Kell antigen of all the patients were done using gel card and not bottle reagent so as to match patient's given H/o, no blood transfusion prior to this test, which could be corroborated and confirmed. (Gel Card can detect mixed field). The study revealed that 50 patients were Rh D Positive and 3 were Rh D Negative i.e. 94.3% and 5.7% respectively. Now coming to C,c,E,e and Kell antigens 43 patients were C Positive (81%), while 10 were C Negative (19%); 27 patients were c Positive (51%), while 26 patient were c Negative (49%); 10 patients were E Positive (19%), while 43 patient were E Negative (81%); 52 patient were e Positive (98%) and 01 patient was e Negative (02%); 01 patient was Kell Positive (02%) and 51 patient were Kell Negative (98%).
Discussion: Since in multitransfused patient in due course of time, the patient develops various unexpected antibodies therefore keeping the cost factor in mind, they should be given at least D,C,c,E,e and Kell antigen matched blood as 90.1% of incompatibility develops to the antibodies of the above mentioned antigens.
Case reports of anti-M antibody
Srinivas Rao, Vijay Kumawat, Ashish Jain, Ratti Ram Sharma and Neelam Marwaha
Department of Transfusion Medicine, PGIMER, Chandigarh, Punjab, India.
Introduction: Anti-M is a naturally occurring antibody. Rarely, it has been implicated as a cause of immediate and delayed hemolytic transfusion reactions or hemolytic disease of the new born. Though it is the frequently encountered antibody of the MNSs blood group system, it is not considered to be clinically significant. Most anti-M is only reactive at temperatures below 37°C with an optimum temperature of 4°C. Two cases were referred to the immunohematology laboratory from the crossmatch section, one presenting as crossmatch incompatibility and other as blood group discrepancy.
A 32-year-old multiparous female with a bad obstetric history G7P1140 @ 34 +4WKS with fetal anemia was referred to PGIMER, the blood group of the patient was typed as B Rh D positive in forward grouping. In reverse grouping, agglutination was seen with all three O, A, B pooled cells and auto control negative on conventional test tube method. Antibody screening procedure showed positive reactions with panel II and III (4+) while negative with panel I (FIG.1). The possibilities of antibody were anti c, Fy a , M and S. Antibody showed the probable pattern as anti-M using 11 cell identification cell panel, which was 4+ positive with (panel 1,2,4,5,6,7,8,10) and negative with cells in the panel 3,9,11. The patient was crossmatched and issued M negative packed red cells and the transfusion was uneventful.
A 2-year-old female with bilateral congenital dislocation of hip was posted for surgery without history of blood transfusion. Forward grouping showed B Rh D positive, where as reverse showed reaction with ABO cells with auto control negative. Screening panel results showed possibility of antibody against M,S,K antigen. While presence of anti-M was confirmed on identification panel. Further workup showed presence of IgM type of antibody with wide thermal amplitude reacting up to 37°C and AHG phase. The patient was crossmatch and issued M negative bags. Thus, these case reports on anti-M indicate how this antibody can have varied presentations. Though rare, these antibodies can be of clinical significance when the antibody detected is reactive at 37°C and AHG phase with partial IgG component.
Piperacillin-induced autoantibody presenting as acute hemolytic transfusion reaction a case report
Satyam Arora, Hari Krishan Dhawan, Vijay Kumawat, Suchet Sachdev, Ashish Jain, Ratti Ram Sharma, Neelam marwaha
Department of Transfusion Medicine, PGIMER, Chandigarh, Punjab, India.
Introduction: Drug-induced immune hemolytic anemia (DIIHA) is an uncommon finding. It is characterized by a sudden decrease in hemoglobin (Hb) following ingestion of the drug. Drugs can cause variety of side effects, including immune destruction of RBC's as well as coating the red cells with antibody or antibody with complement or only with complement. Hence, drug mediated problem are often encountered at a tertiary care setting due to variety of patients. We report a case of acute hemolytic reaction due to a drug.
Case Report: Passage of cola colored urine was reported after transfusion of one unit of O Rh D positive packed cells to a 45-year-old female admitted to Respiratory intensive care unit (RICU). There were no hemodynamic changes during or post transfusion except for cola color urine. She was a case of suspected miliary tuberculosis with left lower lung mass lesion with anemia as an indication for transfusion. Her obstetric history showed that she had two children with the younger one 15 years old as well as she was transfused 4 months back, outside PGIMER. Blood bank workup showed no grouping discrepancy in pre transfusion and post transfusion samples. Direct agglutination test (DAT) polyspecific (IgG and C3d) was positive in both pre (2+) as well as post (wk) transfusion samples. Negative results on screening panel of pre and post transfusion sample ruled out the possibility of any alloantibody. 2+ positive DAT in pre sample indicated that some antibody was already attached to the red cells before the transfusion. Eluate from the DAT positive pre sample also showed a negative result on the screening panel. Time gap between issue and transfusion of bag was less than 1 h as well as there was no simultaneous administration of any drug with the same line as the BT set. As none of the cause for cola colored urine was established, therefore patient's records were looked, for any clue. Drug history revealed that piperacillin sodium, Tazobactam sodium and chemotherapy were started 3 days prior to the blood transfusion. Immunohematology workup for drug induced antibody revealed presence of piperacillin sodium induced autoantibody, which might have caused the hemolysis (cola colored urine). The drug was stopped and plasma hemoglobin returned to normal value within 36 h.
Discussion: This case report emphasis on proper checking of the treatment charts of patients having transfusion reactions. As well as keeping drug induced hemolysis as one of the causes of hemolysis post transfusion in patients admitted in intensive care setting and on multiple drugs.
ABO Incompatibility - A Case Report
A. Deshpande, M. Mishra, S. Kalgutkar, S. Shah
Department of Transfusion Medicine, P.D. Hinduja National Hospital and M.R.C., Mumbai, India.
Background: ABO incompatibility in maternal - fetal relationship occurs in 15-20% of all pregnancies, which produces HDN in 10% of these cases. It is restricted almost entirely to group A or B infants born to group O mothers because of antepartum high-titer IgG antibodies A, B. ABO hemolytic disease is difficult to diagnose, as the DAT may be negative or weak, even in case of severe hemolytic disease. We report a case of ABO incompatibility caused by maternal IgG anti-B antibodies. The diagnosis and management of neonates affected with HDN require coordination among obstetric and transfusion medical team.
Aim: Diagnosis and management of neonate admitted with anemia due to ABO incompatibility.
Material and Methods: A 3-day female neonate weighing 3.9kg was admitted in our hospital for investigation of anemia with Hb - 9 gm %, Retic count - 15.97. Peripheral smear showed macrocytic polychromatic RBCs, leukocytosis and adequate platelets. Total bilirubin was 3.8, Direct bilirubin - 0.9, Indirect bilirubin - 2.9. ABO and Rh typing was done on both neonate and mother's sample. DCT was done on neonate's sample and Red cell antibody screening was done on mother's serum sample by Bio-Rad ID Microtyping system.
Results: Neonate's blood group was 'B' positive and DCT weak positive. Mother's blood group was'O' positive and Red cell antibody screening was negative. Since the DCT was weak positive, it was repeated with monospecific antihuman globulin, where only IgG was found to be positive and C3d was negative. Eluate was prepared by Dia cidel (Bio-Rad). Eluate was tested with red cell antibody screening panel cells and adult 'B' cells. Testing revealed a negative antibody screen test and weak positive test result with 'B' cells indicating the presence of IgG anti-B on the neonate's red cells. Mother's serum showed high-titer IgG anti-B by tube technique. One unit of compatible 'O' positive packed red cells was transfused to the neonate. On discharge, the neonate's Hb was 12.1 gm % and retic count was 7.43.
Discussion: In view of anemia, reticulocytosis, no clinically significant jaundice, it appears to be a case of anemia, due to ABO incompatibility (extravascular destruction).
Category 2 - Blood Donors
Profile of deferral blood donor at Regional Blood Transfusion Centre- GTB Hospital, Delhi, India
Bharat Singh, Tanya
Regional Blood Transfusion Centre, G.T.B Hospital and University College of Medical Sciences, Delhi, India.
Introduction: Safety of Blood product is a major problem all over the country. The regulatory bodies have designed certain criterion to be fulfilled by the donor before donation of blood duly checked by the medical officer and with pre donation investigations. The rates and reason for deferral is variable in different centres.
Aims and Objectives: The objective of this study is to assess the rate and reasons for donor deferral and the aim is to guide the proposed donor education and recruitment strategy.
Material and Methods: The retrospective study was carried in the Regional Blood Transfusion centre, attached to GTB Hospital and Medical College, Delhi, India. All the deferred donors from the centre as well as donors attended voluntary blood camps in last 6 month were included in the study and their data was analyzed. Deferred donors were analyzed amongst replacement/ voluntary, male and female, age group categories, temporary/ permanent. The detail information was recorded in the donor deferral register.
Results: A total of 19,125 donors presented to blood centre and in the blood camp. The male donors were 95.9%, whereas the female donors were 4.1%. The voluntary donors were majority (72.7%) comparative to replacement (27.3%) Deferral donors made about 5.1%. The deferral was more in females (32.7%) compared to males (3.9%). The deferral was more in replacement donor (72.5%) compare to voluntary donor (27.5%). Majority of Deferral donors were in the group of 18-45 years of age. Major cause of deferral were low hemoglobin (49.7%), medication (11.8%), alcohol intake ((8.6%), fever/on antibiotics (5.5%). Amongst permanent deferral the major cause is hypertension / cardiovascular disease.
Discussion: About 5 % donors are deferred from blood donation. The female donors are high on deferral list. The major cause for donor deferral is low hemoglobin. Amongst the permanent deferral, major cause is hypertension/cardiovascular problems. The Government should initiate the anemia detection program with iron supplementation.
Prevalence of Adverse Reactions in Whole Blood Donors of Rajindra Hospital, Patiala, Punjab, Indiath
Kanchan Bhardwaj, Mayank Jot Singh, Shashi Prabha, Aradhana Sharma, Poonam Singhal
Transfusion Medicine, Government Medical College, Patiala, Punjab, India.
Background: Only voluntary non-remunerated regular donation is the safest. Blood donation is safe and uncomplicated; occasionally donors experience adverse reaction (AR) during or after donation. ARs can deter voluntary donors for future donations.
Aims: To find out the prevalence of ARs in whole blood donors and to study factors determining them. th
Settings: In Blood bank and at Outreach Camps.
Design: Cross Sectional Study
Material and Method: 10,000 healthy volunteers fulfilling the donor fitness criteria donated 450 ml of whole blood in-house and at outdoor camps. They were observed for ARs.
Statistical Analysis: Chi-square test, Yates statistics.
Results: 95% of blood donors were male. The maximum donors were in the group of 20-29 years of age (47%). There were higher donations in the camps (59%). 85% of the blood donors were above 60 kg of weight and were repeat donors. Overall prevalence of ARs was 6.07% in which mild reactions were 4.63%. 45% of the reactions were found in 20-29 years of age followed by below 19 years (32%). Prevalence of ARs in the females was double (12%) than males. Donors below 60 kg (7% vs 6%) and first time donors (13% vs 5%) had more ARs. Donors donating in camps had slightly higher ARs (7% vs 4%).
Discussion: Young age, female sex, low body weight, prior donation status and donation place determine ARs. Careful handling of these factors can reduce ARs.
Key words: Whole Blood Donor, Adverse reaction, Outdoor camps, Voluntary Donor.
Voluntary Blood Donation among Females
IMA Blood Bank of Uttrakhand, Dehradun, Uttaranchal, India.
Background: Human blood is an essential element of human life and there are no substitutes to blood as yet. 1 Voluntary blood donors are the cornerstone of a safe and adequate supply of blood and blood products. 2 Blood transfusions form a crucial and irreplaceable part in the medical management of many vital diseases. The importance of blood safety and its availability goes hand in hand and invariably points to the paramount significance of voluntary blood donation. The incidences of transfusion transmitted diseases are negligible among voluntary blood donors.According to data on gender distribution of blood donors, India has among the lowest number of female blood donors in the world. Compiled by the World Health Organization, the data bank says that of the 4.6 million donations in 2008, only 6% donations were by women. The rest 94% were male donors. There were only 13 countries including India among the 100 countries, which reported low percentage less than 10 of women blood donors. In this group of 13 countries, the percentage of female donations ranged from as low as 0 in Somalia to 8.8 in Mali. An analysis of the WHO data reveals that 70% of all blood donations globally are collected from male donors. 3 This study was undertaken at stand alone Blood Bank (Regional Blood transfusion Centre) in North India collecting blood from voluntary non-renumerated donors only. It has been observed that the female enthusiasm and willingness for blood donation is much high, when compared to male donors. Unfortunately most of them are not able to become blood donors. Reasons may be varied- medical, socio economical, educational, cultural and the degree of awareness. Nutritional anemia proves to be a major cause of deferral.
Material and Methods: The medical issues principally arising from problems pertaining to menstruation and pregnancy related conditions can only be met with by effective utilization of suitable time spans.Hemoglobin levels in cases of nutritional anemia can be raised by improving their food habits, educating them with information material and supplementing with Iron tablets. Considering the difficulty to access, outreach blood donation camps can be arranged to bring blood donation services at office/house doorstep with help of mobile van. Awareness programme regarding the importance and safety of voluntary blood donation helps to clear many misconceptions regarding the subjects. Good family support especially if husband/father is regular donor.
Call centre frequent follow up.
Proper counseling and IEC material.
Improving the educational status through mass media campaign such as newspapers, T.V, city cable channels, radio etc. so that the importance of blood donations, requirement of blood, collection from voluntary donors and transfusion transmitted diseases and the use of safe blood is understood.
Attractive catchy slogans, batches, keychains, wristbands, cine slides especially for young population.
Active involvement in blood donation camps organized in colleges as volunteers/motivators.
Organizing special activities like essay/quiz/mehandi/rangoli competition and marathon/bicycle race on voluntary blood donation.
Sensitization of High school students through school education programme through lectures on blood donation and its importance, making list of participants along with their blood group can be retained and used as prospective donors.
Organizing voluntary blood donation camps for females on the eve of International Women's Day, World Breast Feeding Week, Safe Motherhood Day, Blood Donation Week, World AIDS Day, World Health Day and World Population Day. Thus, women can prove their existence and come forward to donate blood.
Blood Donation on agenda of Ladies Clubs.
Street plays on blood donation.
Results: After making all above mentioned efforts, during the span of 3years (Jan 2008 to June 2011), total blood collection was 67,453 units with female donation 6,899 units (10.22 %) with repeat female donation (5.59%)
Discussion: If a single female student or worker becomes a donor, her entire family can be motivated, as females are the best motivators in the family. Coordination between health institutions and NGOs especially women groups is important.
1. Action Plan for blood safety - NACO, 2003
2. Voluntary Blood donation Programme,NACO,2007
Role of skin disinfectants in prevention of bacterial Contamination in platelet concentrates - a comparative study
Sreedevi R, Arumugam P
Department of Transfusion Medicine, The Tamilnadu Dr.M.G.R Medical University, Chennai, India.
Background: Bacterial contamination of platelet concentrates is a long standing problem in transfusion medicine worldwide. All blood transfusion services mainly aim to reduce the risk of transfusion related viral transmissions like HIV, HBV and HCV etc. The introduction of routine blood donation screening with antibody testing, followed by Nucleic Acid Amplification Techniques (NAT), have contributed to this risk reduction. Nevertheless, Bacterial contamination of blood products emerges as the most frequent infectious hazard of transfusion. Of this, Septic reactions are more commonly seen in platelet concentrates as opposed to RBCs. This is mainly due to their storage at room temperature, which promotes the growth of even small bacterial inoculums. The major source of bacterial contamination is at the time of blood collection by skin bacteria that gain access to the unit. Other possible mechanisms include asymptomatic bacteremia of the donor, contamination of the collection bag and contamination during blood processing procedures. There is an increased contamination risk in whole blood derived platelets than single donor aphaeresis platelets; due to increased number of phlebotomy involved in the collection of pooled platelets. A wide range of bacteria can proliferate in platelet products and can reach clinically dangerous levels during the storage period. The pathogens are mainly skin commensal Gram positive bacteria like Staphylococcus aureus, Coagulase negative staphylococci, Viridans group streptococci, Bacillus species, Corynebacteria, Propionibacterium acnes ation with gram negative bacteria, though less common, most likely results in septic fatality.
Aim: A study was undertaken to investigate whether adopting a proper skin disinfection protocol could reduce the rate of bacterial contamination of platelet concentrates.
Materials and Methods: Two skin disinfection protocols were used in the routine blood collection setting. Arm preparation for 20 donors (Group A) were done with spirit alone and for the control group(Group B) of 20 donors two stage procedure, using 0.7% Iodophor solution followed by 10% Povidone iodine solution was carried out. All samples were tested for bacteriological culture on the 3 rd day of platelet collection. Initially samples were cultured in heart brain infusion agar medium for 7 days and if they showed positive growth (turbidity), subcultured in blood agar culture medium, nutrient agar medium and MacConkey's medium.
Results: In the Group A, three samples showed growth for gram positive organisms while in the control Group B no growth was noted, indicating that skin disinfection by the two stage procedure (i.e. 0.7% Iodophor solution followed by 10% povidone iodine) is more effective than disinfection by spirit alone; in reducing venepuncture associated contamination of platelet concentrates by skin flora.
Discussion: Our study supports an arm preparation with 0.7% Iodophor and 10% povidone iodine disinfection protocol as an ideal procedure in prevention of bacterial contamination in platelet concentrates.
Predonation Blood Donor Deferrals at Blood Bank, G. G. Government Hospital and M. P. Shah Medical College, Jamnagar
Dimel K. Bhuva, Prakash J. Vidja, J. H. Vachhani, Dhaval A. Mehta
M. P. Shah Medical College, Jamnagar, Gujarat, India
Background: The first and most important step, in ensuring that blood and its products for transfusion do not have any pathogenic virus or bacteria, is the proper selection of blood donors. It should be done carefully. The donor should be in good health in order to avoid any untoward effect to the donor or the recipient. The paucity of healthy, safe blood donors has always been a serious problem for blood banks worldwide. The donors are deferred for several reasons related to the safety of the donor and the potential threat to the recipient. In order to quantify the losses due to deferred donors and to understand the health problems of the donor population, a retrospective study was conducted.
Aim: To analyze the rate and various reasons for deferrals.
Materials and Methods: A retrospective review of the main causes of predonation deferral of blood donors was carried out in blood bank, G. G. Government Hospital and M. P. Shah Medical College, Jamnagar, Gujarat, India. Records of all predonation deferrals from January 2009 to December 2010 were reviewed and analyzed.
Results: There were 25,767 donors, out of which 2,319 donors were deferred (9%) for various reasons. Majority of them (92%) were being deferred for temporary reasons. Anemia was the most frequent cause for temporary donor rejection. Permanent deferral accounted for 8% with hypertension being the most common cause. And deferral rate was about five times more for female (7.5%) as compared to male (1.5%). The most common reason for deferral was low hemoglobin level (41%), followed by underweight (10%), age below or above the accepted limit (8%), presenting for donation too soon i.e. less than 3 months after previous donation (7%), hypertension (6%), history of recent ingestion of contraindicated medications (5%), diabetes mellitus on insulin (4%), history of malaria within 3 months (4%), temperature > 37.5° C (4%) and due to miscellaneous causes (11%) which includes low blood pressure, skin infections at site of phlebotomy, jaundice, high risk behavior individuals and women in menstrual period.
Discussion: Analysis of rejection patterns may help medical personnel to be more focused in donor screening. This will not only help in improving donor and recipient safety, but also in maintaining a healthy donor pool in the long run, provided the potential donors are appropriately counseled and managed to improve the efficiency of the donor program. Temporary donor deferrals need to be actively and aggressively managed, so as not to lead a diminished supply of future donors.
Key Words: Blood donors, Donor screening, Predonation deferral.
Adverse Donor Reactions in Normal Healthy Blood Donors-Experience of a Tertiary Health care Centre in India
Jijo Paul, Prashant Pandey, Aseem Kumar Tiwari, Surbhi Dixit, Vimarsh Raina
Department of Transfusion Medicine, Medanta-The Medicity, Gurgaon, India
Introduction: Donor reactions are of concern not only because it can be disturbing to the donor and disruptive to the flow. Moreover, a blood donor who experiences reaction is less likely to come back again for repeat donation. A reduction in these donor reactions would not only have a beneficial impact on the donor safety but also would help improve donor retention. It has been estimated that 2 to 3% blood donors experience vasovagal reactions and 0.08 to 0.3% of these reactions progress to syncope. The reaction may result from psychologic influence or by a neuro- psychologic response to the actual blood donation. This study was performed with the objective to demonstrate the prevalence of vasovagal reaction (VVR) in blood donors at a tertiary healthcare centre in India.
Materials and Methods: This retrospective observational study was conducted at the Department of Transfusion Medicine in Medanta the Medicity a tertiary healthcare centre from December 2009 to July 2011 (20 months). At our blood center, according to the departmental standard operating procedures (SOP) all donors underwent the process of administration of health history questionnaire and physical examinations of parameters like general appearance, weight, blood pressure, pulse, body temperature and hemoglobin estimation. Donors weighed more than 50 kg and with hemoglobin of equal to or more than 12.5 gm/dl were selected for blood donation. According to SOP all vasovagal reactions were divided into three categories viz, mild, moderate and severe. During or after blood donation, if the blood donors presented with anxiety, tachypnea, tachycardia, pallor, sweating, dizziness, nausea/vomiting, cold or clammy skin, it was categorized into mild category. If they presented with signs and symptoms of transient loss of consciousness (syncope), it was categorized into moderate category. Those donors who presented with mild reaction but recovery took longer than 15 min; it was classified in moderate category. Donors presenting with convulsion and /or incontinence (fecal/urine) were placed in severe category.
Results: A total of 32,100 blood donations took place. Majority of blood donors at the blood center were young male replacement donors. Demographic profiles of donors are shown in [Table 1]. 280 (0.87%) vasovagal reactions (VVR) were reported during the period of observation. The incidence of mild vasovagal reactions (0.81%) was highest, while the incidence of severe vasovagal reaction was lowest (0.01%). Results of VVR are shown in [Table 2].
Discussion: The prevalence of vasovagal reactions among the normal healthy blood donors was less than 1% which reflects a good management of blood donors during and after the blood donation.
Hemoglobin ranges of blood donors rejected for low hemoglobin at a blood centre of a tertiary hospital in South India
S. Kingsley, Mary P.C., Daniel D
Transfusion Medicine and Immunohematology, Christian Medical College, Tamilnadu, India.
Background: The hemoglobin cutoff for blood donation for both males and females is 12.5 gm% according to Indian blood banking regulations. Donor deferral due to low hemoglobin is one of the major reasons of temporary rejection of blood donors. However, studies in the Indian population document hemoglobin of 12 gm% as the lower limit of the range for females. This study analyses the hemoglobin profile of donors deferred due to low hemoglobin, and estimates the proportion of donors with hemoglobin between 12.0 and 12.4 gm% to assess the impact of the acceptance threshold of 12.5 gm% as against 12 gm% on our donor base.
Aim: To assess the proportion of blood donors rejected due to hemoglobin values below 12.5 gm%, and analyze what proportion of them have hemoglobin values between 12 and 12.5 gm%.
Materials and Methods: All donors screened between May 2011 and July 2011 was included in the study. The minimal hemoglobin cutoff for donor selection was set at 12.5 gm% for both male and female donors. Screening for Hemoglobin cutoff was performed on venous blood using the copper sulfate specific gravity method. All donors deferred using this method had their hemoglobin rechecked on either the Coulter counter DXH or the cyanmethemoglobin technique.
Results: A total of 9,793 donors were screened, of which 2,760 (28.18%) were deferred. Of those deferred, 1,082/2,760 (39.20%) were deferred due to hemoglobin levels of <12.5 gm%. Of the 1,082 donors deferred due to hemoglobin <12.5 gm%, 674 (62.29%) were females and 408(37.70%) were males. Among these 1,082 donors, 155 donors had hemoglobin between 12 and 12.40 gm%, of which 96(14.24%) were females and 59(14.46%) were males.
Discussion: Hemoglobin <12.5 gm% is a major cause for temporary donor deferral. However, 1.5% of donors' hemoglobin was between 12 and 12.40 gm%. Change in policy regarding hemoglobin cutoff to 12 gm% will result in a proportionately larger number of donors to the pool.
Adverse donor reactions: Experience at our blood centre
Sood T, Kaur R, Basu S, Kaur G, Kaur P, Madan L
Transfusion Medicine, Government Medical College and Hospital, Chandigarh, Punjab, India.
Introduction: Blood donation is a relatively safe procedure with minimal risks but occasionally adverse reactions of varying severity may occur during or after collection. These reactions may decrease donor return rate and adversely affect blood collection activities. The aim of our study was to find the frequency, type and causes of adverse donor reactions at our blood centre and determine the impact of these adverse events on donor return rate.
Materials and Methods: This study was conducted for a period of 13 months at the Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, Punjab, India. All adverse events occurring during or after blood donation both in the blood bank and at voluntary blood donation camps were noted. Various parameters such as type and site of donation, age, sex, donor weight, number of previous donations and volume collected were recorded. All donors who experienced adverse events, were contacted personally and the impact of such adverse events on donor return rate was evaluated
Results: Out of 13,273 blood donations during the study period, 276 (2.08%) experienced an adverse event. Reaction rate was significantly higher in female donors (4.4%; p value<0.0001) as compared to male donors (1.9%). Amongst males, maximum reactions were seen in donors in the group of 18-24 years of age, while in female donors the reaction rate was highest between 25-30 years of age. Donors having weight between 45-60 kg had highest reaction rates in both sexes. Reactions were commonly seen in the camps during hot and humid months. The most common adverse donor reaction was a vasovagal event (62.7%) but it was mostly mild in nature (87.3%). Majority of the donors (71.8%) when contacted were willing to donate blood in future.
Discussion: Adverse donor reactions are not uncommon. Better management of adverse donor events help to improve donor safety and donor return rate. However, mild reactions do not have an impact on the donor return rate. The necessity to set up hemovigilance programmes for donors is also emphasized.
Impact of stringent donor selection criteria with comprehensive screening tests
Pallavi P, Jayashree K, Manjunath GV
Department of Pathology and Blood Bank, JSS Medical College, JSS University, Mysore, Karnataka, India.
Background: Blood is life. Transfusion of blood and blood components, as specialized modality of patient management saves millions of lives worldwide each year and reduces morbidity. However, transfusion transmissible infectious agents such as Human immunodeficiency virus (HIV), Hepatitis B virus (HBV), Hepatitis C virus (HCV) and Syphilis are among the greatest threat to blood safety for the recipients. Screening of blood before transfusion is an effective strategy to reduce transfusion transmissible infections (TTI). Blood transfusion departments not only screen TTI but also give clue about the prevalence of these in healthy population.
Aims and Objectives: The purpose of this study was to compare the present prevalence of TTI among blood donors of a university hospital blood bank with that of its past prevalence as a factor to assess the measures taken to reduce TTI among the blood donors, who indirectly reflect the society.
Materials and Methods: A retrospective review of donors' record covering the period in between January 2009 to December 2010 at the blood bank, JSS Hospital, Mysore, Karnataka was carried out. All samples were screened for HIV, HbsAg, HCV, Syphilis and Malaria. The prevalence of these TTI were noted and compared with the past prevalence of these, during the period of January 2004 to December 2008.
Results: Of the 17,605, 12,017 (68.26%) were voluntary donors and the remaining 5,588(31.74%) were replacement donors. The overall prevalence of HIV, HbsAg, HCV and Syphilis were 0.37%, 1.06%, 0.22% and 0.15% respectively. No blood donors tested showed positivity for malarial parasite. Majority of the blood donors were voluntary with male preponderance. In all the markers tested, there was increased prevalence of TTI among the replacement donors as compared to voluntary donors. The past prevalence of HIV, HbsAg, HCV and Syphilis during the period of January 2004 to December 2008 was 0.44%, 1.27%, 0.23% and 0.28% respectively. Comparing the two results, a decreasing prevalence of TTI has been noted.
Discussion: A decreasing prevalence of TTI has been noted among the blood donors over the recent years reflecting the effectiveness of implementing the strict donor criteria and highly sensitive screening tests in reducing their prevalence.
Analysis of temporary deferrals and follow up to become regular donors
IMA Blood Bank of Uttrakhand, Dehradun, India.
Background: The IMA Blood Bank has witnessed close to one hundred thousand donations, since its inception in May 2006. It was also observed that there were nearly 10,000 donors that were deferred due to various reasons such as low hemoglobin, high pulse, low weight, high blood pressure etc. The prospect is very disappointing for both, the blood bank, as well as the donor who is already motivated towards a noble cause, but is unable to donate blood due to certain reasons.
Aims: The Blood Bank aims to follow up on deferred donors, counsel them appropriately, help them overcome the reasons for deferral and retain them as regular blood donors.
Material and Methods: Deferred donors were counseled by the doctors of IMA blood bank. Educational material and guidance was provided to overcome reasons of deferral.Calls were made from the call center, in an attempt to encourage deferred donors to come back and donate blood after the deferral period was over.
Results: The results obtained from the call center have not been very encouraging. From a sample of 1,300 deferrals from the year 2010, 563 donors were contacted successfully, but only 21 could be persuaded to donate blood again, indicating an extremely low turnover of 1.61%.
Discussion: The extremely low turnover rate of deferrals can be changed for better results. Efforts can be made to encourage deferred donors to donate blood. Proper counseling at camp site and later during follow up to overcome deferral reasons and regular follow up of the concerned is required. A dedicated team of call center staff can play a vital role in this endeavor. With a proper analysis of donors that can be contacted in a day, call center activities can be planned to obtain the best possible turnover rate. A prospective study has been planned at IMA blood bank to collect and analyze data for an initial period of 12 months.
Relevance of the History of Jaundice during Blood Donor Screening
Meenu Bajpai, Ekta Gupta, Kailash Chand Saini
Institute of Liver and Biliary Sciences, New Delhi, India.
Background: During routine screening blood donors are asked regarding whether they have had jaundice in the past. The guidelines regarding deferral of donors with a history of jaundice is not clear. Some centers, defer donors with a history of jaundice within 1year of donation, while some the cut-off of 2 year period, while others may take a period of 5 years or more. The relevance of this and the scientific data on this is scarce.
Aim: The aim of the present study was to find if there was a correlation between the history of jaundice and seropositivity of Hepatitis B (HBV) and hepatitis C (HCV).
Materials and Methods: We collected and analyzed data from October 2009 to May 2011 regarding history of jaundice and correlated it with seropositivity for HBV and HCV. HBV was screened using ELISA for HbsAg, while HCV was screened using ELISA for anti-HCV (BIORAD). We compared the results with over all seropositivity among blood donors in order to find out if there was greater seropositivity among donors with a history of jaundice.
Results: During the study period, a total of 3,114 blood donors donated at our institute. Donors with a history of jaundice within the last 2 years were deferred. None of the donors recalled having been tested for HBV and HCV. Over all 29 (0.97%) donors were seropositive for HbsAg, while 19 (0.61%) donors were positive for HCV. 207 donors gave a history of jaundice, among these 2 (0.9%) for HBsAg and 2 (0.9%) for anti-HCV. The difference between prevalence of markers for HBV and HCV was not much.
Conclusions: The results show that deferring donors with a remote history of jaundice does not decrease the number of seropositive units collected and deferring such donors is of dubious relevance. Such donors should only be deferred, when they give a definite history of HBV or HCV.
Psychological Morbidity in Donors: A Pilot Study
I.H and Blood Transfusion, Indira Gandhi Medical College, Shimla, HP, India.
Background: There are very few studies that have assessed psychological morbidity and psycho-behavioral aspects in donors. NACO guidelines advise for screening to ensure that the potential donor is in a healthy state of mind and body i.e. 'psychologically' and 'physically' healthy. From India, there is no available study assessing psychological morbidity in healthy donors.
