Asian Journal of Transfusion Science
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   Table of Contents - Current issue
Coverpage
July-December 2019
Volume 13 | Issue 2
Page Nos. 79-152

Online since Tuesday, December 3, 2019

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REVIEW ARTICLE  

Umbilical cord blood quality and quantity: Collection up to transplantation Highly accessed article p. 79
Seyed Hadi Mousavi, Morteza Zarrabi, Saeid Abroun, Mona Ahmadipanah, Bahareh Abbaspanah
DOI:10.4103/ajts.AJTS_124_18  
Umbilical cord blood (UCB) is an attractive source of hematopoietic stem cells for transplantation in some blood disorders. One of the major factors that influence on transplantation fate is cord blood (CB) cell count, in addition to human leukocyte antigen similarity and CD34+ cell number. Here, we review the factors that could effect on quality and quantity of CBUs. Relevant English-language literatures were searched and retrieved from PubMed using the terms: CB, quality, collection, and transplantation. The numbers of total nucleated cells (TNCs) and CD34+ cells are good indicators of CB quality because they have been associated with engraftment; thereby, whatever the TNCs in a CB unit (CBU) are higher, more likely they led to successful engraftment. Many factors influence the quantity and quality of UCB units that collect after delivery. Some parameters are not in our hands, such as maternal and infant factors, and hence, we cannot change these. However, some other factors are in our authority, such as mode of collection, type and amount of anticoagulant, and time and temperature during collection to postthaw CBUs and freeze-and-thaw procedures. By optimizing the CB collection, we can improve the quantity and quality of UCB for storage and increase the likelihood of its use for transplantation.
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ORIGINAL ARTICLES Top

Role of plasma exchange in postpartum microangiopathies: An experience from a tertiary care center p. 90
Rekha Hans, Satya Prakash, Divjot Singh Lamba, Ratti Ram Sharma, Pankaj Malhotra, Vanita Suri, Neelam Marwaha
DOI:10.4103/ajts.AJTS_16_19  
BACKGROUND: Postpartum microangiopathies are rare but are associated with high maternal and fetal mortality requiring early diagnosis and prompt treatment to improve the outcome. AIMS AND OBJECTIVES: This retrospective study aims to assess the efficacy of plasma exchange (PE) therapy in postpartum thrombotic microangiopathies. MATERIALS AND METHODS: We did retrospective analysis of all plasma exchange procedures performed in patients of postpartum thrombotic microangiopathies over a period of 1 year (2015-2016). Patient's pre- and post-plasma exchange hematological and biochemical parameters were recorded and compared for analyzing the response to the therapy. Patients were followed telephonically even after their discharge from the hospital. RESULTS: Hematological and renal profile improved in 8 out of 9 patients after PE therapy. Survival after PE therapy was 40% in post partum atypical HUS and 75% in patients with HELLP syndrome at 4 months of follow up. CONCLUSION: Early initiation of PE therapy in postpartum thrombotic microangiopathies can reduce morbidity and mortality associated with them.
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Comparison of UV spectrometry and fluorometry-based methods for quantification of cell-free DNA in red cell components p. 95
Dheeraj Khetan, Nitesh Gupta, Rajendra Chaudhary, Jai Shankar Shukla
DOI:10.4103/ajts.AJTS_90_19  
BACKGROUND: Stress and shear force applied on blood components during processing and storage may induce cellular damage leading to release of cell-free DNA (cfDNA). In this study, we have compared ultraviolet (UV) spectrophotometry with UV-induced fluorescence for the quantification of cfDNA in red cell supernatant. MATERIALS AND METHODS: cfDNA was extracted from 200 μL sample of supernatants from 99 packed red blood cells using QIAamp DNA Blood Mini Kit (Qiagen, Germany). Quantification of cfDNA was done using two different methods: one based on spectrophotometry (NanoDrop 2000c, ThermoFisher Scientific, USA) and another based on fluorometry (Qubit 2.0, Life Technologies, ThermoFisher Scientific, USA). Interassay variability of both the methods was estimated using serial dilutions of standard with known DNA concentration. RESULTS: DNA quantification by both the methods was close to actual amount of known standard in dilutions with higher concentration of DNA (21.68 to 2.71 ng/μl). While at higher dilutions, quantification by NanoDrop was neither precise nor accurate. Median cfDNA concentration in the study units was found to be 1.60 ng/μl (25th–75th percentile range: 1.10–2.10) by UV spectrophotometry (NanoDrop) compared to 0.080 ng/μl (25th–75th percentile range: 0.050–0.130) by fluorometry (Qubit). CONCLUSION: Due to high interassay variability between the two methods and the better precision and accuracy of Qubit, it is recommended that fluorometry-based method be used for the quantification of cfDNA in blood components.