Aim of the Study: To assess psychological morbidity in blood donors
Materials and Methods: Cross-sectional study carried out in the Department of I.H and Blood Transfusion, Indira Gandhi Medical College, Shimla, India. The donors were recruited through voluntary blood donation camps and replacement donors attending the department were also included in the study. 72 participants were assessed using consecutive sampling method as per NACO guidelines (for screening for physically healthy donors). All were given General Health Questionnaire-12 (GHQ-12) for assessing psychological morbidity, wherein GHQ score ≥ 1 was deemed as being positive. These were completed with the help of a counsellor, wherever deemed necessary.
Results: The mean age of the sample was 35 years. Of the total donors, 92% were males; 81% were of urban background; with predominant occupation being professionals. 51 (71%) were voluntary donors and 21 (29%) being replacement donors. 24/72 (33%) had a GHQ-12 score of ≥ 1 (i.e. GHQ Positive). Positive GHQ scores were seen more frequently in 'replacement donors' (10/21; 47 %) compared to 'voluntary donors' (14/51; 27 %). The GHQ items most frequently (more than 25%) scored as positive by the sample were- presence of sleep disturbances (11/24; 46%), feeling tense (9/24; 38%), difficulty in handling problems (8/24; 33%), not being able to enjoy daily life (7/24; 29%), and not feeling as happy as before (6/24; 25%).
Conclusions: There is a very high potential psychological morbidity in blood donors; more so in 'replacement donors'. The main symptoms reported were indicative of general stress-related and depressive problems. There is a need to incorporate appropriate screening for potential psychological morbidity for donors in order to fully adhere with NACO guidance. The preliminary results point towards a need for more in-Departmenth studies into psychological aspects of donors. We recommend a need for specialist psychiatric training for department counsellors in order to screen and assess for psychological morbidity and appropriate management by counselling or triaging onto psychologist/psychiatrists.
Retention and Recruitment of Youth as Regular Voluntary Non-Remunerated Blood Donors-Need of the Hour for Safe and Quality Blood
Sandeep Malhotra, Nishi Jaswal, M.L. Kaushal
Department of Immunohaematology and Blood Transfusion. Indira Gandhi Medical College Shimla, India.
Background: Availability of safe and quality blood and blood products round the clock, throughout the year, to meet the needs of all patients requiring transfusion, is the need of the hour. As per the data of NACO there is a need of about 10 million units of blood every year in our country. Out of this, 79.4% of blood units are obtained from voluntary blood donors. Rest all comes from replacement blood donation from relatives or friends. Regular repeat VNRBD from low risk population are the corner stone for availability of safe and quality blood. A blood supply dependent on the voluntary blood donor remains the gold standard for safety for the foreseeable future. The youth especially the college students who tend to be healthy, idealistic and motivated, are an excellent pool of potential donors who play an important role in the voluntary blood donation movement.
Aim: The present study was undertaken in the Department of Immunohaematology and Blood Transfusion, Indira Gandhi Medical College, Shimla, India to compare the participation of the youth especially the college students in the voluntary blood donation camps, over a period of last 3 years.
Material and Methods: The study includes the analysis of the data of number of camps organized during last 3 years i.e. January 2008 to December 2010 and the number of the youngsters especially college students who donated blood in these camps. The screening and the selection of the voluntary blood donors was done as per standard guidelines of NACO.
Results: Total numbers of 214 camps were organized in last 3 years in which there were 12,266 blood donations out of which 3,644 youngsters, mostly college students donated blood voluntarily. The results of the study show that there is a rising trend in terms of number of blood donation camps organized and donor participation. The contribution of the youth in the blood donation in voluntary blood donation camps has increased from 26.3% in 2008 to 33.6% in 2010.The increase in participation of youth in the voluntary blood donation movement is due to effective awareness and education campaign by blood bank in addition to maintaining cordial relationship with student and youth organizations.
Discussion: Recruiting and retaining young donors not only improves the long-term safety and sufficiency of a country's blood supply, but can also reduce the prevalence of HIV/AIDS by promoting safe lifestyles among young people. College students are healthy, enthusiastic and approachable group of voluntary blood donors who are not only safe blood donors, but motivators also. More efforts should be made for the recruitment and retention of young donors in the form of awareness campaigns in the schools and colleges and promotion of youth programmes like Club 25/Pledge 25.
Comparison between Various Methods of Hemoglobin Estimation in Blood Donors
Jaymin Bhatt, Sadhana Saraiya, Nidhi Bhatnagar, M.D. Gajjar, Pritesh Rajani, Rajesh Sonani, Shweta Gupta
Department of IHBT Civil Hospital, Ahmadabad, Gujarat, India.
Background: Hemoglobin estimation forms essential criteria in preliminary medical screening in blood donors. A value of greater than 12.5 gm/dl is required to qualify for blood donation (so as to ensure post donation safety of the donor as well as superior quality of the blood products).
Aims: To compare hemoglobin estimation by Copper sulphate, Hemocue (1 and 2) with Cell counter as the standard.
Materials and Methods: A study comprising of 120 donors was conducted in the Department of IHBT, Civil hospital, Ahmedabad, whose hemoglobin was estimated by three different methods namely Copper sulphate (specific gravity), Hemocue 1 and 2, and Cell counter. The readings obtained by calibrated cell counter were taken as standard. Copper sulphate (with specific gravity of 1.053, which is equivalent to hemoglobin of 12.5 gm/dl) was freshly prepared and was discarded after every 25 tests. The capillary samples were tested with Copper sulphate and Hemocue 1 and 2 and the venous samples collected were run by all the three methods.
Results: Hemoglobin values of 7 samples were found to be low by copper sulphate, were matching with the results of cell counter (i.e. less than 12.5) Out of 7, two results found to be greater than 12.5 gm/dl by both the Hemocues. In the samples with Hb greater than 12.5 gm/dl by CuSO 4, a difference of 0.5 to 1 gm/dl was found between the Cell counter reading and Hemocue reading .The difference was increased to the value of 2 to 3 gm/dl when the hemoglobin of the donor exceeded 15 gm/dl. A difference of 0.5 gm/dl to 1 gm/dl was found between readings obtained from capillary and venous samples with capillary values were higher.
Discussion: In a similar study conducted at AIIMS, they have concluded that hemocue provides consistently higher values in comparison to cell counter by an average margin of 0.5 gm/dl. We have also observed a similar result in our study. This does not pose any problem in actual very high or low values; but can cause false selection of donors with hemoglobin equal or near to12.5 gm/dl which can compromise donor's safety and quality of product.
Discussion: Hemocue and Copper sulphate methods were found easy to use, rapid and portable as compared to cell counter. Hemocue showed 0.5 gm/dl to 1 gm/dl higher than the actual values, which may lead to false selection of donors with borderline hemoglobin values. Besides being costly, Hemocue had the disadvantage of not being precise and results were not reproducible, thus questioning its reliability. Copper sulphate on the other hand, was a cheaper alternative but unable to show the exact reading and it requires strict quality control measures. Cell counter was found to be both precise and accurate with advantage of printed results but it requires venous collection. Thus various methods have their own advantages and disadvantages with their use being defined by the specific requirements.
Blood Donor Profile in Jaipur
Gupta M, Dhot P S, Mishra K K, Agarwal S S, Kakkar S, Dhuria U, Kedia R, Agarwal A.
Swasthya Kalyan Blood Bank and Thalassemia Research Centre, Jaipur, India.
Background: Blood Donors may be voluntary or replacement donors. Voluntary donations were obtained from walk-in donors, students and employees of institution, neighboring colleges and outdoor blood donation camps. Replacement donors were family members, close relatives or friends of the recipient.
Objectives: To find out the percentage of voluntary and replacement blood donors. To check the age, sex and blood group wise distribution of blood donors.
Materials and Methods: A total of 46,665 blood donors were analyzed for voluntary and replacement blood donors from 1 st January 2009 to 31 st July 2011, at Swasthya Kalyan Blood Bank and Thalassemia Research Centre, Jaipur, India. The voluntary donors were 82.5% and replacement donors were 17.5%. Total donations collected in outdoor camps were 37.2%.
Results: Apart from the predominance of voluntary donors 82.5%, the age wise distribution was maximum, in the group of 18-27 years of age (46.8%). Male donors contributed 97.8% of total blood collection. The commonest blood group was B Positive (35.1%) followed by O Positive (30.8%), A Positive (19.7%) and AB Positive (8.3%). 6.1% were Rh Negative blood donors.
Discussion: It is encouraging to note that 82.5% were voluntary donors. IEC activities along with pamphlets, advertisements, both in electronic and print media including National Voluntary Blood Donation Day Rally has immensely contributed to provision of safe blood for the needy patients. Even a token gift, a thank you with a smile to the blood donor, a birthday or anniversary card and public felicitation of voluntary blood donors go a long way in retaining blood donors.
Knowledge, Attitude and Practices study on Voluntary Non - Remunerated Blood Donation among the students of Degree Colleges of Jammu City
Sonam Kumari, T.R Raina
0Government Medical College, Jammu, India.
0Background: Blood donation is safe and harmless act and is a binding and social responsibility on the part of every human being. A Voluntary non-remunerated blood donor donates blood out of his or her free will without expecting anything of monetary benefit.
Aims: The study was conducted with two main objectives. First, to find out the prevalence of voluntary non - remunerated blood donors and second, to study the Knowledge, Attitude and Practices (KAP) of the college students of Jammu City regarding Voluntary Non - Remunerated Blood Donation (VNRBD).
Materials and Methods: The study was conducted in the Department of Immunohematology and Blood Transfusion Medicine, Government Medical College, Jammu, India over a period of 1 year i.e. from 1 st November 2008 to 31 st October 2009. It involved 1,520 college students of 6 degree colleges. The Age group of the subjects was from 18 to 26 years. Donor Questionnaire Proforma regarding Knowledge, Attitude and Practices (KAP) on Voluntary Non - Remunerated Blood Donation (VNRBD) were distributed among the college students.
Results: 1,520 College students with 880 females and 640 males were involved in the study. Out of 1,520 students, 210 were voluntary donors and 1,310 were non donors. Prevalence of voluntary donors was 13.81% with CI (Confidence Interval): 12.09 to 15.53. In this study, 81.57 % of students were aware of and 18.42% of students were not aware of Voluntary Blood Donation. 57.10% students were not aware of their blood group. 62.5% of the students had awareness regarding spread and transmission of HIV orAIDS and they were also aware of the fact that blood donation does not cause HIV or AIDS. 49.34% students were not aware of the fact that paid or professional blood donation has been banned in India. 76.68% of the students had knowledge that blood donation has medical benefits. From this study, it was found that the main reasons for voluntary blood donation were "Altruism", doing good to others", "Sense of social responsibility" and "For helping friends or relatives". The main reasons for not donating blood were "fear of needle or fear of sight of blood", "fear of illness or ill effects", "objection from elders" and " never been asked for blood donation. In this study, 90.13% of the students were willing to donate blood in future.
Conclusions: In this study, prevalence of voluntary blood donors was 13.81%, which is very low. The students must be counseled, so that all the myths and false beliefs regarding blood donation can be mitigated. To increase the prevalence of Voluntary Blood Donation, specific campaigns targeting the youth, motivating them to become Voluntary Non Remunerated Blood Donors should be conducted. Efforts must be undertaken to bring this knowledge and positive attitude towards voluntary blood donation into application, in future to achieve the goal of 100% Voluntary Non Remunerated Blood Donation and to provide the safest blood to the needy patients.th
Frequency of Adverse Events in Plateletpheresis Donors in Regional Transfusion Centre in North India
Gopal K Patidar, R R Sharma, Jyotdeep Kaur 1 , N Marwaha
Department of Transfusion Medicine, PGIMER, Chandigarh, Department of Biochemistry 1 , PGIMER, Chandigarh, India
Background: Although automated cell separators have undergone a lot of technical refinements, attention has been focused on the quality of platelet concentrates than on donor safety. We planned this prospective study to look into donor safety aspect by studying adverse events in normal healthy plateletpheresis donors.
Materials and Methods: The study included 500 healthy, first time (n=301) and repeat (n=199) plateletpheresis donors after informed consent. The plateletpheresis procedures were performed on Trima Accel (5.1 version, GAMBRO BCT) and Amicus (3.2 version FENWAL) cell separators. The adverse events during procedure were recorded and classified according to their nature. The pre and post procedure hematological and biochemical profiles of these donors were also assessed with the help of automated cell counter and analyzer respectively.
Results: A total of 18% (n=90) adverse events were recorded in 500 plateletpheresis donors, of which 9% of were hypocalcemia in nature followed by hematoma (7.4%), vasovagal reaction (0.8%) and kit related adverse events in (0.8%). There was significant post procedure drop in Hb, Hct, platelet count of the donors (p<0.0001), whereas WBC count showed a statistically significant rise (p<0.0001). Divalent cations (iCa + , TCa + , TMg + ) also showed a statistically significant decline after donation (p<0.0001). However there were no statistically significance difference between adverse events in Trima Accel (5.1 version, GAMBRO BCT) and Amicus (3.2 version FENWAL) cell separators.
Discussion: Donor reactions can adversely affect the voluntary donor recruitment strategies to increase the public awareness regarding constant need for blood and blood products. Commonly observed adverse events in plateletpheresis donors were hypocalcemia, hematoma formation and vasovagal reactions, which can be prevented by pre-donation education of the donors and change of machine configuration. Nevertheless, more prospective studies on this aspect are required in order to establish guidelines for donor safety in apheresis and also to help in assessing donor suitability, especially given the present trend of double product apheresis collections.
Key words: Plateletpheresis; hematological values; biochemical values; cell separator; donor safety; platelet count.
Blood Donor Deferral in a Teriary Care Hospital in South India - An Analysis
Purnima S. Rao
Kasturba Medical College Hospital Blood Bank, Ambedkar Circle, Mangalore, India.
A blood donation programme is essentially a human operation that interacts with the community and relies totally on the support and goodwill of individual donors. The purpose of donor screening and deferral programs is to minimize the possibility of transmitting infectious agents and to ensure the welfare of the donors and recipients. 1 In India, generally the people are replacement donors and not voluntary donors. This is basically due to lack of awareness and many misconceptions in the minds of the donors. 2, 3, 4 The goal of any blood donation system is to have a stable, safe, and adequate blood supply. Continual monitoring of the demographics of the blood donor population of any community is required to identify problems in, and direct efforts towards, reaching this goal.
Aims and Objectives: To find out the reasons for deferral.
Materials and Methods:
Study Design: A retrospective hospital-based study was conducted, from the donor records available in the hospital.
Study setting: The study was conducted in the blood bank of the KMC Hospitals, Mangalore, a super-specialty hospital.
Study subjects: All those who had come for blood donation to the hospital over a period of 6 months from July 2008 to December 2008.
The data is presented in the form of tables and pie charts.
The commonest reason for deferral was the donor being on medication in the past 72 h (16%) followed by hypertension (12.75%), then came alcohol intake (12.24%) and anemia (12.24%). These causes agreed with other similar data-mining studies published from other regions of the country. 1,3,4
Summary and Conclusions: The retrospective hospital based study was conducted over a period of 6 months from July 2008 to December 2008.
On the basis of results of the study conducted, it was found that out of a total of 6,509 people who came for blood donation 10% were deferred due to various reasons.
The commonest reason for deferral was that the patients were on medication for the past 72 h. The other common reasons for deferral were hypertension and alcohol intake during past 72 h. th
Blood Donor Motivation
IMA Blood Bank, Coimbatore, India.
What is the matter, why is there a need for blood donation?
The reasons are manifold, but I shall not dwell on all the aspects but touch upon the medico-social problem at the outset, let us analyze as to why is there dearth of blood donors unlike in western countries, in my personal opinion, I would say it is mere ignorance. The irony of it is that many of the medicos and qualified medical personnel deter or does not encourage their wards/friends/relatives to donate blood.
Now, off late i.e., in the last 8 to10 years, since the scare of aids has erupted like a volcano, even the medicos have started thinking twice about blood donation. There is a fear that the needles are not hygienic, here again the aids epidemic has on one hand, many of the regular donors are scared and question the authenticity of some of the blood banks integrity as far as disposable needles and syringes are concerned. They claim that why should we unnecessarily stick out our neck and embrace the deadly diseases.
Let us first of all get the media, the electronic and newspapers to support voluntary blood donation movement. Appeal to the famous or not so very famous heroes and heroines of the sliver screens and televisions to come out in the open and appeal to the public at large to shed the fear of the needle and support slogans, such as "A prick of the needle is all you have to suffer to ensure the life of a human being." Surely you can not weigh or consider the time spent for donating blood to the life of an individual. Donate blood save life, should be the main theme of all voluntary blood donors.
All blood donors can not be called altruistic donors as those of such am who donate blood only for their kith and kin and friends are called replacement donors. Altruistic are those who donate blood irrespective of caste, creed or religion, only with the sole purpose of saving a fellow human being.
The need to educate the layman should necessarily be given prime importance. There have innumerable instances when the very kith and kin slink away when requested (called upon) to donate blood. Every blood bank in the country, specially those attached to the hospitals or nursing homes should have a lot of propaganda material about the life saving yet simple act of altruistic blood donation. In mofussil areas, where literacy rate is rather low the incentive scheme for blood donors can be introduced. Though, monetary involvements should not be indulged, in badges, stickers and t-shirts can be given only with the sole purpose of encouraging more and more people to join the voluntary blood donation programmes.
The professional sellers will be out of business and so will the professional blood banks, who rob peter to pay paul and by doing this the poor ill fed professional blood sellers becomes more sick and the unscrupulous blood banks (commercial) pass on the disease to the patient i.e. amount received by the blood bank range from 500/- to 5000/-
I very strongly feel that the health authorities should take to task all the erring commercial blood banks and the punishment should be very severe so that it will deter such exploitation. The main idea behind this kind of severe punishment is manifold:-
Stops the spreading of diseases like aids and jaundice.
The relatives of persons needing blood will compulsorily have to donate blood and there by will shed their inhibitions/fear of donating blood.
Social workers can quote the example, so many blood donors who have scored a century and more in their lifetime.
Availability of fresh blood at a very short notice.
Study of Blood Donor Profile in Outdoor Blood Donation Camps in Jaipur
Dhuria U, Dhot P S, Mishra K K, Agarwal S S, Kakkar S, Gupta M, Kedia R, Agarwal A.
Swasthya Kalyan Blood Bank and Thalassemia Research Centre, Jaipur, Rajshthan, India.
Background: Outdoor blood donation camps provide voluntary blood donors. These camps are organized by colleges, institutions, NCC, Charitable Trusts, Religious Organizations, Police, Armed Forces, Banks, etc.
Study Objectives: To analyze the age, sex and blood group wise distribution of blood donors.
Materials and Methods: A total of 16,374 blood donors from outdoor blood donation camps conducted by Swasthya Kalyan Blood Bank and Thalassemia Research Centre, Jaipur were analyzed from 1 January 2009 to 30 September 2011. All blood donors donated blood voluntarily.
Results: The maximum age wise distribution was in the group between 18 to 27 years of age. Male donors contributed 95.3% of total blood collection. The commonest blood group was B positive (31.5%) followed by O positive (30.8%), A positive (19.7%), AB positive (8.3%). Rh negative blood donors were 6%. All blood donors were voluntary.
Discussion: Outdoor blood donation camps are a boon for society as they provide blood from voluntary donors, which have remarkably less incidence of TTI. Effective IEC activities along with leaflets, advertisements both in electronic and print media have immensely contributed to provision of safe blood for patients.
Category 3 - Blood Components
Implementation of a cost effective method for blood irradiation: Experience of a tertiary care referral center from South India
Shamee Shastry, Sudha S Bhat, Donald J Fernandes 1 , B Ramya 1 , Jefy Ninan 1
Department of Immunohematology and 1 Blood transfusion, Kasturba Medical College, Manipal, India.
Background: Blood component irradiation is the only proven method of preventing the risk of Transfusion Associated Graft vs Host Disease. Since the dedicated devices for blood irradiation are available only at a few centers, blood irradiation remains a service with limited availability in India due to prohibitive cost.
Objective: To implement a blood irradiation program at our center using a non-dedicated device (linear accelerator).
Materials and Methods: The study is performed detailing the specific operational, documentation and quality assurance measures employed in providing a blood component-irradiation service at our 2,000 bedded tertiary care hospital, which is also a referral center for cancer patients. Electron beams produced by a medical linear accelerator was used to irradiate the blood components. To facilitate and standardize the blood component irradiation, a blood irradiator box was designed and fabricated in acrylic. Based on the geometry of the blood irradiation box, radiation dose was planned. Plans were normalized to deliver 25 Gy at the center of the box at the isocenter. Departmental policies and procedures for blood irradiation procedure and quality control have been created. Validation of the radiation dose was done using TLD and indicator labels. Standardization of the blood irradiation program was done using 5 units of blood bag obtained from healthy voluntary blood donors. Each unit was divided to two parts. One aliquot was subjected to irradiation and the other one is taken as control sample. Biochemical and hematological parameters and change in temperature of the irradiated component and control sample were analyzed. Total time taken for the entire procedure was noted. Cost involved for irradiation of blood components was estimated. Irradiation log book was implemented in the department.
Results: In the implementation phase 5 red cell units were irradiated at 5 separate treatment sessions. There was progressive increase in plasma hemoglobin, potassium and lactate dehydrogenate levels indicating the damage to the red cells by X-ray irradiation. All the hematological parameters were within the acceptable range indicating the suitability of the product for transfusion. Irradiation time ranged from 7-10 min after a set up time of approximately 10 min. The entire irradiation process is typically completed in less than 30 min with minimal interference in the patient care activities of radiation therapy unit. The average additional expense for each unit was mainly related to the indicator labels for the QC was minimal.
Discussion: The utilization of the linear accelerator for the irradiation of blood products has proven to be safe and feasible. Establishment of a blood component irradiation program requires scrupulous physics and dosimetry support, to ensure the quality of the irradiated component. This study shows that the blood component irradiation is within the scope of most of the hospitals in India, even in the absence of dedicated blood irradiators at affordable cost.
Use of Random Donor Platelets in Rajindra Hospital, Govt. Medical College, Patiala
Poonam Singal, Kanchan Bhardwaj, Aradhna Sharma, Shashi Prabha
Department of Transfusion Medicine GMC, R.H., Patiala, India.
Background: Platelet transfusions play a major role in the management of thrombocytopenia. Baseline information regarding platelet usage in individual, center is crucial for co-ordination of clinical and transfusion services.
Aims and Objectives: To study the pattern of platelet transfusion usage in Rajindra Hospital, Govt. Medical College, Patiala.
Material and Methods: A retrospective study of platelet transfusions over a period of 6 months (Jan 2011 to June 2011) was done and details were obtained from the blood bank records.
Results: Total Number of 6,708 units of whole blood was collected over a period of 6 months. A total of 1,718 units of RDPs were prepared (25.6%), out of which 560 (32.59%) were transfused. Of the total requisitions received, 36% were inappropriate in which either the specific indication for platelet transfusion was not mentioned or transfusion trigger was above the recommended guidelines. Further, data was collected on the usage of platelets for therapeutic (22.97%), vs prophylactic use, hemotological (10.81%) vs non hematological conditions, paediatric (11%) vs adult patients, intensive care (14%) vs non intensive care patients and male (58.39%) vs female patients. Common non hematological conditions for platelet transfusion were thrombocytopenia with fever/ sepsis and common hematological conditions were aplastic anemia and acute leukemia.
Conclusions: The review indicates there is a need for continuous audit of the usage of platelet transfusions and sensitization of clinicians for appropriate use.
Usage of Fresh Frozen Plasma in Rajindra Hospital, Govt. Medical College, Patiala
Aradhna Sharma, Kanchan Bhardwaj, Poonam Singal, Shashi Prabha
Department of Transfusion Medicine GMC, R.H., Patiala, India.
Background: Demand for Fresh Frozen Plasma (FFP) has increased substantially over the past few years due to increased therapeutic use in surgeries and liver diseases. Rational use of this blood component is essential in view of the perennial shortage and safety issues surrounding this precious resource. But this blood component is more often misused due to misconceptions regarding its hemostatic effectiveness and inadequate knowledge of the conditions in which its use is inappropriate.
Aims and Objectives: To describe the pattern of FFP usage in R.H., Govt. Medical College, Patiala.
Material and Methods: A retrospective study of FFP usage was carried out at Department., of transfusion Medicine Govt. Medical College and Rajindra Hospital Patiala between January 2011 to June 2011 over a period of 6 months and details were obtained from the blood bank records. We evaluated all the FFP transfusion request forms to assess the rational usage of FFP and classified them as appropriate and inappropriate.
Results: Total units of whole blood collected during this period were 6,708. A total of 954 units (14.2%) of FFP were prepared, out of which 712 (74.6%) units were transfused. Overall 57.77% of these FFP units were appropriately used and 42.23% were inappropriately used. The common conditions for FFP transfusion were chronic liver disease with bleeding, guillain-barre syndrome for plasmapheresis, chronic renal failure RF and burns with sepsis.
Conclusions: In spite of having limited resources, only 57.77% of FFP was appropriately used. This is mainly due to lack of awareness of the national guidelines and ignorance of conditions in which its use is inappropriate. The review indicates that there is need for continual medical education of the clinical consultants and transfusion guidelines should be followed.
Blood Components Requirements in Orthotopic Liver Transplantation
Annapurna Ramesh, Naveen Kumar K, Tapan Chakraborty
Department of Transfusion Medicine, BGS Global Hospital, Bangalore - 560 060, India.
Background: In cases of end stage liver diseases (ESLD), transplantation of liver is the sole treatment available. ESLD patient for orthotopic liver transplantation (OLT) are admitted on availability of cadaver liver. Requirement of blood components are varying as per patient's hematological profile and disease condition. Blood bank needs to keep ready the ABO and Rh (D) group specific (normally) blood components with short notice. Few cases of alloantibodies to minor blood groups also may be experienced. Blood components required are log 4 Leukoreduced packed red cells, Fresh Frozen Plasma, Cryoprecipitate, Leukoreduced Platelet Concentrate. Monitoring of the patient is done by thromboelastography and with hematological parameters.
Material and Methods:
- Blood Components utilization for 7 cases of orthotopic transplantation at our center.
- Internet search for Data of Blood Components utilization for orthotopic transplantation at various centers.
Discussion: Blood bank needs to be dedicated and supportive in liver transplantation with triage like preparations and blood transfusions are crucial in saving ESLD patients life. Complications of transfusion are minimized during OLT transplantation by usage of good quality Leukoreduced blood components, accurate testing for TTI, use of SDP, closed system component separation, intra operative cell saver / auto transfusion and preparedness for the surgery. Successful liver Transplantation are rewarding to the blood bank.
- Patient may require preoperative blood transfusion if already has severe abnormal hematological profile (coagulation profile / platelet count/ Hb).
- Possibility of Orthotopic Liver Transplantation (OLT) informed to blood bank telephonically. We reserve 20 units Leukoreduced RBC, 20 units FFP, 10 units Cryo and 3 units Leukoreduced SDP earliest and on priority basis.
- OLT Surgery consists of three steps i.e. preanhepatic, hepatic and post perfusion phase. Blood components transfusions vary as per clinical condition of an individual patient. Transfusion of blood components is correlated with intra operative hemorrhage, coagulopathies and TEG. Blood components are issued without losing valuable time during transplantation.
- The use of cell saver and reinfusion of autologous blood is practiced during OLT. Efforts are made to reduce blood components requirements for OLT surgeries such as using drugs (factor VIIIa).
- During the OLT surgery, blood components minimum 21 units to maximum 118 units were utilized and 4 patients received >50 units blood components.
- 2 patients did not require platelet transfusions. Transfusion of higher units of platelet showed poor prognosis, which may be in relation with severity of ESLD.
- Requirement of blood components minimum during post operative period. Post operatively transfusion support provided to 4 patients and among them one only received >25 units of blood components.
Managing shortage of blood components - Adopting multiple strategies to overcome the shortage of blood components in a tertiary care hospital
Naveen Kumar 1 , Blood Kumar 2 , Annapurna Ramesh 2
Transfusion Medicine and Blood Bank, BGS Global Hospital, Bangalore, India.
Background: Shortage of the blood components are reviewed specially via mass media throughout the world .Various innovative steps are taken to recruit blood donors in order to overcome the shortage of blood components and to have rational stock of blood components and steady availability and issue of blood components in order to save life. Individual blood bank needs to know the reasons for shortage of blood components and also have strategies to cope up the situation.
Aim: To understand and analyze shortage of blood components in a tertiary care hospital and to take active measures including Innovative donor motivation to keep steady availability of blood components.
Material and Methods: Reference books, research papers and journals, Guidelines laid by NACO, AABB, Australian association BB, European association BB, Previous pattern of blood donation, Daily blood stock checks, Daily blood requirement checks, Media reports, Analysis of registers retrospectively, Day to day internal discussions among key persons ,Internet search for the topic
Observations: Factors and reasons reviewed for shortage of blood components in our tertiary care hospital are-
Results: Various strategies adopted to overcome the shortage of blood components are-
- Accidents and emergencies-mass casualty, Outbreak of diseases such as hemorrhagic Dengue,
- Natural disasters-Earthquake, Surgeries/ Organ Transplantations requiring massive transfusions, ICU and RTA patients requiring massive transfusions, Shelf life of particular components,
- Presence of rare blood group in a patient, Seasonal variation in blood donation, Medical tourism.
Discussion: Understanding and analyzing the shortage of blood components in a tertiary care hospital provides insight for day to day availability and issue of blood. Multiple strategies are based on technological advances in transfusion medicine, Adopting multiple strategies definitely has an advantage in overcoming shortage of blood components according to the situation.
- Shifting of blood groups among available blood components.
- Getting particular group/particular components from other blood banks/regional centre.
- ophisticated technology- Plateletpheresis
- Autologous blood donation, blood salvage, alternatives to blood
- Innovative Donor Motivation
Analysis of the partial units issued at S. P. Mehta Blood Bank of Guru Gobindsingh Government Hospital and M. P. Shah Medical College, Jamnagar, Gujarat
Dharmesh Rathod, J. H. Vachhani, D. A. Mehta, P. M. Santwani
M. P. Shah Medical College, Jamnagar, Gujarat, India.
Background: The partial units issue by aliquots is mostly indicated in neonates, the volume required for transfusion is as per patient's weight. Instead of issuing entire bag, the required volume to be transfused, should be made into aliquots and issued. This will also help in inventory management.
Aim of the Study: To analyze the issue of partial units data.
Materials and Methods: The period of study is from January 2010 to June 2011. Total number of crossmatch done is 28,592 to 21,659 issue units. Aliquot was prepared using sterile tube connecting device and laminar air flow system, which is a closed system. Hence, the expiry date remains same, which is 35 days from date of collection; entries were made in aliquot issue register.
Results: Total number of partial units issued 1,598, which are 7.38% of total issue. Commonest group for which aliquot was done was O+ve, which is 34.23%. Minimum and maximum volume was 10 cc and 320 cc respectively. Maximum numbers of partial units were issued in the month of September 2010 which was 143. Minimum numbers of partial units were issued in the month of April 2010 which was 49. The remaining Blood volume of the mother bag if not used was issued to other patient after doing crossmatch.
Discussion: O+ve group partial units were maximum issued as O+ve units were compatible with mother and baby's sample. Depending on the weight of neonates the volume of aliquots can be prepared. Thus remaining blood volume which was used to be discarded after 24 h due to open system, now can be reduced as sterile tube connecting device and laminar air flow system are used. Maximum issue of total blood units was in the month of September 2010; hence partial units issued were also increased.
Discussion: By issuing partial units to the neonates and infants using sterile tube connecting device and laminar air flow, helps to maintain the same expiry as that of mother bag, also the same bag can be issued to same patient for 2-3 times as per requirement, and thus enabling us to manage our blood bank inventory.
Usage of Fresh frozen plasma at a tertiary care hospital in Andhra Pradesh
B. Suresh Babu, A.Yashovardhan, K.V. Sreedhar Babu, D.S. Jothi Bai
Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Andhra Pradesh, India.
Background: Fresh Frozen Plasma (FFP) has been available since 1941. Initially it was used for volume replacement, but now it is used to prevent excessive bleeding in those patients with abnormal coagulation tests and in those who are undergoing invasive procedures. It has been used as a substitute in plasma exchange for diseases like Thrombotic thrombocytopenic purpura (TTP).
Aims: To assess the extent of usage of FFP in the tertiary care hospital attached to our blood bank.
To evaluate the appropriate use of FFP.
To study the outcome of patients treated with FFP and to note any adverse reactions.
Materials and Methods: A retrospective study was undertaken to evaluate the use of FFP; in the tertiary care hospital attached to our blood bank, for a period of 1 year, i.e., from 1 July 2010 to 30 June 2011. The case records of the patients for whom FFP was requested were retrieved. The particulars of the disease, hemostatic status, coagulation profiles, particularly the Prothrombin time (PT), Activated partial thromboplastin time (APTT) and International Normalized Ratio (INR) were noted. The number of units of FFP transfused, the pre and post coagulation profiles of the patients, progress of the patients noted.
Results: During the above period of 1 year, a total number of 2,136 FFP units had been transfused to 476 patients. Among these, FFPs issued to 68 patients outside our hospital were not included in the study. On an average each patient was given 4-8 units of FFP. FFPs were requested for the following categories of patients. The maximum number, 198(48.5%) were from bleeding patients of post operative Cardiothoracic surgery. Others were from Surgical gastroenterology, 70(17.1%), patients with liver disease, 32(7.8%), Guillain-Barre syndrome (GBS), 25(6.1%), traumatic bleeding, 35(8.6%), snake bite with DIC and bleeding, 29(7.2%), and Urology patients undergoing invasive procedures, 19(4.7%). As FFPs are indicated in abnormal Coagulation Profiles; In 141(34.6%) patients for whom, the pre and post transfusion coagulation profiles were not available, the transfusion of FFP was considered inappropriate. No adverse events like transfusion related acute lung injury, anaphylaxis, sepsis etc., had been recorded. FFP usage in conditions like snake bite with DIC and bleeding had been noted to show a favorable outcome and so also in patients undergoing plasma exchange for GBS.
Discussion: Abnormal PT and APTT may indicate the transfusion of FFP, but not in all situations. In case of patients admitted in ICU, Vit K administration may correct the prolonged PT and in post operative bleeding following CABG, administration of certain pharmacologic agents may curtail bleeding. In spite of the potential risks associated with FFP transfusion, when intravenous immunoglobulin is unaffordable by the patient due to high cost, it is the other alternative for plasma exchange. FFP should be transfused after careful clinical evaluation.
Quality Monitoring of Blood Components-Experience of a Tertiary Healthcare Center
Dharmendra Kumar, Prashant Pandey, Aseem Kr Tiwari, Surbhi Dixit, Vimarsh Raina
Department of Transfusion Medicine Medanta, The Medicity Sector-38, Gurgaon-122001, India.
Introduction: The objective of blood transfusion services is to provide high quality blood components for transfusion, which would have maximum efficacy. A comprehensive and coordinated approach of total quality management has quality monitoring of blood components as the most important feature. Therefore, this study was performed with the objective to assess the monitored quality of blood components prepared at our blood center.
Materials and Methods: This retrospective study was conducted at Department of Transfusion Medicine Medanta- the Medicity from December 2009 to July 2011. In brief, at our blood center only those donors weighed more than 50 kg and had hemoglobin of more than 12.5 gm/dl were selected for blood donation. According to the departmental Standard Operating Procedure (SOP) 450 ml of blood was collected from blood donor. According to the SOP, platelets were prepared using platelet rich plasma method. All the whole blood units were processed within 6 h of collection. All cellular blood components (red cell concentrate and platelet concentrates) were leukodepleted using red cell and platelet filters (BioR and BioP, fresenius, Germany). For quality control of blood components, we used PocH 100i (Sysmex, Kabe Japan) for parameters like platelets, hemoglobin, hematocrit count. For measurement of pH, we used pH paper (Merck). For analysis of residual leukocyte count in red cell concentrate and platelet concentrates, we used Nageotte chamber. Quality control of plasma products was done on the coagulometer (C A 1500Sysmex, Kabe Japan).
Result: During the period of observation, a total of 28,878 units of red cell concentrates, 26,698 units of FFP, 17,103 platelet concentrates and 2,180 units of cryoprecipitates were prepared. 315 units of red cell concentrates (1.1%), 286 units of platelet concentrates (1.7%), 78 units of FFP (0.3%) and 5 units of cryoprecipitates (0.2%) were used for quality control. Results of quality control parameters are shown in [Table 1] and [Table 2].
Discussion: Quality control program of blood components assures the efficacious use of blood components. Results shown in our study reflects high standard of quality. Hb content per bag in our study reflects the high standard of component processing. Nageotte chamber is a very good and cost effective option for the estimation of residual leukocytes in leukocyte depleted components.
1. Technical Manual, Transfusion Medicine , Directorate General of Health Services, ministry of health and family welfare, government of India, 2nd edition, 2003.
2. Drug and Cosmetic Act, 1941.
Audit of blood donation and utilization of blood products at a tertiary care hospital - A 1 year study
Manish Patil, Dhume V, Kavishwar V, Puranik G
Topiwala National Medical College and BYL Nair Hospital, Mumbai, India.
Background: For optimal functioning of any transfusion service it is essential to study the patterns of blood collection and audit blood utilization practices
Aim: To analyze patterns in blood donation and blood utilization
Methods and Materials: Retrospective study from July 2010 to June 2011 at a tertiary care hospital blood bank. Data of blood collected by our blood bank services through outdoor camps by means of voluntary blood donation and indoor blood collection by family voluntary blood donors (i.e. friends and relatives of patients) was statistically analyzed to study prevalence of ABO-Rh blood group and serology. Blood utilization trends were analyzed from blood issue records maintained at the time of issue of blood products with regards to age, sex, diagnosis of patient, indication wise utilization, number and type of blood products issued and associated adverse reaction (if any)
Results: Total 15,529 blood units were collected, of which 82% were outdoor voluntary donors and 18% were indoor family voluntary donors. Majority donors were 18-30 years of age with male preponderance. Female donors constituted 8.4% of outdoor voluntary donors and 1.8% of indoor family voluntary donors. Most prevalent blood group was O+(32.1%) followed by B+(29.9%) , A+(24.7%) , AB+(8.4%). Negative blood groups comprised 4.68% of total donors, most common being O negative. Out of all negative donors 9 were Du positive. Rare blood groups detected were 6 cases of A2B, 4 cases of A2 and 2 cases of Bombay blood group. Following components were prepared at our blood bank i.e. packed red cells, fresh frozen plasma, random donor platelets, cryoprecipitate, factor 8 defecient plasma, liquid plasma. More than 85% of total blood collection was utilized for component preparation.
Out of total collection 5.6% blood units were discarded, various reasons being i.e. Seropositivity 1.5%[ HBV-1.2%, HCV-0.25%, HIV-0.2%, VDRL-0.09%], Icteric bags(1.1%), quantity insufficient bags(0.5%), expired unutilized bags(2%), leakage(0.1%) while 0.06% bags discarded due to presence of irregular antibodies.
Of the total 15,317 blood bags issued, 76% were for in house patients, while 24% issued to other hospital patients. Anemia being most common indication for blood transfusion. Single unit transfusion accounted for 29% of total patients receiving blood. Fresh frozen plasma was most commonly utilized for volume replacement. Commonest indication for platelet utilization was thrombocytopenia. 0.07% of patients receiving blood reported adverse transfusion reactions.
Conclusions: This study observes that percent of voluntary donors were in accordance with NACO (national aids control organization) guidelines. The percent of components prepared out of total collection were well above NACO requisites. Indoor voluntary donors should be encouraged because it saves crucial transit time for component preparation and improves quality of components prepared; hence donor awareness needs to be created amongst the masses for the same. Single unit blood transfusion needs to be reduced by creating awareness amongst clinicians for rational use of blood and safe transfusion practices. Lastly, performing internal blood bank audits and reviewing statistics are vital tools for any achieving continuous upgradation of blood transfusion services.
Keywords: Donors, blood, transfusion
Blood Component Utilization Audit: Interventions to change transfusion practice
P. Kaur, S.Basu, R.Kaur, G.Kaur, I. Hameed
Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, India.
Background: An analysis of transfusion practices in a hospital set up can be of help to identify key areas, where there is need to change policy and formulate strategies for clinician education. One important tool for improvement in clinical transfusion practice is an audit of blood requisition forms and blood component utilization.
Aim: To review the pattern of blood component requisitions, utilization, transfusion probability and feasibility of implementation of type and screen policy.
Material and Methods: A total of 1,000 blood requisitions and 300 requisitions for FFP/platelets were reviewed retrospectively for indications, type of component requested, pretransfusion hematological values, utilization trends and appropriateness.
Results: Out of 1,000 requisitions screened for blood 67.8% were for packed red cells and 32.2% were for whole blood. The urgency of requirement and indication for transfusion was mentioned on 18.1% of forms. Pre transfusion hemoglobin values were available for 11.1% patients. The maximum CT ratio was for department of Obstetrics and Gynecology (3.6:1) followed by Orthopedics (3.2:1) and General Surgery (3:1) 4.6% of crossmatches were requested by immediate spin technique. Out of a total of 300 requisitions screened for FFP/platelets, 67.33% were for FFP and 32.6% were for platelets. Pretransfusion hematological values (PTI / platelet count) were provided in 25.66% of requisitions. The major users of FFP were the department of Medicine (26.1%) followed by Surgery (24.4%), ICU (14%) Obstetrics and Gynecology (12.7%) and other departments. The most common indication for FFP transfusion was liver disease. Over ordering was seen in 37.33% of requisitions. 60.2% of platelet transfusions were for patients admitted for medical conditions.
Discussion: A review of the pattern of blood and component utilization can be of help to determine transfusion probability and to formulate guidelines for usage. The present study showed a high CT ratio for the departments of Obstetrics and Gynecology, Orthopedics and General surgery. Pretransfusion hematological values were not provided in majority of forms and demand for components was more than actual transfusion. Implementation of type and screen policy in elective cases can reduce the CT ratio. There is constant need for generation of awareness and education among clinicians to ensure appropriate use of blood. The role of a functioning hospital transfusion committee cannot be over emphasized.
Comparison of Factor VIII levels between O and non-O blood types in Cryoprecipitate
Ramesh Kumar N.R.
Life Line Blood bank and Research Centre, Vannerpettai, India.th
Background: Cryoprecipitate prepared from the whole blood donation was tested for Factor VIII activity and Fibrinogen before issuing to patients as a routine measure for quality control. Interestingly, it was found that individuals with type O blood are more likely to have reduced factor VIII levels compared to their non-O counterparts.
Materials and Methods: 45 healthy blood donors from A blood group, 66 healthy blood donors from B blood group, 57 healthy blood donors from O blood group and 42 healthy blood donors from AB blood groups were tested for factor VIII activity and fibrinogen from the cryoprecipitate prepared from the whole blood collected at our blood bank on various occasions before issuing to the patients.
Results: The mean factor VIII activity (in IU/ml) for "A" blood group was 116 ± 2.2 , for "B" blood group 115 ± 3.1 , for "AB" blood group 119 ± 1.8 whereas for "O" blood group 83 ± 2.6. The reference range for factor VIII activity on cryoprecipitate is 80 to 120 IU/ml. The mean fibrinogen level (in mg/dl) for "A" blood Group was 320 ± 21.2 , for "B" blood group 342 ± 24.1 , for "AB" blood group 331 ± 27.1 whereas for "O" blood group 344 ± 21.5. The reference range for fibrinogen is 200 to 400 mg/dl.
Conclusions: The mean factor VIII activity was low in "O" blood group when compared to non "O" blood group although "O" blood group factor VIII activity within the reference range, where as no significant difference is seen in the fibrinogen levels.
As per our study, if we issue 4 units of cryoprecipitate to 1 patient, which amounts to 328 ± 2.2 of factor VIII activity whereas when we issue 3 units from non "O" blood group the total yield we get 350 ± 2.4 factor VIII activity.
It is suggested that if we use non "O" blood group cryoprecipitate, we can reduced the number of units given to patients, so that the multiple exposure and the complication to the patients can be reduced.
In Vitro Survival of Leptospires in Ellinghausen-McCullough-Johnson-Harris broth with Acid Citrate Dextrose solution concentration at par with the ACD concentration in the whole blood
KK Sharma, Madhavi Latha P, Kalawat U, Jothi Bai DS
Sri Venkareswara Institute Of Medical Science, Tirupati - 517507, Andhra Pradesh, India.
Background: Leptospirosis is an emerging zoonotic disease having nonspecific clinical signs and symptoms. Susceptible hosts recover without any treatment in 90% of cases. Most common symptoms are fever, cough, body ache, which mimic the symptoms common cold. Mildly symptomatic patients are not debarred from the blood donation. Mice and rat, cattle, pigs, squirrel, etc are reservoir animals; these are common house hold pet animals and easily seen in the cultivation fields and urban slums. Most often leptospirosis is transmitted by urine of infected animals. Whole blood is stored at 4°C up to 35 days in blood banks. ACD solution is added as preservative to the whole blood.
Aims: This study was done to know the duration for which leptospires can survive in vitro in leptospira culture media (EMJH broth) with the acid citrate dextrose (ACD) concentration at par with the concentration in whole blood at 4°C and 30°C.
Material and Methods: Ellinghausen-McCullough-Johnson-Harris (EMJH) broth was prepared with ACD solution at par with the ACD concentration in whole blood. Since, 63 ml ACD solution is added to 450 ml of blood accordingly ACD concentration was calculated in EMJH and dispensed in screw capped test tubes 3 ml each and inoculated with pure culture of L. icterohaemorrhagiae. The test was performed in duplicate and the tubes were incubated at 4°C and 30 °C. Test tubes were examined by Dark Field Microscopy (DFM), on Day 3, 4, 5, 6, 7 and after that weekly once for 7 weeks. Smear was prepared and examined under DFM for flexion, extension, cork- screw motility of leptospires and sub cultured in EMJH broth and incubated at 30°C, it is optimal temperature for growth of leptospires in vitro. Culture tubes were shaked daily for optimal growth. When turbidity was observed, dark field microscopy was done for motility of leptospires to know the viability. Gram staining was done to rule out contamination.
Results: We observed actively motile leptospires up to 5 th week of incubation at 4°C and 30°C. After 5 th week leptospires became sluggish and were reduced in number. There was not much difference between observations at 4°C and 30 °C.
Discussion: Since blood in blood banks is stored in ACD solution at 4°C, possibility of transmission of leptospirosis to the recipient by transfusion of infected blood can not be ruled out. But it is a laboratory based in vitro study, and storage conditions simulate blood storage conditions only partially. So it needs to be further studied and confirmed.
Evaluation of Pall Enhanced Bacterial Detection System in routine use for Detecting Bacterial Contamination in Packed Red Blood Cells
Vimal S, Marathe AN, Ojha S, Rajadhyaksha SB
Department of Transfusion Medicine, Tata Memorial Centre - Advanced Centre for Treatment, Research and Education in Cancer, Kharghar, Navi Mumbai, Maharashtra, India.
Background: Sepsis and death caused by transfusion of red cell units contaminated with bacteria continues to be a concern in transfusion medicine. The development of an effective bacterial screening method is important in the process of minimizing bacterial contamination and improving transfusion safety. We present our experience with Pall eBDS in routine screening of packed red blood cells (PRBC) for bacterial detection using oxygen consumption as surrogate marker.
Aim: To evaluate the performance of Pall eBDS for bacterial contamination in fresh and stored PRBCs after 48 and 72 h of incubation
Material and Methods: 150 PRBC (< 3 days old) were selected from current inventory. These PRBCs were prepared from whole blood using CPD-SAGM triple blood bags according to standard platelet rich plasma method. PRBCs were leukodepleted using laboratory filters (Fresenius / Pall) and sampled with eBDS as per manufacturers instruction. The head space oxygen concentration was measured using an oxygen analyzer (PBI -Dansensor) after 48 and 72 h of incubation at 35°C in a flat bed platelet incubator and agitator (Helmer laboratories).The oxygen concentration was measured and named the unit as eBDS Pass/ Fail against the threshold of 14.4%. PRBCs of different age from 1, 3, 7, 14, 21 and 28 days (10 each) were also sampled before and after leukodepletion. Volume, hemoglobin (Hb), hematocrit (Hct), white blood cell (WBC) and platelet count of all units were calculated.
Results: Mean oxygen concentration (MOC) at 48 and 72 h of incubation were 15.05% and 15.90% respectively. 109 (72.6%) of eBDS pouches passed at 72 h of incubation. 67 (44.6%) pouches failed initially at 48 h (MOC 13.34%), 42 (62.7%) among them later passed when measured at 72 h (MOC 16.72%) and remaining 15(10%) were eBDS failed (MOC 11.52%). Failed PRBCs were sent for culture, but no growth was found. PRBCs initially failed after 48 h incubation has a mean Hb and Hct of 18.43 g/dl and 56.34% respectively compared to pass one with 17.17 g/dl and 54.79% respectively. MOC is almost similar when compared PRBCs with (15.21%) and without (15.34%) leukodepletion irrespective of age of the unit.
Discussion: Determination of head space oxygen concentration after 48 -72 h of incubation has been recommended by the manufacturer for bacterial detection in PRBCs. However we have seen more failures at 48 h of incubation compared to 72 h. This may be due to high Hb and Hct content of red cell units. The confounding effects of residual WBCs and platelets in oxygen consumption were found negligible based on pre and post leukodepleted PRBCs. Based on our experience we recommend a longer incubation time of 72 h in detecting bacterial contamination in PRBC units.
Factors Affecting Platelet Count and Platelet Yield
Sapna Rathore, Pankaj Jain, Raju Singh, Meenu Bajpai
Institute of Liver and Biliary Sciences, New Delhi, India.
Background: The purpose of the study is to observe the effect of various factors on platelets count and platelets yield of platelet concentrates during storage period, which are as follows: weight of donor, age, hemoglobin, hematocrit, pre-platelet count, volume of PC (platelet concentrates), pH (last day of storage), post platelet count in PC and yield.
Aim: Qualitative assessment of various factors to elicit their effect on platelet count and platelet yield during the storage period.
Materials and Methods: Whole blood was collected in 450 ml bags containing 63 ml of CPDA1 anticoagulant. They were kept at room temperature (20-24°C) and PRP-PC was prepared within 6 h of collection. The whole blood was mixed by turning the bag upside down several times before centrifugation. The volume of PRP-PC was determined with the equipment composcale CS 300. Hemoglobin, hematocrit and platelet count were measured using Sysmex KX-21. pH were determinate using indicator paper (pH 2.0-10.5)
Result: A total of 100 platelet concentrates (PRP-PC) were studied. The mean volume of PRP-PC is 65.9 ± 2.7 ml. The mean Pre platelet count of platelet is 9.3 ± 3.07 × 10 10 /unit, hemoglobin 13.9 ± 09 and HCT 42 ± 2.6. A total of 100 units was analyzed for pH, which is 7.0 on the last day of storage (fifth day) .Platelet count was 5 ± 2.85, 7.6 ± 4.3, 8.5 ± 5.39 and 6.3 ± 3.4 on zero, first, second and fifth day respectively. Platelet yield was 51.3 ± 20.9, 79 ± 31.7, 87 ± 38 and 65 ± 24.3 on zero, first, second and fifth day respectively. In 100% case of PRP-PC count and yield increases from time of collection to first day, 80% case of PRP-PC count increases first to second day and decreasing count of PRP-PC started on third day till the last day of storage. 20% case of PRP-PC count decreased on the second day.
Discussion: On the basis of study no effects was observed on PRP-PC count and yield by the factors of weight, age, Hb and Hct of donor. PRP-PC count and yield are affected by the pre platelet count of donor. High platelet count gives high yield of PRP-PC and vice versa.
Bacterial contamination of platelet concentrate - visual inspection to rescue
Suchet Sachdev, Harikrishan Dhawan, Dheeraj Khetan, Ashish Jain, Ratti Ram Sharma, Neelam Marwaha.
Department of Transfusion Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab, India.
Background: Bacterial contamination of blood has been in knowledge since the time blood used to be collected in glass bottles. The introduction of closed system plastic blood collection has definite advantage, but the risk of bacterial contamination still persists, moreover, assumes importance due the reduction in the risk of viral transmission. It is estimated that 1 in 3,000 platelet concentrates (PCs) may induce sepsis in the recipient, whereas the risk of viral infection transmission is 1 in 200,000 for HBV to approximately 1 in 2,000,000 for HIV and HCV. Bacterial sepsis accounts for between 14 and 24% of transfusion associated fatalities reported to the US Food and Drug Administration. Worldwide following strategies are available to reduce the risk of transfusion-related sepsis e.g. improved donor selection, optimal skin disinfection, removal of the first 10-30 ml of blood, bac≠terial detection, and pathogen inactivation methods. Platelets manufactured at our institute are prepared after blood collection following stringent donor selection and skin disinfection, culture is done for 1% of units prepared as per the departmental SOP. Thus, visual inspection is relied upon to evaluate the swirling prior to issue.
Observation: We are reporting the detection of Acinetobacter contaminated platelet concentrate on day 4 of shelf life, stored strictly between 20 -24 °C on flat bed agitator cum incubator. On visual examination, the platelet bag demonstrated a large fibrinous coagulum that was characteristically clinging to the inlet port. The bag was quarantined immediately along the packed red blood cells and fresh frozen plasma prepared from the unit. There was no swirling noted in the unit and the biochemical testing reported acidic pH (6.5), markedly reduced sugar (0.2 mmol/l) and increased ionized calcium (0.73 mg/dl). The culture and sensitivity done on BD Bactec blood culture system 9240 (Becton, Dickinson and Company). Spark MD 21152) using both aerobic and anaerobic methods detected growth of Acinetobactercalcoaceticus- baumannii complex.
Discussion: Bacterial contamination of whole blood or blood components can occur at several points viz production of the blood bag, asymptomatic blood donor bacteremia, donor phlebotomy or during the blood component preparation manipulations. Contamination at the time of blood collection is the major cause of bacterial contamination of platelet units, however often it is difficult to identify the source. Acinetobacter spp are ubiquitous bacteria that have been isolated from patients, the environment, soil, and water. The increasing clinical interest in the genus Acinetobacter is mainly attributed to its capability to cause a wide range of nosocomial infections due to the unusual ability of this gram negative organism to survive in dry conditions. Acinetobacter has been reported in platelet contamination cultures. Although, contamination of platelets with Gram-negative bacteria is less common, it is more likely to result in septic fatality (60%).
Discussion: In the present era, in which the risk of transmission of many blood borne viruses, has been significantly minimized, it is paradoxical that the earliest recognized infectious transfusion complication, bacterial contamination, is now the more frequent and is proving the most difficult to eradicate. This event describes the importance of visual examination of blood and blood components in a very subtle way as an important hemovigilance tool.
The pattern of blood components replacement in liver transplant recipients
Deepti Sachan, Joy Varghese 1 , Olithselvan 1 , Rajshekhar 2 , Gomathy 2 , Venugopal 2 , Rela M 2
Department of Transfusion Medicine, 1 Hepatology, 2 Hepatobiliary and Liver transplant surgery, Global Hospital and Health city, Chennai, India.
Background: Liver transplantation (LT) is a growing treatment modality for the treatment of end stage liver disease. Although, the blood requirement has declined over the last decade due to improvement in surgical techniques and use of pharmacological alternatives, transfusion support remains an integral part of transplantation. Massive blood loss during surgery, associated coagulopathy and thrombocytopenia in the liver transplants recipients create a challenge to transfusion services to effectively deliver massive transfusion support.
Aims: To review retrospectively the pattern of blood and component replacement in patients who underwent liver transplantation at our centre from August 2009 to August 2011.
Material and Methods: The study was performed in department of transfusion medicine. Global hospital and health city, Chennai. Data was collected retrospectively for the LT recipients during the study period. Patient demographics, operative details, blood transfusion data (including preoperative, intraoperative and operative) was collected from blood bank records, hospital information system, and patient records.
Results: During the study period, a total of 82 live donors (LDLT) or diseased donors (DDLT) liver transplant surgeries were performed, which included 18 pediatric and 65 adult liver transplant recipients. The mean age of transplant recipients were 38 (range 1- 69) and M: F ratio was 3:1. The average number of components used during the study period were 11 (range 0 - 99) leukodepleted packed red cells in additive solutions (LD-PRC), 9 units (range 0-67) of fresh frozen plasma (FFP), and 1.2 units (range 0-13) of single donor platelets (SDP), 8.5 units (range 0-86) of leukodepleted random donor platelets (LD-RDPs), 8.7(0-51) units of cryoprecipitate. There is a significant decrease in mean LD-PRC (mean 15.6 vs 7 units), FFP (11.3 vs 7.3 units) transfusion in past 2 years, while mean single donor platelet transfusion is increased (0.8 vs 1.5 units).
Discussion: Although the blood utilization has declined significantly in past 2 years in our centre, but still blood requirements remains unpredictable and require efficient transfusion services to provide timely blood and blood components.
Study of Single Donor Platelets and Random Donor Platelet Concentrates in Jaipur
Mishra KK, Dhot P S, Agarwal S S, Kakkar S, Gupta M, Dhuria U, Kedia R, Agarwal A
Swasthya Kalyan Blood Bank and Thalassemia Research Centre, Jaipur, Rajashthan, India.
Background: Transfused platelets are either pooled random donor platelet (RDP) Concentrates or single donor apheresis platelets (SDP). When stored for 5 days all of these products are equally efficacious.
Study Objectives: To study the availability of SDP and RDP concentrates.
To study the efficacy of platelet transfusion using SDP and RDP concentrates
Materials and Methods: A total of 1,472 SDP were prepared using Hemonetics 3p cell separator at Swasthya Kalyan Blood Bank and Thalasemia Research Centre, Jaipur from 1 January 2003 to 31 July 2011. 37,696 RDP concentrates were prepared during the same period.
Results: A total of 1,472 SDP were issued to needy patients. 28,264 (76%) RDP concentrates were issued out of a total of 37,696. The clinical and laboratory response of patients was satisfactory.
Discussion: SDP and RDP concentrates are a boon for patients with thrombocytopenia, and sometimes, life saving in conditions like Dengue Hemorrhagic Fever, Aplastic Anemia etc. A 10,000 microlitre prophylactic platelet transfusion trigger has been documented to be both hemostatically efficacious and cost effective in reducing platelet transfusion requirements.
Category 4 - Transfusion Medicine Clinical Practice
Transfusion medicine in clinical practice -Blood component utilization review at tertiary care hospital
Ivy Hospital, sector 71, Mohali, Punjab, India.
Aim and Objectives: Optimal utilization of blood and blood products is the need of the hour. The purpose of blood component utilization review was to assess the pattern of blood and blood components usage for process improvement of the transfusion services.
Materials and Methods: We conducted a retrospective study at 180 bedded Super-specialty hospital providing facilities of oncology, onco-surgery, cardiothoracic surgeries, renal transplant and trauma. Blood component utilization pattern was studied over a period of 6 months from Nov 2010 to April 2011. The request forms were analyzed for indications for transfusion, diagnosis, laboratory indices and compared with the standard guidelines to assess the clinical transfusion practices.
Results: Our hospital got drug license for making blood components in October 2010. During this period, hospital transfusion committee was reformulated as part of preparation for NABH audit. We carried out a retrospective analysis of 822 request orders for 432 patients during the study period. The total units of blood and blood components supplied were 1,956. Packed red blood cells (PRBCs) were the most utilized blood component. The requests for supply of PRBCs to the medical wards constituted 63.6% of all demands, with highest requirement from patients with renal disorders on renal dialysis. Anemia was the most common indication (45.2%) for PRBCs transfusion followed by elective surgery (21.1%). Demands related to hepatic disorders were responsible for most of the Fresh Frozen Plasma (9.5%) used, for patients with deranged coagulation profile. The most common indication for platelet transfusion was thrombocytopenia post chemotherapy.
Discussion: Blood component utilization review was focused on the rational use of blood and blood products. Special emphasis was on high usage clinical units (dialysis, CTVS and critical care), patients requiring special products and transfusion requirements with increased risk of adverse effects. Conducting utilization review is part of accreditation requirement for NABH.
Obstetric and Gynaecological Transfusion practices in a Tertiary care centre
Department of Transfusion Medicine, Medical college Hospital, Trivandrum, India.
Introduction: Practice of Transfusion owes much to 19 th century work of pioneering English obstetrician Dr. James Blundell. Dr. Blundell, concerned with loss of blood in puerperal hemorrhage, successfully reintroduced blood transfusion in medical practice, after 150 years of mandated prohibition in Europe.
Background: For most major and minor gynecological procedures blood use is uncommon (<10%). Thus, maximum surgical blood order schedule (MSBOS) require only a blood type and antibody screen. Approximately, 0.5-2.5% of pregnant women receives blood at or near the time of delivery. Despite the fact that obstetric transfusions are infrequent and require very few units of blood, obstetric hemorrhaged remains the main cause of maternal mortality. Considering the red cell problems in pregnancy, hemolytic disease of newborn (HDN) mainly Rh related is the most common. All obstetric patients at the outset of pregnancy should do blood type and an antibody screen. Further evaluation should be done according to the type of antibody and its critical titer. The platelet problems unique to pregnancy include neonatal alloimmune thrombocytopenia (NAIT), Gestational thrombocytopenia and patients with isolated thrombocytopenia.
Materials and Methods: This is a retrospective analysis of the transfusion requirement in O and G department of Medical college hospital Trivandrum for a period of 1 year.
Results: Out of total blood units issued to various departments, O and G received 3.7% blood units, among which 39% were used for patients undergoing abdominal hysterectomy. These were mainly single unit transfusions. Obstetric transfusions included LSCS (25%), PPH (3.3%) APH (7.5%) and others (DUB, PET, HELLP-25%) Frequency of Rh D alloimmunization in Rh D negative mother was found to be 3.12%. Failure to administer RH Ig leading to alloimmunization accounts for 65.6% (Out of total alloimmunization). Frequency of affected newborn, who were Rh +VE and DCT+ was 89.1%. Only 6.9% of affected newborn needed exchange transfusion.
Discussion: There should be a definite protocol in O and G transfusion practices, thus avoiding unnecessary transfusion. Appropriate and rational use of blood and blood components is recommended to ensure their availability to needy patients. Use of single unit transfusion is strongly discouraged and should be used only when indicated.
Setting up transfusion triggers in a tertiary care hospital
Annapurna Ramesh, Venkatesh H.K, Hemanth H.R, Gagadhara D.S
BGS Global Hospital, Bangalore, India.
Background: Blood transfusions save many human lives every day worldwide, but at the same time blood transfusion causes well explored transfusion reactions and also less understood adverse effects. There are two sets of thinking and the following transfusion practices adopted
Liberal Transfusion Strategy -Maintenance of Hb >10g/dl
Restrictive Transfusion Strategy -Maintenance of Hb >7g/dl
Similarly, platelets and FFP has to be used cautiously with indication for them.
Whenever possible alternatives to blood such as using drugs Erythropoietin, Hematinics, factor VIII conc, aprotonin, tranexamic acid, albumin, crystalloids, colloids, plasma expanders etc to be advocated and blood components transfusion has to be justified. Autologous blood transfusion, cell salvaging, exposure to minimum donors (use of SDP) are also set practices.
Aim: To provide a transfusion triggers policy for our tertiary care hospital in order to avoid unwanted blood transfusion, rational use of blood, maintenance of good stock of blood components, to reduce treatment cost and to maximize the therapeutic effect of blood transfusion.
Material and Methods: Reference books, research papers and journals, Guidelines laid by AABB, Australian association BB, Clinical Guidelines for blood usage America's Blood Centers, Previous pattern of blood transfusion. We had discussions and debating at our hospital transfusion committee meetings among specialists. Factors considered while setting transfusion triggers were enormous and are-clinical and hematological parameters, clinical condition and diagnosis, Medical / surgical / ICU / Transplantation /Trauma indications, acute onsets /chronicity /disease progression, associated clinical conditions, hemoconcentration in a patient, internal bleeding, anticipated bleeding in RTA cases, beneficial effects of blood components transfusion adverse effects of blood transfusion, post transfusion oxygen carrying capacity of PRBC, patient tolerance towards hematological abnormalities, bench markers, storage effects on red cells, medico legal aspects of treatment etc .