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Reversal of warfarin-coagulopathy: How to improve plasma transfusion practice in a community hospital setting? p. 100
Lubna Bashir Munshi, Braghadheeswar Thyagarajan, Aasems Jacob, Shil Patel, Steve Zheng Liu, Arpad Szallasi
DOI:10.4103/ajts.AJTS_110_17  
BACKGROUND: Plasma is often given inappropriately to reverse warfarin-induced coagulopathy, wasting health-care resources and exposing the patients to transfusion-associated risks. AIMS: The clinical practice at our institution was evaluated in order to reduce the number of unnecessary plasma transfusions. MATERIALS AND METHODS: Retrospective audit of plasma transfusions was done (July 2014 to June 2015). DESIGN: To improve the clinical practice, a two-prong strategy was implemented: (1) in-service was given to clinicians on the warfarin-reversal guidelines and (2) for a 30-day period, plasma orders were placed on the approval list of the Transfusion Medicine Service. RESULTS: Of the 729 units of plasma, 189 (26% of total) were given for the reversal of warfarin-induced coagulopathy. The medical charts of these patients were reviewed: 46 units of plasma (~25%) were given inappropriately (e.g., patients with minimally elevated international normalized ratio, no evidence of bleeding, and no surgery within 24 h). To check the effectiveness of our intervention, two audits of plasma transfusions were done. During the first audit (January 1–February 29, 2016), 24 patients received plasma to reverse warfarin-coagulopathy. Medical chart review revealed that the vast majority of plasma orders (96.66%) followed the guidelines. A second audit was carried out a year later (January 1–March 31, 2017): during this 3-month period, 47 patients were transfused with plasma for warfarin reversal with a 94% adherence to the guidelines. CONCLUSION: We conclude that plasma transfusion practices may be improved by a combination of education and active enforcement of warfarin reversal guidelines.
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Mutational analysis of thalassemia in transfusion-dependent beta-thalassemia patients from central India p. 105
Manisha Shrivastava, Rashmi Bathri, Nirupama Chatterjee
DOI:10.4103/ajts.AJTS_115_18  
BACKGROUND: Thalassemia and hemoglobin (Hb) disorders are the most common genetic disorders among humans. These disorders entail huge morbidity, economic, and psychological burden on the families of the affected. Genetic counseling and prenatal diagnosis are the steps, which helps to reduce this burden. At present, there is paucity of data on the mutational spectrum of thalassemia from the central Indian region. METHODS: Blood samples were collected from 62 transfusion-dependent patients, demographic and relevant data were collected and screened for the two rare mutations − 88 (C-T) and CAP + 1 (A-G) using amplification refractory mutation system-polymerase chain reaction (PCR) and GAP PCR technique. PCR was performed for rare Hb disorders such as Hb Lepore and δ β chain disorder by GAP PCR in addition to five common Indian beta-thalassemia mutations IVS1-5 (G-C), IVS1-1 (G-T), Cd41/42 (−TCTT), Cd8/9 (+G), 619 bp deletion. RESULTS: Overall 93.5% of the mutations could be identified. Among the abnormal Hb, sickle cell and HbE were found at 4% and 3% of all the loci studied. We also reported two loci with Hb δ β and one locus with Hb Lepore in the present samples. IVS I-5 (G–C) was the common mutation (46%) followed by IVS I-1 (G–T) (12%) and 619 bp (9%). CONCLUSION: The identification of the genotypes helps to define the severity of the phenotype, plan therapy and form the basis of the comprehensive diagnostic database that would be useful not only for genetic counseling but prenatal diagnosis as well, contributing to the current focus of the National Policy to prevent and control hemoglobinopathies.