Results: Responsibilities and practices of transfusion expected from blood bank and practices expected from clinicians are formatted. Protocols prepared for transfusion triggers for minimum threshold, leukopoor-packed red blood cells, threshold for platelet transfusion, threshold for fresh frozen plasma and threshold for cryoprecipitate prepared based on hematological parameters.Protocol configured for reservation of leukopoor blood components for surgeries/ transplantations. Decision to order and transfuse blood components based on patients clinical condition and co morbid condition also incorporated in the policy.
Discussion: Efforts should be made by clinicians to keep the lower hematological thresh holds (Restrictive Transfusion Strategy) to rationalize the blood transfusion practices. However, hematological parameter based transfusion triggers alone does not cover the individual patient's ability to tolerate anemia, thrombocytopenia, coagulation disorders as the associated clinical co morbidities may be intangible. Hence, the decision to transfuse blood components need to be individualized; primarily based on physiological triggers of the patient assessed by treating clinicians and to follow the guidelines based on hematological parameters.
Role of Transfusion Medicine in Disaster Management
Umesh D, Arumugam P
The Tamil Nadu Dr. M.G.R Medical University, Chennai, India.
Background: We live in an era, where we have to expect the unexpected. Disaster -Natural or Manmade can be devastating with loss of human lives and property. The cycle of disaster management includes mitigation, preparedness, response and recovery. Continuity of operations plan (COOP) is the key for successful completion of a disaster management. A risk assessment chart to identify the functional areas and hazards during a disaster should be prepared to avoid failures during disaster management.
Objectives: The Emergency management department which heads the recovery process is under pressure. The morbidity recovery of the injured is taken care of by the health department. The health department should be well equipped with its staff, drugs, equipments, power, transportation and mainly blood.
The department of Transfusion medicine plays a pivotal role during disaster management by taking care of the demand for blood, storage of blood products and its transportation.
The recommended acronym "BEST CODDE" of disaster management are:
Building and infrastructure, Electricity, Staff members, Transportation, Communication system, Donor surge, Demand for Blood.
In case, the Building which houses the blood bank is damaged, alternative measures to temporarily reconstruct the blood bank should be done. In such instances, the shifting of blood storage system and products should be quickly done with the available manpower without any decrement in its quality.
As Electricity supply may be disrupted, early measures should be taken for continual storage of blood products without any decrement in its quality. Generator with its fuel and battery backed power supply should be well serviced for an uninterrupted power supply to the blood banks and its storage centers.
Staff members should be sorted out in teams so that they will be available round the clock. The family members of the staff should be informed about the issue and their emotional quotient dealt with.
The Transport department should be informed about transportation of blood products so that they reach the hospitals in time.
Communication systems may come to a standstill. Landline, mobile services and internet services may be disrupted .Short text messages may be used. Ham radios and two way radios can be used in such situations.
Donor surge may occur at blood banks .The staff members should counsel the donors and donor deferral should be carefully dealt with.
In the event of Biowar or radiation hazard, the donor screening should be carefully done and the incubation period and longevity of the biological or radiological material be taken care of.
In situations, where Demand for blood products is high, the screening of blood products is delayed. In such instances, whether screening of blood products is important than life saving is always in debate. Retrospective testing of blood samples should be done.
Discussion: The mistakes and lessons learnt during disaster management should always be discussed, reviewed and included or excluded in the protocol. Careful planning of availability of blood products can save a numerous lives. However, one has to plan according to the resources available for the given circumstances.
Management of Critical Case of Hemolytic Auto Antibodies
Anupam Chhabra, Alpana Srivastava, Amit Jain, David Raj, Jitendra Kumar, Pradeep Negi, Brijesh Tomar
Pushpanjali Crosslay Hospital, Ghaziabad, U.P., India.
Background: A 20-year-old female, weight 33kg was admitted with diagnosis of Rheumatic Heart Disease, Severe Calcifc Mitral Stenosis, Mild Mitral Regurgitation, Aneurysmal LA, Severe Tricuspid Regurgitation, PAH, Atrial Flutter, CHF, NYHA class IV and was operated -Mitral Valve replacement with # 29 ATS AP valve, LAA ligation +TV repair. At the time of surgery, the patient turned to be allergic to protamine sulphate, hence heparin was not reversed. Patient developed hypotension, shifted to cardiothoracic vascular surgery intensive care unit and was re-explored after few hr. Blood group determined at the time of crossmatch was 'B' positive, hence initially matched units of 16 Packed Red Blood Cells, 11 units of Fresh Frozen Plasma, 24 units Platelet Concentrate were transfused during and after the surgery. After the surgery, patient complained of yellow discoloration of skin, loss of appetite, altered sensorium. A significant rise in total bilirubin (22.48 mg/dl), direct (16.22 mg/dl) and indirect bilirubin (6.26 mg/dl) and decrease in hemoglobin (6.5 gm/dl) was recorded.
Aim: To detect the cause of Severe Hemolysis and stabilize the patient by bringing down the deranged hematological parameters.
Materials and Methods: Auto control and Direct Coombs Test was graded 3+ positive by Dia Med -ID Micro Typing System (Gel Card). Both, cold (C3d)and warm (IgG) antibodies were found positive (2+) in DC screening. Blood group at this stage was not determined probably due to the presence of auto antibodies. Antibody screening and Identification was negative in Coombs and Enzyme phase. As a protocol blood group 'O' Rh, Kell matched Leukocyte Depleted Packed Red Blood Cells (Least Incompatible) suspended in SAGM were transfused. In order to extract the circulating autoantibodies, three consecutive Therapeutic Plasma Exchanges under the supervision of transfusion medicine specialist were performed and Intra venous Dexamethasone was administered.
Results: A total of 10,951 ml Plasma Volume was processed and 5,722 ml of plasma was extracted, which was compensated by 50% Colloids (Blood Group 'AB' Fresh Frozen Plasma, 25% Albumin, 6% HES) and 50% Crystalloids (9 % normal saline). Dexamethasone was tapered after few days. The patient showed a striking clinical improvement. A significant decrease in total bilirubin (4.22mg/dl), direct (2.96 mg/dl) and indirect bilirubin (1.26mg/dl) and increment in hemoglobin (8 gm/dl) were recorded after the procedures. Urine for hemoglobin and hemosidirin was reported negative.
Conclusions: Therapeutic Plasma Exchange can play an important role in extracting the circulating antibodies. The case probably falls in category II: Disorders for which Apheresis is acceptable as a second line therapy, either as a standalone treatment or in conjugation with other mode of treatment.
A case study on Hemolytic disease of the new born - Analysis and management
Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Four Bunglows, Andheri West, Mumbai 53, India.th
Introduction: The Perinatal Hemolytic Disease affect the fetus and the new born due to the placental transfer of maternal antibodies against the antigens present on the fetal erythrocyte membrane, which are not present on maternal RBC. Direct Antiglobulin Testing and Antibody screening is an essential component in the analysis of hemolytic diseases of the new born, where mother's serum is tested for the presence of any clinically significant antibodies capable of causing hemolytic diseases of the fetus, and the fetus blood sample tested for the presence of sensitized RBCs and antibodies in the serum or plasma. This helps in understanding the cause of the disease and clinical management of the disease in a better way.
Aim: The purpose of this study was to analyze the cause and pattern of hemolytic disease of the new born and the management of the disease by providing safe compatible blood by doing antibody screening, phenotyping and compatibility testing.
Materials and Methods: A new born baby with HDN presented to our blood bank for the need of compatible blood units for transfusion was analyzed along with maternal serum to identify the cause of the disease and to provide compatible blood to the baby. The baby's blood sample was subjected to blood grouping and DCT by Column Agglutination Technology using Ortho AutoVue Innova system. Further, Rh and Kell phenotyping was carried out to understand the Rh Phenotyping using CAT. The plasma sample was subjected to irregular antibody screening using 3 cell panel from Diamed. The mother, father and elder brother's blood samples were collected and subjected to blood grouping, Rh and Kell phenotyping, antibody screening using 3 cell panel and identification by 11 cell panel using column Agglutination technology, to understand the cause of the disease. The donor's samples were phenotyped and crossmatched by CAT. The compatible blood (PRBC) units were transfused and followed.
Results and Discussion: The Baby's blood group was found to be AB Positive, DAT Positive and Antibody screening Positive. The Rh and Kell phenotyping showed the presence of Rh antigens C, E, c and e and absence of Kell antigen on the RBC. The mother's blood group is B Positive and Antibody screening positive. The antibody identification using 11 cell panel showed the presence of 'Anti-E' antibody. The Rh phenotyping of mother's RBC showed the presence of only C, c and e antigen and absence of E and K antigen, confirming that the presence of Anti-E antibody in maternal serum. The father's blood group is 'A Positive' and the Rh phenotyping showed the presence of E, c and e antigen. The baby's elder brother blood group is 'AB Positive' and Rh phenotyping showed the presence of C, E, c and e antigen. This shows that mother got exposed to 'E antigen' during first delivery and she developed 'anti-E' antibody. Mother's anti-E antibody crossed the placenta and affected the fetus red blood cells leading to hemolytic diseases of the new born. The baby was treated with immunoglobulin and phototherapy. The compatible donor blood samples were selected by doing crossmatching and the compatible blood units were subjected to Rh phenotyping and found to be having C, c, e antigen, but absence of E antigen as well as K antigen. The two compatible blood units without E antigen was transfused without any complications, managed clinically and discharged.
Therapeutic phlebotomy; an experience at a tertiary care hospital
Yashovardhan, Chaitanya Kumar I. S, K. V. Sreedhar Babu, D. S. Jothi Bai
Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Andhra Pradesh, India.
Background: Blood letting i.e., withdrawal of considerable quantities of blood from a patient, to cure or prevent illness has been practiced from ancient times; even leeches were used for this purpose. Therapeutic phlebotomy (TP) refers to drawing of a unit of blood in specific cases in the treatment of few diseases like Hemochromatosis, Polycythemia Vera etc., to reduce the amount of red cells. In patients with cyanotic congenital heart disease, before surgery when hematocrit is high, thrombotic complications or hemorrhagic diathesis may occur. In such cases, reduction of hematocrit is undertaken by TP. Secondary polycythemia with increased thrombogenesity has higher incidence of severe coronary disease and stroke. In case of iron overload, either primary or secondary, "deironing" is accomplished through TP to prevent complication of organ damage like hepatic cirrhosis, cardiomyopathy etc.
Aims: To review the nature of disease and progress of patients treated by TP at our blood bank attached to a tertiary care hospital.
Materials and Methods: It is a retrospective study. The records of the past four and a half years were reviewed to assess the diseases/causes for TP. The age, symptoms, clinical diagnosis, lab parameters pertaining to Hemoglobin, hematocrit (Hct), Ferritin level etc., were noted and tabulated. The number and frequencies of TPs performed and the follow up notes were reviewed to evaluate the progress of the patient.
TPs were done on the request of the Consultant at intervals of 4 days to 7 days. In case of children, 10 mL blood/Kg body weight has been removed, while in adults 350-450 mL of blood was removed during each TP. The initial Hct, levels were >60% (60%-79%). Serum ferritin levels were available only in 1 patient who had secondary hemosiderosis following >250 blood transfusions for Myelodysplasia; her initial ferritin level was >2000 ng/ml. TPs were done till the Hct levels were reduced to 45%.
Results: During the past four and a half years, 27 TPs were done; 16 in adults and 11 in children. 22 (81.5%) TPs were done for secondary polycythemia; 50% of these secondary polycythemia patients had congenital heart disease; they were children between 6 to 12 years of age. TPs were done on an average of 2 times; maximum being 7 times. 27.3% of these secondary polycythemia cases presented with neurological complications like hemiparesis. 4 cases (14.8%) were diagnosed as Primary polycythemia and one case (3.7%) was finally diagnosed as Methemoglobinemia. The maximum number (13 times) of TPs was done in this patient and his Hct level was reduced from 79% to 56%. TPs were observed to decrease the symptoms like claudication pain.
Discussion: The management of secondary polycythemia is correction of the underlying cause and new drugs are available for the treatment of Polycythemia Vera; however TPs may be undertaken for the temporary relief of the symptoms due to hyperviscosity. TPs are essential to decrease the iron overload and improve the lifespan of the patients with hemochromatosis.
Blood donor Turn around Time: Quality parameter for transfusion services
Archana D, A.A Tendulkar, S B Rajadhyaksha
Department of Transfusion Medicine, Service Block, Tata Memorial Hospital, Mumbai, India.
Introduction: Blood donation activity is the basic framework upon which the transfusion service rests. One of the key factors that directly affect the donor return is the donor experience during prior donations. The turnaround time (TAT) taken for donation is a very objective quality indicator to assess the services. Turnaround time is defined as the time taken by the blood donor for the entire donation process i.e. from time of entry to time of exit.
Aims and Objectives:
1) To calculate the total time taken for blood donation by donors who donated in-house in the blood bank.
2) To evaluate the reasons for increase in donation time.
3) To plan improvement strategies for the donation process.
Materials and Methods: The donor records of approximately 1,000 blood donors, who had donated blood in-house, were assessed. Time of registration, hemoglobin test, medical history, phlebotomy time and donor exit time is recorded on the donor card. If there is a delay in donating blood or there is a donor reaction, the details are documented on the card, which helps to assess the reason for the delay.
Results: The turnaround time for our in-house donors is approximately 45 min. Statistical evaluation of the same shall be presented.
Discussion: The factors that can cause an increase in the donation process are time taken to understand the donation procedure, excessive rush of donors during peak hr and weekends, unexpected transient donor reactions and manpower shortages. The strategies to improve and prevent delays, include appropriate staff presence at the appointed counters for physical examination and phlebotomy, predonation counseling by the trained staff, prompt attention to donor reactions and their effective management, team effort by all staff members to overcome any challenges during the donation process.
Discussion: Turnaround time helps transfusion services to evaluate the loopholes in the chain of events from donor entry to exit. Once the shortcomings are detected with the help of the TAT, necessary measures need to be implemented. This is vital to improve all aspects of donor retention and thus make it a worthwhile experience for all blood donors.
Anaphylactoid Transfusion Reaction with anti Ig A antibody in an Ig A deficient female - A Case Report
James Chitra, Jacob Sharon, Usha K C
Government Medical College, Trivandrum, India.
A Case of anaphylactoid transfusion reaction associated with IgA deficiency and anti IgA antibodies is reported. Anaphylactoid reactions are rare events estimated to occur in 1 in 20,000 to 47,000 transfusions. A 52-year-old multiparous female was referred to our centre with a history of anaphylactoid reaction following few drops of crossmatch compatible packed cell transfusion, in view of anemia due to menorrhagia. A detailed family history, obstetric history and previous transfusion history revealed no clue to diagnosis. The patient was worked up for IgA deficiency. Nephelometry assays revealed an IgA level of 0.04 g/l and was diagnosed as a case of IgA deficiency. In view of anaphylactoid reaction, patient was screened for the presence of anti IgA antibodies using ID-PaGIA anti IgA test and was positive. Family was screened for IgA deficiency using ID PaGIA card test. Anemia was corrected pre operatively with intra venous iron and washed Packed Cell Transfusions as IgA deficient donors were unavailable. Transfusion was uneventful. Definitive surgery was done for the patient and washed packed cells were administered intraoperatively. Post operative period was uneventful.
A Study of Blood Transfusion Support in Patients of Aplastic Anemia on Immunosuppressive Therapy
Singh A, Verma A, Chaudhary R
Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
Background: Aplastic anemia (AA) is a disease characterized by bone marrow aplasia and peripheral blood pancytopenia. Management of aplastic anemia constitutes, support with packed red cell (PRBC) and Platelet transfusion, when required with prevention or treatment of infectious complication, and restoration of hematopoietic stem cells (HSC) function using immune suppressive therapy or stem cell transplantation. Immunosuppressive therapy (IST) is the best treatment for elderly patients and those without HSC donor. This prospective study was planned in our department, to study the transfusion support in Aplastic anemia patients undergoing IST.
Methods and Materials: We monitored 28 patients suffering from aplastic anemia over a period of 24 months. Transfusion records were obtained from the requisition form sent to our department. Effects of transfusions were assessed by testing the post-transfusion samples obtained from the patient at 3 weeks, 3 months, 6 months and 12 months after the start of immunotherapy.
Results: Majority of platelet transfusion was done in patients having counts less than 20,000/μL, and most of red cell transfusion (57%) was done in patients having hemoglobin between 5-7 gm/dL, followed by 32% of transfusion at a hemoglobin of less than 5 gm /dL.Tranfusion reaction was very less, especially due to introduction of buffycoat reduced packed red cells.One patient had red cell alloimmunization (constiuting rate of sensitization to be 3.6%) with in 6 months of follow up peroid. 30 patients (46.4%) were found to be refractory and 15 (53.6%) were non-refractory to Single Donor Platelet transfusion.
Discussion: We found a low degree of alloimmunization. Very few incidence of transfusion reactions were observed in these patients, due to provision of leukodepleted blood components.
Transfusion related complications in a multi transfused thalassemic -A Pandora's box
Jayashree Sharma, Julie Jose, Shashikant Patil
Seth G.S. Medical College and KEM Hospital, Parel, Mumbai, India.
Background: Transfusion needs in a thalassemic, are complex and an area of concern for the transfusion medicine physician. The requirement generally restricted to red blood cell transfusions may transform into a need for transfusion of other blood components in the event of development of pancytopenia. The multiple blood transfusions, inadvertently give rise to numerous issues of importance to both the clinician and the transfusion medicine physician. An insight into the less discussed transfusion aspects of such multi transfused patients, especially the pediatric age group, would be of use to optimize the care and minimize the complications.
Objective: The case presented aims at creating awareness about:
Case Report: A 7-year-old male child. Diagnosed case of Thalassemia major develops an episode of generalized tonic-clonic convulsion following transfusion. Concurrently the transfusion requirements of the child too increase. Investigations showed a pancytopenic picture with Hb-5.5, Platelet count-34,000/mm3, total count-3600. Abdominal examination showed Liver 9 cms below the costal margin, spleen 12 cms below the costal margin. The transfusion requirements on admission were as high as once a week. Also a serum calcium level done on at least three occasions during the ward stay showed a persistently low calcium level. Patient was diagnosed with hypersplenism and advised splenectomy following which the transfusion requirements reduced drastically and the patient was discharged.
- The metabolic complications of transfusion which are less thought of.
- Causes of hypocalcemia and pancytopenia in multi transfused individuals.
- auses of convulsions post transfusion in the multi transfused child.
Discussion: The case discussed herewith brings to notice the issue of convulsion post transfusion, which may be due to hypocalcaemia induced by transfusion of citrated blood. Convulsion in multi transfused individuals is a known and reported entity, awareness regarding the same is a must. Causes of hypocalcaemia and pancytopenia in a multi transfused patient must be kept in mind, when such a clinical scenario arises. Alloimmunization to platelets arising from repeated red blood cell transfusion, which may pose a problem in the thalassemic, who develops pancytopenia and may require a platelet transfusion. The transfusion support is to be given to a patient, prior to splenectomy.
Since long, pre transfusion testing has been a part of the care provided by the blood bank to ensure safe transfusion However, with the advent of transfusion medicine as a specialty, it is time to broaden the horizon and provide better care with special attention to the multi transfused patients, who will benefit from customized transfusion care, which will suit the patient after taking into consideration the clinical background.
A Case of Complicated Hemolytic Disease of New Born Due to Inadequate Monitoring of Alloimmunization - A Case Report
Jayashree Sharma, Shashikant Patil, Julie Jose
Seth G.S. Medical College and KEM Hospital, Parel, Mumbai, India.
Background: Rh haemolytic disease is the most common and severe form of Haemolytic disease of newborn. The use of prophylactic anti-D changed the scenario, but in developing country like India, Rh Haemolytic disease of newborn continues to pose a serious threat and the case being presented brings to light the various aspects of the disease. The common errors and the corrective actions that can be taken to prevent occurrence of the disease and minimize the complications.
Objective: To highlight the significance of routine and regular titration of anti-Rh alloantibodies in sensitized antenatal females. Use of appropriate tests to determine fetomaternal haemorrhage to calculate exact dose of anti-D to be administered to prevent Haemolytic disease of newborn. To highlight causes of occurrence of Haemolytic disease of newborn, in spite of previous anti-D immunization.
Case Report: A 2-day-old newborn girl, 2.5 kg, 4 days old , Blood group was A +ve, Maternal blood group was A negative. Baby was full term normal delivery. Maternal obstetric history was Gravida 5, Para2, Abortion 2, Live births 3.
Child was admitted with c/o lethargy and yellowish discoloration of skin progressed, since day 3 of life. The mother did not receive anti-D prophylaxis following the 2 episodes of abortions. However, she did receive anti-D after each of live births. Investigations on day 4 on child's blood showed Direct Antiglobulin Test: +4, Total Bilirubin: 13.6 and Direct Bilirubin: 6.4. Normoblasts-20/100 WBCs. General condition was poor, icterus++, edema++. Exchange transfusion was done on day 5 and day 7. Laboratory parameters did not reach normal levels, even after exchange transfusion. Patient was simultaneously treated with Barbiturates, Phototherapy and Vitamin-k. During the hospital stay, the baby required 2 FFP transfusion, 1 platelet transfusion and 3 packed cell transfusion for anemia. Symptoms started resolving after day 20 of life.
Discussion: Post delivery administration of anti-D as well as anti-D administration for events known to cause fetomaternal haemorrhage during pregnancy has reduced the incidence of alloimmunization in Rh negative females. But residual alloimmunization still occurs due to:
Alloimmunization during pregnancy as a result of "silent "fetomaternal haemorrhage.
Not giving anti-D, post abortion or birth of normal Rh positive baby.
The case discussed above signifies the importance of timely monitoring of alloimmunization in sensitized women, by regular titration of Rh alloantibodies and measurement of fetomaternal haemorrhage by Rosette test, Kleihauer-Betke test, Flow cytometry, which will help in calculating appropriate dose of anti-D.
As transfusion medicine is growing as a speciality, steps must be taken to incorporate these measures as a routine antenatal care at every level of health care system, which will help to decrease the incidence of Haemolytic Disease of Newborn further and help in better outcome of child.
Ratio of Crossmatch to Transfusion (C/T Ratio) - A Quality Indicator for Appropriate Utilization of Blood Components
Nandram, Aseem Kr. Tiwari, Prashant Pandey, Surbhi Dixit, Vimarsh Raina, Prashant Pandey
Department of Transfusion Medicine Medantathe Medicity, Gurgaon, India.
Introduction: In modern clinical practice, transfusion of blood and blood components play a crucial role in patient management. Transfusion of blood components is life saving but inappropriate transfusion may lead to deleterious effects in patients. Moreover, inappropriate use of blood components can widen the gap between supply and demand and contribute to shortage of blood components for needy patients requiring transfusion. Every hospital should have guidelines for the appropriate use of blood components and maximum surgical blood order schedule (MSBOS) for elective surgical procedures. This prospective observational study was planned to assess the utilization pattern of blood components in elective surgical procedures of various clinical specialties by evaluation of C/T (cross match to transfusion) ratio.
Materials and Methods: This prospective observational study was conducted at the Department of Transfusion Medicine in Medanta the Medicity, a tertiary healthcare centre. This hospital has all major surgical and medical specialities like cardiac surgery, solid organ transplantation (kidney and liver transplantation), bone marrow transplantation, gastro surgery, nephrology and urology. A total of 215 blood requisition forms for elective procedures from different specialities were evaluated prospectively for the calculation of C/T ratio.
Results: We observed that a total of 1172 units of red blood cells were cross-matched for patients of elective surgical procedures from different clinical specialities. A total of 550 units were transfused. Thus the overall C/T ration in our study was found to be 2.13 (1172/550). Among all the specialities Department of liver transplantation had the lowest C/T ratio of 1.59 however the utilization of red blood cells in the department of orthopedic surgery was highest with C/T ratio of 4.40. Results are shown in [Table 1].
Discussion: The most pragmatic figure of C/T ratio is two. In our study we found it 2.13 which were close to published literature and indicative of efficient usage of red cell concentrate at our hospital. Blood and blood components are critical in elective surgery. The possible explanations for the controlled C/T ratio could be the well formulated maximum surgical blood order schedule (MSBOS) right from the beginning and continuous monitoring of C/T ratio by the hospital transfusion committee (HTC). Thus C/T ratio is a very good quality indicator for the appropriate utilization of blood components.
1. Standard Operating Procedures (SOP) - appropriate clinical use of blood components-Medanta- the Medicity
2. Technical Manual, Transfusion Medicine, Directorate General of Health Services, ministry of health and family welfare, government of India, 2 nd edition, 2003.
3. Technical Manual, American Association of Blood Banking 15 th edition, 2003.
Feedback Monitoring of Blood Transfusions - An implementation of New Policy
Kiran Mishra, Aseem Kumar Tiwari, Prashant Pandey, Surbhi Dixit, Vimarsh Raina, Prashant Pandey
Department of Transfusion Medicine Medanta, The Medicity, Gurgaon, India.
Introduction: In modern clinical practice, blood supply has become increasingly safer through improved donor selection, sensitive techniques of transfusion transmitted disease (TTD) testing, robust pre-transfusion testing like irregular antibody screening and Coombs crossmatches. However, it is equally important to monitor the patient at bedside and provide feedback on actual transfusion events to the blood bank to complete the loop. Collection of feedbacks from all transfused patients would allow for more careful monitoring of patients and the entire transfusion chain as a whole and thereby enhancing the overall transfusion safety. This study was conducted to find out the results of implementing a universal feedback policy in the hospital.
Materials and Methods: This prospective observational study was conducted at the department of Transfusion Medicine at Medanta-the Medicity hospital from May 2011 to August 2011. The universal feedback policy was meant to collect feedbacks of all transfused patients. The feedback from these had the type of blood component, time of initiation and completion of transfusion, and event if any. All adverse events were worked up according to standard operating procedure (SOP) to find out the probable cause and type of reaction.
Results: During the period of observation, a total of 4,832 patients received 14,496 units of blood components (6,601 red cell concentrates [RBC], 3,630 random donor platelet concentrates [PC], 3,548 Fresh Frozen Plasma [FFP],162 Cryoprecipitate [CRYO] and 555 single donor platelet concentrates [SDPC]) in various clinical specialties. Despite the policy of universal feedback, 85% of feedbacks were received. Of these feedbacks, 99.5% were uneventful transfusions, while 0.5% was reported as adverse reactions. While 13 were allergic, the rest were non hemolytic febrile transfusion reaction (NHFTR). As shown in the [Table 1], the average time taken to transfuse RBC, PC and CRYO was within the limits recommended by the World Health Organization (4 h for RBC and 20 min for PC/CRYO), FFP and SDPC took almost double the time than recommended(20 min for FFP/SDPC).
Discussion: We could achieve a reasonably good feedback percentage of 85%, which were mostly uneventful. A very small percentage (0.5%) of feedbacks had allergic etiology followed by FNHTR.
1. The Clinical Use of Blood-Handbook. World Health Organization. 20 Avenue Appia, 1211 Geneva 27, www.who.int/bct.
Hemovigilance in Blood Transfusion Services at Sir J. J. Mahanagar Raktapedhi
Hitesh Pagare, Girish Choudhary
Sir J. J. Mahanagar Raktapedhi, India
Introduction: The term Hemovigilance has become widely used over the past decade to describe the systematic surveillance of adverse transfusion reactions and events, accompanying the whole transfusion, chain and aimed at improving the safety of transfusion process from donor to recipient, "vein to vein"
Aim: Aim of the study is to analyze the donor reactions, transfusion of reactive blood unit and adverse blood transfusion reactions.
Material and Methods: Period of study from Feb 2009 to July 2011.
Donor reactions during and after blood donation were noted, entries were made in the donor reaction register and were classified as mild, moderate and severe.
Data of patient reaction after blood transfusion was available from the Transfusion reaction card filled by the physician and entries were made in the register after investigations. Investigation was done to find the reason of transfusion reaction and the severity of the reaction was noted.
Transfusion of reactive blood unit to patient was recovered in adverse incident register.
Results: Period of study: Feb 2009 to July 2011
Total no. of voluntary blood donors - 51053
Total donor reactions - 588 (1.15%)
Total no. of components issued - 113079
Total patient reaction - 16 (0.01%)
Donor reactions were then classified as mild, moderate and severe.
Percentage of mild donor reaction - 97.10%
Percentage of moderate donor reaction - 2.38%
Percentage of severe donor reaction - 0.52%
Percentage of patient reaction was 0.01% and all the reactions were mild febrile illness mostly, there was no incidence of mismatched blood transfusion.
There was no incidence of transfusion of reactive unit to the patients.
Discussion: Percentage occurrence of donor reaction and adverse transfusion reaction were relatively low. Hemovigilance in blood transfusion services helps to reduce the occurrence of the errors. Analyzing the documented errors will guide us to take corrective measures. By implementing hemovigilance for clinical practice of transfusion standards of blood safety can be raised.
Evaluation of Serum Thrombopoietin in Patients of Aplastic Anemia
Singh A, Verma A, Chaudhary R
Department of Transfusion Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
Background: Thrombopoietin (TPO) is the key hematopoietic growth factor that is responsible for regulating the production of platelets from bone marrow megakaryocytes and maintaining platelet hemostasis. In order to find out any relation between the levels of thrombopoietin and the severity of aplastic anemia, we measured endogenous serum thrombopoietin in 52 patients of aplastic anemia by a sensitive sandwich enzyme linked immunosorbent assay method.
Materials and Method: Serum samples were collected from 52 patients (44 males and 8 females) with a confirmed diagnosis of aplastic anemia and 45 normal healthy blood donors (42 males and 3 females), over a period of 24 months and TPO was estimated by using commercially available TPO-specific enzyme linked immunosorbent assay (R and D systems, Minneapolis, USA: lower detection limit, 29.8 pg/ml)
Results: The median TPO level of 1127 pg/ml (range 625-7651 pg/ml) in aplastic anemia patients was significantly higher than the median TPO level of 126.8 pg/ml (81.25-237.7 pg/ml) in normal healthy blood donors (P=0.00). No significant difference was observed in TPO levels of male and female patients (P=0.196). The median TPO level in very severe AA (1124 pg/ml), severe AA (1167 pg/ml) and non-severe AA (1111 pg/ml) did not showed any statistical significance.
Discussion: TPO levels in aplastic anemia patients were significantly higher than normal healthy persons, however the TPO levels in aplastic anemia patients showed no significant variation to the severity of disease.
Post-transfusion platelet count at 1 hour and 24 hours; a comparative study
Sharon Jacob, Geetha N, Mayadevi S, K C Usha
Department of Transfusion Medicine, Medical College, Trivandrum, India.
Background: Monitoring the response to platelet transfusions gain considerable significance in leukemic patients owing to a variety of immune and non-immune factors. The absolute platelet count has been one of the most commonly used measurements to assess the platelet response despite its limitations. The significance of platelet counts measured at various intervals such as 10 months, 60 months, 4 h, 18-24 h has been identified. In this study we try to know how far these counts reflect on each other and the factors affecting their differences
Aims and Objectives: To compare the difference between the post-transfusion platelet count at 1 h and 24 h. To identify the factors contributing to a significant difference between 1 h and 24 h post transfusion platelet count
Materials and Methods: This was a prospective study conducted in medical oncology patients admitted in Regional Cancer Centre, Thiruvananthapuram. Leukemic patients with thrombocytopenia receiving platelet transfusions prophylactically and therapeutically at a trigger less than 20,000 were selected randomly. The absolute platelet count was measured pre- transfusion, 1 h (10-60 months) and 18 - 24 h following transfusion, using Automated Beckmans Coulter Counter. Response to transfusion in relation to non-immune clinical factors such as fever, splenomegaly, active bleeding /DIC and Amphotericin B administration were analyzed by the Chi square test. Statistical determinations to compare the 1 hr and 24 hr count was done by Pearson's correlation.
Results: Platelet count increments were evaluated in 38 patients who received 148 pooled random donor platelet transfusions .The mean pre-transfusion trigger was 11,600 /μL (N=155). The mean 1 hr count was 21,077 versus 15,012 for 24 hr count, showing significant difference between the two (P=0.002) .Both the counts showed a positive linear correlation (r value +0.801 and P=0.001). Risk factors contributing to a significant reduction between the 2 counts were active bleeding (p=0.003), splenomegaly (p=0.03) Amphotericin B administration (P=0.0001) and gamma irradiation. Fever and ABO incompatibility were not associated with a significant difference.
Discussion: This study shows that both 1 hr and 24 hr counts are equally important tools in the assessment of platelet transfusion response, providing varied information. Non immune clinical factors like active bleeding, splenomegaly, Amphotericin B and irradiation can lead to a decrease in 24 hr count alerting the physician towards the presence of an adverse factor.
Therapeutic Phlebotomy in Post renal transplant erythrocytosis: SGPGI experience
Chaurasia R, Verma A, Chaudhary R, Elhence P, Agarwal P, Sonkar A
Department of Transfusion Medicine, Sanjay Gandhi Post grasuate Institute of Medical Sciences, Lucknow, India.
Introduction: Therapeutic phlebotomy (TP) is a safe, simple and inexpensive procedure, very similar to a regular blood donation except that patient's physician has prescribed it as a form of medical treatment in patients suffering from diseases, characterized by iron overload and erythrocytosis (Hct > 50%).
Materials and Methods: A retrospective analysis of renal transplant recipients, who underwent therapeutic phlebotomy, for post-transplant erythrocytosis (PTE) was done. Frequency of phlebotomy was based on Hct levels as well as patient's general medical conditions. True PTE was defined as hematocrit (Ht) above 52% and hemoglobin (Hb) above 18 g/dl in males, and Ht above 50% and Hb above 17g /dl in females. The protocol for phlebotomy was performed as per the departmental SOP.
Results: Total 112 procedures performed for a total 52 patients. It includes 50 males and 2 females. The mean age was 39 years. The hemoglobin level ranged between 16-22 gm/dl with a mean of 18.7 gm/dl. The mean blood withdrawn was 334 ml+/-25 ml. A total of 17 out of 54 patients were asymptomatic with rise in hemoglobin levels was the only indication. The other indication for therapeutic phlebotomy included headache: 20, redness of eye: 12, blurring of vision: 13, hypertension: 9, weakness: 9, flushing: 5, and arthralgia/abdominal pain: 5.
Conclusion: Secondary erythrocytosis in cases of post renal transplant resulted, due to disordered regulation of erythropoietin. Therapeutic phlebotomy helps in alleviating the symptoms, which resulted due to rise in hematocrit.
Changing the Clinicians Transfusion Practices: from Whole Blood to Blood Components
Vandana Mishra, Nikhil Jadav, Sahjid Mukhida, Rajesh Sawant
Rajkot Voluntary Blood Bank and Research Centre, Rajkot, Gujarat, India.
Background: Although, blood component separation facility is available in many blood banks in our country, appropriate blood component therapy still remains a challenge. Many clinicians in our region still prefer to use whole blood over components for transfusion therapy in their patients.
Aim: i) To understand the local trend of whole blood transfusion by a retrospective audit of transfusion requisition. ii) To study the effectiveness of the intervention pre-transfusion audit and approval for changing transfusion practice of whole blood in our region.
Material and Methods: i) A retrospective audit was planned to study the trend of use of whole blood and blood components in our region. The indication for transfusion and clinical speciality wise use of whole blood over a period of 1 year for study. ii) A specialist trained for 'Transfusion Therapy' was appointed for auditing all transfusion requests prior to cross-matching. This individual was also responsible for liaisoning with the clinicians for rational use of blood components. Brochures and posters were designed and disseminated and clinical specialty wise targeted Continuing Medical Education programs were arranged. The use of whole blood v/s blood components was analyzed for a period of 1 year and compared with the results of the retrospective audit.
Results: Top four clinical specialties requesting for whole blood were General Surgeons (41%), Cardiac Surgeons (17%), Gynecologist (7%) and General physicians (4%). During the corresponding period, whole blood issued by our centre was 23.5% of the total blood issued. The major indications for which whole blood was requested for were blood loss (22%), CABG (17%) and anemia (13%). After introduction of pre-transfusion audit and approval, there was a significant reduction (P<0.01) in the use of whole blood by general physicians for treatment of anemia (13% to 5%), and by general surgeons for blood loss (22% to 9%). The use of whole blood by gynecologist for treatment of Post Partum Hemorrhage reduced marginally (7.0% to 5.5%). The use of whole blood by cardiac surgeons still continues. Monitoring of above practices is ongoing. Currently, the issue of whole blood from our centre is 3.5% of the total components issued.
Discussion: The intervention of pre-transfusion audit and approval, coupled with intensive Continuing Medical Education Programs for clinicians has resulted in a significant reduction in the use of whole blood and improved the utilization of appropriate components in our region. Monitoring the clinical transfusion practices has helped us in choosing the correct intervention to change clinician's transfusion practices. Multi-centric, randomized controlled studies that evaluate the effectiveness of intervention to change transfusion practices are needed.
Error Detection and Reduction in a Blood Center: Experience of a Tertiary Care Center in India
Muthu Kumar P, Gethziyal D, Rema Menon
Transfusion Services, Apollo Hospitals, Chennai, India.
Background: Error management plays a major role in facility up gradation and process improvement in an organization. Errors can be managed by identifying reportable errors; which play a direct or indirect role in transfusion safety.
Aim: The current study documents, the need for an error detection system at the department of Transfusion Medicine at the Apollo Hospitals, Chennai, India. The need was due to increasing reportable errors such as wrong blood in tube, pretransfusion sample labeling error, issue of wrong component and mix up of compatibility reports. Another factor identified was the shortage of trained man power. Corrective measures had to be instituted for error reduction.
Material and Methods: Policy changes were made to facilitate implementation of bar coding and automation in all possible areas of whole blood donation testing and processing. Automated systems replaced the existing manual methods in red cell serology, infectious disease screening, and component separation. Computerization improved record keeping.
Results: The study revealed a significant reduction in the incidence of reportable errors and an improvement in the quality and safety of blood transfusion in our hospital. The transition from manual to automation improved productivity and optimsed the use of human resources, as the number of staff required reduced by 25%, despite the increasing workload.
Conclusion: The current environment of resource constraints, due to staff shortages substantiates the value of automation in blood banks. The decreased hands-on- time with resultant productivity improvement ultimately improves efficiencies and reduces errors in the blood bank laboratory.
A Case Report of Patient with Evan's Syndrome
Pritesh Rajani, Shweta Gupta, Rajesh Sonani, Piyush Patel, Nidhi Bhatnagar, M. D. Gajjar
Civil Hospital, Ahmedabad, India.
Background: Evan's Syndrome is an uncommon condition defined by the combination (either simultaneously or sequentially) of immune thrombocytopenia (ITP) and autoimmune haemolytic anemia (AIHA) with a positive direct antiglobulin test (DAT) in the absence of known etiology.
Case Study: A 73-year-old female patient with c/o fatigue and breathlessness for past 4 months was admitted in Civil Hospital, Ahmedabad with Hb of 4.6 gm% and platelet count of 17,000/Cu mm with normal Total Count and Differential Count with increased reticulocyte count and increased Mean Corpuscular Volume and Mean Corpuscular Hemoglobin Concentration. On serological investigation, forward grouping was confirmed to be O+ve after washing the cells with normal saline for 3 times, while reverse grouping showed discrepant results at different temperatures with clumps in A and B cells at 22°C, no clumps at 37°C and clumps in A,B and O cells at 4°C. Patient had DAT and Indirect Antiglobulin Test grade 3 positive with positive auto-control. Test with Diacell panel- 3 cells and 11 cells showed pan-positive reaction while acid elution too showed similar reaction with the eluent.
Result: Patient had developed auto-antibodies without any specific cause, which were responsible for this condition. Patient was put on intravenous steroids namely methylprednisolone (MPS) following which 2 units of least incompatible O+ve Packed Cells were transfused leading to clinical improvement.
Conclusion: Evan's syndrome generally runs a chronic course characterized by frequent exacerbations and remissions with steroids being the first line of treatment due to unknown etiology. Options for second line of therapy include immunosuppressive agents in which presently Rituximab has shown quite satisfactory results. IVIg (Intravenous Immunoglobulins) also forms an alternative modality in refractory cases. Splenectomy has also been included in the treatment modality.
Incomplete Blood Component Requisition Forms and its Implications on Transfusion Safety
Pankaj Jain, Raju Singh, Sapna Rathore, Meenu Bajpai
Institute of Liver and Biliary Sciences, New Delhi, India.
Background and Aim: Requisition forms are important documents as they represent the patient to the blood bank. They are of great importance in legal issues as only registered medical practitioners (Allopathic) may prescribe blood component transfusion therapy. Incomplete or wrongly filled requisition forms hinder transfusion safety and may cause unnecessary delay in transfusions. In the present study, we have retrospectively studied requisition forms received over the last 4 months and reviewed them to understand the implications of incomplete/wrongly filled requisition forms.
Materials and Methods: We studied 1,927 requisition forms during the period of 4 months from May 2011 to August 2011. Errors were categorized into four groups:
- Critical error- Errors which may lead to wrong issue of blood component:
- Missing ABO and Rh
- Wrong ABO and Rh
- Specify routine and emergency
- Causing difficulty in patient's identification:
- Patient name
- UHID/IP No.
- Clinical history error:
- Clinical diagnosis
- Vitals(Hb, Platelet count, PT, APTT)
- Causing delay:
- Ward/Bed no
- Dr. Name /Signature
- Reason of Transfusion
- No. of units required
Result: There were 559 incident of wrong and incomplete requisition form noticed during the above mentioned period. In all these cases 2.6% critical errors, 36.5% error causing difficulty in patient identification, 12.8% clinical history error and 48.1% error causing delay.
Conclusion: Properly filled blood component requisition forms are critical to transfusion safety. Manual filling of forms often leads to errors in part of clinicians due to lack of time or lack of awareness regarding information of blood component requisition forms. Clinician education, computerization and installation of hospital information systems may lead to better compliance in this regard and improve transfusion safety.
Assessing the patterns of blood donor supply and issue of red cell components
Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Ponducherry, India.
Background: Every transfusion center should assess the demand on its products and the pattern of its blood supply periodically. This enables a judicious change in policy, resource acquisition and planning, to enhance functional efficiency and quality of transfusion services.
Aims: A pilot study to analyze the patterns of blood donors and the demand of red cell units at a tertiary care center in South India.
Materials and Methods: Blood donor turnout, their deferral, component preparation was analyzed for a month. The issues of red cell units were analyzed by studying the request forms for red cell transfusion for a month. Patterns of use by different departments were deduced.
Results: The voluntary donors were more than replacement donors. There was a small but regular turnout of voluntary donors at the blood bank. Maximum deferral was due to anemia. 98% component separation was achieved. Average daily donation was 35 units.An average daily request received was 65 and units of red cell issued were 30. Maximum utilization was by the departments of Obstetrics and Gynecology, Pediatrics, Surgery and Medicine. 96% of requests were supported by ready inventory availability. For the rest 4% donor registry was used. Major user departments were the best at returning unused units in specified time.
Conclusion: Better recall of voluntary blood donor is achieved by using updated donor registry. Sterile connecting device is important for a rational transfusion protocol for pediatric patients. The policy for components that are issued but not transfused needs to be reformulated and reemphasized with acquisition of resources if necessary.
Blood Transfusion in Thalassemia
M.E. Raja, Zarin Bharucha, D.M. Chouhan, R.N. Makroo, V.H. Talib, A.B. Duttta, Denise M. Harmening
Red Cross Blood Bank, Nellore, Andhra Pradesh, India.
Background: The congenital hemolytic disorders constitute a group of intrinsic red cell defects; include disorders of hemoglobin, red cells enzyme deficiency and abnormalities of red cell membrane and Cytoskeleton. Hemoglobinopathies are disorders affecting globin portion of hemoglobin molecule, caused by DNA mutations in or near globin genes. They are conveniently classified into (i) Qualitative abnormalities e.g. Sickle cell disease, (ii) Quantitative disorders of globin Synthesis that is Thalassemia.
Aim: Thalassemias are the heterogeneous group of hereditary disorders arising from mutations in the globin genes that reduce or totally abolish the synthesis of one or more globin chains. This results in hypochromic microcytic anemia. There are various types of Thalassemias depending upon the type of globin chain affected e.g. Alpha Thalassemia, Beta Thalassemia Major, Thalassemia Minor, Beta Thalassemia intermedia, Hereditary Persistence of Fetal Hb, combination of Thalassemia with hemoglobinopathies like sickle cell (HbS), HbC, HbD or HbE etc., Most prevalent in our region and widely studied are Beta Thalassemias and combination of thalassemia with Sickle cell.
Thalassemias are classified as:
Thalassemia Major, Thalassemia Minor, Thalassemia Intermedia.
Materials and Methods: Thalassemia Major: - It is a Clinical Problem that requires the blood transfusion to sustain life. Every year, more than 5,000 children are born in our country with Thalassemia major. It is observed in certain communities like Kuchhi, Bhanushali, Lohanas, Memoas, Sindhies, Jains etc., however no community is immune to this disease. It usually presents in infancy with symptoms of failure to thrive not feeding well, respiratory infection and splenomegaly. The diagnosis is established by blood examination, showing anemia, absence of adult Hb and presence of large band of fetal Hb on Electrophoresis. Family study, demonstrates presence of Thalassemia minor in both the parents.
Results: Blood Transfusion in Thalassemia. Bone marrow transplantation or gene therapy may cure Thalassemia; these facilities are not available for most of the patients. Saline washed red cell concentrate blood transfusion is the only way to sustain the life at present.
The purpose of transfusion is two-fold:
To alleviate anemia
To suppress the process of ineffective erythropoiesis
Regular transfusions should be started as soon as the diagnosis is established. Severe Thalassemia occurs in the first year of life. Once it is decided, the hemoglobin level of 11gms /dl is to be maintained and it should not fall below 9 gms/dl. This will improve growth of a child; suppress unnecessary ineffective erythropoiesis and its complications and improving cardiac status. Pre and post-transfusion record of hemoglobin should be maintained. Regular measurement of iron status of patient is desirable.
The problems of repeated blood transfusion are:-
i) Iron overload, ii) Antibodies to leucocytes, iii) Transmission of diseases like Hepatitis B (or) C, HIV, CMV Malaria etc. Iron overload leads to deposition of iron in various organs, leading to darkening of skin, cardiac Failure, hepatic dysfunction, diabetes mellitus, gonadal failure, sterility etc. Use of iron chelating agent Like Inj. Desferoxemine or Keltfer can control the iron overload.
Discussion: To avoid antigen antibody reactions, expensive leucocytes filters are used. To reduce the cost saline washed red cells are used. Providing quality blood transfusion to thalassemic child by giving washed red cells by adapting 6 voluntary donors at regular interval, which will prevent TTD. Who undergoes Splenectomy requires pneumococcal Vaccine.
Fresh Frozen Plasma Transfusion-An Audit and its Effect on International Normalised Ratio in Critically Ill Patients
Transfusion Medicine, Government Medical College, Trivandrum, India.
Background: Fresh Frozen Plasma (FFP) is a blood product extracted from plasma and frozen to -18 0 C or below within 6 h after collection. The use of FFP has significantly increased in the past 10 years and it is the most common inappropriately used product despite the existence of guidelines. Its usage can lead to adverse effects like transfusion reactions, transfusion associated acute lung injury, viral transmission etc. Moreover, FFP is frequently transfused in patients with abnormalities in prothrombin time (PT) and INR (International Normalized Ratio) under the twin assumption that, these test results imply a coagulopathy and that FFP transfusion will correct the coagulopathy. An audit was conducted with the aim of improving the quality of care provided to patients by ensuring the appropriate use of FFP and also this study tries to assess the effect of FFP transfusion on INR in critically ill patients.
Aims and Objectives:
Materials and Methods: A retrospective review of blood bank transfusion request forms for FFP from January 2011 to June 2011 was undertaken. The criteria set by the British Committee for standards in hematology were used as standards. Pre- and Post-transfusion INR of 30 critically ill patients admitted in intensive care units were recorded and the effect of FFP on the pre-transfusion INR was studied. Relationship between the pre-transfusion INR and the improvement in the INR per unit of FFP was studied using Pearson's correlation.
- To determine the usage pattern of Fresh frozen plasma in Government Medical College, Thiruvananthapuram
- To determine, if FFP use is aligned to clinical practice standards developed from international guidelines (BCSH Guidelines)
- To know the indications for which FFP was transfused
- To assess the effect of FFP transfusion on INR in critically ill patients admitted in various intensive care units
Results: 3,354 Units of fresh frozen plasma were used during the study period for 1,449 transfusion episodes. Highest number of transfusion requests came from Department of General Surgery followed by Department of General Medicine and Paediatrics. Percentage of inappropriate request was highest in Department of General Surgery (89%), followed by Department of Thoracic surgery and Orthopaedics (76%). FFP used in the setting of hypoalbuminemia, inadequately prolonged coagulation profiles or absence of bleeding or surgical intervention was the commonest reasons for inappropriate use. Mean improvement in the pre-transfusion INR per unit of FFP was 0.386(median-0.255, range-0.02-2.5, SD-0.505). A significant improvement in the pre-transfusion INR per unit of FFP was seen in 53.3% of total 30 patients studied. A linear relationship was noted between the pre-transfusion INR and improvement in INR per unit of FFP(r=0.930).
Discussion: The study showed significant proportion of Fresh frozen plasma used outside of established international criteria. There may be several reasons for this and so a continual system of staff education and administrative intervention may help to reduce the inappropriate usage. Also, a significant improvement in INR was seen with a high pre-transfusion INR.
Understanding clinician's Knowledge and Attitude towards Blood Safety in Saurashtra region of Gujarat, India:
A questionnaire based study
Vandana Mishra, Dhrupal Kothari, Rajesh Sawant, Sahjid Mukhida
Rajkot Voluntary Blood Bank and Research Centre, Rajkot, Gujarat, India.
Introduction: In the current scenario, with the increase in cost of blood and its components, pressures on the transfusion service to curb unit cost without compromising on quality have increased. A fine alignment between the decisions on implementing new safety measures and their economic consequences is very essential. The clinicians view and acceptance of new technology plays a crucial role in the decision making process.
Aim: To understand knowledge level and perception regarding blood safety amongst clinicians in our region prior to implementation of NAT technology
Materials and Methods: A questionnaire survey on blood safety was developed and administered to 358 clinicians in Saurashtra region. The response rate was 67% (240 complete responses)
Results: 67% of clinicians were not aware of the current measures available to reduce the risk of TTI's to their transfused patients. 70% of the clinicians believed that blood donated by the patient's family member or close acquaintance was safe, while only 55% believed that blood collected by transfusion service from non-relative donors and certified as TTI negative is safe. While about 50 % clinicians had knowledge about the concept of window period transmission, only 38 % knew the difference between rapid tests, ELISA based tests and NAT technology. 55 % clinicians denied having even slightest information regarding the NAT technology. 17% clinicians attributed the responsibility of ensuring blood safety and TTI prevention to the transfusion service alone, 5% thought that it is the government's responsibility, while 78% clinicians believe that it's a combined responsibility of the medical fraternity, transfusion service and government. 66% clinicians thought that NAT technology should be implemented in our region and also showed their willingness to prescribe NAT tested blood for their patients. Very few minority (18%) clinicians admitted of having observed seroconversion for any TTI in their transfused patients in their clinical practice. An additional increase by 10 % to 50 % of the current cost of blood would be acceptable to all patient groups as per the clinician's opinion.
Discussion: Overall, the clinicians had a positive attitude towards improving blood safety and implementation of the NAT technology in our region. The knowledge of clinicians regarding window period transmission and sensitivity, specificity and limitations of rapid, ELISA and NAT tests needs to be enhanced. This study provides useful information about the clinicians knowledge and attitude towards blood safety in our region, identifies areas for improvement and shall facilitate our decision making process for NAT implementation.
Type and Screen Approach
Department of Transfusion Medicine, Kokilaben Dhirubhai Ambani Hospital and Medical Research institute, Mumbai, India
A transfusion service may follow any of several policies that lead to more efficient use of blood inventory levels and consequently a reduction in blood bank operating cost. The most important is a type and screen policy whereby compatibility testing is completed up to the point of the major crossmatch. Units are not crossmatched until an actual need for transfusion occurs. This works extremely well for surgical procedure that rarely requires transfusion. However, the transfusion service must be in a position to respond immediately to the request for blood. Blood of the appropriate type must be in inventory and available for issue. An immediate spin or electronic (computer) crossmatch to demonstrate ABO compatibility can usually be completed before issue or before transfusion of the blood. If an abbreviated crossmatch is the policy of the transfusion service, the compatibility test is complete. Otherwise, a full major crossmatch can be completed with greater than 99% confidence that no significant antibody will be found in the antiglobulin phase of testing. It is important that the physician have total confidence that blood will be immediately available on request. Any problem that may interfere with an immediate response should be communicated to the physician.
For e.g. the patient may have an unexpected antibody present, that would require selecting antigen-negative blood of the appropriate blood type and the completion of a full crossmatch. The physician should be notified of the problem and given an estimate of the additional time that may be required before blood could be issued. Usually, the appropriate decision is to crossmatch the unit before surgery rather than leave the order as a "type and screen."(TS)
The TS test policy has proven to be safe, efficient, and beneficial to the transfusion practice. Hospitals that are currently experiencing a high C/T ratio and blood expiry rate or that have a large workload of elective surgeries, should consider adopting such a policy to allow better transfusion management.
Comparative Evaluation of Platelet-rich Plasma and Guided Tissue Regeneration Membrane in the Healing of Apicomarginal Defects: A Clinical Study
P.K. Sehgal, Bhawna Goyal, Sanjay Tiwari, Jigyasa Duhan, Rama Sikka, Jasjeet Kaur
Department of Transfusion Medicine, Rohtak, India.
Introduction: The aim of the study was to compare the healing responses of platelet-rich plasma (PRP), PRP + a collagen sponge, and a collagen membrane used as guided tissue regeneration (GTR) materials for the treatment of apicomarginal defects.
Material and Methods: 30 patients with suppurative chronic apical periodontitis and apicomarginal communication were selected and allocated randomly into 3 groups accordingly, to the barrier technique to be used during periradicular surgery: the collagen membrane group, the PRP group, and the PRP + collagen sponge group. Clinical and radiographic measurements were determined at baseline and every 3 months after surgery up to 1 year. Cases were defined as healed, when no clinical signs or symptoms were present, and radiographs showed complete or incomplete (scar tissue) healing of previous radiolucencies.
Results: The PRP and PRP + Collagen sponge groups depicted 83.33% and 88.89% healing, respectively, in terms of combined clinical-radiographic healing as compared with 80% in the collagen membrane group. All the three treatments showed highly significant (P<.05) reductions in the periodontal pocket Department (PD), the clinical attachment level (CAL), the gingival margin position (GMP), the size of the periapical lesion, the percentage reduction of the periapical rarefactions and periapical healing. No significant differences between the 3 groups were evident for these parameters (P>.05).
Conclusions: GTR applied to apicomarginal defects using PRP or PRP + collagen sponge lead to similar enhancements of the clinical outcome of periradicular surgery in terms of periapical healing, gain of periodontal support, PD reduction, and PRP may be an alternative treatment for GTR membrane in the treatment of apicomarginal defects.
Transfusion Audit in a Super Speciality Hospital
Reeta Rai, M. Chandrashekhar
Max Super Speciality Hospital Patparganj, Delhi, India.
Background: Transfusion audit in blood bank is very important tool for appropriate blood usage. Inadequate knowledge of transfusion guideline is the main reason for irrational use of blood. Rational use of blood depends on ordering practices and aim to provide right blood product to right patient and in right quantity.
Aim: To identify the areas for improvement and formulate the strategies to minimize irrational use of blood.
Materials and Methods: Transfusion audit was conducted in a Super Speciality Hospital blood bank from November 2010 to March 2011 regarding blood transfusion triggers. One patient was randomly selected every day from issue register and file of patient audited for transfusion triggers.
Result: Audit for blood transfusion was done for 151 patients during November 2010 to March 2011. For packed red cell transfusion trigger of Hb varied from 5 gm/dl to 10 gm/dl, except in 12 cases. In 12 cases, transfusion trigger for Hb was more than 10 gm/dl. Out of 12 cases, 4 of neurosurgery, 2 cases of CABG, 2 of lower GI bleeding, 2 cases of carcinoma ovary (surgery) and one each of orthopedics and obstetrics. 22 cases were given single unit transfusion. Out of 22 cases, 7 cases were of CRD coming for dialysis regularly, 5 cases of Orthopedics (TKR), 2 case each of carcinoma, septicemia and fever with anemia, one case each of encephalopathy, CABG, Aneurysmal bleed and endometrial hyperplasia. Platelet transfusion trigger varied from 3,000-25,000, except in few neurosurgical and cardiovascular surgery cases. FFP transfusion was given appropriately to patient with prolonged PT and PTT.
Discussion: Single unit transfusion was given irrationally by some of the department as revealed by the figure. Unnecessary transfusion of single unit should be avoided. Due thought to indication and hazard should be given before ordering single unit of blood. Main concern of clinician is well being of the patient. Decision for transfusion is a complex procedure. For appropriate use of blood, regular audit on blood transfusion and assessment of transfusion trigger is needed. Regular interaction with clinicians, education of guidelines would help to improve transfusion practice.
Trouble Shootings in Transfusion Medicine
Alexander S, Krishnamoorthy R, Panicker V.K, Febe R.S
Department of Transfusion Medicine, Sri Ramachandra University, Chennai, India.
Introduction: Safe blood transfusion is the need of the hour. Safe blood begins with careful donor selection. Cold chain has to be maintained from (donor) vein to vein (patient). Appropriate methodology and trained manpower are needed for all blood bank processes including infectious disease testing and immunohematology work-up to ensure a safe transfusion.
Aim of the study: To identify areas those are prone for errors in blood transfusion services, so that appropriate corrective action can be taken to make blood transfusion safe.
Materials and Methods: This study was conducted by the Department of Transfusion Medicine, Sri Ramachandra University, Porur, Chennai (South India), during the period June 2010 to May 2011. All processes from the point of donor blood collection to the point of transfusion at the bedside was followed up on at least two donor units, each day (randomly selected) during the study period (sample size = 700 donor units). The blood bank registers were also scrutinized to check for proper documentation.
Results: It was observed from our study that the following areas were error prone:
Discussion: Blood transfusion services are the back bone of a hospital. Blood transfusion is intended to save life. It should be made risk free by ensuring zero error. Bar coding of blood units would help minimize clerical errors. Appropriate training of manpower and automation will help in eliminating technical errors. Proper maintenance of equipments will help in optimizing storage conditions. Quality control checks have to be done on all reagents, components and equipments at recommended frequency. The weakest link in vein to vein chain appears to be the interval between the time of issue of blood units from the blood bank and the start of transfusion at the bedside. Frequent blood audits have be undertaken by the Blood transfusion service.
- Sample blood collection of the patient at the bedside.
- Labeling the donor units in the blood bank and
- Storage conditions of blood units.
Category 5 - Transfusion Transmitted Infections
Introducing NAT: A Challenge for Blood Banks
Lions Blood Bank, New Delhi, India.
Background: Testing of each blood donation is the most effective protective barrier against disease transmission; serologic methods have improved sensitivity and specificity to detect viral antigens or antibodies against viral antigens in blood donor samples. In spite of this, infectious donations during window period have posed a challenge to the blood safety. NAT assays target viral genetic sequences and signal their presence through amplification methods can identify viruses in concentrations that are several orders of magnitude lower than antigen tests and are capable of detecting infectious samples earlier then serologic tests. However, it is difficult to set up and maintain NAT testing with limited resources. The recipient's safety should be the single most criteria in deciding the crucial question - NAT or NOT? With the sole objective of making safest blood available and accessible to the common man of Delhi, Lions blood bank took the lead and started individual donor NAT testing for each donation with effect from March 2011.
Material and Methods: Each donor unit is tested by enhanced chemluminiscence immune assay for HBsAg, HIV 1 and 2 and HCV antibodies on automated Vitros 3600 automated system. HBV/HCV and HIV-1 by NAT on individual donor samples is done with Ultrio. Discriminatory NAT for HIV /HBV/HCV is done on all Ultrio positive samples. Till mid August, approximately 12,000 voluntary donor units have been tested (data under compilation).
Results: Till 31 st May, total 6,218 donor units were tested. 6,154 units were negative by both CLIA and NAT. 64 units were found to be infected, out of which 50 units had concordant results, 5 units were reactive only by CLIA and 3 units only in NAT (NAT yield). All the three pure NAT yields were HBV positive in discriminatory assay. 5 units had single infection in CLIA but co-infection in discriminatory NAT.
(Note: we are still analyzing the remaining data and if accepted will be able to present the data of about 15,000 voluntary blood donors)
Discussion: NAT testing has helped in enhancing blood safety to the recipient and has been well accepted by the users.
An analysis of TTD reactivity in different categories of voluntary blood donation camps
Department of Pathology, HIHT University, Swamiramnagar, Doiwala Dehradun Uttarakhand, India.th
Background: Screening of blood for Transfusion-transmitted diseases (TTD) is mandatory for all donated units, whether they are replacement or voluntary blood donations, in order to ensure safe blood supply.
Aims: The present study was done with the aim of analyzing TTD reactivity among different groups of voluntary blood donors.
Method and Material: This study was done on all voluntary blood donations over a period of two and half years. All results of TTD screening including those for HIV, Hepatitis B and C Syphilis and Malaria during this duration were analyzed. ELISA technique was used for HIV (Fourth generation kits), HBsAg HCV. Syphilis screening was performed by RPR Kits and Malaria by slide/ strip method. All replacement donors formed the control group. Various voluntary blood donation camps were categorized into -Educational, Factories, Offices, Clubs, Religious gatherings and a Miscellaneous group comprising of general social workers. TTD Reactivity was studied among the various groups and analyzed.
Result: It was found that the biggest groups in terms of number of camps available and also number of voluntary donor units obtained were educational, religious and social worker groups. A total of 86 camps were organized involving 6,132 voluntary blood donors. Maximum number of camps 26/86 was in two groups- Educational and Social worker groups. Maximum number of blood units- 2279/6132(36.5%) was obtained from Religious group.
A total TTD positivity of 170/6132(2.8%) was found among all voluntary blood donors. Highest percentage of reactive units-107/170(4.7%) was in Religious group. This was followed by 29/170(2.7%) in Factory workers group. The lowest incidence- 7/170(0.9%) was in the social worker group.
Among the various TTDs it was found that the highest incidence was that of HCV 73/170(42.3%) followed closely by HBsAg reactivity 62/170(35.9%). HIV reactivity was seen in 18/170(10.4%), VDRL was reactive in 11/170(6.4%) cases and MP in 2/170(1.1%) cases.
A total of 44/86 camps had no reactive donors. This was most common in social worker groups (21/44 camps) and educational (14/44 camps).
Discussion: It is essential to categorize the voluntary blood donation camps and to study the pattern of TTD reactivity among these group. This can help to delineate groups that show high positivity and ensure safe blood supply in future.
Trends of prevalence of syphilis among blood donors in the last decade: a ten year study in a tertiary care hospital blood bank (2001 to 2010)
Maj Kushwaha Neerja, Col Philip J, Col Sarkar R S
Department of Blood Transfusion and Immunohematology, Armed Forces Medical College, Pune, Maharashtra, India.
Introduction: Transfusion-transmissible infectious agents such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and syphilis are among the greatest threats to blood safety for the recipient. This study aimed to determine the seroprevalence and temporal trends of syphilis infections among blood donors in a tertiary care hospital blood bank over the last 10 years
Materials and Methods: A retrospective analysis of screening results of 80,749 voluntary and replacement donors from 2001 to 2010 was done. Testing for Syphilis was done using rapid plasma reagin (RPR) card test. Prevalence of syphilis per 100 donations, gender, age wise distribution and prevalence based on type of donors (replacement or voluntary) were calculated. Statistical analysis was done using Epi Info 6 (version 6.04d) software.