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Evaluation of molecular typing and serological methods in solving discrepant results of weak and partial D (Rh) in South Egypt p. 110
Rania M Bakry, Eman Nasreldin, Ashraf E Hassaballa, Samar M Mansour, Sahar A Aboalia
DOI:10.4103/ajts.AJTS_162_18  
INTRODUCTION: Rh discrepancies produced by partial and weak D phenotypes are a problem during routine testing. Some blood units with weak and partial D expression may be missed by serology. Overcoming the limitations of serology can be achieved by molecular typing. Our objective was to evaluate currently used serologic methods with the molecular analysis in solving discrepant results of weak and partial D (Rh) in South Egypt. PATIENTS AND METHODS: Fifty blood donor and patient samples with undetermined D phenotype were subjected to serology to define their phenotype using identification (ID)-Card “ID-partial RhD typing set” using six monoclonal anti-D panels, followed by molecular typing using polymerase chain reaction sequence-specific primer kit. RESULTS: Molecular typing confirmed most of the serology results; two samples previously resolved as partial D Type 3 and DFR by serological methods were clarified by molecular techniques – one sample as weak Type 4 and the other sample as weak Type 3. Among the weak D alleles found in our study, Type 4 was the most common, with a frequency of 20%, followed by Type 3 (14%), Type 1 (8%), Type 2 (6%), and finally, Type 5 with a frequency of 3%. The most common types of partial D were partial D Type D5 (14%) and Type D3 (10%). CONCLUSION: Our study identified D variants (weak D and partial D categories) of the antigen D and determined the frequency and composition of partial D and weak D alleles in our population. Molecular typing also confirmed most of the results obtained from serological methods.
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Comparison of a column agglutination technology-based automated immunohematology analyzer and a semiautomated system in pretransfusion testing p. 115
Ravi C Dara, Aseem Kumar Tiwari, Subhasis Mitra, Deviprasad Acharya, Geet Aggarwal, Dinesh Arora, Gunjan Bhardwaj
DOI:10.4103/ajts.AJTS_116_17  
INTRODUCTION: Semi-automated equipment using Column agglutination technology (CAT) is widely used where centrifugation and incubation are automated but substantial amount of the work is still executed manually. Larger laboratories are moving towards automation to eliminate errors, reducing exposure to bio-hazardous samples, assuring traceability, reliability, turnaround time (TAT) and throughput. Moving towards automation and greater reliability, we therefore, decided to install an automated immunohematological (IH) analyzer “Vision”. In this study we evaluated reliability and performance before clearing “Vision” for routine use. MATERIALS AND METHODS: Study was conducted in the Department of Transfusion-Medicine. The primary objective was to assess the reliability of results and compare with routine use semi-automated BIOVUE system (Reference system). Secondary objective was to evaluate the performance (TAT and throughput) of the Vision to handle routine and emergency workload. RESULTS: Total of 1276 known samples were used to assess 2640 pre-transfusion tests (1229 ABO/Rh D typing; 1229 antibody screening; 54 antibody identification; 86 crossmatch and 42 DAT). All 1229 ABO Rh typing results were concordant between the two systems. Overall agreement between the Vision IH analyzer and reference system for ABO Rh typing was 99.95%. All antibody screening, crossmatch and DAT results were concordant between the two systems. TAT of Vision was substantially shorter than the reference system for all test profiles. CONCLUSION: Based on study results, Vision was approved for routine use in laboratory. It was found to be reliable with considerably shorter TAT and capable of handling high throughput of immunohematological tests.
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Effectiveness of bone marrow-derived mononuclear stem cells for neurological recovery in participants with spinal cord injury: A randomized controlled trial p. 120
Rajeshwar Nath Srivastava, Ashok Kumar Agrahari, Alka Singh, Tulika Chandra, Saloni Raj
DOI:10.4103/ajts.AJTS_44_18  
BACKGROUND: Complete lesion after spinal cord injury (SCI) remains irreversible with little hope of neurological recovery. Newer interventions such as re-stimulation of damaged neurons using artificial agents and the use of stem cells for neuronal regeneration have shown promising results. AIM: This study was undertaken for evaluating the neurological status of acute SCI participants after stem cell augmentation and comparing them with other treatment methods. SETTING AND DESIGN: Randomized controlled trial in the northern Indian population. MATERIALS AND METHODS: A total 193 SCI participants of complete paraplegia with unstable T4–L2 injury having thoracolumbar injury severity score ≥4 were enrolled in this study. Participants were randomly allocated for three different treatment modalities, namely, conventional with stem cell augmentation (Group-1), conventional (Group-2), and conservative (Group-3). Neurological recovery after 1 year was evaluated through the ASIA Impairment Scale (AIS)-grading, sensory, and motor scores. STATISTICAL ANALYSIS: T-test for sensory-motor score analysis of each group and analysis of variance for comparison of same variables between the groups. RESULTS: After 1-year significant difference was observed in the AIS-grade, sensory and motor scores in-Group 1 (P < 0.001). In Group-1 versus 2, the mean difference at 1 year for AIS grade, sensory and motor scores were 0.40 (P = 0.010, 95% confidence interval [CI] 0.075–0.727), 8.52 (P = 0.030, 95% CI 0.619–16.419), and 4.55(P = 0.003, 95% CI 1.282–7.815), respectively. In Group-1 versus 3, 1.03, 19.02 and 7.22 (P < 0.001 for each of the parameters) and in Group-2 versus 3, 0.63 (P < 0.001), 10.49 (P = 0.009), and 2.68 (P = 0.019), respectively. CONCLUSIONS: Significant motor neurological recovery and AIS-grade promotion was observed in Group-1 as compared to Group-2 and 3.