Results: A total of 80,749 donors were screened over a period of ten years, of which 40,201 (49.78%) were voluntary and 40,548 (50.21%) replacement donors. 77,074 (95.44%) were male and 3,675 (4.5%) were female donors. Total of 352 units (0.43%) were positive for syphilis. Of these 103 (0.25%) were voluntary donors and 249 (0.61%) were replacement. Positivity was maximum in the group of 21-30 years of age (150, 42.6%). Number of syphilis positive female donor was 10(2.8%). The overall prevalence shows a significant decrease from 53(0.57%) in year 2001 to 18 (0.21%) in year 2010.
Conclusion: There has been a overall decreasing trend in the prevalence of syphilis in blood donors, over the last decade. This may be due to better awareness, exclusion of paid donors, self exclusion by donors, wide availability of curative treatment and better screening tests.
Key Words: Syphilis, voluntary and replacement donors, decreasing trends
Prevention of transmission of HIV through blood; How far have we succeeded?
Chaitanya Kumar I. S, Anju Verma K. V. Sreedhar Babu, D.S. Jothi Bai
Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Andhra Pradesh, India.
Background: The efficiency of transmission of HIV through blood transfusion is very high >90%. The HIV prevalence in Andhra Pradesh (AP) remains the highest of all states in (1.07% in males and 0.73% in females). One of the private blood banks in AP was closed last year for issuing HIV seroreactive blood, which was tested nonreactive in their blood bank. During a recent review meeting, an official pointed out our high HIV seroreactivity, and attributed it to the bleeding of professional donors. In view of these, we wanted to make an audit into the operative methods at our blood bank, to prevent the HIV transmission through blood products.
Aims: To compare the HIV seroreactivity of the recent one year, with that of the previous year.
To review the effectiveness of the selection process for low risk donors at our blood bank.
To compare our voluntary blood donation status of the recent one year with that of the previous year.
To evaluate the implementation of our efforts to follow the guidelines of World Health Organization (WHO) for the prevention of HIV.
Materials and Methods: It is a retrospective study conducted at a blood center attached to a tertiary care hospital. Data of the past 2 years, i.e., from 1 st August 2009 to 31 st July 2011 were retrieved and analyzed. Apart from the samples collected at our blood bank, the total number of samples received from the local blood collection centers, where the pilgrims donate was also verified. The screening register for donor HIV seroreactivity was reviewed. We verified the results of the initial seroreactive samples after repetition to exclude false positive results. The Donor register was scrutinized to get the voluntary blood donation status for the above period. The deferral register was scrutinized to review causes of deferral.
Results: A total of 11,980 samples were screened (5,925 in between Aug 2009- Jul 2010 and 6055 in between Aug 2010- Jul 2011). We found a statistically significant decline in the HIV seropositivity from 0.80% during the past year, to 0.28% in the present year at our center. This decrease may be due to the elimination of false positivity by repeat testing in the current year. The donor samples received for screening from other blood collection centers showed a higher HIV seroreactivity rate i.e., 0.51% compared to our rate 0.28%. Donor selection was strictly followed at our blood center, which may not be feasible at the pilgrimage centers. We found a statistically significant increase in the voluntary blood donation rate from 25.54% to 58.55% in the current year. The WHO guidelines to prevent HIV transmission through blood are followed.
Conclusion: Blood safety is a much more broader issue than HIV testing alone. The seroreactive donors donated in the above collection centers are voluntary donors; repeat entry of such donors into safe donor pool, should be prevented by targeted intervention, particularly at pilgrimage centers.
Incidence of Infections in Blood Donors in Area in and Around Aligarh
Aroonima Misra, Gunjan Agrawal, Shamssuzaman, S.M. Vasenwala, Ghazala Mehdi, Veena Maheshwari, S.H. Arif
Department of Pathology, J.N. Medical College, Aligarh Muslim University, Aligarh, U.P, India.
Background: Blood transfusion related infections are common among blood donors. We carried out this study on 45,748 donors from January 2007 to June 2011 and screened them for Hepatitis B, Hepatitis C, HIV, syphilis and malaria.
Objective: To find out the incidence of HBV, HCV, HIV, syphilis and malaria infections in blood donors in area, in and around Aligarh (a four and a half year study).
Material and Methods: Screening results for HBsAg (microELISA and rapid), HCV (microELISA and rapid), HIV (microELISA and rapid), syphilis (RPR) and malaria (Leishman's stain) were recorded on 45,748 subjects reporting for voluntary or replacement blood donation over a period of 4½ years from 2007 to 2011.
Results: Incidence of single or multiple infections increased in blood donors from 2.3% in 2007 to 10.44% in 2011. Percentage incidence was found to be higher in males (4.9%) and highest incidence was noted in 3 rd and 4 th decades (84.4%).Incidence of infections in 2007 and 2011 shows marked increase in HBV from 2.3% to 9.16%, slight increase in incidence of HCV from 0.2% to 0.5% and HIV from 0.08% to 0.5% and a decrease in incidence of syphilis from 0.24% to 0.04%.
Discussion: The study shows that, there is a definite increase in HBV infection in general population with a relatively mild increase in HCV and HIV.
Sero Diagnosis of Malarial parasites in Voluntary Blood Donors at Sir J. J. Mahanagar Raktapedhi
Bhavna Patil, Hitesh Pagare, Girish Choudhary
Sir J. J. Mahanagar Raktapedhi, Maharastra, India.
Introduction: In India, most of the blood banks do identification of Malarial parasites in blood donors by peripheral smear examination. Mumbai being in endemic zone for Malaria, it is necessary to identify the infection using test having better sensitivity and specificity. Transfusion transmitted malarial is rare, but serious and sometimes even fatal complication of blood transfusion.
Aim: To check the positive rate for Malarial parasites in Voluntary Blood Donor using PAN Malarial card.
Material and Methods: Total 35, 972 donors were screened during period from Feb 2009 to December 2010, using Pan Malaria Card by J.Mitra. Pan Malaria card by J.Mitra is visual rapid and sensetive immunoassay for qualitative diagnosis of infection with all plasmodium species. Detects pLDH Pan antigens of all malarial species. Identification of malarial species was done using differentiation card for Vivax and Falciparum.
Total numbers of donors screened - 35,972
Number of units positive - 39
Percentage positivity for MP - 0.10%
In which 38 were males and 1 female.
Confirmatory test was done using differentiation card by J. Mitra, out of which 34 were P. vivax positive, and 4 were P. falciparum positive.
Discussion: Identification and documentation of Malarial parasites detection in blood donors is not been given much importance at all the blood centers. Antigen Detection test by Rapid method helps in identification and document of pre test result and helps in transfusion of safe blood. 0.10% positivity for Malarial parasites cannot be ignored, so we should switch to sensitive method like antigen detection.
Evaluation of Combiquic HIV / HCV rapid test with Elisa results at Sir J.J. Mahangar Raktapedhi
Bhavna Patil, Hitesh Pagare, Girish Choudhary
Sir J. J. Mahanagar Raktapedhi, Maharastra, India.
Introduction: Once a donor passes the medical screening and donor questionnaire, required serological testing is performed for Anti-HIV I and II, HBsAg, Anti-HCV, VDRL and Malarial parasites. Rapid test are used at some centers for issue of blood on emergency basis. Study deals with the performance of rapid test having combined detection of Anti-HIV I and II and Anti-HCV against Elisa results.
Aim: Comparison of the result for Combiquic HIV / HCV rapid test by Tulip diagnostic against the Elisa result.
Material and Methods: Total number of donors screened 3,005.
Period of study was 15 March 2011 to 28 May 2011.
Screening by Combiquic HIV I and II and HCV, by rapid test is qualitative, immunoconcentration assay for the simultaneous and differential detection of antibodies to HIV I and II and HCV Tulip was done as the kit insert.
Results were compared with Elisa results for the same sample. Elisa test was performed on Evolis 4PS complete automated system using Bio-rad kit 4 th generation for HIV I and II and J. Mitra kit for HCV Test.
Results: Total number of donors screened - 3,005
Total units HIV positive by Elisa - 04, out of which 02 weak positive, on repeat it was negative.
Total units HCV positive by Elisa - 05, out of which 03 weak positive, on repeat it was negative.
Samples which were Elisa Reactive and Spot Negative HIV - 00, HCV - 00
Samples which were Elisa Negative and Spot Positive HIV - 01, HCV - 04 (False positive as Elisa results negative)
Discussion: Combiquic by Tulip combined test for HIV / HCV has good specificity and sensitivity as there were no false negative results, but false positive cases noted. Positive results for rapid test may be due to cross reactivity or low or borderline titers. Positive results should be confirmed using appropriates supplemented test like Elisa.
Trend of HBV, HCV and HIV seroprevalence among blood donations at a blood bank of a tertiary care hospital in southern India
Rani K, R. Molly, Mary P.C., Daniel D
Department of Transfusion Medicine and Immunohaematology, Christian Medical College, Vellore, India.
Background: Transfusion transmissible infections remain an important threat to safety of blood transfusion. The trend of such infections among replacement and voluntary blood donors depends on the donor selection process as well as the prevalence of these infections in the community.
Aim: To study the trends in the prevalence of common transfusion transmissible infections among blood donations at a blood bank of a tertiary hospital in southern India.
Materials and Methods: Donors underwent a structured preliminary clinical screening selection, before blood donation. The results of transfusion transmissible infection testing based on the universal donor screening protocol, was collected retrospectively from April 1999 to March 2011, from blood bank database. Replacement and voluntary blood donors were defined as per standard definitions. In addition, from 2009, donors were also reclassified based on the broadened NACO definition for voluntary donors. Anti-HIV Ab, HBsAg and anti-HCV Ab were tested by ELISA. Manual ELISA till 2002, AxSYM (Abbott laboratories) automated ELISA between 2002 and 2003 and Vitros automated ELISA (Ortho-Clinical diagnostics) from 2003 till now. Positive or borderline HIV tests were confirmed by western blot assay. Differences in the mean of continuous variables were assessed using independent samples t test. Time trend analysis was performed using linear regression. Data was analyzed suing SPSS and MS Excel software.
Results: Among the 239,643 blood donations during the 12 years study period, 205,733 (85.9%) were from replacement donors and 34,196 (14.3%) were from voluntary donors. There was a significant increase in the number of donations over the last 12 years (Regression coefficient = +1056.3; P<0.001). However, there was no significant time trend in the proportion of voluntary donations. HBsAg was tested positive in 4,398 (2.14%), anti-HCVAb in 1,843 (0.77%) and anti-HIV Ab in 898 (0.37%). Among those positive for anti-HIV Ab by ELISA, 489 (0.20%) were confirmed positive by western blot. Over the 12 years, there is a significant decline in the prevalence of both HIV and HBV infection among blood donations, but not HCV (Reg.coeff = -0.018, -0.016, +0.003; p = 0.001, 0.008, 0.841 respectively). Prevalence of HBsAg, anti-HCV Ab and anti-HIV Ab were significantly higher among replacement donors compared to voluntary donors (2.14% vs 1.38%, 0.80% vs 0.55% and 0.40% vs. 0.20%, respectively; P¡Ü0.001). Application of the broadened NACO definition of voluntary donors from the year 2009 April onwards, resulted in reclassification of 30.1% of donors from ¡°replacement¡± into the ¡°voluntary¡± category. After implementing the new NACO definition of voluntary donors, the prevalence of HBV, HCV and HIV infections markedly increased in the voluntary donors and was not different from that among replacement donors (1.67% vs 1.91%, 0.70% vs.0.76% and 0.31% vs.0.26%; p=0.468, 0.372, 0.681, respectively).
Discussion: There is a decline in the prevalence of HIV and HBV (but not HCV) prevalence among blood donations in our blood bank. Replacement donors have a significantly higher prevalence of HIV, HBV and HCV infections compared to voluntary blood donors. The broadened NACO definition of ¡°voluntary¡± donors dilutes this difference between the replacement and voluntary donors.
Transfusion Transmitted Infections in Voluntary Blood Donors
Lions Blood Bank, New Delhi, India.
Introduction: The first line of defense in providing a safe blood supply and minimizing the risk of transmitting infections to the recipients is to collect blood from healthy, well selected, voluntary blood donors from low risk population. The prevalence of transfusion transmitted infections (TTIs) is generally lower in voluntary blood donors than family/replacement donors. The Lions blood Bank is stand-alone blood bank, collecting blood only from healthy voluntary blood donors.
Aim: To analyze the prevalence of transfusion transmissible infections (TTIs) in voluntary blood donors.
Materials and Methods: All donor units collected are tested by enhanced chemiluminiscence immunoassay on Vitros 3600 automated system for HBsAg, HIV 1 and 2 and HCV antibodies. Rapid Plasma Reagin test for Syphilis and Rapid Test for Malaria Parasite are done as per manufacturer's instructions. We analyzed the data from 1 Jan 2007 to 15 Aug 2011.
Result: Total 139,712 blood units were collected during the study period. Overall reactive units for HIV 1 and 2 antibodies were 427 (0.30%), HBsAg 1471 (1.05%), HCV antibodies 1419 (1.01%) and RPR for Syphilis 271 (0.19%), not a single unit was positive for Malaria Parasite.
Conclusion: The results are consistent with the fact that, reactivity rate of TTIs is less in voluntary donors. However, it is important to analyze the trends of repeat voluntary donors.
Core Antibody (Total) Screening in Presence of NAT Testing for Improving Blood Safety
Ranjay Kumar Choudhary, Jaswant Singh, Harprit Singh
Manav Rachna International University, Faridabad, Haryana, India.
Background and Aim: The screening for Anti-HBV core antibodies (HBcAb) is employed by various blood centres to decrease the transmission of HBV and enhancing the blood safety. However, In India, HBcAb is not mandatory test as per Drug and Cosmetic Act, 1940.
Recently, Nucleic Acid Test (NAT) testing has been adopted for routine screening of blood for screening HIV, HBV and HCV in some blood centers. But the addition of tests leads to increase in the cost of transfused blood and implies resource limitation. Therefore, this study was carried out to look into the possibility of obviating the need of screening of HBV core, if a facility of NAT testing exists, so as to optimize the resource utilization.
Materials and Methods: Donated blood was evaluated collected between October 2008 and April 2010, covering 8,221 samples. All samples were screened for serology and NAT. Serological screening was performed by random access Chemiluminescence Immuno Assay (CLIA) for TTI including HBsAg and HBcAb - Total (Vitros ECI; OCD; JNJ USA). Individual donor screening and confirmatory NAT was performed by Transcription Mediated Amplification (TMA) technology (Novartis Diagnostic USA).
Results: Of the 8,221 blood donors, 581 (7%) were reactive for HBV marker [Table 1]. All the samples screened reactive by serological markers- HBsAg and HBcAb (Total), were compared with ID-NAT. Of all the samples reactive for HBV, 7.6% is positive by confirmatory NAT. About 2% of solitary HBcAb reactive samples were positive by ID-NAT. However, no non- reactive sample was observed to be reactive by ID-NAT, over the study period.
Discussion: Screening of blood by Anti- HBcAb does enhance the blood safety. In addition, NAT facility can enhance the blood safety but can not replace anti-HB core Screening. The policy should be based on available resources, potential human economic value in the target population, technical competence and presence of viral strains that can be detected by the NAT.
Prevalence of Hepatitis C Infection in Blood Donors of the Amritsar District, Punjab. (a 6 ½ Year Study)
Harjot Kaur, Mridu Manjari, Gagandeep Singhth
SGRD Medical College, Amritsar, India.
Background: HCV is a small, enveloped, RNA virus belonging to the flaviviridae family. An important feature of the HCV genome is its high degree of genetic variability, and different mutants of the parent strain co-exist as quasi-species in a single infected individual. This genomic instability and antigenic variability have seriously hampered the efforts to develop an HCV vaccine. Punjab has been found to have maximum number of HCV carriers due to use of unsterilized syringes, recycled needles by the drug abusers, and lack of awareness about prevention and treatment of the disease. More recently, blood transfusion has emerged as one of the most common transmission pathways of HCV, which is now the major cause of acute hepatitis after a blood transfusion that is neither related to Hepatitis A nor to Hepatitis B.
Aim: To study the prevalence of hepatitis C infection in blood donors of the amritsar district, punjab.
Materials and Methods: The present study was done at Sri Guru Ramdas Hospital Blood Bank, Vallah, Amritsar. Blood donations collected from Jan 2005 to July 2011 were screened for anti-HCV using third and fourth generation (for confirmation) ELISA kits (HCV microlisa;J.Mitra/Elisacan HCV;RFCL/Qualisa HCV;Qualpro) with reported sensitivity and specificity of 100% each (for 4 th generation).
Results: 35,793 units of blood were collected over a period of 6 ½ years, with 19.5% among them from voluntary donors and 80.5% from replacement donors. The voluntary donations have increased in number, comparatively, in more recent years, though the replacement donors still continue to comprise the major chunk of donations. The % age of HCV seropositivity has shown a gradual downward trend from 2.03% in 2005, 1.8% in 2006 and 2007, 1.3% in 2008, 0.94% in 2009, 0.96% in 2010 to 0.87% till July 2011, with an overall seropositivity of 1.38%.
Discussion: The prevalence of HCV, as apparent from the study, has gradually declined. But still, the seropositivity of HCV in blood donors of Amritsar is high, when compared to the studies from other parts of India. The reasons are not far to seek, with widespread drug abuse and lack of awareness about the prevention and treatment being the major culprits, especially in rural areas. Besides the difficulty in developing a vaccine against HCV, there is an added handicap that elevated titers of anti-HCV IgG occurring after infection, do not confer active immunity. Moreover, HCV is able to actively evade the Interferon mediated cellular antiviral response. And to add to the problem, the window period for HCV has a long range (6-12 weeks), during which anti-HCV cannot be detected in blood, making the blood donation very dangerous and life threatening for the recipient. So in such a scenario, propaganda and education of the masses regarding the prevention and consequences of acquiring HCV infection becomes extremely important, as the prevention is the only effective cure available at present for HCV infection.
Trends of HIV, Hepatitis B Virus, Hepatitis C and Co-infection Among Blood Donors in Amritsar, Punjab- A Six and Half Year Study
Harjot Kaur, Mridu Manjari, Parul Garg
Pathology/Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, India.
Background: The transfusion of blood and blood products is a life saving measure but at the same time the transfusion of infected blood or one of its component carries a significant risk of the transmission of many blood transmitted diseases like HIV, HBV and HCV, which do not have any specific treatment and are potentially life threatening.
Aims: To calculate the prevalence of HIV, HBV and HCV along with the prevalence of co-infection among the blood donors from January 2005 to July 2011 in Sri Guru Ram Das Institute of Medical sciences and Research, Amritsar.
Material and Methods: Present study was conducted at Sri Guru Ram Das Hospital blood bank, Vallah. Every unit of blood was screened to exclude HIV, HBV and HCV. Data was collected from January 2005 to July 2011.In a six and half year period, 35,793 donors were tested after selection by standard criteria for donor fitness .Screening of HIV, HbsAg and Anti-HCV was done by micro plate ELISA test using kit of J Mitra.
Results: A total of 35,793 healthy donors were tested, out of which 80.5% were replacement donors and 19.5 were voluntary donors. Viral markers were positive in 2.13% donors. Hepatitis C was present in 494(1.380%) donors, 228(0.636%) were positive for Hepatitis B and 41 (0.114%) had shown seropositivity for HIV. Co-infection of Hepatitis B and C was seen in 4(0.011%) and co-infection of Hepatitis C and HIV was seen in 1(0.0027%). Pattern of seropositivity of HCV showed continuous high trends throughout the year followed by HBV seropositivity.
Discussion: It is concluded that safety of blood supply is dependent on collecting blood from voluntary donors from low risk population, screening donated blood for transmissible infections and avoiding unnecessary transfusions. These activities need to be carried out by a well coordinated blood transfusion service with high quality control implemented at all levels. Innovative programs for donor questionnaire in donor selection are recommended to ensure a safe donor population.
Testing for the Malarial Parasite in Blood Bank: Important lessons learnt scope for improvement
Rupal Chavda, Khyati Maniyar, Nayana Andipara, Sahjid Mukhida, Rajesh Sawant
Rajkot Voluntary Blood Bank and Research Centre, Rajkot, Gujarat, India.
Background: Screening of blood donations for evidence of malaria is not without its problems. Although, the examination of peripheral blood smears is still the basis for laboratory diagnosis of malaria, in most situations, it is not sufficiently sensitive for blood donor screening.
Aim: To identify and validate an appropriate screening strategy for testing blood donors for malarial parasites. To explore an appropriate deferral strategy (3 month vs 1 year) for donors with history of malaria and thus reduce the risk of Transfusion Transmitted Malaria to a minimum.
Material and Methods: Rapid test from 5 different manufactures were analyzed for sensitivity and specificity for detection of Malarial Parasites. Peripheral Smear examination using a thin smear was considered as a standard reference method and clinical co-relation with the donor's health status was done. Donors with history of malarial fever within 3 months period were deferred for blood donation. The positivity rate for malarial parasites in this group was compared to that in the donors, who had history of malaria greater than 1 year before donation.
Results: 4 out of 39,000(0.01%) donors were found to be positive for malarial parasites by peripheral smear examination. All the above yielded positive results with the entire antigen based as well as antibody based tests. While each rapid tests yielded variable positivity rates, the results of the pLDH based test (26 out of 39,000 positive = 0.07%) showed the greatest extent of clinical co-relation with donor's past history of malaria. All the above donors had not revealed their past history of malaria/ fever during pre-donation counseling. All the above cases showed Plasmodium vivax infestation. There was a statistically significant (P< 0.01) co-relation of the history of malaria within 3 months- 12 months of donation and test positivity for Malarial Parasites. The pLDH based rapid test was implemented for routine blood donors screening in our blood bank and the criteria for donor deferral for history of malaria was changed from 3 month to 1 year period.
Discussion: Appropriate donor deferral strategy along with proper laboratory screening test has reduced the risk of Transfusion Transmitted Malaria to a minimum in our region.
Mixed Malaria and a Positive Coomb's Test
Jayashree Sharma, Julie Jose, Shashikant Patil
KEM Hospital, Parel, Mumbai, India.
Background: Malaria is still a persistent problem in India, with a peak in the number of cases every monsoon. Anemia in malaria is due to a wide array of reasons ranging from physical damage to red blood cells due to parasitic schizonts, marrow suppression as well as splenic sequesteration. There are various studies, which suggest a combined mechanism of parasite mediated and immune mediated hemolysis contributing to the anemia caused by Plasmodium falciparum. The case being presented has a complex picture with ongoing hemolysis, which seemingly exacerbated on transfusion and showed a positive Direct Coombs test.
Objective: The case being presented aims at: Discussing the significance of a positive Coombs test in malaria. Finding the correlation between a positive Coombs test and the clinical outcome.
Case Report: A 4-year-old male child admitted to the hospital with fever, weakness and lethargy. The child was previously healthy. On examination, the child was febrile with severe pallor, pulse-116/min, respiratory rate-26/min. Abdominal examination showed a spleen 6 cms below the costal margin. Laboratory analysis-Hb-4.6 g/dl, WBC count-4800/μl, Platelet counts normal, Peripheral smear examination nucleated RBCs and a few spherocytes. Malarial parasites were seen with a very low index. The patient was transfused on 4 occasions, during the hospital stay. No problems were encountered during compatibility testing. However the first three transfusions were associated with hemoglobinuria. Investigations for transfusion reaction showed no finding besides a positive DCT, which was seen in the pre transfusion sample as well. Resolution of the malaria and completion of therapy coincided with clearance of the DCT positivity and the next transfusion was uneventful.
Discussion: Malaria leading to a positive DCT, has been reported and hypothesized to be evidence pointing towards immune mediated hemolysis contributing to anemia. The case discussed shows a definite evidence of hemolysis in collaboration with the positive DCT. Literature reports autoimmunity too, to be associated with malaria, which cannot be ruled out as a possibility in the case presented. Antimalarials too are known to cause autoimmunity by immune complex mechanism, where DCT may be the only finding. Some correlation has been found between DCT positivity and clinical severity; further studies are needed to sreaffirm that.
Performance evaluation of the new Vitros HBsAgES assay in screening for Hepatitis B infection
K. Cheirmaraj, Amol Pandit, K. Krishnan
Ortho Clinical Diagnostics, Johnson and Johnson Ltd., Chennai, India.
Background: India has intermediate endemicity of Hepatitis B virus (HBV) with Hepatitis B surface antigen (HBsAg) prevalence between 2% to 10% among population studied. It has been estimated that up to 40 million people out of the 350 million Hepatitis chronic carriers worldwide arise in India. Screening for HBV infection is primarily based on the detection of HBsAg in the serum or plasma samples. The sensitivity of immunoassays for the detection of HBsAg may be hampered by the presence of mutants involving the major antigenic determinant of the protein. There is a need for a sensitive screening assay to detect HBsAg mutants known so far and need for better discrimination of non-reactive and reactive results with less grey zone results, which helps in enhancing the safety of blood or blood components for transfusion.
Aim: This study is undertaken to evaluate the performance of the new high sensitive Vitros HbsAg ES assay in donor samples, in comparison with the current Vitros HBsAg assay, in terms of clarity index between non-reactive and reactive population.
Material and Methods: This study was carried out in Vitros ECiQ immunodiagnostics system based on enhanced chemiluminescence technology, at various prestigious blood banks in India. The healthy donors, both voluntary and replacement donors, attending the blood bank were screened for HBsAg in serum samples using both Vitros HbsAg ES assay and Vitros HBsAg assay simultaneously. All the results are normalized to the cut-off value; S/Co = Signal / cut-off signal.
Results: A total number of 1,102 blood samples were screened for the detection of Hepatitis B infection, by both Vitros HbsAg ES and Vitros HBsAg assay. Vitros HBsAg assay showed reactive for 29 samples whereas Vitros HbsAg ES assay showed reactive for 30 samples. Out to 1,102 samples screened, 3 samples showed discordant results between both assays. Out of 2 samples picked up by the Vitros HbsAg ES assay, 1 sample was found to be in the borderline and the other sample was below the borderline reaction in Vitros HBsAg assay. The sample, which showed below borderline reaction in Vitros HBsAg assay was subjected to HBV NAT test and found to be 'Reactive'. This sample may be HBsAg mutant form and is missed by Vitros HBsAg and picked up by Vitros HbsAg ES assay. One sample showed, 'initial reactive' in Vitros HBsAg and 'Non-reactive' in Vitros HbsAg ES assay was also found to be 'Non-reactive' in HBV NAT test. This may be due to false positive reaction in Vitros HBsAg assay. Further the discrimination between both Reactive and Non-reactive samples were much better in Vitros HbsAg ES assay, when compared to Vitros HBsAg assay based on the frequency distribution of the signal vs cut-off (S/Co) ratio. The Non-reactive samples on an average showed lower readings by 41% in Vitros HbsAg ES assay, when compared to Vitros HBsAg assay. The Initial reactive samples on an average showed higher readings by 36% in Vitros HbsAg ES assay, when compared to the existing Vitros HBsAg assay.
Discussion: This study showed that, Vitros HbsAg ES assay showed better clarity in differentiation of Reactive and Non-reactive samples and hence better sensitivity and specificity with the new Vitros HbsAg ES assay.
TPHA seroreactivity amongst healthy blood donors of Delhi and its association with other markers of Transfusion Transmitted Infections
Sangeeta Pahuja Sindhwani, Santosh Gupta, Mukta Pujani, Manjula Jain
Lady Hardinge Medical College, New Delhi, India.
Background: There is an ongoing controversy in FDA regarding inclusion of screening for syphilis as a mandatory marker. In India, Screening for five markers of TTIs has been made mandatory by Drug Controller General, India.
Aim: The study was conducted to assess the prevalence of syphilis infection in blood donors of Delhi and to study its correlation with other markers of TTIs including HCV, HIV and HBsAg.
Materials and Methods: The study was conducted in Regional Blood Transfusion Centre, LHMC and Assoc. Hospitals for a period of one year (June 2009-May 2010.). Total number of 8082 serum samples of blood donors was screened for HIV, HCV, HBsAg, malaria and TPHA.
Results: Overall prevalence of syphilis by TPHA was found out to be 4.4% (663 out of 8082). Prevalence of anti HIV antibodies in TPHA positive group was significantly higher than in TPHA negative group (2.24% and 0.69% respectively, Odd's ratio: 3.27). However, no statistically significant correlation was found between HBsAg or HCV and TPHA.
Discussion: We concluded that in high prevalence settings of syphilis like India, testing of donor blood for syphilis should be continued, not only as a marker of syphilis per se but also as a valuable marker of high risk behavior.
The role of Anti-HBc antibody screening in enhancing the safety of blood
Rema Menon, M.A. Thirunarayanan Gethziyal D
Apollo Hospitals, Chennai, India.
Background: To enhance the safety of blood, dual testing strategy was carried out at Apollo Hospitals, Chennai. A highly sensitive serological screening assay based on enhanced chemiluminescence technology (Vitros ECiQ) and Nucleic Acid Test (Roche MP NAT) was used for the screening of blood donors for HIV, HBV and HCV infection. In serological assays, the donor samples were screened for anti HIV 1 / 2 antibodies, anti HCV antibody, anti-HBc antibody and HBsAg. The samples were screened for HIV, HBV and HCV by NAT also.
Aim: To study the role of Anti-HBc antibody screening in conjunction with NAT screening to enhance the safety of donor blood.
Materials and Methods: All the donor and recipient samples were screened for infectious disease markers at the Apollo Hospitals, Chennai. A total of 9,482 donor samples and 1,432 recipient samples were screened by both serological and NAT assay. The period of study was from January 2011 to August 2011. All the samples were subjected to two tier screening for infectious diseases. In the first tier, the samples were screened for the presence of anti HIV 1 / 2 antibodies, anti HCV antibody, HBsAg and anti-HBc antibody using enhanced chemiluminescence technology in Vitros ECiQ immunodiagnostics system. In the second tier testing, all the samples were subjected to mini pool NAT for HIV, HBV and HCV using Roche 0 Cobas® TaqScreen MPX assay. The NAT yield samples were further subjected to Hepatitis profile testing, which included HBe, anti-HBe, anti-HBc IgM antibody and anti-HBs antibody titer using enhanced chemiluminescence technology. A liver profile test was conducted by biochemical assay.
Results: All NAT reactive samples were concordant with serological assay and hence the NAT yield was nil among donor samples. In recipient samples, there were about 5 discordant samples that were reactive by NAT for HBV infection and non-reactive for HBsAg. However, all the 5 samples were reactive in anti-HBc antibody assay. All the 5 NAT and anti-HBc reactive samples were further subjected to hepatitis profile assay to evaluate the status of hepatitis viral markers and to analyze the stage of infection. Of the 5 samples, 3 samples showed the presence of anti-HBs antibody and one sample showed the presence of anti-HBe antibody.
Discussion: Based on the results obtained with recipient samples, this study showed that inclusion of anti-HBcore antibody assay in blood screening helps in identifying the HBsAg negative donors who are HBV infective. This study also reconfirms that dual testing strategy helps in enhancing the safety of blood transfusion.
Prevalence of transfusion transmitted infections in Blood Donors
Kakkar S, Dhot P S, Mishra K K, Agarwal S S, Gupta M, Dhuria U, Kedia R, Agarwal A.
Swasthya Kalyan Blood Bank and Thalassemia Research Centre, Jaipur, Rajashthan, India.
Background: Transfusion of blood and its components is life saving as well as it has life threatening hazards. With every unit of blood there is a 1% chance of transfusion associated problems including transfusion transmitted diseases. A majority of known cases of post transfusion diseases have been caused by HIV (Human Immunodeficiency Virus), HBV (Hepatitis B Virus), HCV (Hepatitis C Virus), Treponema pallidum d Malaria parasites.
Study Objectives: To find out the prevalence of transfusion transmitted infections (TTI) in voluntary and replacement donors. As an aid in evaluating the safety of the collected donations
Materials and Methods: At Swasthya Kalyan Blood Bank and Thalassemia Research Centre, Jaipur, a total of 46,665 blood donors were analyzed for the prevalence of TTI from 1 st January 2009 to 31 st July 2011. These included both replacement and voluntary donors. Care was taken to eliminate professional and paid donors by taking history and clinical examination. All samples were screened for Hepatitis B Surface Antigen (ELISA - Bio-rad), Human Immunodeficiency Virus (ELISA - Bio-rad), Hepatitis C Virus (ELISA - GBC), Rapid Plasma Regin (RPR - RFCL and Co.) confirmed by TPHA and malaria by Tulip. All the reactive samples were repeated in duplicate before labeling them seropositive. The statistical analysis was done using the Chi square.
Results: From amongst the analyzed samples, it was found that 2.91% of these had prevalence of TTI. These included varying percentage of infection due to HBV (2.05%), HIV (0.35%), HCV (0.34%) and Syphilis (0.17%).
Discussion: Optimal donor selection and screening procedures will help in improving blood safety
Comparison of detection limits of an Analyte by three Immunoassays for HBsAg, Anti-HIV, Anti-HCV using serial dilution method
Laxmi Mantrala, Priti Desai, S. B. Rajadhyaksha
Department of Transfusion Medicine, Tata Memorial Centre, Mumbai, India.
Background: In India Microplate Enzyme Linked Immunosorbent Assay (ELISA) is widely used for screening blood donors for HBsAg, Anti-HIV and Anti-HCV. Rapid tests and Microparticle Enzyme Immunoassay (MEIA) are used in some centers. In Blood Transfusion Services, where asymptomatic and healthy donors are screened, the kit which can detect low levels of analyte is considered to have high analytical sensitivity. The use of highly sensitive assays is crucial for blood transfusion safety.
Aim: Comparison of detection limits of an Analyte by Microplate ELISA, Rapid test (Immunoassay) and MEIA using serial dilution method in order to study sensitivity of seroreactivity for HBsAg, Anti-HIV and Anti-HCV.
Material and Methods: A strong HBsAg reactive sample by Microplate ELISA, which was also reactive by Rapid test and MEIA was serially diluted using known negative plasma (1:2 to 1:131072). The dilutions were run on the above three assays and the highest dilution showing reactivity by each testing method was noted. The same procedure was followed using a strong Anti-HIV and Anti-HCV sample. Using these serially diluted samples all assays were carried out as per manufacturer's kit manual instructions.
Results: On testing serially diluted HBsAg reactive sample, the Microplate ELISA detected reactivity up to 1:2048, Rapid test detected up to 1:256 and MEIA detected up to 1:32768 dilutions. On testing serially diluted Anti-HIV reactive sample, the Microplate ELISA detected reactivity up to 1:4096, Rapid test detected up to 1:256 and MEIA detected up to 1:131072 dilutions. On testing serially diluted Anti- HCV reactive sample, the Microplate ELISA detected reactivity up to 1:128, Rapid test detected up to 1:16 and MEIA detected up to 1:256 dilutions.
Conclusions: MEIA test detected analyte at higher dilutions indicating its detection limits at lower concentration of analyte. In-house evaluation of detection limits of an analyte in blood donor screening assays can be used as a parameter to choose the assay/s for routine use.
Seroprevalence of HIV, HBsAg and HCV Infection among Blood Donors in Teritary Care Centre, Jammu
Urvershi Kotwal, Meena Thappa, T. R. Raina, Raman Kapoor
Department of Immuohematology and Blood Transfusion Medicine, GMC Jammu , India.
Background: Evaluating the trends in Blood Donor Infectious Disease rates is essential for monitoring the safety of blood supply as well as donor screening effectiveness.
Aim: To see the Seroprevalence of HIV, HBsAg and HCV Infections among Blood Donors in our Centers.
Material and Methods: A total of 70,458 units of blood collected, both from Voluntary and Replacement donors over a period of 3 years i.e. January 2008 to December 2010 were screened for anti HIV Antibodies, HBsAg and anti HCV Antibodies using 3 rd generation ELISA kits and Rapid kits.
Results: Out of the total cases i.e. 70,458, which were screened for Infectious Disease Markers, HIV positive cases came out to be 22 for year 2008, 18 for year 2009, and 23 for year 2010 respectively. Thus, total of 63 cases were seropositive for HIV with over all seropositivity for HIV being .089%. For HBs Ag cases, which came to be positive for years 2008, 2009, 2010 came out to be 155, 82 and 171 respectively. Total seropositive cases were 408 and overall seroprevalence of HBsAg came out to be .58%. Similarly, cases detected for HCV were 32 for the year 2008, 44 for the year 2009 and 41 for the year 2010 respectively. Total cases were 117 and overall seropositivity of HCV came out to be .166%. We also detected 5 cases of co-infection among the Blood donors. One case was seropositive for both HIV and VDRL, One case was seropositive for HBsAg and VDRL and 3 cases were having both HCV and VDRL co-infection. Seroprevalence of co-infection among positive cases was 85%.
Discussion: The overall seroprevalence of these 3 Infectious markers came to be lower as compared to various other studies done in other parts of the country. This probably may be due to the low prevalence of these Infectious Diseases in Jammu Region. Co-infections are not so uncommon, so VDRL should be done as a surrogate marker.
Key Words: HIV, HBsAg, HCV, Seroprevalence
Comparison of HIV seroprevalence in blood donors using fourth generation ELISA versus third generation ELISA assay: An Indian experience
Sheetal Malhotra, Neelam Marwaha, Karan Saluja, Ratti Ram Sharma
Department of Transfusion Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Background: The percentage of HIV cases attributable to blood transfusion has decreased significantly in the last decade. The newer fourth generation ELISA has been shown to have increased sensitivity compared to third generation ELISA.
Aims: To estimate the seroprevalence of HIV among blood donors using fourth generation ELISA assay and to compare it with the third generation ELISA.
Materials and Methods: This prospective study involved 10,200 blood donors- 6,800 were voluntary donors (3,400-students and 3,400-non students) and 3,400 were replacement donors. All blood units were tested for HIV antibodies using third generation ELISA as well as fourth generation ELISA. All samples found positive or in grey zone with either 3 rd or 4 th generation ELISA were reconfirmed by Western Blot.
Results: The seroprevalence of HIV was estimated to be 1.37/1000 donations (0.14%) with 3 rd generation ELISA compared to 3.62/1000 donations (0.36%) with 4 th generation ELISA (P>0.05). Of the 11 samples, which were ELISA and WB positive using 3 rd generation ELISA, all were positive with 4 th generation ELISA. Of the 17 samples, which were ELISA positive (or in grey zone) and WB positive using 4 th generation ELISA, only 11 were found to be positive and the remaining 6 were false negative with 3 rd generation ELISA. The additional yield with fourth generation ELISA was found to be 6 confirmed positive samples per 10,200 donations or 0.58 window period units per 1,000 donations. The seroprevalence of HIV among voluntary donors was estimated to be 1.91/1,000 donations (0.191%) with 3 rd generation ELISA and 2.35/1,000 donations (0.24%) with 4 th generation ELISA. The prevalence of HIV among replacement donors was 1.47/1,000 donations (0.15%) with 3 rd generation ELISA and 3.52/1,000 donations (0.35%) with 4 th generation ELISA.
Conclusions: Fourth generation ELISA detects a higher number of seropositive donors compared to 3 rd generation ELISA. We recommend the nationwide replacement of 3 rd generation ELISA with the newer 4 th generation ELISA as the method for screening blood units in blood banks.
Seroprevalence of Transfusion Transmitted Infections among various blood group donors in a tertiary care hospital
NTR Memorial Trust Blood Bank
Background: A major challenge in transfusion medicine is to provide safe blood, free from transfusion transmitted infections. Blood is one of the major sources of transmission of infectious diseases viz., HIV, HBV, HCV, Syphilis and many other infections in India. As large volume of blood or blood components are given to patients during transfusion therapy, even a blood unit with a low viral load may cause infection in the recipient. Infectious disease screening assays with maximum analytical sensitivity and uncompromised specificity helps to enhance the safety of the blood by reducing the diagnostic window period as much as possible.
Aim: This study is carried out to evaluate the data on the seroprevalence of transfusion transmittable infections viz., HIV, HBV and HCV among blood donors in a tertiary care hospital in Andhra Pradesh and the assessment of the pattern of these infections among various ABO groups in blood donor population and the safety of collected donations. This study also gives an idea of the epidemiology of these diseases in the donor population.
Material and Methods: A total of 10,601 blood units collected from the donors (both voluntary and replacement donors) at Department of Transfusion Medicine, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad were screened for the transfusion transmittable infections viz., anti HIV 1 and 2 antibody, anti HCV antibody, anti-HBcore antibody and HBsAg by Enhanced Chemiluminescence assay on Vitros ECiQ immunodiagnostics system. The ABO and Rh blood grouping was done for all the donors and the association of infectious disease markers among various blood groups were evaluated.
Results: Out of 10,601 donor samples collected, 97% of were from male donors and 3% from female donors. About 41.2% of donors were belonging to O group followed by B Group (31.8%), A group (21.4%) and AB group (5.6%). Among Rh grouping, 93.8% were Rh Positive and 6.2% were Rh negative. The seroreactivity among blood donors were as follows: anti HIV 1 and 2 antibody - 0.25%; anti HCV antibody - 0.28%; anti-HBcore antibody alone - 3.25% and HBsAg - 1.28%. When we study the association of infectious disease markers with various blood groups, HIV prevalence was high in O+ve and B+ve blood group donors and HCV was high in O+ve blood group donors. HBsAg and anti-HBcore antibody reactivity in donors did not show any variation among various blood groups.
Discussion: There are significant differences in the frequency of seroreactivity for HIV and HCV among various blood groups, observed. The analysis of relationship showed a tendency of high association of HIV and HCV seroprevalence in subjects with O positive blood group. Further, this study showed that serology testing for anti HIV 1 and 2 antibody, anti HCV antibody, HBsAg and anti-HB core antibody, based on high sensitive Enhanced Chemiluminescence assay helps in enhancing the safety of blood or blood components for transfusion therapy.
How reliable is a valid rapid test: An unusual experience
Pratul Sinha, S.P. Subbiah, Mohandoss M, Sabari Priya E, Suresh S, Sivakamy T.
Department of Transfusion Medicine, Jawaharlal Institute of Postgraduate Medical, Ponducherry, India.
Background: Rapid tests for screening of blood donors are allowed as per Drugs and Cosmetic Act. This technique is usually used in cases of emergency and mostly for screening donors for plateletpheresis. These are done on individual samples and validity is for a single test result. There are no tests for reliability or for a continuous quality monitoring like the levey jenning chart for ELISA.
Aims: We report a case of a donor's sample, which gave a reactive and non-reactive test result with two different rapid test kits.
Materials and Methods: The policy of screening of blood donors at our center is to confirm the ELISA reactive results as per our institute protocol. The unit of blood is discarded as per guidelines of NACO and our institute policy. However, as a quality control procedure, all samples that are screened reactive are then retested in duplicate on the same ELISA, another ELISA kit by different manufacturer and also by a rapid test.
Result: One such sample, which was reactive on two different ELISA kits in duplicate, gave a non-reactive result on rapid test (manufacturer X). The test was repeated on a different rapid test kit (manufacturer Y), where the result was reactive and in concurrence with the ELISA results.
Discussion: Rapid tests are useful in emergency. However, the reliability of these tests is not well established. It is advisable to have a policy guideline dictated by the Hospital Transfusion Committee for the use of rapid test under specific conditions. We also recommend the use of rapid test in duplicate from different manufacturers for increasing the reliability of these tests.
Correlation of Nucleic Acid Amplification Testing and Eia Results in A Tertiary Care Hospital in India
Dr.Anand Deshpande, S. Kalgutkar, P. Satawase, M.Mishra, N. Shetge
Department of Transfusion Medicine, P.D.Hinduja National Hospital and M.R.C., Mumbai, India.
Background: In India, all the blood donor units are screened for HIV I and II (EIA), HCV Ab (EIA), HBsAg (EIA), VDRL and Malarial Parasite. In addition, we have introduced Nucleic Acid Amplification Testing (NAT) in our laboratory, since March 2009. We are presenting our data correlating NAT results with EIA results for last 29 months.
Aim: To correlate the results of EIA test and NAT test for HBV, HCV and HIV.
Material and Methods: 15,827 donor samples were tested by both EIA and NAT. EIA test for HBsAg and HCV antibody was carried out using 3 rd generation EIA kit. However, testing for HIV was carried out using 4 th generation EIA kit. All these tests were carried out using Abbott AxSYM / Architect kits. ID-NAT for HBV, HIV and HCV was carried out using Procleix Ultrio triplex assay by Novartis Chiron, which uses Transcription mediated amplification (TMA) technique. We have considered cut off (S/CO) as 1 as recommended by Abbott AxSYM kits for HIV, HCV and HBsAg and for HIV and HCV by Abbott Architect kit. Cut off for HBsAg was 0.050 IU/mL by Abbott Architect Kit. We have considered weak reactive as 10 % of the cut off mark.
Results: Total number of units tested - 15,827
EIA negative / NAT Positive - 0.
Conclusion: There was no NAT yield in all the donors tested, till today. There was 100 % correlation between EIA and NAT results, in case of both HIV and HCV test. There was discordance observed between EIA and NAT results, in case of HBV test 10/169 (5.9%).
- Very low number of viral copies, in spite of, strong positive HBV EIA results.
- Disappearance of viral genome after production of antigen.
HGV-HCV/HBV CO-Infection in Patients and HGV in Healthy Blood Donors: A Pilot Study
Anand Deshpande, A. Pathare
Department of Transfusion Medicine, P.D. Hinduja National Hospital and M.R.C. Mumbai, India.
Background: Hepatitis G virus (HGV) is newly identified virus, transmitted by infected blood and blood products. Effect of HGV infection on liver diseases is not well known.
Aims: The presence of HGV has been reported along with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in patients as well as in healthy blood donor population all over the world however; very limited data is available from India. Therefore, we have performed a pilot study for the presence of co-infection of HGV in chronic liver disease patients and in healthy blood donors.
Methods and Materials: Forty HBV, HCV related chronic liver disease patients were recruited for the study from tertiary care hospital in Mumbai. 100 voluntary healthy blood donors visiting blood bank were selected randomly for the study. Biochemical estimations, such as serum bilirubin, ALT, AST and ALP were performed to assess their role in HGV infection if any HGV infection was detected by using reverse transcriptase moloney murine leukemia virus (M-MLV) with the help of HGV 340/625IC kit (Sacace, Italy). We have validated the kit using a HGV positive patient's serum having viral load of 10 7 copies/ml. This sample was gifted by National Institute of Health, Bethesda (U.S).
Results: One HCV positive patient was found to be co-infected with HGV among 40 HBV/HCV chronic liver disease patients. None of the healthy blood donors were positive for HGV infection.
Discussion: Larger trials and follow-up are needed to understand the occurrence of HGV in HBV/HCV patients as well as in healthy blood donors.
Blood Donor Profile and prevalence of Transfusion Transmitted Infections
Kedia R, Dhot P S, Mishra K K, Agarwal S S, Kakkar S, Gupta M, Dhuria U, Agarwal A.
Agrasen Blood Bank, Jaipur, Rajashthan, India.
Background: Blood Transfusion has its advantages and is life saving but it has certain hazards if not processed optimally.
Study Objectives: To find out the percentage of voluntary and replacement blood donors. To study the prevalence Transfusion Transmitted Infections (TTI) in voluntary and replacement blood donors.
Materials and Methods: A total of 19,508 blood donors were analyzed for voluntary and replacements from 1 January 2005 to 31 July 2011. The voluntary donors were 62.9% and replacement blood donors were 37.1%. Care was taken to eliminate professional and paid donors by taking history and clinical examination. All samples were screened for Hepatitis B Surface Antigen (ELISA - Bio-rad), Human Immunodeficiency Virus (ELISA - Bio-rad), Hepatitis C Virus (ELISA - GBC), Rapid Plasma Reagin (RPR - RFCL and Co.) confirmed by TPHA and Malaria parasite by Tulip. All the reactive samples were repeated in duplicate before labeling them seropositive. The statistical analysis was done using the Chi Square
Results: Apart from the predominance of voluntary donors (62.9%), male donors contributed 96% of the total blood collected and females constituted 4%. From amongst the analyzed samples it was found that 1.68% had prevalence of TTI. These included varying percentage of infection due to HBV (1.15%), HIV (0.23%), HCV (0.15%) and Syphilis (0.13%).
Discussion: Voluntary Donors constituted 62.9% which is encouraging. IEC activities along with pamphlets, advertisements both in electronic and print media including National Voluntary Blood Donation Day Rally has immensely contributed to provision of safe blood for the needy patients. Optimal donor selection, screening procedures and encouraging voluntary blood donation will help in improving blood safety.
Category 6 - Advances in Transfusion Medicine
A study on plateletphersis donor profile and comparative analysis on two cell separators in a teriary care hospital in Eastern India
Prasun Bhattacharya, Somnath Mukherjee, Kushal Chatterjee, T.K. Gupta, Biplabendu Talukder, Suvro Sankha Datta.
Department of IHBT, Medical College and Hospital, College Street, Kolkata, India.
Background: Plateletpheresis is safe procedure routinely performed in many transfusion medicine centers nowadays. Platelets aid in the clotting process to stop or prevent bleeding and are used in the treatment of serious illness or surgery. However, the concept of donor plateletpheresis in Eastern India is still in its infancy. Routine single donor platelets are not available even in many major blood centers.
Aims: To motivate the blood donors for the apheresis procedure. To study the donor profile in plateletpheresis among the Bengali and other Potential donors in the metropoliton. To compare the operational efficacy of cell separators of different manufacturers in terms platelet yield and leukoreduction.
Material and Methods: Donors were screened as per DGHS guideline. Any donor having poor venous access on the antecubital vein of both arms, platelet count <1.5lac/cumm, Hb < 12.5gm/dl and having any history of intake of NSAIDS in last 72 hours were deferred. The donors who qualified were screened for mandatory testing of infectious markers. All serologically nonreactive healthy donors were finally accepted. Two cell separators of different manufacturers (Amicus, Fenwal USA and MCS+, Hemonetics USA) were used for performing plateletpheresis.
Result: A total of 675 blood donors volunteered for plateletpheresis from October 2009 to August 2010. Out of them, 48 were deferred due to poor venous access, 141 donors deferred due to either low platelet count (132) or low Hb (9) level and 11 were deferred due to reactive serology. 475 potential healthy donors were selected for plateletpheresis. However, 97 of the above 475 donors did not require plateletpheresis Out of 378 plateletpheresis, 288 procedures were performed in Amicus and 90 procedures were performed in MCS+ Hemonetics separator. Quality control (Q.C.) of the products were performed in terms of the target yield achievement (⪰3X10*11) and leukoreduction (< log3 i.e. <5X 10*6) by MS 95 (Melet Schloesing Lab, France) automated cell counter. Of the 288 procedures done in Amicus, Q.C. in terms of yield achievement and leukoreduction were done in 283(98.26%) procedures. Quality control for the same parameters was done in all the 90 (100%) procedures performed in MCS+. 100% target yield achievement observed in 250 out of 283 procedures (88.33%) performed in Amicus. Leukoreduction for more than log3 was achieved in 273 out of 283(96.46%). Although, target yield achievement was 100% observed in 85 out of 90 procedures (94%) performed in MCS+, Leukoreduction more than log3 was achieved in 80 out of 90 (88.88%) procedures.
Discussion: Both the cell separators performed satisfactorily in terms of the target yield achievement but leukoreduction of 96.46% was observed with Amicus in comparison to 88.88% with MCS+, which is significant. Significant number (93%) of potential donors was deferred due to low platelet count. The low platelet count is a known entity among healthy population in eastern part of this country.
Therapeutic Plasma Exchange in Guillain-Barré syndromes
Sree Devi R, Latha B, Umesh D
The Tamil Nadu Dr. M.G.R Medical University, Chennai, India.
Background: Guillain-Barré syndrome (GBS) is the main cause of acute Polyneuropathy, characterized by progressive motor weakness and areflexia. Sensory, autonomic and brain stem abnormalities are also common. In about 60% of cases, GBS follows closely an infection, most frequently caused by the microbiological agent Campylobacter jejuni. After the infection, molecular mimicry occurs in which epitopes incidentally shared by microbial antigens and nerve structures elicit an auto reactive T-cell (or) B-cell response, triggering the autoimmune process. Antibody cross reaction against target epitopes in myelin (or) superficial membrane of Schwann cells cause AIDP form of GBS and Antibody cross reaction against target epitopes in axonal membrane causes acute axonal form. Therapeutic Plasma Exchange (TPE) is accepted as a standard first line therapy for GBS. TPE constitutes an extracorporeal blood purification technique designed to remove large molecular weight particles from plasma. This can be achieved with centrifugation devices. During continuous or intermittent centrifugation, blood components separate because of differences in density. The removal of circulating auto antibodies, immune complexes, cytokines and other inflammatory mediators is thought to be the principal mechanism of action. In TPE, 1-1.5 plasma volumes are exchanged per procedure per day. With the use of replacement solutions, the exchange of a single volume of plasma will lower the level of a specific macromolecule by 50% to 60%. Routinely 3-5 plasma exchange session are carried out every alternate day. Replacement solution can be fresh frozen plasma (or) albumin.
Aim: To evaluate the clinical outcome of TPE in GBS patients.
Materials and Methods: In our study 12 patients, admitted from May 2011 to Aug 2011, having clinical condition diagnosed as AIDP were performed TPE and assessed for improvement in their clinical condition. Out of the 12 patients studied, 2 patients were on ventilatory support. For all the patients, TPE was carried out for 5 cycles on every alternate day using Hemonetics MCS+ intermittent-flow cell separator. One plasma volume was exchanged for each cycle. Four units of FFP were given as a replacement fluid in all the procedures. Mean procedure time was 95 min. The mean used ACD volume was 220 ml. Central venous catheter inserted in the internal jugular vein (IJV) was used for vascular entrance. 1 technical and 2 vascular problem (Catheter plugging) were observed, which was resolved and the procedures was completed.
Results: Complete and/or partial recovery was observed in 11 out of 12 patients, for whom TPE was performed within 2 weeks of the disease onset. One patient succumbed, due to other complications (Pneumonia).
Discussion: As a result, we observed that TPE is an easy and effective treatment modality in Acute Inflammatory Demyelinating form of GBS. If it is performed within first 2 weeks of the disease onset, it resulted in reducing the period of hospitalization and other potential complications. The treatment is also cost effective in comparison to the available intravenous Immunoglobulins.
Clinical Application of Therapeutic Plasma Exchange-A case of Large Hematoma Reabsorption.
Anupam Chhabra, Alpana Srivastava, David Raj, Jitendra Kumar, Pradeep Negi
Pushpanjali Crosslay Hospital, Vaishali, Ghaziabad. U.P, India.
Background: A patient reported with diagnosis of communited displaced fracture proximal tibia left and distal femur left with blisters over knee with septicemia with severe anemia. At the time of admission, hemoglobin was recorded 4.6 gm/dl. Four units of Leuko reduced packed red blood cells (PRBC) were transfused over 2 days. Initial reports suggested vitamin B12 deficiency. The hemoglobin improved after administration of B12, but a rising trend in the Total, Direct and Indirect Bilirubin, while Hemoglobin was stable.
Aim: To detect the cause of raise in the Total and Indirect Bilirubin levels
Materials and Methods: Fresh EDTA and Plain blood samples were drawn from the patient. All the previous records were cross checked. No discrepancy was found. Negative results were recorded for auto control, Direct Coombs by I.D gel card and antibody screening. A large resolving hematoma was found at the site of injury. One procedure of Therapeutic Plasma Exchange was performed and the extracted plasma was replaced by extracted, which was compensated by 50 % Colloids and 50% Crystalloids.
Results: A drastic decrease in Total, Direct and Indirect Bilirubin was recorded, after which the patient was successfully operated and large resolving hematoma was evacuated, after which Total and Direct and Indirect were normalized. There was a breakage of hemoglobin. The hemoglobin is broken down to heme as the globin parts are turned into amino acid; the heme is turned into unconjugated bilirubin in the reticuloendothelial cells of the spleen. The conjugated bilirubin is not soluble in water. It is bound to albumin and sent to liver.
Discussion: TPE can be used for clinical applications as well. The above case falls in category III (as per ASFP)-Optimum role of apheresis is not established. Decision making should be individualized. Emphasis should be made to find the cause of hemolysis.
Comparison of various adverse reactions in platelet apheresis donors among three apheresis instruments - MCS+ (Hemonetics), Amicus (Fenwal), CS3000 (Baxter): A tertiary care blood bank study
Jain Neelesh, Col Sarkar R S, Col Philip J, Surg Cdr Mallhi R S
Armed Forces Medical College, Pune, India.
Background: Apheresis component collection is a rapidly growing area in the blood collection field. Several instruments with varying capabilities are available. Plateletpheresis procedures are usually well tolerated. Occasionally, adverse events (AEs) of variable severity may occur during or after the procedure. AEs that occur in donors are divided into local reactions and systemic reactions.
Aim: The aim of the study was to compare three different apheresis machines for donor adverse reactions.
Material and Methods: This is an observational retrospective study, where 722 donors donated 722 Single donor platelet (SDP) units, during a 13 months period from June 2010 to July 2011, with three different cell separators, Out of which 111 were on Baxter CS 3000, 142 were on Amicus and 469 were on Hemonetics MCS+ cell separators. Donors were selected as per the set criteria for single donor platelet (SDP) preparation according to American Association of Blood Bank (AABB) guidelines.
Results: 23 adverse events were reported in relation to the 722 procedures for an overall adverse-event rate of 3.18%. Donor adverse events on MCS+ were 2.98% (14/469), on CS3000 were 5.4% (6/111), and on Fenwal Amicus were 2.1% (3/142). Overall, Vascular injury (VI) was 0.83% (6/722), Citrate reaction (CR) was 2.4% (18/722), and Presyncopal/Syncopal attack (PS/S) was 0.69% (5/722). Vascular injuries, citrate reactions, and syncopal reactions were mostly of mild intensity except fainting in one case. All three cell separators were almost equally safe, when AEs were compared with each other.
Discussion: Apheresis procedures performed on cell separators are safe, with a low incidence of significant AEs. No significant difference was noted in AEs among the three cell separators studied. To study the donor adverse events, it is recommended that more studies be undertaken to prove the significant differences in various cell separators.
Assessment of factors affecting quality of apheresis platelets using continuous flow cell separator
Sachdeva P, Kaur G, Basu S, Tehlan A
Department of Transfusion Medicine, Government Medical College and Hospital, Chandigarh, India.
Background: The optimal platelet transfusion dose is dependent on the yield in apheresis platelets. Various donor factors such as predonation platelet count and hemoglobin concentration affect the platelet yield. This study was undertaken to evaluate the variables affecting quality of apheresis platelets using continuous flow cell separator.
Materials and Methods: A total of 153 plateletpheresis procedures performed on a continuous flow cell separator using closed system apheresis kits over a period of 18 months were evaluated for platelet yield.
Results: The relationship between various predonation parameters and the platelet yield was studied using Pearson Correlation. The platelet yield was obtained in the range of 1.9X10 11 to 8.9 X10 11 with a mean of 3.59 X10 11 . Predonation platelet counts have a direct correlation with the platelet yield of the product (r = 0.48, P < 0.01). Higher platelet yield was obtained when the MPV of donor was in the range of 8-9.5(r=0.52, P < 0.01). Also PDW of 34 -39 was associated with better product yield(r =0.47, P <0.04). The yield was more than 3.5 X 10 11 in 83% of the procedures for predonation platelet counts of ≥ 2 X 10 5 /μl. There was no effect of Hb or Hct on the yield(r = - 0.04, P > 0.05). Also the yield obtained was not affected by the total blood volume processed or the time taken for procedure.
Discussion: It is observed that SDP yield is affected by pre donation platelet count as well as by donor MPV and PDW. These parameters should be taken into consideration while selecting a donor for optimal yield.
The effect of plasmapheresis on plasma cholinesterase levels in organophosphate poisoning patients
Ramesh Kumar, S. Shanmugam, H. Sivaramakrishnan, A. Rajkumar
Life Line Blood Bank and Research Centre, Sudharson Hospitals, Vannerpattai
Background: Pesticide poisoning kills hundreds of thousands of people each year. Our aim is to explore the therapeutic effect of plasma exchange on acute organophosphorus poisoning.
Material and Methods: Data of 17 cases with acute organophosphorus poisoning were analyzed. 6 cases in group A were treated by conventional therapy and 11 cases in group B were treated by conventional therapy with plasmapheresis on Hemonetics MCS 3p. All patients were given Atropine, pralidoxime and put on ventilator.
Results: The mean base level of serum cholinesterase (U/L) for group A is 401 1± 26.4 and for Group B is 422 1± 21.2. During the routine treatment on day 2, the level of serum cholinesterase for Group A was 530 1± 16.6 and for Group B was 526 1± 19.1. Reference range for serum cholinesterase is 4900 to 11900 U/L.
On day 2 therapeutic plasma exchange was done for Group B patients removing of 1,200 to 1,500 ml of plasma with infusion of 3 units of FFP as a supportive.
On day 3 plasma cholinesterase was done for group A was 740 1± 28.4, where as for group B the level was 18211± 33.6.
On day 4 again therapeutic plasma exchange was done for Group B patients by removing 1,200 to 1,500 ml of plasma with infusion of 4 units of FFP.
On day 5, plasma cholinesterase level for group A was 922 1± 21.2 and for group B the level was 5520 1± 52.4. Group B patients were removed from ventilator and shifted to ward on 6 th to 7 th day. Whereas level for group A patients came to 5010 1± 41.1 on day 10, Group A patients removed from the ventilator and shifted to ward on day 11 th to 13 th day.
Out of 6 cases in group A 1 died on day 10, but in group B all the patients was shifted toward between 6 and 7 days following 2 plasma exchange .
Discussion: Plasma exchange therapy can be considered for patients with organophosphate poisoning with severity as asses by the serum cholinesterase level and ventilator support, the overall hospital stay and expenses are economical when compared to group A patients, so to conclude the plasmapheresis is a very effective in treating acute organophosphorus poisoning with a possible 100% outcome.
Safety and efficacy of preoperative autologous apheresis platelet donation in CABG patients
Vikas Sharma, T Shyam Kumar, R R Sharma, Neelam Marwaha, Rekha Hans
Department of Transfusion Medicine, PGIMER, Chandigarh, India
Background: Platelet deficiency and dysfunction are thought to be the major causes of excessive bleeding in patients undergoing coronary artery bypass grafting (CABG) under cardiopulmonary bypass (CBP). During CPB, blood is exposed to shear stresses, non-physiological oxygenation process, artificial membrane tubings and hypothermia. Platelets may adhere and become activated on artificial membranes. Activation of coagulation, leading to generation of thrombin contributes to platelet activation. Transfusion of platelet is used to achieve hemostasis after CPB but exposes the recipient to the risks of transfusion reactions, alloimmunization and transmission of infectious agents. Various strategies have been developed to minimise the use of allogenic transfusions like pre and perioperative autologous donation.
Aims and Objectives: The study was designed to assess the efficacy of apheresis platelet concentrate (autologous and homologous) vs Random donor platelets, in terms of postoperative bleeding, blood and blood component requirements and to compare the activation of platelets in vitro (a measure of their responsiveness in vivo) by platelet activation marker- Human soluble P-selectin and quality assessment of platelet concentrates by pH and WBC count.
Materials and Methods: This study was conducted in Department of Cardiovascular and Thoracic Surgery and Department of Transfusion Medicine PGIMER, Chandigarh over 1 year. 30 consecutive patients with coronary artery disease were recruited in the study and divided into 3 groups - group 1- autologous apheresis, group 2- random donor platelets and group 3- homologous apheresis platelets. Each group had 10 patients. Apheresis was carried out in patients who were stable to undergo this procedure and cell separator used was CS 3000 plus. None of the patient had any adverse reaction during or after the autologous apheresis donation. RDPs (random donor platelets) were prepared from whole blood. Platelet activation marker -Human soluble P-selectin was estimated in platelet bags, preoperatively, after CPB, 1 h and 24 h after platelet transfusion.