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CASE REPORTS Top

Detection of a rare subgroup of A phenotype while resolving ABO discrepancy p. 129
Revathy Nair, Harita Gogri, Swati Kulkarni, Debasish Gupta
DOI:10.4103/ajts.AJTS_118_17  
Weaker subgroups of ABO blood group system give rise to discrepancies between forward and reverse grouping and cause diagnostic difficulties in routine blood banking. Weaker subgroups of A blood group that have been reported so far include A3, Aend, Ax, Am, Ay, and Ael. We report a case of a 54-year-old patient whose red cells showed a discrepancy between cell and serum grouping on initial testing. Serological investigation included absorption elution tests and saliva testing after performing initial blood grouping. Molecular genotyping of the ABO gene was performed by DNA sequencing of exons 6 and 7 of the ABO gene. The serological characteristics of the patient's red cells were similar to Ax subtype. The patient was a secretor and only H substance was present in the saliva. Serum did not show the presence of anti-A1. Molecular genotyping confirmed the ABO status as Aw06/O13. The weak A phenotype identified in the propositus had serological characteristics similar to Ax and showed the ABO genotype Aw06/O13. Although Aw06 allele has been previously reported in the Indian population, this is the first study to report O13 allele in the Indian population.
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Deciphering a delayed hemolytic transfusion reactions nightmare – Case of Chido/Roger antibodies p. 132
Soumya Das, PS Priyamvada, Abhishekh Basavarajegowda, Ankit Mathur
DOI:10.4103/ajts.AJTS_152_17  
Antibodies against Rh (CEce) and Kidd (Jka and Jkb) system antigens are mostly implicated in delayed hemolytic transfusion reactions (DHTR), which is a potentially life-threatening complication observed in patients receiving chronic transfusions. Here, we are describing a case of Chido/Roger antibody which presented to our laboratory as DHTR. The clinical presentation and laboratory findings including the immunohematological workups with regard to the reaction are discussed, with a special emphasis on the benefit of identifying such an antibody and obtaining blood unit for transfusion supports the patient with respect to providing a compatible unit.
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Role of de novo DQ donor-specific antibody in antibody-mediated rejection in renal transplant recipient: A case study p. 136
Mohit Chowdhry, Manthan Patel, Yogita Thakur, Vandana Sharma
DOI:10.4103/ajts.AJTS_1_18  
The human leukocyte antigen (HLA) matching plays an important role in determining the clinical outcome of renal transplantation. The development of donor specific antibodies (DSA) against HLA is associated with antibody mediated allograft tissue injury, poor outcome and rejection. The DQ-DSA develops in a denovo pattern and its unfavorable impact on renal transplantation has not yet been widely reported. We investigated the clinical significance of DQ-DSA in a patient diagnosed with hypertension, CKD stage V on maintenance hemodialysis (MHD) for second renal transplant. The histocompatibility workup before the first transplant included low resolution HLA-A, B, DR typing of both patient and donor. HLA type of the patient was HLA-A*29, 68, HLAB*44, 44, DRB1*07, 11. HLA type of the donor was HLA-A*03, 68, HLA-B*39, 44, DRB1*07, 10 with a 3/6 match. The HLA antibody screen and complement dependent cytotoxicity crossmatch (CDC) were found to be negative. No therapeutic plasma exchanges (TPE) were done during stay and post-transplant the patient was on triple immunosuppressant therapy. After four years the patient was diagnosed with recurrent membranoproliferative glomerulonephritis and second renal transplant was planned, therefore, histocompatibility workup was initiated. HLA antibody screen was found to be positive for HLA class II. Initially only HLA-A, B, DR typing was performed and that too only low resolution, further, high resolution HLA typing was done for HLA-DR and DQ to rule out if these antibodies are de-novo DQ/DR DSA. We analyzed that the patient had developed de-novo DSA against HLA-DRB1*10:01 (DR10), MFI-2374 and DQB1*06:01 (DQ6), MFI-15315. This study suggests the role of DQ antibodies in determining the graft survival and to highlight the need of HLA DQ typing as a routine of the diagnostic work-up in a solid organ transplant.
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An unusual report of anti-N antibody presenting as ABO discrepancy in an old female patient in Palestine p. 140
Fekri H Samarah, Mahmoud A Srour
DOI:10.4103/ajts.AJTS_28_18  
The MNS is a highly complex immune blood group system which is almost equal to Rh in size and complexity. Anti-N antibody is naturally occurring in general, cold reactive IgM or IgG saline agglutinin and relatively rare when compared with anti-M. The immune type anti-N is seldom encountered. Anti-N antibody is not clinically significant unless it reacts at 37°C. Clinically significant anti-N antibody is reactive at 37°C or in the anti-human globulin phase, which may cause delayed hemolytic transfusion reactions or hemolytic disease of newborn. Here, we report a rare case presented as blood group discrepancy of a naturally occurring anti-N that reacts at 37°C.
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Masquerading of mismatched blood transfusion by underlying autoimmune hemolytic anemia p. 142
Priyanka Samal, Sarita Pradhan, Sudipta Sekhar Das
DOI:10.4103/ajts.AJTS_154_17  
Mismatched blood transfusion due to immunohematological discrepancy is relatively uncommon and in most instances occurs due to Type IV blood group discrepancy which is the discrepancies between forward and reverse groupings. Here, we present a case of a 15-year-old girl with preexisting autoimmune hemolytic anemia (AIHA) who inadvertently received 3 units of wrongly matched packed red blood cell (PRBC), followed by severe intravascular hemolysis. On detailed immunohematological investigation, the patient was found to be autoimmunized and diagnosed with “mixed AIHA” and the patient's blood group was confirmed as “A” positive. Three units of group-specific “best match” PRBC was transfused under close observation without any adverse effect. This highlights the importance of carrying out both forward and reverse blood groupings to avoid mismatched blood transfusion.
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Effectiveness of therapeutic plasma exchange in a critically ill child with secondary hemophagocytic lymphohistiocytosis p. 145
Prashant Kumar Pandey, Esha Kaul, Nitin Agarwal, Shalendra Goel
DOI:10.4103/ajts.AJTS_45_18  
Currently, the ASFA has not included TPE in the management of HLH but many cases reports have reported successful role of TPE in HLH. Here we are presenting a case in which HLH was managed successfully with TPE. Diagnosis of HLH is based on the HLH 2004 diagnostic criteria proposed by HLH society. TPE was done using COM.TEC (Fresenius Kabi, Germany). Patient required three sessions of TPE. After three sessions of TPE patient's clinical condition improved remarkably and he was switched to IV Dexamethasone as maintenance treatment. One standard TPE procedure was 1.5 plasma volume exchanges. In view of deranged coagulation profile fresh frozen plasma was used as a replacement fluid. During follow up after one month of discharge, patient was absolutely normal. In developing countries like India, where infections are still a prime concern to the physicians, making an accurate diagnosis of HLH is a great concern. High suspicion, timely diagnosis and early start of TPE can be life saving in such patients.
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A rare Bombay (Oh) phenotype to 'A' blood group – Live donor liver transplant p. 148
Deepti Sachan, Suryatapa Saha, K Chandan Kumar, Srinivas M Reddy, Ilankumaran Kaliamoorthy, Mohamed Rela
DOI:10.4103/ajts.AJTS_21_18  
Bombay (Oh) phenotype is the rarest blood group in India characterized by the absence of A, B, and H antigens and the presence of anti-H antibodies besides anti-A and anti-B. There is no literature predicting the safety of Oh blood group organ donation to non-Oh blood group recipient. We present the first reported case of successful live donor liver transplantation from an Oh-positive liver donor to an A-positive blood group recipient with hepatitis B virus-related chronic liver disease. The case highlights the need for proper immunohematological workup, national registry of rare group blood donors and need of protocol for perioperative monitoring and blood management in ABO-incompatible organ transplants involving Oh group donor or recipient.
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LETTER TO THE EDITOR Top

Transfusion practice in obstetrics – Indian scenario p. 151
Mohandoss Murugesan, Karishma Doshi, SP Subbiah
DOI:10.4103/ajts.AJTS_161_18  
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2006 - Asian Journal of Transfusion Science | Published by Wolters Kluwer - Medknow
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