Results: Demographic variables of patients were similar between 3 groups. There was significantly lower 24 h blood loss postoperatively in patients receiving apheresis platelets as compared to random donor platelets (P<0.05). There was decreased postoperative transfusion requirements of both red cells and FFP/platelet concentrates in the apheresis group (P<0.05), only 4(20%) patients in the apheresis group received allogenic transfusion, while 7 (70%) patients received postoperative transfusion in random donor group. Coagulation parameters (PT/APTT) were similar in both the groups in pre and postoperative period. Apheresis platelets had better quality control parameters than random donor platelets i.e., pH -7.0 vs 6.5 and WBC count -10 6 vs 10 7 respectively. There was decreased in vitro/in vivo activation of platelets as evidenced by lower P -selectin levels in samples from platelet units and patients receiving those indicating lesser "storage lesions" and decreased post CPB inflammatory response respectively.
Conclusions: Harvesting of platelets by apheresis preoperatively before institution of CPB is one of the good means of providing safe and good quality platelets in adequate therapeutic dose, which minimizes transfusion requirements and decreases the risks associated with it. Also, there is decreased inflammatory response in patients receiving apheresis platelets and hence better postoperative recovery.
A Two Year evaluation of the efficiency of Apheresis or Single Donor Platelet Transfusions by measuring the Corrected Count Increment in the platelet count of patients transfused with Apheresis platelets prepared on Amicus Cell Separator
Amruta Chindarkar, Nidhi Mehta
Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India.
Aim: To assess the efficiency of Platelet Transfusions by measuring the increase in the post transfusion platelet count and the Corrected Count Increment 24 h after the transfusion of Single Donor Platelets or Apheresis Platelets prepared on Amicus Cell Separator.
Materials and Methods: 196 single needle plateletpheresis procedures were performed on the Amicus Blood Cell Separator of Fenwal over a period of 2 years from 2009 to 2010. These Apheresis platelets were transfused in 182 patients. The pre-transfusion platelet count and the diagnosis of each patient were noted. Following the transfusion of the apheresis unit, 24 h post-transfusion sample of the patient was collected to determine the post-transfusion platelet count. The difference in the pre and post platelet count was noted for each transfusion. The CCI or Corrected count increment was calculated for every platelet transfusion using the following formula:
CCI = Observed increment in the platelet count x body surface area (m2) / number of platelets transfused x10 11.
Total 182 patients, who received 196 transfusions, were monitored for CCI. Of the 196 transfusions of Apheresis platelets, 170 transfusions showed an average rise in the patient's platelet count of about 48,000 /uL. The minimum rise was 4,000 /uL and the maximum was 100,000/uL. 20 transfusions did not show a rise in post transfusion platelet count. Of these, 4 transfusions were given to a pregnant patient of DIC and Dengue. The remaining 16 transfusions were given to patients with hematological disorders and malignancies such as NHL, ALL, CML and Multiple Myelomas. These were the patients with history of multiple transfusions.
Conclusion: Our data of 196 SDP transfusions show that the CCI in most of the transfusions was well above the normal value of 20,000/uL. The post count increment seen in the patients was averaging 46,000/uL, which is comparable to the results of similar studies. This further corroborates the established fact that apheresis platelets give a rise of about 50,000 /uL in the patients platelet count. The patients that did not show a significant rise were multi-transfused patients with hematological malignancies. It is possible that this non-responsiveness could be due to the refractoriness resulting from HLA alloimmunization from multiple transfusions. Thus, apheresis platelets show a statistically significant rise in CCI and post-transfusion platelet increment, which further substantiates the fact that Apheresis platelets are safer, less refractory and reduce donor exposure by decreasing the number of transfusions needed.
Efficacy of therapeutic plasma exchange in Thrombotic Thrombocytopenic Purpura:
A Case Report
Rajeswari S, Satyaprakash, Rekha Hans, Hari Krishan Dawan, Ratti Ram Sharma, Neelam Marwaha
Department of Transfusion Medicine, PGIMER, Chandigarh, India.
Prompt recognition of Thrombotic Thrombocytopenic Purpura (TTP) is important because the disease responds well to plasma exchange treatment, but associated with high mortality rate when untreated.
We have a case of TTP in whom remission achieved using 5 cycles of TPE.
A 15-year-old male presented with 12 day history of fever, pain abdomen in a Government hospital and treated with antimalarials, for having suspected as a case of malaria. He had been referred to PGI with history of fever, since 14 days and shortness of breath, since 2 days. Chest X-ray showed patchy consolidation. On admission, blood test reports showed Hb 6.4 g/dl, TLC 5,600/μL, platelet count 83,000/μL, reticulocyte count -24%, LDH 1,851U/l, Electrolytes normal, Blood urea 47 mg/dl and Serum creatinine was 0.5 mg/dl, total serum bilirubin was 0.4 mg/dl, with SGOT/SGPT in normal limits and normal coagulation profile, peripheral smear showing schistiocytes, reticulocyte index >2.5, indicating adequate marrow response. In 24 h, platelet count reduced to 28000/μL and the patient had developed altered sensorium. Diagnosis of TTP with sepsis was considered and the patient was put on mechanical ventilation. Antibiotics and ionotropes were started. Daily plasma exchange was planned.
The patient was transfused with 2 units of PRBC in view of anemia before first procedure. All procedures were done using Cobe Spectra Cell separator. Ionized calcium was monitored before and after each procedure and continuous infusion of calcium gluconate was given to prevent any complication related to hypocalcemia. During each procedure, 1-1.5 times plasma of the patient was exchanged with TTI screened and grouped plasma with no procedural complications.
Ionotropes was stopped after 1 st cycle. Patient was extubated after 3 rd cycle. Reduction in LDH level observed, peripheral smear showing no schistiocytes after 4 th cycle. Platelet count raised up to 45000/μL after 5 th cycle with further reduction in LDH level (LDH-931 U/l).The patient showed significant clinical improvement. The patient was discharged after 2 days and advised for regular follow up for platelet counts.
Conclusion: Thus therapeutic plasma exchange plays a vital role in the treatment of TTP, with better prognosis, when initiated early in the course of disease.
Review of Therapeutic Plasmapheresis Procedures in a Tertiary Care Hospital in India
Anand Deshpande, M. Kulkarni, S. Kalgutkar, M. Mishrath
Department of Transfusion Medicine, P. D. Hinduja National Hospital and M.R.C., Mumbai, India
Background: Therapeutic plasmapheresis is commonly performed in various neurological disorders like GBS (Guillain Barre syndrome). Myasthenia gravis especially during crisis and other conditions like TTP (Thrombotic Thrombocytopenic Purpura) and HUS (Hemolytic Uremic Syndrome). Most of the centers in India carry out plasma filtration rather than apheresis procedures. Ours was one of the first centers in India to establish therapeutic apheresis procedures. Our hospital is a 350 beds tertiary care hospital and not an exclusive neurology reference center and hence the number of cases is limited.
Aim: To carryout retrospective analysis of therapeutic plasmapheresis procedures in our hospital.
Material and Methods: A retrospective analysis of all the therapeutic procedures performed over the last 13 years was carried out. Initially, Hemonetics V50 plus (IFCS) Intermittent Flow cell separator was used, later on we shifted to Cobe Spectra (CFCS) continuous flow cell separator. ACD was the anticoagulatnt used in all the cases. Technical data, indications, complications and clinical outcome were analyzed.
Therapeutic plasmapheresis was carried out in 74 patients - 12 using HV50 plus and 62 using Cobe spectra cell separator.
Total number of procedures carried out was 422 - 92 using Hemonetics and 330 using Cobe spectra.
Myasthenia gravis was the commonest indication (40/74) followed by GBS and HUS. The commonest presenting symptoms in myasthenia patients were difficulty in breathing and deglutition.
There were 17 patients in pediatric age group (< 12 years) and 57 in adults. Out of the pediatrics age group 2 were < 2 years of age.
Low Hb, PCV and Low platelet count were not a contraindication for these procedures.
On an average, 5 procedures per patient were required in neurological disorders. In case of TTP and HUS more number of procedures was required.
Time taken per procedure using Hemonetics V50 plus was in between 130 to 200 mins. However, with Cobe spectra was in between 33 to 130 mins.
FFP was commonly used as a replacement fluid in all the cases till 2005. In last 6 years, we use only colloids and crystalloids in neurological disorders as replacement fluid.
On an average 1.5 volume plasma was exchanged.
Citrate toxicity (tingling around the mouth, numbness) was the commonest complication, which was controlled using calcium gluconate intravenously during the procedure. Other common complication was low access pressure resulting in stoppage of procedure in 2 patients with Hemonetics V 50 plus cell separator. Allergic reaction, particularly rash was seen commonly with FFP transfusions.
Clinical outcome was satisfactory in neurological disorders (95% of the cases) and HUS cases in pediatric age group.
Discussion: Therapeutic plasmapheresis is a safe and effective procedure in various clinical disorders
Therapeutic Red Cell Exchange in a Case of Sickle Cell Anaemia
Anand Deshpande, Mangesh Kulkarni, S. Kalgutkar
Department of Transfusion Medicine, P.D.Hinduja National Hospital and M.R.C., Mumbai, India.
Background: Therapeutic red cell exchange (TREX) has been used for various indications since years. The indications range from infectious diseases like malaria, Babesiosis More Details to hemoglobinopathies like sickle cell disease. Not many reports are available from India regarding use of TREX in sickle cell anemia.
Aim: Use of cell separator for therapeutic red cell exchange in a sickle cell patient with complications.
Materials and Methods: A 22-year-old male with sickle cell anemia, with frequent pain crises underwent TREX twice, using automated cell separator COBE -SPECTRA. During the first cycle of TREX, 2,944 ml of RBCs were removed and replaced with 2,510 ml of group specific RBCs over a period of 118 mins. In second procedure, 2,754 ml of RBCs were replaced with 2,287 ml of group specific RBCs over 97 mins.
Results: After the first cycle of TREX, the patient's HbS improved from 60.3% to 14.1% and patient was asymptomatic for 9 weeks. After the second cycle of TREX, the HbS improved from 49% to 10.9% and his symptoms resolved. Both the procedures were uneventful.
Conclusions: The TREX using cell separators is safer, less time consuming modality against a manual red cell exchange, which is routinely done in cases with sickle cell anemia and its complications.
Incidence of Pre Transplant Anti-HLA Antibodies Detected on Elisa and Luminex Platforms in 124 Renal Transplant Recipients
R Shanthi, Mary P Chacko, Basu G, Daniel D
Department of Transfusion Medicine and Immunohaematology, Christian Medical College and Hospital, Vellore, India
Background: A number of studies have shown adverse graft survival in patients, who have either pre formed anti-HLA antibodies, prior to transplantation or in recipients, who develop the same post transplant. Traditionally, the CDC (complement dependent cytotoxicity crossmatch) has played a decisive role in antibody screening. However, the ELISA and the Luminex platforms, which have greater sensitivity for anti-HLA antibody detection, have become easily accessible but their place in the decision making algorithm is unclear. While the ELISA platform can perform a screen / PRA, the luminex platform, in addition has a provision of a donor specific antibody test (DSA) using donor lysate. Data on the correlation between the ELISA screen and donor specific antibody test (DSA) using donor lysate will help particularly, when newer decision making algorithms incorporating these platforms are formed.
Aim: To compare the ELISA and DSA on the Luminex platform in detecting anti-HLA antibodies in 124 renal transplant recipients, who were crossmatch negative on the CDC platform for IgG antibodies.
Materials and Methods: The pre transplant sera of 124 patients, who underwent renal transplant from year 2008 to 2010, were tested on the ELISA platform using the LATM assay from one lambda inc. and also the DSA from Gen probe inc. using donor lysate on the Luminex platforms.
Results: Of the 124 pre transplant recipient sera samples, on which ELISA and DSA 105 (84.6%) patient samples were negative for both ELISA and DSA. The remaining 19 (15.4%) showed positivity in either or both platforms. On the ELISA platform alone 13 (10.4%) were positive, 4 (3.2%) were both ELISA and DSA positive and 2 (1.6%) were only DSA positive. Of the 13, who were positive only on the ELISA, 4 were historical CDC crossmatch positive, 2 with IgG antibodies, and 2 with IgM. Of the 4 positive on both platforms, 3 were historical CDC crossmatch positive, 2 for IgM and 1 for IgG antibodies. Of the 2 positive on DSA alone, 1 had a historical CDC crossmatch positivity with an IgM antibody. Historical CDC positivity was observed in 13 patients, who were negative on both these platforms, of which 12 had an IgM and 1 had an IgG antibody.
Discussion: The ELISA LATM and DSA on the luminex platform have shown a pick up of 3.2% anti HLA antibodies in patients negative for IgG anti HLA antibodies on the CDC platform. However, the reason for lack of correlation in many needs follow up, with possible panel reactive antibody tests and clinical follow up, the latter to assess clinical applicability, with a focus on those who have shown historical CDC positivity.
Power of Intellichek in enhancing the safety of blood for transfusion
K. Krishnan, K. Cheirmaraj, Amol J. Pandit
Ortho Clinical Diagnostics, Johnson and Johnson Ltd., Mumbai, India.
Background: Blood transfusion safety is largely influenced by the frequency and seriousness of errors that occur in the blood transfusion system starting from vein to vein. It is essential to identify critical performance measures in transfusion medicine and to describe error rates of these measures. Patient safety thereby can be improved by decreasing these errors. According to recent publications on laboratory performance in proficiency testing, erroneous results caused by sample mishandling or instrument malfunctions continue at high levels. It is important to address blood bankers and laboratorians' concern about result integrity by improving sample and reagent process control. Intellicheck technology by Ortho Clinical Diagnostics is specifically designed to establish confidence in results at every sample and assay processing step. A number of new patented processes have been combined with other VITROS® technologies such as Smart Metering and Save the Sample Clot Detection to optimize performance and deliver a level of result integrity not previously attainable.
Aim: The purpose of this study is to analyze the pre-analytical errors detected by 'intellicheck technology' in Vitros ECiQ Immunodiagnostics system at various prestigious medical institutions all over India and its relevance in enhancing the safety of blood for transfusion, by not processing the samples with anomalies.
Materials and Methods: Vitros ECiQ Immunodiagnostics systems are used by several blood banks and laboratories across India, for the screening of infectious diseases and other bio-markers. In Vitros ECiQ system, with the patented Intellicheck technology, the samples are checked automatically during aspiration and dispensing by pressure transducer mechanism. The samples are verified for the anomalies viz., bubbles, clot, short sample, viscosity and thin layer fluid and if identified, the samples will not be processed and immediately reported to the operator about the anomaly. The samples are returned to the original container once the anomaly is identified by the system by means of 'Save the Sample clot detection' features. The number of samples having anomalies viz., clot or bubbles, short sample, viscosity and thin layer fluid, identified by the system for 30 days retrospectively were recovered from the 'System Intellicheck' data. The Intellicheck data were collected from a total of 85 Vitros ECiQ systems at various blood banks and laboratories all over India and analyzed.
Results: The Intellicheck data on bubbles, clots, short sample, viscosity and thin layer fluid were collected from the total number of about 95,083 samples processed in Vitros ECiQ system at 85 different Vitros ECiQ systems over a period of 30 days. Majority of the anomalies detected by the system Intellicheck technology were clots and bubbles. When the sample volume is less than the expected volume, when aspiration takes place, it aspirates air also along with the samples and the error will be posted as Bubbles. Out of 95,083 samples processed, the system Intellicheck identified clots in about 1,444 samples (1.56%) and bubbles in 2,085 samples (2.42%). The anomalies due to viscosity and thin layer fluid were found to be very negligible. A total of about 3.98% of samples processed were identified as having anomalies by the intellicheck system. If these samples are processed without sample verification by the automation systems, they may lead to erroneous results such as a false negative or false positive result for aHIV / aHCV / HBsAg, either due to low volume of samples metered in the wells or due to the non-specific binding of clots especially fibrin clots in the micro wells, respectively.
Discussion: This study showed that Intellicheck technology can help to identify the pre-analytical errors in about 3.98% of samples processed for screening and thus helps in reducing the errors which can impact the safety of blood for transfusion.
Correlation of Umbilical cord blood volume with CD34+ cells concentration
Tulika Chandra, Sheeba Afreen, Ashutosh Kumar, Uma Singh
1 Department of Transfusion Medicine and Blood Bank, 2 Department of Pathology, 3 Department of Obstetrics and Gynecology, Chhatrapati Shahuji Maharaj Medical University Lucknow Uttar Pradesh, India
Introduction: Umbilical cord blood has been recently considered as an alternative source of hematopoietic progenitor cells for clinical application. The parameters commonly used to evaluate a UCB unit and predict transplant outcomes have been total nucleated cell count (TNCs), CD34 + cells concentration and total volume of cord blood collected. The volume of cord blood collection is also important for the high yield of CD34+ cells concentration and TNC.
Aim: The aim of the study is to find the correlation of umbilical cord blood volume with cord blood derived CD34+ cells concentration.
Materials and Methods: Umbilical cord blood was collected from normal vaginal and cesarean deliveries. Total volume of cord blood collection was noted. It was immediately processed and assessed for total nucleated cells count and CD34+ cells concentration. Assessment of maternal and neonatal parameters such as mode of delivery, baby's birth weight and sex was made with cord blood volume and CD34+ cells concentration.
Results: Total volume of cord blood and CD34+ cells concentration were positively correlated with cesarean delivery and higher birth weight of the baby (P<0.01). We also find that, higher CD34+ cells concentration was found in higher collection of cord blood collection.
Discussion: Our study concludes that higher volume of cord blood donors should be preferred samples for processing and stem cell infusion.
Standards of Blood Transfusion Services in Patiala District in 2010
Kusum K Thakur, Rimpreet, Manish Rai, Dalbir Kour, Raj Kumar
Department of Transfusion Medicine GMC, Patiala, India.
Background: Blood transfusion services (BTS) is like a factory with men, money, materials, methods and machines. Governing of BTS in India is being ploughed by fragmented management, a situation not conductive to blood safety. Standards vary from state to state, city to city and even one center to another with in the same city. In order to improve the standards of BTS in our country NACO has formulated comprehensive standards to ensure better quality control system on all aspects. In December 2001, the drug and cosmetic act, has been amended with the objective of setting up blood storage facilities at FRUs/CHCs/PHCs and a notification was issued to regulate and streamline storage facilities at these institutions and small hospitals/ nursing homes, whose requirement is less than 2,000 units of blood per annum, will be called Blood storage centers. Recently in year 2009, NACO assessed and evaluated the performance of States and UT'S in BTS on the basis of NINE parameters and did their grading, where Chandigarh was adjusted the best in the country. Similar studies have been done in Maharashtra, Gujrat, Sri Lanka, Nepal and Bangladesh from time to time. Key words--: Blood transfusion services (BTS).
Aims and Objectives: Present study was under taken to know the standards of BTS in Patiala district, on certain parameters and to compare them with national standards and further suggest recommendations, for better management of BTS and hence better patient care.
Materials and Methods: All 5 blood banks in Patiala district were observed from January to December 2010, for certain parameters like category of blood bank, licensing status, equipment, staff position, annual blood collection, testing of blood, annual utilization, facility of components, voluntary blood donation, V.B.D. camps, IEC activities, regular reporting, financial support, regulatory authorities, hospital transfusion committee, biomedical waste management and quality assurance.
Results: Category of blood banks, on basis of area and utilization of blood do not match. Gian Sagar medical college BTS is utilizing less blood on the basis of bed strength. Two blood banks at civil hospital Rajpura and Nabha are utilizing less than 2,000 units of blood per year. Private blood banks are functioning better than government blood banks in respect of licensing, testing, finance, facility of components, SOP's, equipment maintenance, staff and quality control. Charges are not uniform in Government as well as private blood banks. Most of the equipment is out of order, in Government blood banks.
Conclusion: Civil hospital Rajpura and Nabha blood banks should be made storage centers to save money as well as manpower and better patient care with ELISA tested blood and component therapy. Policy should be formulated for annual maintenance cost of equipment in government blood banks. Gian Sagar Medical College BTS needs to increase utilization of blood. Charges for blood/components should be made uniform in all blood banks. Stand alone/charitable blood banks can also work satisfactorily, when run by qualified staff.
Proteomics: Applications in Transfusion Medicine
Swathandran Hamsavardhini, Arumugam P
The Tamil Nadu Dr.M.G.R Medical University, Chennai, India.
Background and Objectives: Proteomics is the study of structure and function of all the proteins that make up an organism. Proteomics analysis has become a vital research methodology along with the science of genomics. It plays a large role in diagnosis and prognosis of the disease and vital role in the process, storage methodology for blood based treatment. Transfusion medicine is a clinical discipline characterized by one of the most advanced quality management system in the production of blood components and raw material for bio- pharmaceutical fractionation. Blood components are highly complex mixture of plasma protein and cells. During component preparation, pathogen inactivation and storage processes, there is a risk of changes in the integrity of blood components especially at protein level. These changes could be the cause of some of the negative effect of transfusion therapy. Proteomics can play a potentially relevant role in transfusion medicine to assess the protein composition of blood derived therapeutics. Proteomics in transfusion medicine exploits several technologies such as two-dimensional polyacrylamide gel electrophoresis (2D-GE), other non-gel based separation techniques, mass spectrometry (MS) and protein microarrays. Studies have demonstrated that leukocytes depleted RBC's releases few proteins compared to leucocytes undepleted blood, which releases more than hundred proteins. Proteins released during storage of leucocytes depleted RBC's were found in form of microvesicles, nanovesicles and increased band 3, suggesting a release of damage cell components. The copy numbers of CD44, CD58, CD147, glycophorin A (GPA) decreased and annexin-V release is increased in with leucocytes undepleted stored RBC's. Proteomics in platelets asses the protein modification with high coverage through qualitative and quantitative analysis between buffy coat and aphaeresis pathogen inactivated platelet concentrate. It improves the understanding of platelet storage lesions and bio markers. Proteomics provide more detailed understanding of the proteins found in plasma derivatives with particular regard to peptide and protein changes related to the various procedures used for protein purification and pathogenic inactivation. The latter could cause protein modifications, degradation and neoantigen production with the potential to induce adverse effects in recipients.
Conclusion: Human errors are the most prevailing cause of complications related to blood transfusion and transfusion transmitted diseases. Changes in protein composition in the blood component due to inappropriate storage methods also affect the blood transfusion in the recipient. The advance in screening of blood donation and the ability of the proteomics to assess the protein composition and identify modifications in them have significantly reduced such occurrences. Proteomics is a rapidly developing science, which offers the potential for significant improvements in quality of blood components.
Pathogen Inactivation Methods of Blood Component
Deepa Devi G, Arumugam P
The Tamil Nadu Dr.M.G.R Medical University, Chennai, India.
Background: Blood transfusion represents an ideal portal of entry of many endogenous/exogenous bacteria. In developed countries, the risk for bacterial and protozoan infections and emerging infectious agents are the main drive for pathogen inactivation. Pathogen inactivation of pooled fractionated plasma proteins has virtually eliminated the risk of TTIs, without compromising the quality of the products significantly. An ideal Pathogen inactivation (PI) method should not induce neo-antigen or leave any residual toxic substances causing greater damage than, due to any TTI provided the stipulated life span of the original blood component is maintained.
Pathogen inactivation methods:
Solvent/Detergent (SD) treatment: Solvent detergent treatment which has been so successfully applied for plasma products dissolves cell membranes, and can, therefore, only be applied for plasma and not for cellular blood components. It is effective against enveloped viruses and intracellular viruses and target action is lipid envelope solubilization. The most frequently used technique is the combination of 1% tri-(N-butyl) phosphate (TNBP) and 1% Polyethylene-p-t-ocrylphenol (Triton X-100) for 4 h at 30 to 31°C. NAT screening for HAV and parvovirus B19 ensures the safety of solvent/detergent treated plasma, as an essential regulatory requirement. The major advantage of SD treatment is that inactivation reagents in general, do not affect proteins and protein activity in plasma. Nanofiltration or heat inactivation has been introduced as a second PI step for reduction of nonenveloped viruses together with SD treatment.
Methylene Blue Light Treatment: Methylene blue is a positively charged phenothiazine dye with high affinity for negatively charged compounds such as guanine, proteins and some lipids. It interacts with nucleic acids through intercalative binding and produces singlet oxygen-mediated damage, primarily to nucleic acid guanosine residues, upon illumination with visible light. Toxicity of Methylene blue is low.
Psoralen Ultraviolet Light Treatment: Furocoumarins, which includes psoralens are photosensitizers. Amatosalen hydrochloric acid (S-59) is a synthetic psoralen, which crosses the plasma membrane efficiently and demonstrates excellent protection against pathogens. S-59 is activated by ultraviolet-A light. Because hemoglobin absorbs UV-A light, S-59 is not applicable for pathogen inactivation of red cells and is used for platelets and plasma.
Riboflavin Light Treatment: The riboflavin molecule is a planar, conjugated ring structure with a sugar side chain that confers water solubility. Light activated riboflavin oxidizes guanine in nucleic acids, preventing replication of the pathogen's genome. A promising method for Riboflavin treatment of red blood cells, plasma and platelet is under development. Pathogen reduction of red blood cells with Frangile Anchor Linker Effector (S-303) (FRALE) or INACTINE (PEN110) has so far resulted in the formation of antibodies against neo-epitopes on red blood cells. Emerging technologies of pathogen inactivation includes vacuum ultrasound treatment, UVC illumination and ozone treatment.
Discussion: In the advent of several emerging infections and usage of blood components for various ailments, it is imperative to achieve 100% safe blood transfusion by possible implementation of newer foolproof technologies like pathogen inactivation.
Cryopreservation of Blood Products
Raj Bharath R, Arumugam P
The Tamil Nadu Dr.M.G.R Medical University, Chennai, India.
Background: The purpose of cryopreservation is to freeze blood products to maintain the cell viability and potency. The main obstacle to maintaining viability during cryopreservation is the formation of intracellular ice crystals and dehydration resulting in cell lysis. The time required for phase change (the shift from the liquid state to the solid state) and the postphase change freezing rates are important aspects of cryopreservation. The adverse effects caused by the formation of intracellular ice crystals or by cell dehydration can be minimized by a slow cooling rate and the addition of cryoprotective agents. The most commonly used cryoprotectant is Dimethyl sulfoxide (DMSO), which is a small molecule that penetrates the cell membrane and moderates the osmotic balance within the cell thereby decreasing the amount of water absorbed by the ice crystals. RBC Cryopreservation: Glycerol is the most commonly used agent and is added to RBCs within 6 days of collection. Glycerol can be used at both high concentration and low concentration to cryopreserve the RBCs. Frozen RBCs must be stored at -65° C or colder and will expire after 10 years. Polyolefin bags are commonly used for the high glycerol method because the bags are less brittle at -80 ° C. Glycerol must be removed after thawing, before it can be transfused. The final solution in which cells are suspended is 0.9 % sodium chloride and 0.2 % dextrose. Dextrose is used to provide nutrients and has been shown to support satisfactory post-transfusion viability for 4 days of storage after deglycerolization.
Platelet Cryopreservation: 5% to 6% Dimethyl sulfoxide is the most commonly used, mainly for autologous platelet transfusions in patients, who are refractory to allogenic platelets and are stored in a mechanical freezer at - 80 ° C. Cryopreserved platelets can be stored for at least 2 years. Recently, the combination of reduced concentration DMSO (2%) and a platelet storage solution (amiloride, adenosine and nitroprusside) have been used for autologous platelet cryopreservation for patients with malignancies before initiating chemotherapy.
Stem Cell Cryopreservation: The stem cells are cryopreserved by suspending in autologous plasma or in albumin along with hydroxyl ethyl starch and by adding a final concentration of 10% DMSO, before controlled rate freezing can be done. They are stored in liquid nitrogen freezers (-196 ° C). The stem cells are thawed at 37°C water bath and immediately infused through a central venous catheter.
Discussion: Cryopreservation has increased the shelf life of the blood products without affecting the cell viability and function. It does a very important role in the field of stem cell preservation and is sure to have a larger role in the near future.
Role of HLA in Stem Cell Transplantation
Arumugam P, Raj Bharath R
The Tamil Nadu Dr.M.G.R Medical University, Chennai, India.
Background: Human leukocyte antigen (HLA) testing is an integral part of solid organ and hematopoietic progenitor cell transplantation. It has long been recognized that disparity within the HLA system represents an important barrier to successful stem cell transplantation. HLA similarity and compatibility between the donor and the recipient are required for engraftment and to help prevent Graft versus Host disease.
HLA Typing: HLA system is composed of a complex array of genes and their protein products located within the human major histocompatibity complex (MHC) on the short arm of chromosome 6. HLA antigens are classified as class I (HLA - A,-B,-C) and class II (HLA -DR,-DQ,-DP). Typing of donors can be performed by using low or high resolution techniques. The low resolution techniques will discriminate, generally between antigens whereas high resolution molecular techniques will identify allelic differences. Candidate donors and recipients are typed for their HLA A, B, C, DR and DQ alleles and in some cases for their HLA-DP alleles. The goal is to match the alleles of the prospective donor and recipient at the HLA A, B and DRB1 loci with the optimal match being an allele level match. Molecular HLA typing is performed on samples from both the donor and recipient for assessment of class I and class II region compatibility.
Choice of Donors: HLA identical sibling donors remain the best choice for stem cell transplantation. With family size decreasing, the possibility of having an identical HLA matched sibling donor is decreasing. Partially HLA matched family donors, closely matched unrelated donors and umbilical cord blood donors are being increasingly used. The choice between a partially matched family donor and unrelated donor is more problematic. The first issue in the decision tree analysis is how good the matching is and what type of cell processing supports is available. Related donors mismatched for two or more HLA -A,-B or -DR antigens have reasonable success rates but only with aggressive T cell depletion. For the recipient of an unrelated graft, when there is a donor matched by high resolution molecular techniques of HLA -A,-B,-C-DR and -DQ loci, equivalent survival to that reported in a HLA genotypically identical sibling transplant recipient has been observed.
Discussion: HLA plays a very important role in selecting the type of donor for a successful stem cell transplant. There is a need for donor databases regarding HLA matching such as the National Marrow Donor Program for finding matched donors.
A Retrospective Analysis of HLA Antigen Distribution in Indian Population
Anand Deshpande, Suchita Jogale
Department of Transfusion Medicine, P.D.Hinduja National Hospital and M.R.C., Mumbai, India.
Background: India with diverse but endogamous caste groups is an ideal testing ground for studies on selective advantages of the HLA polymorphism. Present study was conducted on 635 individuals, which includes various caste groups of India coming to Mumbai for organ transplantation. This will help in creating a national registry and organ sharing network.
Aim: To carry out a retrospective analysis of HLA antigen distribution in various caste groups of India using PCR-SSP method.
Materials and Methods: A retrospective analysis of 635 individuals of various caste groups who were prospective kidney transplant recipients and donors was carried out. Major caste groups studied were, Marathi - 296, Gujrati - 104, South Indians - 49, Catholic - 32, Sindhi - 22, and North Indians - 132. HLA Class I and Class II typing (HLA -ABDR) was carried using the polymerase chain reaction- sequence specific primers (PCR-SSP) method.
Analysis showed a higher frequency of
HLA -A*01, A*02, A*11, A*24, A*33
HLA- B*51, B*52, B*07, B*44, B*35, B*40
HLA -DRB1*15, DRB1*04, DRB1*13, DRB1*14, DRB1*07, and DRB1*10
In overall Indian and selected populations.
Comparatively lower frequencies of
HLA -A*30, A*31, A*34, A*36, A*74
B*14, B*18, B*27, B*39, B*41, B*45, B*48, B*49, B*50, B*53, B*55, B*56
DRB1*08, DRB1*09, DRB1*12 and DRB1*16 were observed.
Discussion: It is observed that HLA - HLA -A*01, A*02, A*11, A*24, A*33 / HLA- B*51, B*52, B*07, B*44, B*35, B*40 and HLA - DRB1*15, DRB1*04, DRB1*13, DRB1*14, DRB1*07, and DRB1*10 are the most common HLA antigens found in Indian population.
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